Soc Psychiatry Psychiatr Epidemiol
DOI 10.1007/s00127-014-0868-2
ORIGINAL PAPER
Modifying attitudes to mental health using comedy as a delivery
medium
Norman Jones • Maya Twardzicki •
John Ryan • Theresa Jackson • Mohammed Fertout
Claire Henderson • Neil Greenberg
•
Received: 12 July 2013 / Accepted: 16 March 2014
Ó Springer-Verlag Berlin Heidelberg 2014
Abstract
Purpose Beliefs about other people’s potential views or
reactions may be powerful determinants of mental health
help-seeking behaviours. United Kingdom Armed Forces
(UK AF) have made considerable efforts to promote
appropriate help seeking though it is often suggested that
military personnel remain reluctant to seek help. This study
evaluated a novel stigma-reduction method, stand-up
comedy, in service personnel.
Method Personnel viewed a regular comedy show or a
show containing mental health information. Pre, immediately post-show and 3 months later, military stigmatisation,
potential discrimination, mental health knowledge, helpseeking and coping behaviour, talking about mental health,
current mental health and alcohol use were measured.
N. Jones (&) J. Ryan M. Fertout N. Greenberg
Academic Department of Psychological Medicine,
Institute of Psychiatry, Weston Education Centre,
Cutcombe Road, London SE5 9RJ, UK
e-mail: [email protected]
Results Response rates were 81.3 % pre-show, 67.6 %
post-show and 18.9 % at follow-up. Inclusion of mental
health material did not appear to detract from show satisfaction. Post-show, intervention group (IG) participants
reported significantly less stigmatisation and accurately
answered mental health-related questions; in the small
numbers followed up, neither difference was maintained,
however, IG personnel were statistically significantly more
likely to discuss mental health and to advise others about
mental health; adjusted analyses suggested that this was
related to factors other than the show.
Conclusion In UK AF personnel, embedding mental
health awareness within a comedy show format had a
short-term positive effect upon military stigmatisation
regarding mental health. The low rate of follow-up limited
our ability to assess whether this effect was durable. If the
longevity of change can be adequately assessed and demonstrated in further research, comedy could potentially
form a component of a comprehensive stigma-reduction
strategy.
N. Jones J. Ryan M. Fertout N. Greenberg
Academic Department for Military Mental Health,
Institute of Psychiatry, Weston Education Centre,
Cutcombe Road, London SE5 9RJ, UK
Keywords Military Stigmatisation Mental health Barriers to care Health promotion
M. Twardzicki
Public Health, Surrey County Council, Penrhyn Road,
Kingston KT1 2DN, UK
Introduction
T. Jackson
Army Headquarters DPS(A), Level 2, Zone 2, IDL428,
Ramillies Building, Marlborough Lines, Monxton Road,
Andover SP11 8HJ, UK
C. Henderson
Health Service and Population Research Department, Institute of
Psychiatry, De Crespigny Park, PO 29, London SE5 8AF, UK
The United Kingdom Armed Forces (UK AF) conduct
challenging operations which may lead to psychological
health problems [1] particularly for combat personnel [2,
3]. Moral, legal and economic reasons dictate that commanders ensure that effective non-clinical and formal
healthcare support mechanisms exist to mitigate potential
psychological risks. UK AF have sought to improve psychological support by delivering psychological briefings [4,
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Soc Psychiatry Psychiatr Epidemiol
5], using peer support programmes [6], mental health
training for commanders and providing military health
services [7, 8, 9]. However, engaging military personnel
with psychological support can be challenging [10]. Fear
et al. [2] suggest that mental illness in the UK AF remains
stable, and broadly reflects general population levels;
however, although perceived stigmatisation regarding
mental health conditions has reduced over time it remains
common [11] and not dissimilar to civilian patterns [12,
13]. Stigma is an important barrier to help seeking [14] and
UK military research suggests that it is more intense in
those suffering symptoms of mental disorder [15], those
who need help the most. Although Osório et al. [12] argue
that stigma may be inevitable in challenging operational
environments where personnel need to remain hardy, UK
AF remain committed to reducing stigma and promoting
engagement with effective support [16].
