Transcript: Evaluating the Choose Life North Lanarkshire awareness programme


Suicide prevention programme in North Lanarkshire, Scotland.

Podcast Episode: Evaluating the Choose Life North Lanarkshire awareness programme

Category: Social work (general) 


What follows is a transcription of the audio recording. Due to differences between spoken and written English, the transcript may contain quirks of grammar and syntax.

GB - Greg Burgess
MR - Dr Mark Robinson

GB I am Greg Burgess, I am the Choose Life Coordinator for North Lanarkshire which means I am the suicide prevention guy for North Lanarkshire Council. Choose Life started in 2002, it's the national strategy to reduce suicide in Scotland by 20% before 2013, so a 10 year plan. Each local authority was given a pot of money to spend on suicide prevention activity, that was the decision back then, so every local authority would receive a pot of money, pro rata looking at their general budgets and population. It was then down to a local authority and the Choose Life coordinator, if they had one, to decide what to spend the money on, and that could be creating projects, it could be raising awareness, it could be looking at training, most of all it had to look at the objectives. There were a number of objectives set out by Choose Life and there were a number of groups, priority groups, that Choose Life identified at risk of suicide. So those were 3 out of 4 suicides are male, and those at higher risk back then were the 16 to 35 year old males, so for many it was identifying those groups and how to raise awareness amongst them about suicide and the risk of suicide and hopefully reduce it.

In North Lanarkshire, before I came into post in 2007, there was a lot of activity about training, so nationally Choose Life had invested in ASIST Training, Applied Suicide Intervention Skills Training, which was created by Living Works in Canada, it's got 20 years of history and the idea would be that it would be a training course that anybody and everybody could go through to increase their confidence about suicide prevention, identifying risks, identifying people at risk of suicide and asking them if they were thinking about suicide. So that training was for social workers, police, unemployed, doctors, nurses, anybody and everybody. So there has been a suite of training from Living Works that include ASIST, there's also Safe Talk and Suicide Talk, and there were a number of key objectives such as reducing suicide, so in North Lanarkshire we provided the training, raising awareness and encouraging people to seek help early was another one, and we looked ad advertising and promoting things like Samaritans and Breathing Space as well as the whole Choose Life message.

In 2008 we became aware that the original strap line for Choose Life suicide prevention was don't hide it, talk about it, and as we were looking at raising awareness about suicide, we thought that didn't really fit, it was almost saying, don't hide it, talk about it, but we can't tell you what it is. So locally we jokingly said, "is it cheese, it is the remote control, is it the weather", what do we hide and not talk about or talk about, so locally in North Lanarkshire and in some other local authorities we spoke about should it be suicide, don't hide it, talk about it, so we managed to influence not just North Lanarkshire but other local authorities influence the national message. So we looked at raising awareness of that and we tried to do that in kind of unique and different ways to engage the public. A couple of the things we did was looking at how to raise awareness with this sensitive issue, and although I am not a sports fan or certainly not a soccer fan, a football fan, I thought a good way would be to raise awareness using football, so Motherwell Football Club are a big premier league team in North Lanarkshire, and I thought they would be a good partner to work on. They had previously done some work with 'See Me', years and years before I came into post, so we thought, why not work with them? And they were really keen, partly because they had lost ex players, staff members and families of staff to suicide, and they really embraced the concept of raising awareness. However one reservation was they didn't like the black and white adverts that Choose Life Health Scotland, or Choose Life Government at that time had rolled out, we also thought they looked a bit depressing and we wanted to try and engage the football club and the message as one, so we worked with a designer to create an image that was the Motherwell Football top, and instead of having the usual sponsor across the middle of the shirt, because it's almost like 3 bands of colour, claret and amber is how it's made up, and it's usually the claret band that has the advertising logo, so we thought, why not put the 'suicide, don't hide it, talk about it,' message there instead of the advertiser and use that in programme adverts and billboards at the ground, and that went down really well.

Feedback from fans had been great at the time, just anecdotal stuff, but we also worked with a local taxi driver, Craig Thomson, who wanted to put something positive inside of his car, so we put the 'suicide, don't hide it, talk about it' message inside of his car, we trained him in Safe Talk, we gave out receipts so he and his colleagues, and he was the first of 4 drivers really to go through this training, awareness raising, give out receipts and they had, the receipts had numbers for Samaritans and Breathing Space. So if they identified somebody at risk of suicide they might talk to them, but if they identified somebody that was very quiet and just didn't want to talk, they would still be able to give them a card with the numbers on and be able to signpost and give them information, so we are really proud of those things.

