The impact of an educational mental health interventionon adolescents’ perceptions of mental illnessE . S A K E L L A R I 1 M S c R H V , A . S O U R A N D E R 2 P h D M D ,A . K A L O K E R I N O U - A N A G N O S T O P O U L O U 3 P h D R N &H . L E I N O - K I L P I 1 , 4 P h D R N

1PhD Candidate, Department of Nursing Science and 2Professor, Department of Child Psychiatry, University ofTurku, Turku, Finland, 3Associate Professor, Faculty of Nursing, University of Athens, Athens, Greece, and4Professor and Chair, Nurse Director, Hospital District of Southwest Finland, Turku, Finland

Keywords: adolescents, Greece, health

education, interviews, mental illness,

secondary schools

Correspondence:

E. Sakellari

Nikopoleos 39

11253 Athens

Greece

E-mail: evasak@utu.fi

Accepted for publication: 20 February

2014

doi: 10.1111/jpm.12151

Accessible summary

• Positive perceptions towards mental illness are essential for a mentally healthysociety.

• This study explores adolescents’ perceptions of mental illness and examines theextent to which these perceptions changed after a mental health educationalintervention.

• The results of this study demonstrate that there is a positive effect on adolescents’perceptions towards mental illness.

Abstract

Nowadays, in many countries, mental health care is primarily community based.Community perceptions of mental illness are an essential issue for the quality of lifeof people with mental health problems and the promotion of mental health in general.The aim of this study was to explore adolescents’ perceptions of mental illness and toexamine the extent to which those perceptions changed after an educational mentalhealth intervention. The data were collected twice, before and after the educationalmental health intervention. Fifty-nine pupils from two Greek secondary schools wereindividually interviewed, and data were analyzed by inductive content analysis. Thefindings show that adolescents can provide a rich description of mental illness in amultidimensional way. After the intervention, they provide different descriptions,identify various forms of mental illness and express opinions on what mentally illpeople need and how they should be treated. It is concluded that mental healtheducational interventions in schools can be effective in changing adolescents’ percep-tions towards mental illness.

Introduction

Mental health is an essential component of health.Approximately 14% of the global burden of diseasehas been attributed to neuropsychiatric disorders (Princeet al. 2007). It is estimated that nearly 50 million citizensexperience mental disorders, with depression being themost prevalent health problem in many European Union-member states (European Pact for Mental Health andWell-Being 2008). Most people who suffer from severemental illness live within the community (Stark et al.

2004). In high-income countries, between 5% to 20% ofchildren and adolescents need mental health services(WHO 2005). Furthermore, one in eight teenagers under18 years old has a mental disorder (WHO 2004).

Negative evaluations of the mentally ill date back toancient times; public sentiment favoured socially rejectingmentally ill people and continually keeping a social dis-tance from them (Martin et al. 2000). Currently, thepublic’s reactions to mental illness include a plethora ofprejudicial beliefs and emotions and behaviours that leadto discrimination against the mentally ill (Corrigan 2004).

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Studies have shown that the general public sees people withmental illness as being dangerous and that other peopleshould fear them (Corrigan et al. 2001) and keep a socialdistance from them (Link & Phelan 1999). This fear isbased on the perceived association between mental illnessand violence (Monahan & Arnold 1996). The generalpublic associates mental illness with hallucinations, delu-sions, psychomotor abnormalities and incoherent speech(Sartorius 1998).

Researchers have identified stigma and discrimination asimportant obstacles to people with mental illness beingintegrated within society (Bjorkman et al. 2008). Thus,community perceptions of mental illness should be studiedand efforts should be made to foster a positive awareness ofmental illness, especially among adolescents who will soonassume adult responsibilities within the community.

Education enables the public to make more informeddecisions about mental illness (Corrigan & Penn 1999).Furthermore, modifying public perceptions about mentalillness could promote policy changes favourable to psychia-try (Austin & Husted 1998). Because the promotion ofmental health is a more extensive concept than preventingmental health problems (Puolakka et al. 2011), it is crucialto promote an understanding of the nature of mental healthand mental illness as a means of changing policies andpractices in education, employment, law and healthcare,which are critical to mental health (Herrman 2001).

Adolescence is an age when views are formed on a rangeof topics that impact future adult behaviour (Pinfold et al.2005) and define later attitudes (Fitzgerald et al. 1995), andshould include the promotion of respect, tolerance, empathyand an appreciation of diversity (Sabir Ali & Iftikhar 2006).It is a time of rapid development in cognitive skills withintense acquisition of new information that establishes thebasis for a productive adult life (Golub 2000).

