Better Health For All

• by Maya Twardzicki – Public Health Lead Surrey County Council, and
• John Ryan, comedian, Lift the Lid Productions

There is “growing international acceptance of the notion that participation in the creative arts can be beneficial for wellbeing and health” (1) (2).  Although little of this research has focused on comedy as a creative art form, a review of effective health education approaches with young men showed humour is effective when communicating about sensitive topics such as mental health. (3)

Findings from a recent randomised control study suggest that mental health comedy might generally reduce stigma in people who use affiliative style humour (4). In a series of innovative public health projects in Surrey, post-show evaluation also showed comedy to be an effective way to raise awareness, get people talking and generate more positive attitudes about mental health in both the general and prison populations. (5)

Much stigma still surrounds mental health: 87% of service users reported its negative impact on their lives. (6) Stigma in the military population is also common, (7) more so among those with a mental disorder. It is an important contributing factor to the challenge of engaging military personnel with psychological support (8)   as it is known to be a barrier to seeking help. (9)

The challenge in reducing stigma in both public and military populations, is to achieve lasting attitude change. Although evaluation of the Time to Change public campaign indicates longer term attitude change, several anti-stigma interventions implemented in the UK armed forces have failed to modify stigmatising beliefs at longer follow up.

So together with the Academic Department of Military Mental Health at Kings College London, we tapped into the strong role of humour in military culture to evaluate the short and longer term impact of stand up comedy as a novel stigma-reduction in a sample of Army service personnel.

Focus groups were run with Army service personnel to help inform the mental health comedy show script and explored their experiences of mental health, related attitudes and barriers to help seeking.

“We asked the men how they exercise their most important organ, they were surprised to realise it was their brain and how it benefits from wellbeing.” John Ryan, Comedian.

Personnel viewed a regular comedy show, which acted as a control, or a show containing mental health information and an additional comedian with experience in the military and of mental health problems. `Social contact` between those with and without mental health problems is an effective way to encourage more positive attitudes. (10)

John Ryan: “I said a good way to take control of your anxieties is to always finish what you start.  A lad replied ‘I finished my pint and watched the rest of the football match but didn’t feel any better’ “.

Before the show, immediately after and three months later, measures were taken (using recognised instruments/scales) of: military-based stigmatisation, potential discrimination, mental health related knowledge, self reported help-seeking and coping behaviour, talking about mental health, current mental health and alcohol use. Response rates were high pre and post show, but unfortunately very low at three month follow up due to many of the sample preparing to be or being deployed.

• Satisfaction with the comedy show format was very high showing that it was an acceptable way to present mental health related messages.
• Post-show, intervention group participants reported significantly less stigmatisation and were significantly more likely to answer mental health-related questions correctly
• In the small sample at follow up, neither difference was maintained. However, there was a borderline significant reduction in potential discrimination; and intervention group personnel were statistically significantly more likely to discuss mental health and advise others about mental health. Adjusted analyses suggested that this may have been related to factors other than the show (e.g. greater opportunity to do so as the intervention group had higher levels of common mental health problems)
• Knowledge of effective coping strategies rose in both intervention and control groups post show, and was significantly higher in the control group at follow up. Although this was encouraging as the project did aim to increase personnel knowledge about help seeking, as this effect was seen in both groups, it may have resulted from both unintentional confounding  (project staff who viewed both shows reported that there was some unplanned overlap in the content of the control and intervention shows), and from low follow up numbers.

In conclusion, embedding mental health awareness within a comedy show format had a short-term positive effect upon military mental health stigmatisation in a sample population of UK Armed Forces personnel and was a well accepted/popular format. The reduction in stigma was not sustained at the longer three-month follow up (a finding reflected in other anti-stigma interventions in military populations using mental health awareness or psycho education). (11)

However, the low rate of follow-up limited our ability to assess whether this effect was lasting. It may also be that the intervention has maximum immediate impact and if the Armed Forces finds a way to reinforce the key messages over time, the positive post show changes may prove more 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. (12)