The British Army (BA) has conducted a specific stigmareduction campaign entitled ‘Don’t Bottle it Up’ using a
variety of media, not including stand-up comedy, to deliver a
public health message; this approach is used in other settings
with some success. A review suggested that humour was
effective when communicating sensitive topics such as mental
illness to young men [17]. An external evaluation of such an
approach suggested that audiences engaged with and related
to the comedians with issues staying with them after the show
[18]. Given that humour is integral to service culture in the UK
AF, we sought to evaluate stand-up comedy as a medium for
delivering mental health awareness which could form part of a
comprehensive stigma-reduction programme if it could be
shown to elicit a positive effect.
We sought to answer four research questions: first, can
attitudes to mental illness and help seeking in a military
context be influenced by embedding mental health awareness material in a comedy show? Second, can discrimination towards those with mental health problems be reduced
using comedy? Third, can awareness of mental health rates,
stigmatisation and coping strategies be increased and
fourth, can military personnel be encouraged to talk about
mental health using a comedy approach?
Method
The authors J.R., a professional stand-up comedian with
experience of military audiences, and MT designed a
mental health awareness comedy show. Firstly, four focus
groups were run with between 10 and 15 personnel in
each, to explore experiences of mental health, related
attitudes and barriers to help seeking and to help inform
development of the show script and key messages. Fifteen
key Intervention Group (IG) messages were then finalised
by the project team which were grouped under four
123
themes: mental health problems (definition, incidence,
contributory factors); mental health-related stigma (incidence, emphasising that seeking help is actually a sign of
strength); help seeking (effectiveness, sources of help in
the AF, self-help strategies); and alcohol (incidence of
problems in the AF, ineffectiveness as a coping strategy
for mental health problems/stress; negative links regarding risk of and existing mental health problems). The IG
shows were designed to convey each of the fifteen key
messages via the medium of comedy, delivered by J.R.
and another comedian with experience of military service,
mental health and alcohol problems. The CG show was a
straight stand-up show containing no reference to any of
the key messages. Knowledge of the key messages was
evaluated pre-show, post-show and at 3-month follow-up.
Serving members of the BA volunteered to take part in a
comparative evaluation of the intervention vs. a placebo
condition delivered during working hours within their military
unit. Participants were chosen at random to receive either the
intervention or a show with no mental health content. Subjects
were not told in advance which form of intervention they were
to receive. To assess whether the inclusion of mental health
awareness influenced perceptions, a four-point Likert scale
measuring acceptability and utility was administered postshow. Other measures were obtained pre- and post-show and
at follow-up 3 months later; help-seeking and mental health
measures were administered pre-show and at follow-up.
Measures
In a pre-show survey, strength of belief about help seeking
was assessed using an 11-item scale measuring potential
stigmatising beliefs about mental health and perceived
barriers to care (Stigma/BTC) adapted from a US military
research scale [19, 20]. A four-point Likert scale generated
scores ranging from 11 to 44; higher scores reflected
greater stigmatisation.
Potential future discrimination against people with
mental health problems was assessed in four contexts:
living with, working with, living nearby and continuing a
relationship with a mental health problem sufferer using
items 5–8 of the Reported and Intended Behaviour Scale
(RIBS) [21]. Scale scores ranged from 4 to 20 with lower
scores reflecting greater discrimination. Specific knowledge was assessed using items 1–6 of the Mental Health
Knowledge Schedule (MAKS) [22]. A six-point scale
generated MAKS scores ranging from 5 to 30 with higher
scores reflecting greater knowledge. To assess change postshow and at follow-up, the military stigma/BTC, MAKS
and RIBS scales were analysed as continuous measures.
Post and follow-up scores were subtracted from pre-show
scores to generate change scores. Tertiles were calculated:
middle and lower tertiles, representing no change, minimal
Soc Psychiatry Psychiatr Epidemiol
change or increased scores, were combined so that upper
tertile change scores, representing greater reductions in
stigma and potential discrimination or positive increases in
knowledge, could be compared with all others.
At baseline and post-show, personnel were asked about
current levels of discussing mental health problems,
advising others about help seeking, interest in receiving
support and actual help seeking at baseline and follow-up
only.
Levels of awareness of key show messages were
assessed at baseline, post-show and follow-up using a
Likert scale. Responses were grouped to form a binary
variable and summed to generate a count variable indicating low to high knowledge levels. Knowledge about
mental health problem prevalence, military and general
public stigmatisation and military alcohol use was
assessed with three additional questions; correct answers
were embedded in the show and the ability to answer
questions correctly was re-assessed post-show and at
follow-up.