Schools play a very important role in promoting mentalhealth (Johansson & Ehnfors 2006). Puolakka et al.(2011), support that mental health promotion in schoolshas risen as a very important developing area in publichealth service. Considering all this, adolescents are an idealtarget group for addressing a study concerning mentalillness, which will increase their awareness about mentalillness and provide them information, and furthermorepotentially promote mental health in the community.

A review of the literature demonstrates that educationalinterventions for adolescents about mental illness are not apopular subject. The limited number of published studiesprimarily focuses on knowledge of and attitudes towardsmental illness. The results are encouraging with regard toincreasing adolescents’ knowledge about mental health andillness and reducing their negative attitudes towards peoplewith mental health problems (Sakellari et al. 2011).

However, the previous studies do not provide informationregarding how adolescents understand mental illness andtherefore, our study begins to address this gap.

The aim of our study was to explore perceptions ofmental illness among adolescents and to examine the extentto which these perceptions changed after a mental healtheducational intervention. The ultimate goals of our studyare to provide information for community mental healthnurses internationally, to increase awareness about mentalillness among adolescents and to stimulate further mentalhealth educational interventions among this target group.

The research questions are:1. What is the perception of mental illness among

adolescents?2. Does the perception of mental illness change after a

mental health educational intervention?

Methods

Setting

The study took place in two randomly selected secondaryschools in different districts of Athens, Greece, with bothschools following the national curriculum (Ministry ofEducation 2013). Because all schools in Greece follow thesame curriculum and have the same structure, which isdetermined by the Ministry of Education, there were noexclusion criteria. The random selection of the two schoolswas made by a lottery draw.

Participants

Fifty-nine pupils aged 13–16 years participated in thisstudy. There were two groups of participants from twoschools. One school was the intervention group (n = 28),while the second school was the comparison group (n =31), to avoid possible contamination. Determination of theintervention and comparison group was also done byrandom selection. The 31 participants in the comparisongroup did not receive any mental health education inter-vention. Two participants dropped out of each group.

Data collection

The data were collected twice from both groups; oncebefore and once after the intervention. We chose individualstructured interviews to know all possible ways in whichthe respondent views or experiences phenomena (Parahoo2006). The baseline interviews were conducted over 1week, during the same time period for both the comparisonand intervention groups. The second interviews com-menced 1 day after completion of the intervention and

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636 © 2014 John Wiley & Sons Ltd

were conducted over the same time period for both theintervention and comparison groups.

Individual interviews with the same open-ended ques-tions before and after the intervention were conducted bythe primary researcher (ES) in a classroom. The researcherasked the participants to present themselves to the class-room where the interviews took place. The researcherintroduced herself at the first interview. Firstly, she askedthe participants to answer some background informationquestions and then moved to the main research questions.The interview was digitally recorded throughout its wholeduration. The same process was followed for both partici-pant groups before and after the intervention. Anonymitywas ensured because no names were used in any part of thedata collection. Because the same person conducted all theinterviews, achieving an adequate level of trustworthinesswas established.

In the interviews, the following questions were asked:What is mental illness? Could you describe a mentally illperson? In addition, we asked for the following back-ground information: their age, the educational level of theirparents, whether or not they had ever met a mentally illperson, whether they would ever visit a mental hospital ora guest house where people with mental health problemslive and finally if they had ever discussed mental health ormental illness with their parents or siblings.

Mental health educational intervention

The mental health educational intervention was designedby the researchers for this study using definitions, conceptsand evidence from the existing literature. The mentalhealth educational intervention included the following; (1)an introduction; (2) defining and describing mental healthand the experience of mental health, as well as mentalhealth prevention; (3) identifying different types of mentalillness (bipolar mood disorder, depression, schizophrenia),their causes (biological, psychological, social factors), howpatients experience mental illness (symptoms, etc.) andforms of treatment (medication, psychotherapy, counsel-ling, rehabilitation interventions); (4) discussing myths andtruths about mental health and mental illness; (5) focusingon some things to remember (help-seeking, facing difficul-ties, mental health promotion, etc.); (6) mental health careservices in Athens (about 60 min in total); and, (7) discus-sion (about 30 min).

The intervention was implemented for the interventiongroup after the baseline interviews were completed. It wasconducted in a classroom by the primary researcher (ES)who is a health professional qualified in health education.It lasted for two teaching hours (including the discussion)during a standard school day and was included as part of

the general curriculum. The teaching methods used werelecture and discussion. Lecture is a primary method forhealth education and the adolescents are familiar to thismethod because it is a method widely used in schools forteaching. As the health education methodology literaturesupports (e.g. Gilbert et al. 2011); slides were shownemphasising the key points. The lecture gave the opportu-nity to provide factual information in a logical sequence.Because of the long time of the lecture, the educator sum-marized and reviewed the key points and also checked to becertain that the participants were following and under-standing as well as allowing questions at any time. At theend of the education, there was time for the participants toask additional questions, seeking clarification and challeng-ing and reflecting on the subjects presented.