1)  Clift S (2012)  Creative arts as a public health resource: moving from practice-based research to evidence-based practice.  Perspect Public Health 2012 May, 132(3):120-7
2)  Stuckey H L, and Nobel J  The Connection Between Art, Healing and Public Health: A Review of Current Literature.  Am J Public Health. 2010 February, 100(2); 254-263
3)  Lloyd T (2002)  Boys and young men’s health: what works.  Health Development Agency. London
Corrigan P W, Powell K J, Fokuo J K, Dosvluk K A (2014)
4) Does humor influence the stigma of mental illnesses?  J Nerv Ment Dis 2014 May 202(5):397-401
5)  Evaluation reports: Dr Claire Henderson and Steve Wright from the Institute of Psychiatry, Kings College London (2010)  and  from Nottingham University Self Harm Research Group (2009)
6)  Stigma Shout Survey: Time to Change
7) Osorio C, Jones N, Fertout M, Greenberg N (2013)   Changes in stigma and barriers to care over time in UK Forces deployed to Afghanistan between 2008 and 2011. Mil Med (in press)
8)  Kim P, Thomas J, Wilk J, Castro C, Hoge C (2010)  Stigma, barriers to care and the use of mental health services among active duty and National Guard soldiers after combat. Psychiatr Sev 61(6):582-588
9)  Capeda-Benito A, Short P (1998)  Self-concealment, avoidance of psychological services and perceived likelihood of seeking professional help. J Couns Psychol 45:1-7
10)  Pinfold V, Huxley P, Thornicroft G et al (2003) Reducing psychiatric stigma and discrimination: Evaluating an educational intervention with the police force in England.  Social Psychiatry and Psychiatric Epidemiology, 38: 337-344.
11)  Mulligan k, Fear NT, Jones N, Wessely S, Greenberg N (2010) Psycho-educational interventions designed to prevent deployment-related psychological ill-health in armed forces personnel: a review. Psychol Med 41:673-678
12) Jones N, Twardzicki M, Ryan J, Jackson T, Fertout M, Henderson C, Greenberg N (2014)  Modifying attitudes to mental health using comedy as a delivery medium. Soc Psychiatry Psychiatr Epidemiol DOI 10.1007/s00127-014-0868-2 Published online 09 April 2014

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• By Dr John Middleton
• Acting President, Faculty of Public Health

The public health settlement announced last week signifies a real-terms decrease in allocations for public health in England.

Local authority officers may have got used to the year-on-year austerity meted out by central government. It has taken out over £10bn since 2011. But the public health community will not be happy to be drawn into the race to the bottom.

The sector’s move from the health service to local authorities was intended to protect public health from decades of stifling under the juggernaut of acute care; to put public health where it belonged and to protect and grow it.

The sum of £2.79bn for 2015-16 is the same amount as last year’s public health ringfence. It is particularly galling at a time when clinical commissioning groups in the health service have had funding increases.

It does not enhance this government’s reputation, nor does it aim to prevent more illness and disability. And it does not suggest central government is any closer to thinking and acting in an integrated way on improving health and independence, and reducing disability and disease.

Figures from Local Authority Revenue Expenditure and Financing: 2014-15 Budget, England show public health budgeted expenditure is £2.84bn, so it would appear that councils are planning to fund the £54m balance from other sources.

The scope for local authorities to apply their funds in a discretionary fashion towards major public health issues is limited – £2.18bn goes on prescribed functions and major commissions in sexual health, drugs and school nursing. In all the other budget areas the amounts committed are puny given the scale of the problems.

There are about 30 director of public health vacancies nationwide and this vacuum enables councils to use public health funds to prop up budgets elsewhere.

We are a huge distance away from ‘industrial scale’ services to prevent smoking, alcohol, dietary and inactivity related ill health.

There is not so much a risk as a certainty that public health money will be diverted to other spending areas. There are about 30 director of public health vacancies nationwide and the senior management vacuum enables councils to use public health funds to prop up budgets elsewhere.

The faculty’s local advisory committees tell us this is happening around the country. Some councils do so for survival; others use finesse to move it to “public health wider determinants budgets” or use funds to reshape existing council services towards more defined health outcomes.

Some directors of public health, striving to be corporate players, are concerned with the reality of protecting services that we have championed as public health services – early years, young people’s job opportunities and welfare rights.

The UK Faculty of Public Health believes the funding allocation for public health is far too small. The amount transferred from the NHS for all public health services was only £4bn although I made the case for another billion to be moved across. Then health secretary Andrew Lansley professed his commitment to protecting and growing public health and getting the nation healthy.

However, it is clear that aspiration remains empty political rhetoric. It is disingenuous of the government to talk in terms of two-year allocations and to answer every challenge from fat and fitness to food poverty and accident prevention by saying “£5bn is available” to tackle them.

Public health services represent less than 3% of local government funding. The overall cut in public services should be the major public health concern. Local government budgets have been hammered relentlessly over recent years. And that hammering has disproportionately affected the poorer, mainly northern, councils with the highest mortality rates. The councils with the highest death rates had the highest cuts in revenue support grant.

Few councils have seriously risen to the ‘health in all policies’ challenge. The idea of health impact statements in all policy documents is seen as bureaucratic.

We are seeing rises in suicide rates associated with economic decline. The movement in policy has been to exacerbate public health inequality – less invested in early years, adolescent health and jobs, workplace health and in reducing income inequalities. The only area in which we may see a genuine capacity for councils to improve health is through their commitments and interest in healthy town planning and the housing improvement agenda.

FPH would like to see whole council expenditure shift towards health improvement. Few types of council have seriously risen to the ‘health in all policies’ challenge. Some councils are looking to use the housing revenue account towards healthy repairs and warm homes, to use the roads maintenance budgets to reduce deaths and disability to pedestrians, or develop the health outcomes achieved through leisure services.

However, the idea of health impact statements in all council policy documents is seen as a bureaucratic imposition on hard-pressed officers. The big prize will not only be to commit the ringfenced funds wisely, but to commit to health improvement in all council spend.

• This article was first published by the Local Government Chronicle

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