We used brief scales throughout to ensure that the survey was not overly lengthy. The intervention show targeted
alcohol use and common mental disorder (CMD) as both
are relatively common in UK AF personnel [23], and
posttraumatic stress disorder (PTSD) as it is a potential
outcome in those exposed to potentially traumatic events.
Alcohol use was assessed pre-show and at follow-up using
the 3-item Alcohol Use Disorders Identification Test
(AUDIT-C), a brief validated screening tool used to identify hazardous drinking or active alcohol use disorders [24].
Symptoms of CMD were assessed using the 12-item
General Health Questionnaire (GHQ-12) [25, 26]. Symptoms of PTSD were assessed using the Primary Care PTSD
scale (PC-PTSD) [27]. The screening positive score
(caseness) on the AUDIT-C was C4, for CMD the caseness
score was C4 and for the PC-PTSD this was C2 symptoms,
all representing the screening measures commonly used in
research to detect possible mental health symptoms
requiring further assessment.
Analysis
The study was powered to detect a 5 % change in reporting
one or more stigma scale items, which in our previous
studies had a frequency of approximately 60 % [11],
among 212 personnel with 95 % confidence. All analyses
were conducted in the SPSS v20. Continuous measures
were analysed using analysis of covariance with pre-show
scores as covariates. Where between-group pre-show
measures were imbalanced, linear regression was used with
pre-show scores as confounding variables. Categorical data
were analysed using Pearson’s Chi-square test. Multivariable logistic regression was used to generate odds ratios
with 95 % confidence intervals which were adjusted for
observed confounding variables that might influence both
reporting stigmatising beliefs and response rate including
baseline mental health status. Numbers and percentages for
valid answer are reported whereas missing data are not;
percentages and numbers may not sum to sample totals.
Statistical significance was p B 0.05. The study was
approved by the Ministry of Defence Research Ethics
Committee (study number 315/GEN/12).
Results
Response rates
594 personnel were recruited into the study, 59.9 %
(n = 356) received the intervention and 40.1 % (n = 238)
the control condition. 38 IG personnel returned, spoiled or
blank questionnaires compared with 72 control group (CG)
personnel. The response rates pre-show were 89.3 %
(n = 318) in the IG and 69.8 % (n = 166) for CG; postshow 76.7 % (n = 273) for the IG and 54.2 % (n = 129)
for the CG. At follow-up, 21.4 % (n = 76) of the IG
responded compared to 15.1 % (n = 36) of the CG
(Fig. 1). There were no significant differences between
responders and non-responders at follow-up in baseline
Fig. 1 Sample size at baseline,
post-show and follow-up
Sample n=594
Intervention
Control
Pre-Show Allocated
n=356
n=238
Pre-Show Responded
n=318
n=166
Post-Show Responded
n=273
n=129
3 Month Follow-up
n=76
n=36
123
Soc Psychiatry Psychiatr Epidemiol
around 50 % were in a long-term relationship; the CG
contained statistically significantly fewer of these personnel (53.7 vs. 67.2 %). Private soldiers formed the bulk of
the CG and there were significantly more junior ranks in
this group (71.2 vs. 57.5 %). The study groups were similar
in all other respects; around half had served B4 years; the
majority were full-time regulars, were predominantly male,
around 40 % had dependent children and around half had
been on operations previously (Table 1).
levels of mental health caseness (p = 0.20), alcohol caseness (p = 0.27), reporting C3 stigma/BTC items
(p = 0.16) and other socio-demographic factors.
