Journal of Psychiatric and Mental Health Nursing, 2011, 18, 166–176

Educational interventions in secondary education

aiming to affect pupils’ attitudes towards mental
illness: a review of the literature
E . S A K E L L A R I 1 m s c r h v , H . L E I N O - K I L P I 2,3 p h d r n &
A. KALOKERINOU-ANAGNOSTOPOULOU4 phd rn
1
PhD Student, 2Professor and Chair, Department of Nursing Science, University of Turku, 3Director,
South-Western Hospital District of Finland, Turku, Finland, and 4Associate Professor in Community Nursing,
Department of Public Health, Faculty of Nursing, University of Athens, Athens, Greece

Keywords: adolescents, attitudes Accessible summary

towards mental illness, education,
secondary schools • Promoting mental health and fostering understanding within the community about
mental illness are essential.
Correspondence:
E. Sakellari
• This systematic review is concerned with intervention studies which aim to affect
secondary school pupils’ attitudes towards mental illness through education.
39 Nikopoleos Street
Athens 11253 • While the results indicate a positive impact, research on this topic is quite limited
Greece and further research is needed.
E-mail: evasak@utu.fi
Abstract
Accepted for publication: 14 September
2010 Dealing with persons who have mental health problems is an issue that many people
are likely to face with, whether they are health professionals or not. Positive attitudes
doi: 10.1111/j.1365-2850.2010.01644.x
towards people with mental illness play a major factor in their quality of life and social
inclusion. Since adolescents will become active adult members of their communities in
the near future, this paper reviews educational interventions in secondary education
and how they aim to affect adolescent attitudes towards mental illness. Twelve studies
conducted on the relevant issue have been identified. The results indicate a positive
impact on attitudes towards mental illness and improvements in the knowledge of
mental health and illness among secondary school pupils. However, the limited number
of studies highlights the need for further research.

Furthermore, studies among the general population

Introduction
Mental health is an essential issue in health care world-
wide. According to the WHO (2003), 450 million people
worldwide suffer from a mental or behavioural disorder
and it is predicted (WHO 2005a) that, by 2020, 15% of the
total disease burden worldwide will be attributed to mental
and behavioural disorders. Mental health is the base for
understanding mental illness, and it is difficult to draw a
line between the two. In most parts of the world, as stated
in the World Health Report, mental health and mental
health problems are not considered as important as physi-
cal health (WHO 2001).
have shown widespread antipathy towards people with
mental health problems. Rutz (2001) has stressed the
importance of mental health education as an early form of
intervention against stigmatization. Negative attitudes
among children have been seen to persist for over a decade
(Byrne 1997). For adolescents, one important barrier to
seeking mental health treatment is stigma (Pinto-Foltz &
Logsdon 2009), which is caused by a lack of understanding
of mental health by society (British Medical Association
2006). Moreover, Wilson et al. (2000) claim that the stig-
matization of mental illness develops among young people
through what they see on television programmes.