We looked at trying to work with pubs, publicans, because possible links with suicide and alcohol but we know that pubs have staff that are responsible, that know their regulars and will care, and we wanted to try and raise awareness about suicide in different ways in places where you can buy alcohol, so we worked with the local licensing forum to say, look we would like to do this, possible beer mats, adverts in the bathroom, how can we help, and they, the licensing forum, I think the average age must have been late 60's, early 70's, the majority of them male, and they said we don't like those adverts, they are depressing because they are black and white. So we had to go back to the drawing board, work with the designer to come up with something that was bright and engaging, we then returned to the group, said this is the advertising, what do you think, and we got the good old 'Scottish Silence', which my mother told me to take as that means it's okay son, you have done all right, go with it. So we did, so we designed 4 beer mats, 2 bathroom adverts and we used the adverts actually in bus advertising as well, so the beer mats went out, they were delivered by other partners, so it wasn't Health Scotland, it wasn't local authority, it wasn't NHS, it wasn't voluntary organisations, it was the police that delivered these to the pubs and they got a really warm reception. Publicans liked free beer mats, but because it had a message the bar staff really liked it. The only place the police did have a concern about is, they went to one pub and the guy said, "we love the mats, we love the message, but we are having a wake for a family and the person had died by suicide", so they said we won't put them out today, we will do it tomorrow. But it said to us that people get it.

So that's kind of some of the stuff we have done and although we had worked with football clubs, we had done some advertising on buses and taxis and done some training, my concern was that so what, what does it do, if we look at suicide figures for North Lanarkshire they do fluctuate every year, you need to look at 10, 20 years of work to see if we had any impact and with the Choose Life money being fairly limited in terms of time, we don't have the time to do that longitudinal research and evaluation. However I felt we needed to do something and speaking with our local partners, now the Choose Life person, or Choose Life coordinator doesn't do these things in isolation, it works as part of a Choose Life group, it's directed by an implementation group with an action plan etc, and our group also felt concerns that they were spending money but weren't sure about the affects of it. So after a couple of years we decided we need to evaluate, we need to find out is this advertising, is the training actually doing anything and although there had been, well there had been research carried out on the impact of ASIST training and other training courses, so that was taken care of, so we thought why not focus on the awareness raising, does it do anything, is it a waste of money. So we worked with Health Scotland, Tamara Mulherron, who was previously with Health Scotland, fantastic, fantastic person when it comes to making research exciting and interesting, she manages to make it really interesting and she is very passionate about research, so we worked with her to say how can we research and evaluate what we are doing. So with her we came up with 3 questions and then liking with Tamara again, we put out for notice of interest, so we received I think it was about 14 notes of interest, and then we had to go through a selection process and decide who we were going to recruit and we were really fortunate that Leeds Metropolitan University and Centre for Men's Health as it were, were interested.

Their lead was Dr Mark Robinson, so we had to go through interview processes and one Friday we had a couple of face to face interviews, we did a telephone interview and we did a video interview with Mark and the team down in Leeds, so we all sat in a room, big TV, doing this interview, it went well. Afterwards we decided to offer the contract of evaluation to Mark and his team at Leeds, they were delighted, they said yes, they got on board and then it was a year's piece of work for Mark and the team to carry out the evaluation, linking with ourselves to form discussion groups, where to interview people, how to interview them and it went really well, a very positive experience.

You know I did some research study when I was at University, studying psychology where I discovered it's not about people, it's really about statistics and numbers, but working and seeing Mark and his team work was fantastic, and the level of detail and I know that Health Scotland have fed back that it's one of the best pieces of research they have seen and I don't think if was fair to say they were envious, I think they were delighted that we have got a good piece of quality research, because although Choose Life has been going for a number of years, there's not a lot out, in terms of evaluation out there, and we have got a good piece of work.

Yes it talks about suicide, yes it's North Lanarkshire, but there are pieces of learning that could be used anywhere, whether it's suicide, it could be a piece of learning where it's talking about, how do we talk to men about breast cancer, prostate cancer, UTI's, bladder cancer, it could be anything. So there might be bits of learning, and North Lanarkshire is a fairly urban environment, it's very different from the highlands, the islands, but there might be pieces of work that we have learned that have worked well and haven't, and what I am delighted about Mark's work is that places such as, they have said Motherwell and Wishaw are very aware of suicide prevention and Choose Life, but Coatbridge, Airdrie and Cumbernauld haven't been, so this year we have focused a lot on linking with taxi companies in Cumbernauld and Airdrie, bus advertising, washroom advertising. There's a brand new health centre in Airdrie and they are not allowed to have a lot of advertising around due to risk and bacterial transfers of illness - health people know this better - but we have managed to get vinyl advertising in all the bathrooms and that's for suicide prevention. So just things like that we have learned that we haven't done it perfectly but you have got to learn from the things you haven't done well and I think we are taking those on board and really open ... I think it's been an important critique of what we've done, I don't think it's a ... I don't think the evaluation is just a round of applause, I think it does give us quite a lot to think about and push us into different areas. So it's been a great piece of work, it's been a pleasure to work with Mark and the team from Leeds and I am delighted we have got the evaluation of what we have achieved.