Sample description
Three quarters of study personnel were aged\30 years; the
CG contained statistically significantly greater numbers of
younger personnel (56.7 %) than the IG (48.9 %). Overall,
Table 1 Stigma and comedy intervention study sample characteristics
Socio-demographic factors (n) (%)
v2, df, p
Initial n (%)
CG
IG
Age (n = 481)
16–19 (50) (10.4)
26 (16.0)
24 (7.6)
20–24 (197) (41.1)
66 (40.7)
131 (41.3)
25–29 (114) (23.8)
37 (22.8)
77 (24.3)
30–34 (77) (16.1)
25 (15.4)
52 (16.4)
8 (4.9)
33 (10.4)
17 (10.9)
21 (6.9)
35? (41) (8.6)
Service length (n = 459)
\1 year (38) (8.3)
2–4 years (197) (42.9)
69 (44.2)
128 (42.2)
5–12 years (182) (39.7)
61 (39.1)
121 (39.9)
13–22 years (37) (8.1)
9 (5.8)
28 (9.2)
C22 years (5) (1.1)
0 (0.0)
5 (1.7)
161 (98.8)
310 (98.4)
2 (1.2)
5 (1.6)
Male (447) (95.3)
155 (97.5)
292 (94.2)
Female (22) (4.7)
4 (2.5)
18 (5.8)
Not in a long-term relationship (179) (37.4)
75 (46.3)
104 (32.8)
In a long-term relationship (300) (62.6)
v2 = 11.30, df 4, p = \0.05
v2 = 6.18, df 4, p = 0.19
Engagement type (478)
Regular forces (471) (98.5)
Reserve forces (7) (1.5)
*p = 0.55
Sex (469)
*p = 0.08
Relationship status (479)
87 (53.7)
213 (67.2)
Dependent children (449)
None (258) (57.5)
85 (57.8)
173 (57.3)
1 or more (191) (42.5)
62 (42.2)
129 (42.7)
116 (71.2)
183 (57.5)
v2 = 8.33, df 1, p = \0.01
v2 = 0.01, df 1, p = 0.93
Rank (481)
Junior rank (299) (62.2)
Junior non-commissioned officer—JNCO (138) (28.7)
42 (25.8)
96 (30.2)
Senior non-commissioned officer—SNCO (37) (7.7)
5 (3.1)
32 (10.1)
Junior officer (6) (1.2)
0 (0.0)
6 (1.9)
Senior officer (1) (0.2)
0 (0.0)
1 (0.3)
B1 (343) (71.2)
115 (70.1)
228 (71.7)
C2 (139) (28.8)
49 (29.9)
90 (28.3)
v2 = 14.39, df 4, p = \0.01
Previous deployments (482)
C control, I intervention
* Fisher’s exact test
123
v2 = 0.13, df 1, p = 0.72
Soc Psychiatry Psychiatr Epidemiol
Satisfaction with utility and quality of the show
There were no significant between-group differences in
subjective impressions of the show. 96.4 % (n = 133) of
the CG (n = 138) were somewhat or very satisfied compared to 93.9 % (n = 275) of the IG (n = 293, p = 0.28).
82.9 % (n = 107) of the CG (n = 129) felt that the show
was somewhat or very useful compared to 82.5 %
(n = 235) of the IG (n = 285, p = 0.90). 93.6 %
(n = 131) of the CG (n = 140) would recommend the
show to others compared with 92.4 % (n = 266) of the IG
(n = 288, p = 0.65). All p values shown are for Pearson’s
Chi-square test.
Follow Up % Caseness
Initial % Caseness
77.9
*Intervention Alcohol Use
79.2
81.5
*Control Alcohol Use
81.8
25.9
**Intervention PTSD
17.1
19.8
**Control PTSD
14.3
28.9
***Intervention CMD
17.3
Mental health outcomes
14.6
***Control CMD
At baseline, the IG were significantly more likely to report
CMD symptoms, (IG 28.9 vs. CG 14.6 %, v2 = 12.10, df
1, p = 0.001) but possible PTSD symptoms (intervention
25.9 vs. control 19.8 %, v2 = 2.21, df 1, p = 0.14) and
excessive alcohol use levels (IG 77.9 vs. CG 81.5 %,
v2 = 0.82, df 1, p = 0.36) were not significantly different.
At follow-up, CMD and PTSD levels had fallen and were
not significantly different between groups; excessive
alcohol use levels remained constant. At follow-up, the
rates of caseness had fallen substantially in both the IG and
the CG for CMD (IG 28.9–17.3 %, CG 14.6–8.6 %) and
for PTSD (IG 25.9–17.1 %, CG 19.8–14.3 %) but not for
excessive alcohol use (IG 77.9–79.2 %, CG 81.5–81.9 %)
(Fig. 2). The rates of remission at follow-up from caseness
at time one for CMD, PTSD or alcohol misuse were not
statistically significantly different between groups (CG
remission rate 36.0 % (n = 9) vs. IG remission rate 43.3 %
(n = 26) (v2 = 0.39, df 1, p = 0.53).
Knowledge about sources of help and support
for mental health problems
The groups did not differ significantly in their baseline
levels of mental health-related knowledge (potential sources of help v2 = 0.28, df 1 p = 0.34; possible coping
strategies v2 = 0.33, df 1 p = 0.58). The CG knew significantly more about potentially helpful coping strategies
at follow-up; otherwise, there were no statistically significant between-group differences in awareness of potential
help sources either post-show or at follow-up (Table 2).