166 © 2010 Blackwell Publishing

 School mental health education

Promoting an understanding within the community 4. What measurement instruments have been used in order
about mental health and mental illness is the key for chang- to evaluate the outcomes of these interventions?
ing policies and practices in education, employment, law 5. What is the impact of the interventions concerning the
and health, which are essential to mental health (Herrman knowledge about and attitudes towards mental illness?
2001). Integrating prevention and promotion programmes The purpose of this systematic review within the broad
for mental health as a part of overall public health strate- field of mental health is to raise awareness among nurses
gies will help to reduce the stigma attached to persons with about mental health and mental illness, and encourage
mental health problems (WHO 2003). them to implement mental health educational programmes
Adolescence is an opportune time to encourage positive within schools by offering suggestions for those who wish
attitudes, reduce stigma related to mental disorders and to be engaged in mental health promotion.
reduce the illness burden across the life span (Pinto-Foltz &
Logsdon 2009). The school environment, as well as the
curriculum content, provides a good opportunity to dis- Methods and analysis
seminate information, foster good habits and raise chil-
We carried out the librarian-assisted search using the Ovid
dren’s awareness about mental health (British Medical
interface and the following databases: Medline (1950 to
Association 2006). Finally, a holistic school approach to
November 2008) and CINAHL (1982 to November 2008).
mental health promotion increases mental well-being and
We used the following keywords in the computer searches:
reduces the risk for mental disorders among children and
mental health, health promotion, health education, school
adolescents (Jane-Llopis & Anderson 2005).
health education, school health, schools, secondary
This systematic review focuses on the outcomes of edu-
schools, students, high school. When combined the key-
cational interventions designed to affect knowledge and
words yielded 149 references. We also conducted a search
attitudes about mental illness among pupils aged 12–18
using the Psychinfo database (1860–2008), which yielded
years (i.e. adolescents). The age range is broad because the
504 references.
studies among pupils have been conducted in different
According to the inclusion criteria, the articles should:
countries with different educational systems. The target
1. include a mental health educational intervention,
population of this review are those pupils in secondary
aiming to affect the level of knowledge and the attitudes
education.
towards and about mental illness,
During adolescence, young people begin to concern
2. include the outcomes for the mental health educational
themselves with developing of a sense of personal identity
interventions conducted,
(Mussen et al. 1990). Rew, in her editorial, states that
3. be written in English,
adolescence is a special developmental period during which
4. have secondary school pupils aged 12–18 years as par-
lifelong identities are explored and eventually established
ticipants (also high school would not be excluded), and
(Rew 2007). Furthermore, adolescence is a time of rapid
5. include any methodological design.
advance in cognitive skills and a period of intense acquisi-
Ultimately, 12 articles satisfied the inclusion criteria and
tion of new information, which establishes the foundation
were obtained in full text. We read through the titles and
for a productive adult life (Golub 2000). Thus, we have
decided whether or not they address our research questions
chosen adolescents, with the cognitive level to comprehend
and inclusion criteria. Once the search was completed, we
mental health and mental illness concepts and at the age
analysed the articles according to their aims, the type of
when educational interventions can have an impact, for the
mental health education implemented, the instrumentation
current literature review.
used and their outcomes.
The guidelines of the process of a systematic literature
review (Glasziou et al. 2004) have been followed in order
to conduct the current systematic literature review. The
Results
research questions that guided this systematic literature
review are as follows: The studies were conducted in seven countries (Table 1).
1. What educational interventions have been conducted The number of participants varied, ranging from 40 (Esters
among secondary school pupils with the aim of affecting et al. 1998) to 1566 (Watson et al. 2004), while one study
the level of knowledge about and attitudes towards (Bronwyn & Dale 1993) did not clearly state the total
mental illness? number of participants. Six studies included control groups
2. What is the content of these interventions? (Petchers et al. 1988, Esters et al. 1998, Rahman et al.
3. What educational methods have been used in these 1998, Ng & Chan 2002, Schulze et al. 2003, Rickwood
interventions? et al. 2004) and six did not (Bronwyn & Dale 1993,

© 2010 Blackwell Publishing 167

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Table 1
Brief description of the reviewed studies
Authors, year, country Participants Methods and length of intervention Outcomes
1 Spagnolo et al. (2008), 426 (high school students, adolescents) • Presentation • Discussion Stigmatization attitudes decreased
USA (New Jersey) • Fact sheets • Contact with mentally ill 60–90 min
E. Sakellari et al.