You know in a few years there probably won't be as much Choose Life activity, but at least people can look back and say, well there is that piece of work and there's a bit of learning we have achieved from that. I mean the seminar paper that's been ... there's people who have shown real interest from parliament and Scotland parliament and England as well, because there's recently more money put into suicide prevention in England and Wales, so they are delighted to see what's going on and what they can maybe learn from it, are there bits they can cherry pick and are there bits that we have maybe gone down a cul-de-sac and thought, we are not doing much, and they can go, maybe that's not a place to go, so maybe we can help save some money as well as try and save some lives.

SECOND SPEAKER

MR It's a pleasure to be here to present the findings of the evaluation of the Choose Life North Lanarkshire campaign. I would like to first of all explain a little bit about this evaluation and what it is and what it isn't. The Centre for Men's Health at Leeds Metropolitan University, with our partners from the MRC Public Health Sciences Unit in Glasgow and the Men's Health Forum in Scotland were commissioned to conduct the Choose Life North Lanarkshire evaluation. This was an evaluation of the public awareness campaign, not of the training programme, which as we have already seen this morning has been a very large part of the overall process, so we were looking at the public awareness campaign and it started in March 2011, our evaluation went on for about a year. The questions that Greg and the steering committee wanted us to look at included, how has the marketing approach which was called a Social Marketing Approach increased the awareness of crisis service numbers and how has it de-stigmatised understandings and attitudes about suicide, how well has it worked, has it been effective, which parts of the programme were effective. So quite a few questions, has the programme been of benefit to the community, in particular young men in the most targeted age group, 16 to 35, and what contribution has the community made to the effectiveness of the campaign, so several questions, quite a complicated number of questions to look at, and that's in response to the fact that the campaign itself nationally and regionally was a complex campaign. Greg has already said some things about this, the national campaign being complex, having a number of different goals, having a number of different priority groups, the national campaign priority groups were including children, young people, people with mental health problems, people who attempt suicide and recently bereaved, people unemployed. Putting together a number of priority target groups and then recognising there's a lot of local variation in the conditions between different regions, so North Lanarkshire has its own situation as we have been hearing and its own particular context.

The North Lanarkshire programme had multiple aims and outcomes, Greg summarised them, and just to remind you I will say again, reduce the incidence of suicide through increasing awareness of crisis service numbers and de-stigmatising understandings and attitudes with the desired outcomes including the outcomes of the actual awareness raising programme including improving access to information on suicide and deliberate self harm, more people would have access to information. Increasing knowledge of suicide and self harm, reducing the cultural stigma associated with suicide. So those were the outcomes aimed at in, and we can call them intermediate or medium term outcomes, greater knowledge, greater awareness, reduced stigma, culture change, those are the middle term outcomes of the campaign aimed towards, as stepping stones towards this long term reduction in suicide. So we were evaluating the middle term outcomes and the ways in which the campaign was working to those.

It's a challenge, it's a complex challenge to reduce suicide, therefore in the evaluation we knew we needed more than one method, and so we tried to put together a number of methods that would enable us to look at these medium term outcomes and see if they are being attained, how they are being attained and what still needs to be done. Because this evaluation was a formative evaluation, not an end point evaluation, and we see ourselves as working in partnership with Choose Life in North Lanarkshire and our partnership is to help the campaign move forward, not to produce an end of term report, nothing like that. So Phase One, we carried out a review of current data sets including calls to Samaritans, calls to Breathing Space, and statistics of attendance and also admissions to hospital A & E departments.

Phase Two involved a survey of public awareness where we surveyed using a questionnaire, 500, over 500 people from the general public using what we call a quota method which means that we targeted specific numbers and by age and by sex, I should use the word gender, and location, place. So in other words we aimed for a certain number in the different towns that were the high risk areas. At Phase Two we had interviews with 20 experts, people who have been involved in the campaign and who knew quite a bit about it. And then at Phase Three we held discussion groups, in-depth, with members of the general public to try to find out how the campaign might be working, to explore in detail the results of the survey with members of the general public. And those discussions groups, there were actually 10 small groups in Motherwell, Cumbernauld and Newarthill, of which 3 were the young males, 16 to 25, 2 young females, 1 26 to 35, still rather young males and 3 over 36 males and 1 over 36 females. So this to some extent represented 2 things, 1 the targeting of young males in the campaign, but secondly the campaign was directed to the general public and the general public who have influence on young males are not only young males, but also could be females, could be other generation, older generation, and also although the campaign primarily targeted young males, it didn't only target young males, it was a broader campaign than that, with young males as the priority group. So that explains a little bit about why we spread our net a bit broader than that and yet while we skewed to interview more males than anyone else.

So going on, here's the material, the messages. Greg has already shown you those messages. Suicide, don't hide it, talk about it, was the main message, the lead message, and how effective were those messages? Again the slide showing the materials, we looked at the effectiveness of the panels, the billboards, the posters, the video, pocket sized cards, how did people react to these materials? Materials on the taxis and also on the bus there, you see another panel, slightly different appearance, we began to look carefully at the appearance of the message, the brand, the colours, the design and we asked the general public about those things.