The ability to correctly answer mental health prevalencerelated questions did not differ significantly between
groups at baseline (How many people have MH problems?
IG 15.9 %, CG 11.4 %, v2 = 1.65, df 1 p = 0.20; How
many UKAF have MH Problems? IG 16.4 %, CG 9.9 %,
v2 = 3.42, df 1 p = 0.06; How Many UKAF have alcohol
problems? IG 22.2 %, CG 21.8 %, v2 = 0.10, df 1
8.6
0
20
40
60
80
100
Fig. 2 Mental health outcomes. *AUDIT-C Score C4. **PC-PTSD
endorsed C2 symptoms. ***GHQ 12 endorsed C4 symptoms
p = 0.92). Post-show, but not at follow-up, the IG was
statistically significantly more likely to answer all three
questions correctly. The research groups did not differ
significantly in baseline beliefs about alcohol and its
potential effect upon mental health (alcohol is not effective
in dealing with mental health problems v2 = 0.83, df 1
p = 0.36, alcohol increases vulnerability to mental disorder v2 = 0.27, df 1 p = 0.60, alcohol worsens mental
health v2 = 0.55, df 1 p = 0.46). The between-group levels of alcohol-related beliefs post-show and at follow-up
were not statistically significantly different (Table 2).
There was no significant effect of intervention on postshow MAKS score after controlling for the effect of preshow score (pre-show IG mean 21.34, SD. 3.18 vs. CG
mean 21.63, SD. 3.28, post-show IG mean 22.45, SD. 3.94
vs. CG mean 22.08, SD. 4.02), F(1, 348) = 1.08, p = 0.30.
At follow-up, there was no significant effect of intervention
on MAKS score after controlling for the effect of pre-show
score (FU IG mean 22.54, SD. 2.60 vs. CG mean 21.20,
SD. 2.82), F(1, 81) = 2.15, p = 0.15.
Stigmatising beliefs and discrimination
There was a significant between-group difference in preshow military stigma scale scores. After controlling for
pre-show scores, there was a significant between-group
difference in post-show stigma scores (Pre-show IG mean
25.85, SD. 4.85 vs. CG mean 24.76, SD. 4.37, post-show
IG mean 24.94, SD. 4.82 vs. CG mean 24.93, SD. 5.18),
B = -0.99, SE B = 0.44, b = 0.09 (p = \0.05). Postshow IG stigma/BTC scores reduced by a mean of 1.10
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Soc Psychiatry Psychiatr Epidemiol
Table 2 Mental health and alcohol knowledge
Mental health knowledge
outcomes
Group
Initial n (%)
Post n (%)
v2, df, p
F Up n (%)
a 2
168 (68.9)
v2 = 0.16, df 1, p = 0.69
60 (82.2)
v2 = 2.89, df 1, p = 0.89
v2 = 0.78, df 1, p = 0.78
46 (63.0)
v , df, p
For mental health problems, I know a lot about
Where to get informal or
formal help
I
141 (48.5)
C
65 (45.8)
66 (66.7)
Effective coping
strategies
I
90 (32.0)
130 (54.4)
C
41 (29.3)
49 (52.7)
Alcohol is not an effective
way of dealing with
symptoms
I
C
196 (65.1)
88 (60.7)
145 (59.4)
54 (55.1)
v2 = 0.54, df 1, p = 0.46
55 (75.3)
24 (68.6)
v2 = 0.55, df 1, p = 0.46
Makes one vulnerable to
more mental illness
I
198 (65.8)
184 (75.7)
v2 = 0.77, df 1, p = 0.38
52 (71.2)
v2 = 0.61, df 1, p = 0.43
v2 = 3.34, df 1, p = 0.07
59 (80.8)
33 (94.3)
v2 = 7.55, df 1, p = \0.01
31 (88.6)
Alcohol use
Makes existing mental
health problems worse
C
99 (68.3)
69 (71.1)
I
249 (83.8)
207 (85.2)
C
115 (81.0)
73 (76.8)
21 (63.6)
v2 = 2.95, df 1, p = 0.09
23 (65.7)
General MH knowledge correct answers
How many people have
mental health problems?
How many UK service
personnel have mental
health problems?
How many UK service
personnel have alcohol
Problems?