2 Essler et al. (2006), • 104 pupils (13–14 years) • Quiz, drama, games and stickers Slightly (but significantly) improved
UK • No control group (two phases) knowledge and attitudes scores
3 Stuart (2006), • 330 students (13 or younger–18 • Presentation • Questionnaires • Improved knowledge
Canada or younger) • Video • Answer sheets • Improved behavioural intentions and
• No control group • Discussion • Overhead templates social distancing
• Role playing (two lessons)
4 Watson et al. (2004), 1566 students (middle school, grades 6–8) • Classroom activities • Knowledge improvement
USA (16 states) • Web-based activities (scenarios, simulations, animations, • Negative attitudes scores decrease
videos) 8 class sessions ¥ 45 min
5 Rickwood et al. • 457 high school students (14–18 years, mean • Presentations • Moderate impact on stigma and
(2004), Australia age 16 years) • Interactive activities social distance
• Experimental group: 309 students • Written material 50–90 min • Knowledge increase
• Control group: 148 students
6 Pinfold et al. (2003), • 472 secondary school students (14–15 years) • Workshops designed around group exercises • Increased mental health literacy
UK • No control group • Talk • Discussion • Positive attitudes scores rise
• Video • Leaflets
• Contact with mentally ill 2h
7 Schulze et al. (2003), • 150 secondary school students • Discussion (and with a young person with schizophrenia) • Positive effects on stereotypes
Germany • Experimental group: 90 students (mean • Artwork • Reduction of social distance (not
age: 14.8) • Games 1 week statistically significant)
• Control group: 60 students (mean age: 15.4)
8 Ng & Chan (2002), • 169 secondary school students • Education • Exhibitions • Positive changes in separatism and
Hong Kong • Experimental group: 79 students (mean • Mental health promotion day stigmatization
age: 15.04) • Talks • Contact with mentally ill 10 weeks • Not reinforce in benevolence
• Control group: 90 students (mean age: 14.96) • Higher restrictiveness in both groups
9 Rahman et al. • 100 secondary school students, 12–16 years • Activities of the school curriculum (essay writing, annual • Significant positive change in pupils’
(1998), Pakistan (25 girls and 25 boys in each of the speech, poster-painting competitions, short plays, skits) awareness of mental health issues
experimental and control groups) • Lectures • Less stigmatizing
• 100 parents • Posters display (with mental health slogans)
• 100 friends who did not attend school 4 months
• 100 neighbours
10 Esters et al. (1998), • 40 high school students (13–17 years old, • Video Pupils’ scores on the opinions about
USA (Mississippi) mean: 14.7) • Information supplement mental illness rise
• Experimental group: 20 students 3 days
• Control group: 20 students
• Teachers
11 Bronwyn & Dale Grades 11 and 12 high school students • Role playing • Contact with mentally ill Impressions towards mental illness
(1993), Canada • No control group • Guided imagery 2h changed
12 Petchers et al. (1988), 102 high school students (mean age: 17 years) • Video Higher scores on knowledge and opinions
USA (Pittsburgh) • Experimental group: 46 students about mental health and illness