Okay so now I am moving onto findings, having very briefly sketched in what we did. I am going to try and explain these in pen ... well you probably can't read them from the back, but I will try and explain a little bit about these findings, I am going to go through a few of the findings quite concretely to explain what our results were, okay? This is where the respond ... this is where the findings about where the respondents to the survey said they had seen the campaign materials and the bottom line in this, the bottom colour on these bars represents the numbers of people who had seen the materials in particular places. So the highest number there is the taxis, the largest number of the people in the survey had actually seen the materials in the taxis, and then Motherwell Football Club, then the bus advert with fewer numbers, for example, the library and the community centre. So the Motherwell Football Club and the taxis were the places which were most successful, and also the bus advert. But we also have to look at the red section, the red section represents the numbers of people in each setting who actually didn't see the materials, and the green represents the numbers who don't go to those places. So, for example, the football club in North Lanarkshire, so an early findings is that one of the things that's been talked about this morning is the importance of the real time person who spoke this morning on the video, the importance of the community itself spreading the message, of getting community and voluntary organisations spreading the message, because for every 100 people you make aware of the campaign there's another 500 who you haven't made aware of the campaign, and therefore it's very important to think carefully about how that 100 are going to pass the message on, that's one of the key findings for the future.

As far as materials recalled is concerned, the type of materials recalled best were the posters and billboards, young people recalled the football related products and the radio adverts very well. The over 56 year olds didn't recall the material so well in the survey but we must remember the whole campaign was not really directed at the over 56 year olds, the materials that were recalled best were those that were seen as being part ... encountered as being part of people's everyday life activities, for example you go and catch a bus, you see the bus with the panel on the side, it's part of your daily routine, people recalled best those materials which were seen as part of their daily life routines. Motherwell Football Club, it's a weekly routine for those who go, to go along and watch the football, they recalled very well what they saw there. So in terms of areas, we have already perhaps picked up this impression that the Motherwell campaign was very strong: our evaluation reinforced that very strong awareness of the campaign in Motherwell, not quite so strong in some of the other areas. We can see that as being positive because of the strong emphasis on partnerships within Motherwell but we can also bear in mind the need to think about how to continue to spread out, particularly to some of the rural areas and some of the other towns that didn't achieve quite such high awareness.

In terms of age, the survey findings, the age group least aware of the campaign, those over 56, the age group most aware was all the way from 16 to 55, and in fact the most aware of the campaign were the 46 to 55 year olds in this, but I don't think we should read too much into the differences when they are small differences. So what we see here is that the campaign is reaching the younger age groups up to 55. In terms of awareness of services, this is important, so being aware of the campaign means you know that there's a campaign called Choose Life. Being aware of services means the campaign has actually registered so that you remember that you can call the Samaritans, that there's Breathing Space, that there are different services that can offer help and that's a distinction.

Of those aware of the campaign in this survey, of the general public, 39% said it made them more aware of services - it's an ambiguous question, 42% said they were already aware. We don't quite know from that question exactly what people mean by being more aware of services, it's just an indication from the survey. A higher percentage of male respondents said the campaign made them more aware of services, a slightly higher percentage of females said they were already aware of those services. Important point that this campaign targeting males, nevertheless women are aware of it, women are aware of the campaign and of services in quite high numbers and therefore we have to think about influences among the general public, that not only men might influence men, but also women, family members may influence men and that they are aware of this campaign.

So awareness of services among those respondents who were aware of the campaign measured by age, this bar, again difficult to read I know, the red section shows, for each age group, the proportion of people who had been made more aware and the blue section shows the proportion of people who were already aware. So looking at the red section, the ages between 16 and 45, that at least 40% of those who were aware of the campaign were now more aware of services, but moving to the older age group, above 46, the level drops to around 30%. So the campaign is reaching people in the younger age group all the way up to middle age and it's making them aware of the campaign and then within that group it's making people more aware of services. It's a bit different when you get to the much older age range, but the campaign is primarily targeted through the football club, through the music festivals and through the 5-a-side at the very active and younger age groups.

Now here's another seemingly complicated table showing an important question, if you raise people's awareness by this campaign, have you actually tackled the problem of cultural stigma of changing attitudes? The survey won't give you all the answers but it gave us an indication. So if you compared the results down the left hand side here about levels of campaign awareness and then along the top, levels of altered attitude during the campaign, we asked people 2 different questions about this. Only those ... only the people who were very aware of the campaign who said they were very aware, were very likely to also have their attitudes altered a lot, so to try and put this as clearly as I can, the proportion of those who were very aware who's attitudes changed a lot was high, because on the right hand side here were people had a level, a self assessment of 6 for awareness, their attitude had 52.4% of those people said their attitude had changed a lot. But where they assessed their awareness as only being medium level 3, only 14% of those people said that their attitude had changed a lot.