I
49 (15.9)
90 (35.3)
C
I
17 (11.4)
50 (16.4)
14 (12.0)
79 (30.7)
C
14 (9.9)
14 (12.2)
I
63 (22.2)
120 (47.4)
C
32 (21.8)
18 (15.4)
v2 = 21.67, df 1, p = \0.001
10 (13.3)
*p = 0.09
v2 = 14.61, df 1, p = \0.001
1 (2.9)
13 (17.2)
v2 = 0.00, df 1, p = 0.99
6 (17.6)
v2 = 35.13, df 1, p = \0.001
23 (30.7)
v2 = 1.19, df 1, p = 0.28
7 (20.6)
I intervention, C control
a
v2 Statistic is for the difference between initial and follow-up scores
* Fisher’s exact test
(SD. 4.33) and increased in the CG by a mean of 0.40 (SD.
4.26). At follow-up no statistically significant betweengroup differences were present (IG mean 22.67, SD. 4.60
vs. CG mean 22.09, SD. 5.34), B = 0.06, SE B = 1.06,
b = 0.01 (p = 0.96).
There was no significant effect of intervention on RIBS
score after controlling for the effect of pre-show score (preshow IG mean 14.76, SD. 3.31 vs. CG mean 14.46, SD.
3.46, post-show IG mean 15.02, SD. 3.41 vs. CG mean
14.72, SD. 3.46), F(1, 356) = 0.80, p = 0.37. There was a
borderline significant effect of intervention on follow-up
RIBS score after controlling for pre-show score (FU IG
mean 16.05, SD. 2.93 vs. CG mean 14.37, SD. 2.76), F(1,
81) = 3.79, p = 0.06.
Illness behaviour, talking about and giving advice
about mental health
Pre-show, there were no significant between-group
ences in the desire to receive support (CG 25.7 %
n = 24.5 %, p = 0.79), also in discussing mental
with others (CG 33.8 % vs. IG 40.2 %, p = 0.17)
the proportion of those advising about mental
123
differvs. IG
health
and in
health
problems (CG 21.9 % vs. IG 21.0 %, p = 0.82). At followup 17.2 % of the CG were new help seekers compared to
6.5 % of the IG (p = 0.11); the IG were significantly more
likely to have discussed mental health than the CG (38.2
vs. 17.6 %, OR 2.88, 95 % CI 1.06–7.79) and IG personnel
were statistically significantly more likely to have advised
about mental health than the CG (38.7 vs. 14.3 %, OR
3.78, 95 % CI 1.32–10.86). Both of these effects became
non-significant when adjusted for observed confounders
(Table 3).
Discussion
Our study investigates the effects of embedding mental
health awareness material in a comedy show within UK
AF. Our main finding was that whilst show satisfaction and
acceptability were not affected by the inclusion of mental
health awareness material; post-show there was a statistically significant reduction in military stigma/BTC and an
increase in the ability to accurately answer mental health
knowledge questions. As a consequence of the limited
numbers completing follow-up, we were unable to
Soc Psychiatry Psychiatr Epidemiol
demonstrate a sustainable beneficial effect at the level of
measurable beliefs, attitudes and behaviour.
Strengths and limitations
The strengths of this study were that it used multiple outcome measures following National Institute for Health and
Clinical Excellence (NICE) guidelines for public health
interventions [28] to assess outcomes and used a control
condition against which to make comparisons. The most
important limitation of the study was that the follow-up
response rate was very low as many of the study participants were deployed on operations or engaged in other
military duties, and this severely limits our ability to draw
any firm conclusions about the longer-term effects of the
intervention. The post-show response rate was also lower,
particularly within the CG and this may be a further source
of bias. To increase the acceptability of our survey, we
used brief measures only and although the instruments that
we chose to use were reliable and valid, abbreviated or cutdown versions of full scales may have diluted our study
findings. Although we asked about behavioural intention
and attitudes, we have no independent verification, such as
behavioural observation, of whether actual changes in
behaviour occurred.
Post-show, military stigma/BTC significantly reduced in
the IG but the effect was not evident in the small numbers
followed up (research question 1). The lack of effect at
follow-up may have been due to response bias or a lack of
power to detect any change. For potential future discrimination (research question 2), mental health, coping and
rates of stigma-related knowledge (research question 3),
the intervention appeared to have no substantial modifying
effect post-show. Immediate knowledge about potential
help sources rose substantially; however, this outcome was
seen in both groups and there were no between-group
differences at post-show or follow-up. This is encouraging
in a sense that the comedian set out to educate the participants about help seeking, but as the effect was seen in both
groups, this effect may have come about as a result of
unobserved confounding that we are unable to comment
on. Some senior members of the military units involved
who viewed both shows reported that there was some
overlap in the content of the control and intervention
shows.