© 2010 Blackwell Publishing


Pinfold et al. 2003, Watson et al. 2004, Essler et al. 2006,
Stuart 2006; Spagnolo et al. 2008).
Nine of the studies had been published in journals on
mental health (Petchers et al. 1988, Bronwyn & Dale 1993,
Pinfold et al. 2003, Schulze et al. 2003, Rickwood et al.
2004, Watson et al. 2004, Essler et al. 2006, Stuart 2006;
Spagnolo et al. 2008), two in journals on adolescents
(Esters et al. 1998, Ng & Chan 2002) and one in a general
medical journal (Rahman et al. 1998). The publications
that met the criteria begin in the year 1988 (Petchers et al.
1988), with the most recent article having been published
in 2008 (Spagnolo et al. 2008) (Table 1).
Moreover, even though we included all the methodologi-
cal designs used in the publications, we did not find any
examples of qualitative studies that have been used. Most
of the studies conducted both a pre-test and a post-test
(n = 10), whereas the earlier studies (n = 2) conducted only
a post-test, which make them methodologically weak. The
timing of the tests was different in each study and was not
always clearly stated. Three of the studies conducted a
follow-up test as well (Table 2). Each study was unique and
no intervention was repeated.
Aims of the mental health educational interventions
The aims of each intervention were specified according to
their planned outcomes, but not always clearly stated. The
two main aims of the educational interventions were an
increase in the knowledge about mental health and a posi-
tive effect on attitudes towards mental illness. The studies
stated in particular that they aimed to change conceptions
about mental illness (Esters et al. 1998), to improve atti-
tudes about mental health problems (Rahman et al. 1998),
to change (negative) attitudes (Ng & Chan 2002, Watson
et al. 2004), to challenge negative stereotypes (Pinfold et al.
2003) and to promote positive attitudes towards people
with mental health problems (Essler et al. 2006). Others
stated as their aim reducing the stigma towards mental
illness (Schulze et al. 2003, Rickwood et al. 2004) or
decreasing stigmatizing attitudes (Spagnolo et al. 2008).
Furthermore, they aimed to increase the level of knowledge
about mental illness (Pinfold et al. 2003, Rickwood et al.
2004, Watson et al. 2004, Essler et al. 2006) or improve
awareness about mental health problems (Rahman et al.
1998).
The objective of Stuart’s study (2006) was to evaluate
the impact of the intervention. While the study did not
identify specific aims, it evaluated the impact of the inter-
vention by assessing knowledge, behavioural intentions
and social distance. Furthermore, Bronwyn & Dale (1993)
do not state the aim of their study either; however, they
claim that they discuss the impact of the education pro-
© 2010 Blackwell Publishing
School mental health education
gramme on stigma reduction and its role in the prevention
of mental illness. Finally, the earliest study (Petchers et al.
1988) does not clearly state its aim either, but the question-
naire used for the evaluation of the educational programme
focused on knowledge and opinions about mental health
and mental illness.
Additionally, two of the studies also aimed at the
improvement of help-seeking for mental health problems
(Esters et al. 1998, Rickwood et al. 2004), while the target
of one study was to promote participants’ mental health
(Schulze et al. 2003). Furthermore, another study also
aimed at raising awareness about mental health among
participants’ parents, friends and neighbours who did not
take part in the school mental health programme (Rahman
et al. 1998). However, the results of the latter aims will not
be presented in this paper, as they do not fit the inclusion
criteria of the current systematic literature review.
To summarize, the primary aim of the studies was to
measure the impact on attitudes or opinions towards
mental illness, stigma reduction and an increase in knowl-
edge about or awareness of mental health and illness.
Content of the mental health educational interventions
The interventions were, in general, only explained to a
limited extent. Half of the authors (n = 6) provided a brief
description of the mental health educational interventions.
However, researchers in the Pakistani intervention did not
provide information regarding the content of the educa-
tional intervention which was conducted (Rahman et al.
1998). On the other hand, researchers in the German inter-
vention (Schulze et al. 2003) provided all the content of the
intervention in detail, as did researchers in one of the US
studies (Watson et al. 2004).
Most of the educational interventions dealt with mental
health and illness issues by providing factual information