So a conclusion from that is that to achieve culture change, it's not enough just to make people prolifically aware of a campaign, they had to become really aware of the campaign, and when they do become whatever that means, really aware of the campaign, the chance of change is great in terms of attitude change, actually no longer thinking suicide is shameful and something not to talk about. And following on with this idea of change, raise awareness, change attitudes, change behaviour, those very aware of the Choose Life campaign discussed, got information and sought help for other people more than those who were less aware. At the bottom we see awareness of campaign 6, very aware, among those 42% said they had got information as a result of the campaign, 25% said they had discussed with someone, 17 not so many said they had sought help, but if you were only partly aware, rather aware, the numbers, the percentages of action, of behaviour change come down to below 20. So there's a strong indication you need to get, that attitude change and behaviour change follow on from seriously raised awareness.

But also there's a difference between those 2 forms of behaviour change, and if we look at the types of behaviour change from this campaign, from this campaign, those who had become aware of the campaign, 56% said they didn't yet have an opportunity to do anything. That's not surprising: nothing may have come up for them in the short time since the campaign, but 17% had discussed suicide with someone else, 17% had looked for information, about 10% had got help. The getting help is a bit lower, 14% didn't want to do anything, so there's still a culture problem.

Now very important this impact on behaviour compared by whether you are male or female. The affects on behaviour vary by gender, so in other words, what we find is more women, significantly more women than men as a result of the campaign had talked about suicide issues. That suggests that women in the public are talking to others about suicide to help others or to raise concerns. The most common activity following the campaign among men was getting information on suicide, while the most common activity among women was talking about issues, discussing. So more women than men said they would talk. So firstly women are already aware of the campaign to quite an extent, secondly men were made more aware, some men were made much more aware and then they wanted to look for information. I am being a little bit simplistic here because these are just, these are relative differences ... relative differences, the problem is what can you do to get men to discuss issues when they would rather, if you like, look for information, what can we do to get men to talk to other men? Because there may be two factors at work here, one is what we already said, the cultural taboo around suicide and the other is the reluctance, this thing about masculinity, the reluctance of men to talk about their own feelings of vulnerability, or equally about their friends feelings of vulnerability. So these are two challenges.

In terms of behaviour and place, again we see the big impact on behaviour from this campaign in Motherwell, good impact, reasonably good impact in Cumbernauld, smaller impact in the other locations. The campaign has worked where the resources have been concentrated, now the need is to spread it more, to keep putting resources in, maintain the campaign and spread it.

So quickly turning to what the experts said, what the people who'd had experience of the campaign said, I won't spend long on this ...it was appropriate to target the deprived areas ... the targeting and focused most effectively in Motherwell. It was important to both target the campaign at the general public in public places like the streets for the taxis and buses, and also in places where targeted sections of the population go, Motherwell Football Club for young and early middle aged men and their families. But also need to think about other places to target where the vulnerable and at risk groups are.

The systems focus of the campaign was widely praised that it focused on organisations, training people from the companies and the voluntary sector, it focused on getting into community networks and it focused on individuals and the general public.

The strap line, the suicide message, had challenged stigma, it had offered call numbers and that was a good thing and the campaign at Motherwell impacting on large numbers, not only in person but also through television, and the impact on the organisations, culture change, practice change and service design change. The kind of problems people were facing, you know that in an organisation: there was a strong about one particular organisation, A person wanted to put the Choose Life logo on their desktop and the company said no. An example of a good instance of practice would be, for example, in terms of professionals, individual practice to actually overcome the taboo, to actually talk about suicide at work with your colleagues. In terms of service change, the kind of instances that were given by the stakeholders were debriefs after every incident being a matter of company policy, there must always be a debrief and so on, these were just examples from the stakeholders. And you can ... say you think of better ones, these are just things that I am reporting back.

So stakeholders had certain reservations, how far was it going to have a long term impact, how can you make it have a long term impact, how strong was awareness, what was the reach, could the targeting be made still more effective, still more fine tuned to look at the unemployed, to look at the middle aged people. There's a rising demographic of suicide in Britain and in Europe among middle aged men with the recession, the economic situation in Europe, this campaign has rightly targeted young men but it should also target middle aged men in the future, or at least bear that in mind and consider it because that is ... the statistics have to be looked at closely, but both sectors are at risk. And also organisational and community resistance.

Some quotes, the stakeholders said, "young men are an at risk group but we know that's changing, we need to be alert as things change. More than awareness raising with the general public there's a need to make employers and organisations better trained and make them accountable." Well that's been going on, that's what we have heard about, the organisational training has been happening. The success factors praised by the stakeholders for leadership, fantastic leadership, the partnerships which we have heard about this morning, with businesses, with the community sector. Integrating the campaign with support for valued lifestyle activities, men, it seems, you know we will come back to this a little bit, men it seems don't like to talk about things except they prefer to talk about things while they are doing things, it's easier for a man to talk if I generalise, I am sorry if these are generalisations, in the context of activity and instrumental activities. A lot of men at work are used to the idea, they have friendships at work and that's in the context of doing things. Sitting and just talking not may be quite so easy. So that's something to think about. Continuity was important and had been, and the planning for progression is important. Mainstreaming the campaigning services is important for sustainability, it's important to take the responsibility up the ladder of community involvement. In other words to get people earlier by getting community networks strengthened and developed so that it doesn't have to come to the statutory services, that it's the community that notices problems early. And reaching the disengaged or unemployed through third sector partnerships, people who are unemployed, they are not always going to come into contact with statutory services until it's too late, so these were points that they made. And the priority groups need updating, always need updating was a point that the stakeholders made.