IG personnel were significantly more likely to answer
three questions about mental health, stigma and alcohol
problem prevalence correctly post-show, but not at followup (research question 3). Recognising alcohol as harmful to
mental health was marginally greater post-show in the IG;
however, at follow-up this effect was less pronounced and
not statistically significant. We have evidence from our
own previous studies that alcohol is not regarded as a
particular problem amongst UK AF personnel despite high
general levels of consumption [29]. Whilst help seeking
was unaffected, at follow-up, the IG were statistically
significantly more likely to discuss and advise about mental
health issues (research question 4); however, this was
related to confounding variables such as personal mental
health status, socio-demographic factors and contact with
mental health problems in others, thus providing greater
opportunity to discuss mental health. It may also have been
related to our inability to detect between-group differences
in effect due to low follow-up response rates. Levels of
CMD and PTSD fell in both groups at follow-up, however,
alcohol use remained constant; the level of CMD was
significantly higher in the IG at baseline, however, we
could not attribute any between-group differential reduction in CMD caseness to the intervention alone.
The findings of this study concur with the outcomes of
other interventions seeking to improve mental health and
stigmatisation using mental health awareness or psychoeducation [30, 31]. Mulligan et al. [20] reported that UK
Battlemind, a specific anti-stigma intervention, failed to
modify stigmatising beliefs at 6-month follow-up. A randomised controlled trial of the military TRiM peer support
intervention suggested that it did not affect stigma [31],
though TRiM practitioner training improved stigmatisation
at follow-up [32], this training is intense and carried out
with personnel generally selected for their psychological
mindedness. It may well be that changes in views about
mental health, which the key messages of the comedy were
aiming to influence, take a considerable time to take hold
and a longer follow-up would have been helpful in this
regard. It is also possible that the comedy show messages
could have been effective as part of a more sustained
programme of attitudinal change which our previous
research has shown appears to be effective [16].
Although we did not find any corresponding change in
predicted intended discrimination and knowledge as measured by the RIBS and MAKS, respectively, the significant
immediate reduction in military stigmatisation/BTC has
some value given that stigma/BTC, as Osório et al. [11]
describe, takes time to modify in military personnel. The
reduction was not sustained at follow-up perhaps because
we did not achieve sufficient numbers to adequately assess
this outcome. Alternatively, it may be that the intervention
has maximum immediate impact and if the AF finds a way
to reinforce the key messages, perhaps through supplementary written material or specific leadership by example
training, the positive post-show changes might prove more
durable. Indeed most stigma-reduction research which has
found a positive effect has focused on stigma-reduction
programmes rather than a specific element [33]. This
clearly needs to be assessed in further research.
123
Soc Psychiatry Psychiatr Epidemiol
Table 3 Stigmatisation, discrimination, stigma-related knowledge and illness behaviour changes post-show and follow-up
Measure
Change in score
Unadjusted and adjusted odds ratios (OR) with 95 % confidence intervals (95 % CI)
Large
increase/
same
n (%)
OR 95 % CI
Large
decrease
n (%)
Military stigmatisation and barriers to care scale pre to post (386)
Control 124 (32.1)
95 (76.6)
29 (23.4)
1
Intervention 262 (67.9) 154 (58.8) 108 (41.2) 2.30 (1.42–3.72)
The mental health knowledge schedule (MAKS) pre to post (351)
Control 103 (29.3)
70 (68.0)
33 (32.0)
1
Intervention 248 (70.7) 172 (69.4) 76 (30.6)
0.94 (0.57–1.54)
Reported and intended behaviour scale (RIBS) (359)
Control 109 (30.4)