(e.g. signs, symptoms, causes) in order to provide partici-
pants with an understanding of the issues (Ng & Chan
2002, Pinfold et al. 2003, Schulze et al. 2003, Rickwood
et al. 2004, Watson et al. 2004, Essler et al. 2006, Stuart
2006; Spagnolo et al. 2008) as well as the biological, psy-
chological and social aspects of mental illness (Watson
et al. 2004), while one study reviewed psychiatric terminol-
ogy (Bronwyn & Dale 1993). Myths about schizophrenia
(Stuart 2006) or mental illness were also presented (Rick-
wood et al. 2004; Spagnolo et al. 2008) and misconcep-
tions about mental illness were clarified (Bronwyn & Dale
1993).
Furthermore, the stigma attached to mental illness was
explained (Esters et al. 1998, Rickwood et al. 2004, Stuart
2006, Spagnolo et al. 2008), challenged the use of stereo-
typical labels (Pinfold et al. 2003) and discussed strategies
169
E. Sakellari et al.
Table 2
Instrumentation and test timing
Instrument and author
1 Attribution Questionnaire-Short
Form for Children (Watson
et al. 2004)
2 Quiz (Mindout for Mental Health
activity pack for young people);
Department of Health (2001)
3 Questionnaire; World Psychiatric
Association
4 1. Knowledge Test
2. Attribution Questionnaire
(Corrigan et al. 2002) modified
for use with children
5 1. Two vignettes-social distance
questions Trute et al. (1989)
2. Knowledge questionnaire,
specially developed for this
study
6 Questionnaire; World Psychiatric
Association (WPA 1999)
7 Questionnaire; Specially developed
for this study, which included 4 items
from the WPA (1999) questionnaire
8 Opinions about Mental Illness in
Chinese Community (OMICC); Chu
et al. (1996)
9 Questionnaire; Specially designed
for this study
10 Opinions about Mental illness Scale;
Cohen & Struening (1962)
11 Feedback questionnaire
12 Questionnaire
WPA, World Psychiatric Association.
170
Content of instruments Test timing
• 6 items assessing negative attributions related to 2 groups:
stigma • pre and post (277 participants)
• 3 items evaluating positive feelings and behaviours • only post (149 participants)
towards the individual with mental illness described
in a vignette
• Knowledge of mental health problems • Pre
• Stereotypes of people with mental health problems • Post (1 month after the intervention)
• 12 items measuring knowledge of schizophrenia • Pre (n = 241, 8 schools)
• 7 items assessing social distance • Post (n = 330) immediately after the
• Post-test additional questions; how they found the final class discussion
video, if they would like to spend more time (except one school 3 weeks after the
learning about mental illnesses and open-ended video and class discussion)
comments to identify the programme’s key
messages
1. Five open-ended questions • Pre
2. Eight attitude items on responsibility/blame, anger, • Post
pity, help, dangerousness, fear, avoidance,
segregation
• 1 item added (Watson et al. 2004) on
help-seeking
1. Two vignettes describing a person who met the 4 groups;
DSM-IV criteria for schizophrenia or depression • groups 1 and 3: pre (in the week
• four social distance questions before the intervention) and post
2. Three multiple choice questions and eight (immediately after)
open-ended about knowledge of mental health • group 2: post (two weeks after being
and illness administered the pre-test)
• group 4: post
• 4 factual statements • Pre (at the start of the first session)
• 5 attitude statements • Post (1 week after attending the
• 4 social distance statements second session)
• an open-ended question asking for descriptions of • Follow-up: phase I schools (6
people with mental health problems (pre-test) months later)
• assessment ratings for the overall programme
(follow-up)
• stereotypes of schizophrenia (7 items) • Pre
• social distance (12 items >4 social distance items • Post (1 month after the end of the
from the WPA questionnaire) project week)
45 items • Pre (before the training programme
(6 factors: benevolence, separatism, stereotyping, started)
restrictiveness, pessimistic prediction and • Post (at the last session of the
stigmatization) training programme)
• Follow-up (7 months later)
19 items • Pre (before the school programme
• assess knowledge and attitudes towards the five began)
common mental-health disorders found in the • Post (4 months after the start of the
community (depression, epilepsy, psychoses, drug programme)
dependence and mental retardation)
• items on eyesight and smoking
51 items • Pre (1 day before the instructional
(5 factors; 3 analysed: authoritarianism, social unit)
restrictiveness, interpersonal aetiology) • Post (the last day)
• Follow-up (after 12 weeks)
• Only post
Focusing on knowledge and opinions about mental • Only post
health and mental illness
© 2010 Blackwell Publishing