Efforts were taken to make the content comprehensibleby adapting the language to fit the age and cognitive level ofthe pupils and professional terms were not used. However,the diagnostic labels were used because the aim was for theparticipants to learn the correct names and definitions ofthe different illnesses. However, the diagnostic criteria or theclinical descriptions in terms of the International Classifica-tion of Diseases, ICD-10 (classification of mental and behav-ioural disorders) or Diagnostic and Statistical Manual ofMental Disorders, DSM IV were not presented.

Data analysis

The interviews were transcribed verbatim in Greek. Theunit of analysis was the whole interview as the literaturesuggests (Graneheim & Lundmand 2004). The analysisstrategy used was inductive content analysis, which is asso-ciated with the techniques described for social scientists byStrauss (1987).

The researchers read the interviews several times tobecome familiar with the data. First, the data were opencoded based on the content of the interviews. This phaseincluded unrestricted coding of the data, which was tenta-tive at this point. Then categories were formed using wordstaken directly from the participants’ responses. We did thisthrough labelling to group together similar responses.Finally, we developed emerging categories by combiningsimilar content areas to reduce the number of categories byincluding some of them within similar, yet broader, catego-ries. The final categories illustrated the participants’ per-ceptions of mental illness with the aim of covering whatthey included in their responses.

Ethics

Approval to conduct the study was obtained from theGreek Ministry of Education. Because the participants

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were pupils under 18 years of age, participants as well astheir parents or guardians signed a written informedconsent form. We provided information to the participantsand their parents/guardians concerning the nature of thestudy, how the study would proceed and the objectives ofthe study. Participation was voluntary and no identifyinginformation has been used to ensure the anonymity andconfidentiality of the participant and the right of the par-ticipant to withdraw from the study at any time.

Results

All of the participants were born and raised in Athens. Themean age was 14.3 years [standard deviation (SD) = 1.0years] for the comparison group and 13.7 years (SD = 0.5years) for the intervention group. The two groups of ado-lescents were similar in terms of sex. The educationallevel of the mothers did not differ statistically between thetwo groups (Pearson Chi-square test, asymp. sig. 0,464,2-sided) and neither did that of the fathers (Pearson chi-square test, asymp. sig. 0,341, 2-sided). Also, the sameproportion of adolescents had ever had contact with amentally ill person (41.4% in the comparison group and34.6% in the intervention group). Furthermore, we askedthe participants for other background factors, which arepresented in Table 1.

Perception of mental illness

Pupils in both groups described mental illness in a multi-dimensional way before and after the mental health educa-tional intervention, and they are illustrated in Table 2.

Mental illness is being or not being in a state of . . .Participants described mental illness according to differentstates of being or not being in a state of something. It can

be seen that both groups’ responses did not differ. After theintervention, the responses among the comparison groupremained similar. On the other hand, after the intervention,the intervention group participants offered fewer responsesthat included elements of mental illness as ‘being in a stateof . . .’, while their responses included three new elements:being distant (one participant), that any one of us couldpossibly be mentally ill (two participants) and that a men-tally ill person is afraid of rejection (two participants).Furthermore, after the intervention, several participantsfrom the intervention group said that mentally ill peopleare not dangerous and that they are not so different/special.

Mental illness is doing (behaving)Participants perceived of mental illness as doing somethingor behaving in some way. After the intervention, althoughthe responses among the comparison group are similar,there were few differences among the intervention groupparticipants in the ways they described mental illness. Twoof them stated that mental illness involves behaving differ-ently, which participants had not included in their responseprior to the intervention, and none of the participantsdescribed mental illness as doing crazy things or doingthings that are crazy or not quite normal, right or usual.