So moving on, we also looked to see about call numbers to Breathing Space, to Samaritans, and admissions and visits to A & E, and this data is a little bit difficult to interpret, and we have to be very cautious in making any claims about the results from the secondary data analysis. You can't really say that because a certain number of people rang Samaritans, that that proves a direct causal effect from the campaign, there are 2 reasons why it's difficult to reach these kinds of conclusions from call numbers. One is because other factors are always at work that can influence data on calls or data on visits to hospital. Those other factors include the most obvious one, a change in the local economy or other environmental factors that make people feel worse that can affect what's going on. And the second thing is the data sets across the organisations were not kept in the same way, so in our evaluation we couldn't compare like with like, so these are only kind of suggestive findings but looking at the calls to Breathing Space, from June 2010 to April 2011 most calls were made from Motherwell, and much more calls were made from Motherwell than anywhere else to the Breathing Space, and most were by females, more were by females than males.

Turning onto Samaritans, during 2007 to 2009, calls from females to Samaritans Hamilton reduced, calls involving males increased, so more men made calls. The Scottish path and the data from Samaritan Scotland showed a less clear pattern.

In the A & E departments in North Lanarkshire between 2005 to 2010 there was a higher level of attendance during the campaign than before the campaign where the diagnosis mentioned self harm. Were people going along in some way influenced by the campaign because of an awareness that ... sometimes men who don't feel good don't even quite recognise in themselves how they don't feel good, but the campaign might make people be able to actually say, I don't feel good, be able to recognise something from what it is before it's too late. One the other hand, admissions to the hospital following self harm, the highest percentage reduction was among males in the Motherwell locality of residents, whereas there was an increase from some other areas. It's possible to speculate that the reduction was in some way influenced by the campaign meaning that people were being prevented from having to be admitted to hospital because it never got to that bad stage.

But as you can see there's something inconsistent and not quite convincing about this data of calls, so what we can say is that the data of calls provides general suggestions that the campaign was having an effect, but we can't easily tie together and be sure and that's why we look at the survey results and we look at the discussion groups with the general public to reinforce, to either corroborate this or to suggest that in fact we haven't got it right. So we triangulated the data, we used different methods to try to add together a broad picture.

Now moving onto the discussion groups with the general public. The general public came together to tell us what they thought was making this campaign work, why is it being effective? They said that promoting suicide activities in leisure time locations was effective, the football club, it made people more receptive, they thought the wide visibility of buses and taxis was a good thing, but this business about raising awareness, you know they asked the question, how do you make people pause and think rather than just sort of note it? And so they said, think carefully about how to locate the information in a place where people will stand in front of it and perhaps talk about it. So buses go past, but what about the bus shelters they said, what about shopping centres where people might dwell a little bit, because in any case they are window shopping. These kind of thoughts were passed onto us.

It was also said to be important to try to reach high risk people, what about the people who really are, you know, unemployed, people at risk of drug addiction, other kinds of problems that people have that mean they are not going to the football club, they are not in the networks, they are not there. And so the suggestion was, for example the job centres might help reach these people. The messages, a positive tone was the good thing about the campaign, it was positive, the message was brief, it seemed to be for the most part, clear, and that was good, people liked it. It evoked many emotions in the general public, people told us about the hope they experienced, the feelings of pride they had in the campaign as well as other feelings of sadness and anger because people in their own communities had suffered. The messages were thought to challenge this dominant masculinity as well as cultural stigma, two different things that work together to cause the challenges.

So there were concerns though over who the messages were for and whether they provide a guide to action. Who are these messages for, and so clarity is very important, so the general public agreed that the initial awareness had been raised, the campaign had normalised, had made it normal to talk about depression and it had made it normal to communicate about mental health. But the strapline they said was only a first step and only a first step to changing attitudes, and so the lead message was strong, the lead message was strong but there was a little bit of uncertainty about who the campaign was targeting. So we have seen there are actually different messages but that the message, suicide, don't hide it, talk about it, was the most prevalent message and some of the general public said we weren't quite sure whether that was always targeting ourselves, the general public, or whether it was targeting a person who was actually seriously at risk. And there needs to be more than one message, there needs to be messages out there that say, there is that message that says help a friend, that quite clearly address the person from the general public and give them guidance about what to do. Choose Life campaign has those messages but they weren't the ones that were being seen most by the general public, so that was a little bit of information we got back.