for promoting positive and non-discriminatory attitudes
towards people with mental illness (Spagnolo et al. 2008).
Three of the educational interventions provided informa-
tion on sources of community mental health care (Esters
et al. 1998, Ng & Chan 2002; Spagnolo et al. 2008).
Additionally, two of the studies included issues related
to a positive sense of well-being (Pinfold et al. 2003) and
such issues as understanding what emotions are and
dealing with anger (Ng & Chan 2002). Other studies
included such issues as knowing about the pyramid of life
and identifying aims in life and the meaning of happiness
(Schulze et al. 2003), and even building self-esteem (Essler
et al. 2006), stages of recovery and treatment for mental
illness (Spagnolo et al. 2008) or the role of medications and
psychotherapy in effective treatment (Watson et al. 2004)
and overall wellness (Spagnolo et al. 2008). Describing the
experience of what it is like to have a mental health
problem was the subject of five interventions (Bronwyn &
Dale 1993, Pinfold et al. 2003, Schulze et al. 2003, Essler
et al. 2006; Spagnolo et al. 2008). The video-based pro-
gramme by Petchers et al. (1988) was concerned with
issues such as fear, anger, resentment, guilt, neglect, anxi-
eties about the future, and shame and embarrassment,
which are all basic emotions that an adolescent with a
mentally ill family member will deal with.
Facts and myths about mental illness were present in the
majority of the interventions. Well-being was the subject of
one of the studies. Several of the studies also focused on
experiencing mental illness. Finally, some of the interven-
tions also provided information on sources of community
mental health care.
Educational methods used in the mental
health interventions
The educational methods used in the interventions varied.
They combined several methods in order to fulfil their
aims. Some articles provided more information about the
mental health educational intervention than others, which
made comparison of the methods impossible.
An education/teaching session including discussion and
interactive activities formed part of the interventions,
although this was not always clearly stated. Three of the
interventions provided written material (Pinfold et al.
2003, Rickwood et al. 2004; Spagnolo et al. 2008). Apart
from discussion, other active methods included a poster-
painting competition (Rahman et al. 1998) or exhibitions
(Ng & Chan 2002) and art work (Schulze et al. 2003),
games (Schulze et al. 2003, Essler et al. 2006), group exer-
cises (Pinfold et al. 2003), drama, quiz and stickers (Essler
et al. 2006), questionnaires, answer sheets, overhead tem-
plates (Stuart 2006), short plays and skits (Rahman et al.
© 2010 Blackwell Publishing
School mental health education
1998), and role playing (Bronwyn & Dale 1993, Stuart
2006), as well as guided imagery (Bronwyn & Dale 1993)
and web-based activities, such as scenarios, simulations,
animations and videos (Watson et al. 2004).
Moreover, four of the studies included a video presen-
tation (Petchers et al. 1988, Esters et al. 1998, Pinfold
et al. 2003, Stuart 2006). The video included in the inter-
vention in Canada introduced the signs and symptoms of
schizophrenia (Stuart 2006), while the one used in the
interventions in the UK was about people living with
schizophrenia and depression (Pinfold et al. 2003). The
content of the video used in the intervention in the USA
was not described in the article (Esters et al. 1998). The
earlier study (Petchers et al. 1988) presents teenagers
talking about mental illness in their families, including the
emotions that they felt; these emotions included fear,
anger, resentment, guilt, neglect, anxieties about the
future, shame and embarrassment.
In addition, four of the interventions included personal
contact with mentally ill persons (Bronwyn & Dale 1993,
Ng & Chan 2002, Pinfold et al. 2003, Schulze et al. 2003,
Spagnolo et al. 2008). The Canadian study (Bronwyn &
Dale 1993) included an interview in which participants
asked the mentally ill person questions and another men-
tally ill person talked about his or her personal experiences.
The participants in the intervention in Hong Kong were
asked to visit patients in mental hospitals. Arrangements
were made for the participants to meet patients for indi-
vidual discussions in the day-patient ward of two mental
hospitals (Ng & Chan 2002). In phase II of the UK study,
contact was established with a person who had personal
experience living with mental health problems (Pinfold
et al. 2003). In the German education intervention, a
young person with schizophrenia introduced himself
or herself and discussed his or her experiences with the
participants. This discussion included information on the
illness, available treatments and his or her experiences with
being stigmatized (Schulze et al. 2003). In the most recent
study (Spagnolo et al. 2008), mentally ill persons presented
their personal stories.
In addition to presenting several issues on mental health
and mental illness, the educational interventions also con-
sisted of various active methods for the participation of the
pupils. Video presentation was also one of the methods of
stimulation used in the studies.
Finally, the length of the different educational interven-
tions varied (Table 1). There were several very short inter-
ventions, lasting 50–90 min (Rickwood et al. 2004) or
60–90 min (Spagnolo et al. 2008), while the longest inter-
vention one implemented, which was implemented in
Pakistan, lasted 4 months (Rahman et al. 1998). In addi-
tion, regarding the time issue, two of the interventions did
171
E. Sakellari et al.