80 (73.4)
29 (26.6)
1
Intervention 250 (69.6) 187 (74.8) 63 (25.2)
0.93 (0.56–1.55)
Military stigmatisation and barriers to care scale pre to follow-up (85)
Control 25 (29.4)
17 (68.0)
8 (32.0)
1
Intervention 60 (70.6) 40 (66.7)
20 (33.3)
1.06 (0.39–2.88)
The mental health knowledge schedule (MAKS) pre to follow-up (84)
Control 25 (29.8)
15 (60.0)
10 (40.0)
1
Intervention 59 (70.2) 45 (76.3)
14 (23.7)
0.47 (0.17–1.27)
Reported and intended behaviour scale (RIBS) pre to follow-up (84)
Control 24 (28.6)
9 (37.5)
15 (62.5)
1
Intervention 60 (71.4) 32 (53.3)
28 (46.7)
0.53 (0.20–1.38)
Talked about mental health at follow-up (110)
No
Yes
Control 34 (30.9)
28 (82.4)
6 (17.6)
1
Intervention 76 (69.1) 47 (61.8)
29 (38.2)
2.88 (1.06–7.79)
Advised others about mental health at follow-up (110)
Control 35 (31.8)
30 (85.7)
5 (14.3)
1
Intervention 75 (68.2) 46 (61.3)
29 (38.7)
3.78 (1.32–10.86)
New help seekers for a mental health problem at follow-up (91)
Control 29 (31.9)
24 (82.8)
5 (17.2)
1
Intervention 62 (68.1) 58 993.5) 4 (6.5)
0.33 (0.08–1.34)
a
b
c
d
AOR 95 % CIa
AOR 95 % CIb
AOR 95 % CIc
AOR 95 % CId
1
2.09 (1.28–3.42)
1
2.36 (1.42–3.91)
1
2.06 (1.23–3.46)
1
2.08 (1.20–3.59)
1
0.93 (0.56–1.53)
1
0.97 (0.58–1.62)
1
0.79 (0.46–1.35)
1
0.88 (0.50–1.53)
1
0.93 (0.55–1.55)
1
0.97 (0.57–1.64)
1
0.93 (0.53–1.62)
1
0.92 (0.51–1.64)
1
0.95 (0.35–2.61)
1
0.94 (0.33–2.68)
1
0.86 (0.26–2.82)
1
0.75 (0.19–2.88)
1
0.52 (0.19–1.47)
1
0.59 (0.21–1.67)
1
0.36 (0.12–1.12)
1
0.47 (0.14–1.60)
1
0.56 (0.21–1.52)
1
0.47 (0.17–1.29)
1
0.39 (0.12–1.24)
1
0.30 (0.09–1.05)
1
2.63 (0.96–7.22)
1
2.70 (0.98–7.44)
1
2.07 (0.61–7.06)
1
1.32 (0.35–5.01)
1
3.52 (1.22–10.20)
1
3.59 (1.20–10.78)
1
3.27 (0.75–14.16)
1
2.19 (0.47–10.34)
1
0.42 (0.10–1.72)
1
0.36 (0.09–1.47)
1
0.31 (0.06–1.67)
1
0.33 (0.50–2.22)
Adjusted for screening positive for a mental health problem
Adjusted for contact with a person with a mental health problem
Adjusted for regular vs. reserve, previous deployment, rank group, B24 years of age vs. older, B4 years service vs. longer
Adjusted for all variables
There is tentative evidence that personnel who received
the intervention were more likely to discuss and give
advice about mental health at follow-up. This may be
related to having contact with people with mental health
problems between intervention and follow-up thus affording IG personnel more opportunity to talk with symptomatic people. This finding is supported by the marginal
significant IG reduction in intended discrimination,
although this effect may have been explained by factors
other than exposure to the intervention alone. We suggest
that further research should be conducted with UK AF
personnel to clarify this finding as there is some evidence
that talking about mental health may be helpful in reducing
stigma [34]. The element of the show that provides for
contact with serving personnel who have experienced
123
mental ill-health could be given more emphasis in future
shows [35, 36].
Acknowledgments We are indebted to the service personnel who
freely gave their time to take part in the study; to the Wellcome Trust
and MoD for their financial support and to Headquarters Land Forces
who enabled the study and without whom it could not have taken
place.
Conflict of interest N.G. and M.F. are full-time members of the UK
Armed Forces. N.J. is a full-time reservist. All N.G., M.F. and N.J. are
currently seconded to King’s College London. M.T. is employed by
Surrey County Council and worked with the Academic Department
for Military Mental Health to co-ordinate the study. T.J. is a UK
Ministry of Defence employee. J.R. is an independent professional
comedian who donated his time to the Academic Department for
Military Mental Health for the duration of the study. Although the UK
Ministry of Defence facilitated this study, it gave no direction in the
Soc Psychiatry Psychiatr Epidemiol
gathering, analysing and presentation of data. The MoD provided
funding for military personnel from an annual budget that includes
provision for conducting military research.
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