Positive points from the general public, we all agreed with the campaign, we'd be more alert, we wouldn't say the things that we all used to say, pull yourself up by the boot straps or get your act together. It definitely helped raise awareness and change attitudes because compared to 10 years ago, before the campaign started, we are definitely better off now, very positive message from the general public.

Reservations, small reservations, people might be phoning up Samaritans as a result of the campaign but not willing to talk to other men, men might not be talking to men. It seems to me there's two types of folk, there's you might be talking to somebody who is thinking about killing themselves or you might be the person and we need the messages to pick out the 2 different groups, that's something to think about and maybe it's not quite as simple as what they were saying.

Challenges are the depth and complexity of cultural stigma, one person already asked this question, "why are the suicide numbers this year the same as last year, is the campaign working? " A big message about everything about our evaluation is it takes time to get from those middle term changes in cultural attitude, to make them stick and last, to overcome all the other messages that people have in their heads and to make things last and to produce lasting change. It takes time and ongoing commitment and resources. The challenges are the gender, the masculinity, unwilling to talk to other men, what can be done about men who will ring for help perhaps but they won't talk to their mates. What can be done about reaching different influences so that people who are men, who are trained, can work with other men, and what can be done about establishing a different culture, some of the general public said, "get them young, train people in primary school, get in in primary school and talk to people in the final year, and reaching different generations as well as geographical reach."

Some quotes, because of stigma around mental health, it's difficult to change, it's difficult, it's not to be underestimated. Attitudes are so deep rooted, they are not an easy thing to change. Peer pressure, stops people getting involved, peer pressure for young people is a big factor.

So, building on the strength, it's important to keep going with the wide and narrow targeting, to have personalised messages, some people mentioned ... those who go to, the young people go to festivals and they mentioned, we kept the wristbands with mental health messages on them, that's personalised, a wristband from a festival is a marker of personal identity in your social group, you have been to the festival. If it has a Choose Life message on it, then that's a personalised message, it means something to you because you are proud that you were in that festival.

It's important to go beyond that initial awareness raising where people say right, I know that Choose Life is a mental health awareness campaign, to go beyond that, to go to the point where people become very aware, where they become engaged and where their attitudes change, and one of the things that people said was that after the initial stage of messages, the campaign also needs to have strategies for those who have become aware and who want to become more aware and engaged, and so tell stories, involve them with role models, get narratives of other people who have overcome problems like themselves, success stories, the importance of sports figures and role models like that, targeting the unemployed and the partnerships.

So building on the strengths, what the discussion group said was the campaign needs stories that people can identify with, maybe arrange the stories across the age groups, ideally they give you an idea of how to behave if someone talks to you. If they are aware of Choose Life, Samaritans and Breathing Space at an early enough age, it becomes part of their culture, once they have passed a certain age it's hard to influence them. I would say at primary school, the last year of primary school. Saying this again, some people say, well it's already been tried, but keep trying was the message.

One of the places where you are going to get people who are really depressed is the unemployment centre, we need to think about those who have dropped through the networks. There's nothing in the job centre saying suicide, depression, anything like that ... So these were some of the messages from the general public here, we are not talking about professionals, but he general public and what they thought should be done.

Now then, to summarise the findings of the study, in answer to the evaluation questions, 'how effective was the programme?' It raised the awareness of services of a substantial proportion of the population, but there were others who weren't aware. 'What can be done to get that message from those who are aware to those who are not aware, to engage those who are aware so they take it forward and become champions?' 'What can be done to spread it out?' the awareness varies by age and by area. High awareness, not low awareness but high awareness predicts, it's the same thing as you'll change your attitudes, low awareness you may know about it but your attitude might not change. The campaign has affected health seeking behaviour very successfully, but there are gender and regional differences. That has implications that the approach to working with men and women might vary in subtle ways, something to think about. Men who like to look up information about illnesses aren't always so willing to talk about those illnesses except in trusted context where they trust the social group they are in to talk about those things.

'How has the social marketing campaign worked?' The combination of universal and targeted approach is very effective, but different strategies are maybe needed to continue to build on the initial awareness raising work. Keep the core message which has been effective and keep the brand which has been effective. The Choose Life brand was found to be very effective, people liked the message and they liked the brand. The benefits to the community and to young men are that it's increased the confidence and capacity of people in the community of those highly aware to talk or to seek help. It's made it normal to talk about suicide, it's made it normal to talk about mental health and emotions, the challenge is to spread the benefits. The contribution of the community is a big topic because the resources are such that the model for change and sustaining change can't be for Greg and his team to continue pumping out the same message at the same level in the same way, year on year. There has to be some kind of model for how it's going to spread, what is the ripple effect and who is going to take this message on? So the community contribution is massively important and the partners are the very important agents of change. So the successes have been based on partnerships in business, the community and voluntary sector.