Mental illness is having or not having something . . .Participants before the intervention described mentalillness as having or not having something with the domi-nant description having psychological or other problems.After the intervention, six of the participants from theintervention group described mental illness as havingproblems. Before the intervention, 14 of the participantsdescribed mental illness in this way. Additionally, after theintervention, two participants described mental illness ashaving a disorder of the soul (psyche), while before theintervention, only one participant described mental illnessin this way. Furthermore, the participants included someelements that were not mentioned before the intervention:that mental illness is having an illness (one participant) and

Table 1Willingness to visit a mental hospital and discussion of mentalillness among family

Interventiongroupn = 28

Comparisongroupn = 31

‘Would you ever visit a mental hospital?’f % f %

Yes 11 39.3 9 29No 4 14.3 8 25.8Maybe 7 25 7 22.6Yes, if it was a relative

or friend6 21.4 7 22.6

‘Have you discussed mental illness in your family?’f % f %

Yes, with parents 18 64.3 19 61.3Not with parents 10 35.7 12 38.7Yes, with siblings 21 75 25 80.6Not with siblings 7 25 6 19.4

Table 2Mental illness is . . .

Before the intervention After the intervention

1 . . . being . . . / . . . not being . . .2 . . . doing (behaving) . . .3 . . . having . . . / . . . not having . . .4 . . . not knowing . . .5 . . . seeing . . .6 . . . not being able to . . .7 . . . feeling . . .8 . . . talking to oneself . . .

1 . . . being . . . / . . . not being.2 . . . doing (behaving) . . .3 . . . having . . . / . . . not having . . .4 . . . not knowing . . .5 . . . seeing . . .6 . . . not being able to . . .7 . . . feeling . . .8 . . . talking to oneself . . .9 . . . an illness . . .

10 Expressed by attitudes11 . . . needing . . .

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that it involves having extra stress (one participant), dis-playing extra sadness (six participants) and having asymptom (one participant). Finally, in terms of theresponses about ‘not having something’, after the interven-tion several of the intervention group participants onlymentioned ‘not having logic’ and ‘not having friends’(two participants and one participant respectively). Theresponses of the comparison group did not change after theintervention.

Mental illness is not knowing . . .Before the intervention, participants defined mental illnessas a person not knowing what is going on around them andnot knowing what he or she is talking about or doing.There are still the same responses among the comparisongroup after the intervention. However, after the interven-tion, only a few participants in the intervention groupdescribed mental illness as a person not knowing what isgoing around them and not knowing what she/he is doing.

Mental illness is seeing . . .Before the intervention, participants referred to mentalillness as seeing everything in black and imagining thingsthat are not based on reality. After the intervention, par-ticipants in the intervention group did not include any ofthe above elements in their explanations of mental illness,while one of the participants of the comparison group didas before the intervention.

Mental illness is not being able to do something . . .Before the intervention, participants stated that mentalillness involves not being able to do certain things. After theintervention, participants within the intervention groupdescribed mental illness differently; they did not include allof the same elements that they had before the intervention.Moreover, there were two new responses after the interven-tion: one participant said that mental illness is not beingable to control one’s feelings, and four said it is not beingable to do all of one’s activities. On the other hand, theresponses of the participants of the comparison group aresimilar before and after the intervention.

Mental illness is feeling . . .Before the intervention, participants described mentalillness in terms of feelings of a mentally ill person.However, after the intervention, intervention group partici-pants described mental illness as feeling different, whilenone of the participants of the comparison group includedany elements in terms of feelings.

Mental illness is talking to oneselfBefore the intervention, participants stated that mentalillness involves talking to oneself. The same was expressed

after the intervention by a couple of the comparison groupparticipants. In contrast, after the intervention, none of theintervention group participants described mental illness inthis way.

Mental illness is an illness . . .Before the intervention, only one of the participantsincluded the diagnosis of schizophrenia in his description;this response was among the comparison group and it isalso found after the intervention. After the intervention,several participants in the intervention group included intheir description of mental illness such things as depression,schizophrenia or bipolar disorder. Furthermore, after theintervention, some participants in the intervention groupstated that mental illness is an illness that is no differentfrom any other illness, or they described it as a physicalillness, an illness that anyone is vulnerable to and an illnessthat can be managed.

Mental illness . . . as expressed by attitudesOnly after the intervention and only the participants in theintervention group expressed positive attitudes towardsthe mentally ill people, which they had not done before theintervention. They said that we should be friendly to themand that we should not be afraid of them, not behavedifferently towards them and not leave them in the margins.

Mental illness is needing . . .Only after the intervention and only participants in theintervention group described mental illness in terms ofneeding specialized help; in contrast, participants in thecomparison group did not describe it in this way.

Discussion

This study describes the perceptions of mental illnessamong adolescents and the results of a mental health edu-cational intervention. The findings show that participantsdescribed mental illness in a multidimensional way. Never-theless, the participants changed their descriptions some-what after the intervention and added new elements totheir descriptions of mental illness. The greatest changeafter the intervention involved new categories added by theparticipants in the intervention group.

It has been found that in younger age (8–9 years) there isa lack of understanding of mental illness, lacking well-formed conceptions of mental illness while unable toprovide examples of people with mental illness (Adler &Wahl 1998). On the contrary, the participants in our studywho are adolescents were able to describe their perceptionsof mental illness and provide a rich description of it. Previ-ous research also supports that a young person’s under-

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standing of mental illness becomes more sophisticated asshe/he progresses in age and school grade (Wahl 2002).

One of the dominant answers among the participantsfrom both groups when referring to mental illness washaving psychological or other problems. It has been foundthat young people identified physical and mental disabil-ities, bullying and psychological problems as the main char-acteristics displayed by mentally ill people (Dogra et al.2005). The participants described mental illness as beingshy and sad and causing a person to cry. In the same way,it has been shown that the general public often describedmentally ill people as being more sensitive and that only aminority of them (8%) believed that the mentally ill aremore intelligent than other people (Wolff et al. 1996).Studies conducted in Northern Sweden showed that manyperceived mentally ill people as being more capable ofcommitting violent acts than others (Ineland et al. 2008).However, only three participants in our study describedmentally ill people as being dangerous.

After the intervention, the responses of the participantsalso included the need for specialized care. Similarly, otherresearchers have found that young people and their parentsthink that mental illness is a disability of the brain requir-ing hospitalization (Dogra et al. 2005). Furthermore, it hasbeen found that the young people’s attitudes revolvedmainly around sympathy and fear (Secker et al. 1999).Likewise, earlier it has been found that a minority ofrespondents (9%) objected to ex-psychiatric patients livingin their neighbourhood (Ineland et al. 2008). In our study,after the intervention, the intervention group said that weshould not be afraid of mentally ill persons, treat themdifferently or leave them in the margins.

Overall, the results of our study indicate that smallchanges occurred because of the mental health educationalintervention. Relatively minor changes can be seen amongthe variety of elements used by the participants to describemental illness before and after the intervention. However,the greatest change after the intervention involved newcategories added by the participants in the interventiongroup. They suggested that mental illness is an illness justlike any other (or a physical illness). They suggested that itis an illness that can be faced or that is manageable andmentioned specific illnesses, such as depression or schizo-phrenia. They also included the need for therapy, treatment(medication) and medical consultation in their responses.Finally, they expressed their attitudes towards mentally illpersons by saying that we should not be afraid of them, nottreat them differently or not leave them in the margins.Instead, we should be friendly to them.

The possible limitations of our study were that the edu-cational mental health intervention was short and nottested beforehand, which suggests that the intervention

needs to be further tested. Whereas recall bias could beanother limitation because the participants may repeat thesame responses during the second interviews, we couldclearly see that the responses by the participants in theintervention group differed after the intervention. More-over, the participants did not know the researcher whoconducted the study; this may have influenced theiranswers. Another possible limitation is the use of a quali-tative approach, which does not facilitate reporting theimpact of the intervention. Nonetheless, the responses pro-vided by the participants in the study provide a richwindow into how adolescents perceive mental illness.Finally, the responses of the adolescent participants whoused less sophisticated descriptions resulted in simplewritten categories.

Mental health education is an area that needs to bedeveloped among adolescents. These initiatives should takeinto account the perspectives of adolescents to address theirneeds for mental health education. The findings of ourstudy open up new perspectives and opportunities formental health education as they provide a description ofmental illness as it was perceived by the participants beforeand after the intervention. Our study demonstrates thatmental health education in schools can have a positiveimpact on increasing positive perceptions of mental illnessamong adolescents. Such interventions may improve theoverall health of the community by producing individualswho are knowledgeable about mental illness and who willhave a better understanding of mental illness because ado-lescents are the future adults who will have an impact onthe quality of life of the whole community. Because mentalillnesses affect people worldwide (WHO 2011), mentalhealth educational interventions are relevant internation-ally. Our findings can be used in the context of differentcultures, because similar results have been found in otherstudies (Wolff et al. 1996, Wahl 2002, Dogra et al. 2005,Ineland et al. 2008) and they can be further tested. Com-munity mental health nurses play an essential role in pro-moting mental health in our communities and the currentstudy will be useful for their everyday practice. The find-ings of our study should make community mental healthnurses more aware of the need to give emphasis to mentalhealth educational interventions and introduce initiativesthat promote mental health. Mental health educationalinterventions among adolescents, which strengthen anunderstanding of mental illness and enhance the positiveperceptions of mental illness, should be considered by com-munity mental health nurses. However, further research isneeded on longer mental health educational interventionsso that community mental health nurses can have moreavailable information when implementing such interven-tions in the future.

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