Further steps recommended are to think about targeting men's strategically, to think about the way men will communicate in the context of practical action, for example if a man is helping to organise a community event, he is comfortable talking about the topic, more so than if they are simply being asked to talk about their own feelings.

There's lots of evidence that's true about physical health, there's a need to consider carefully the difference between young men's mental health and suicide and middle aged people, middle aged men. There's a need to consider about both men and women as influences and there's a need to reach the unemployed and older people at risk. A third demographic is the recently retired, vulnerable, older man, I am emphasising maleness, but this campaign wasn't only targeted at males but it was primarily targeted at males.

So further steps, focus the media campaign further, that's what's happening. Continue to tailor the messages to different targeted groups, continue to develop narratives and stories with a dramatic element and to use for example the arts, to interest people in gripping narratives that will engage them. And another message was, train more people from the community, the training has been a massive success story of this campaign, nevertheless all the same, it's possible to train even more people along the lines of the example of the taxi drivers. And to coordinate, training and the community awareness campaign, to think carefully in the future about how the trained can fit in with the community campaign and take it forward, how those who have been trained can work, to take those ripples forward from this community campaign, to coordinate the two. For example, men who work with other men can be trained more even than they have been, that might mean for example homelessness services, people in sport centres, there's a lot of examples of good practice in other parts of the country training people in barber shops, male hairdressers, to become champions and talk to men and to meet support needs of those people who have been trained.

So we are talking about involving ... continuing to involve and train well connected people in the community, voluntary and business sectors and to value very much those partnerships which is what has been happening. One of the points we made is that there are different types of networks that involve men. There are the kind of networks where men at the football ground are with the people they always mix with. It's not always true, I know Motherwell Football Club, people may mix with people from completely different walks of life, but still, there may be men who go to the football ground and meet with their usual support group, their usual mates. The strength of that is that they know each other well and it's an environment where there are very strong networks. The risk of that is that under certain circumstances, as we saw, the campaign may get through to them, but they still, because of the masculinity, they still are in a culture where it's hard to talk,

Another type of network is the network where you bring people together from different backgrounds, for example possibly a music festival which brings people from different generations, an arts festival where people come together who aren't normally together and because one of the foci of that festival is mental health, it provides people with an opportunity to come into a new environment that opens them up to talk and to form networks there that are slightly different. It's worth looking into the different types of networks where men associate, the close knit ones where you have the culture that's so hard to change, I am not talking, the more open ones. Okay and then the unemployed and marginalise where it's important to train the professional gatekeepers and to train and support the public members who might be in their rather weaker networks, the people who have dropped through the net.

So I know we need to finish this off now, couple of more slides, in terms of long term change, the messages are, keep going, sustain and coordinate the elements that have been in this campaign, where I say here vertical coordination means .... Greg has been doing a fantastic job in North Lanarkshire, it's important that the message reaches the national campaign and then that there's coordination, that the national brand and the local brand don't clash. Now as far as possible the resources compliment each other, now for example the materials don't seem to produce a slight confusion in peoples mind. The local materials that have been produced have been very much to do with promoting public awareness and it would be great if they then spread out through Scotland. There are a lot of messages here for people in the rest of Britain and elsewhere about public awareness campaigning. And then in terms of the regional coordination, fantastic jobs being done with the resources that are here, more can be done to look carefully at the links between the training and the public awareness campaign, I'd have those who have been trained, particularly building on the community training, training community members, how they can then work in partnership with the campaign leadership to raise public awareness and to help people to move beyond initial awareness.

So finally coordinating with wider campaigns, there were just slight hints of confusion about how all the different campaigns tie together. So you have got the See Me campaign, you have got Anti Stigma campaigning and then you have got Choose Life, for example Motherwell Football Club have supported different campaigns, it's not always clear that they are all about supporting people to live healthy lives, they are all about health and wellbeing. So the links can be made clearer, it's not the responsibility of Choose Life to do this, it's the responsibility of all the different organisations to address any possible sense that they don't see how it all joins up to produce an unstoppable force.

Okay, conclusions ... the campaign has made huge steps, it's a pathfinder, you should be very proud of all the achievements that can be spread elsewhere and built on here, and I think the big message is you are trying to produce a culture change to a culture of trust, that it's safe to talk about suicide and that that takes time and therefore needs to be supported.

Further steps, continue to look at the way things join together, individuals, organisations, communities, and continue to bear in mind that it's complicated to produce change and so looking for instance end results is not the right way. The right way is to look for the mid term results, see how they join together, how you can build on that towards the long term goal in a very difficult climate where there are a lot of problems facing people in their daily lives. So this campaign has made great success, and finally, all I am is an outsider coming in here to offer some thoughts through a funded evaluation. The praise for this evaluation comes back to Choose Life who commissioned us to do this evaluation, they made it possible for us to do this very rewarding project and we see ourselves as being partners, and any insights that might come from our report, we hand back to you to decide what's valuable and what isn't with your local knowledge, because we, the outsiders, can't know as much as you know as insiders, so thank you very much for this opportunity.


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