not clearly state the duration of the education, only that tions is that they have a positive impact on knowledge
they included two phases (Essler et al. 2006) or two lessons about mental health and mental illness, as well as on atti-
(Stuart 2006), while one study (Petchers et al. 1988) tudes towards mental illness. The earliest studies (Petchers
said nothing at all about the duration of the educational et al. 1988, Bronwyn & Dale 1993) report their findings in
programme. a narrative way, which does not make further analysis easy;
however, they also support the impact of the educational
Instrumentation (Table 2) interventions.
In particular, scores testing participants on their knowl-
In the studies on mental health education, researchers used
edge of mental health problems improved after the inter-
several instruments in order to evaluate the impact of each
vention (P = 0.015) in the study by Essler et al. (2006).
intervention. The instruments used in a study should be
Rickwood et al. (2004) also reported a strong impact on
reliable and valid in order to assess the quality of the study.
knowledge about mental health and mental illness. The
Unfortunately, this was not always the case in the studies
study by Pinfold et al. (2003) showed a positive impact on
that we reviewed.
mental health literacy, where 1% of the participants pro-
All of the studies used structured questionnaires; in
vided correct ratings before the intervention compared
addition, four of the studies used open-ended questions
with 24% on the post-test. Rahman et al. (1998) found a
(Pinfold et al. 2003, Rickwood et al. 2004, Watson et al.
significant change in pupils’ awareness of mental health
2004, Stuart 2006). Furthermore, two of the studies used
issues, reporting that the scores for 13 of the 16 items on
two questionnaires each, one of which was about seeking
mental health had improved up to at least 90%. Partici-
help for mental health problems (Esters et al. 1998, Rick-
pants in the study in Canada (Stuart 2006) were signifi-
wood et al. 2004). One study (Watson et al. 2004) added
cantly more knowledgeable about schizophrenia, with an
an item concerning help-seeking. The questionnaires used
improvement of 78.8% (n = 260) compared with 47.7% (n
were either developed for the current study (Rahman et al.
= 114) at the baseline measurement (P < 0.001). A signifi-
1998, Schulze et al. 2003, Rickwood et al. 2004) or exist-
cant improvement (P = 0.000) in knowledge about mental
ing instruments (Esters et al. 1998, Pinfold et al. 2003,
illness was also found by Watson et al. (2004). Finally,
Rickwood et al. 2004, Watson et al. 2004, Essler et al.
Petchers et al. (1988) found a significant difference between
2006, Stuart 2006, Spagnolo et al. 2008), while the two
the experimental and control group by using a question-
earlier studies did not provide specific information (Petch-
naire on knowledge and opinions about mental health and
ers et al. 1988, Bronwyn & Dale 1993). Finally, one study
mental illness; the mean score for the experimental group
(Rickwood et al. 2004) also used two vignettes. As it can be
was 74.77 (with 100 representing a perfect score), whereas
seen by the brief presentation in Table 2, which lists the
for the control group it was 63.81 (P < 0.001). Addition-
instruments used to measure the outcomes of the interven-
ally, Petchers et al. (1988) claim that the results of their
tions, there are questionnaires used by more than one study
study demonstrate a significant short-term impact on
and the majority of the researchers (n = 8) preferred to use
knowledge; however, the participants indicated that the
a tested tool. While most of the authors mentioned in their
videotape used did not provide sufficient detail about
articles, the instruments they had used, the earlier studies
mental illness and the ways in which families coped with
failed to do so. One study (Bronwyn & Dale 1993) pro-
the situation.
vided no further information about the questionnaire used,
In the study by Essler et al. (2006), scores testing par-
and another one (Petchers et al. 1988) stated that the ques-
ticipants’ attitudes towards people with mental health
tionnaire focused on knowledge and opinions about mental
problems improved during the study period (P = 0.015),
health and mental illness.
and Pinfold et al. (2003) reported that the mean score for
Questionnaires were used to illustrate the outcomes of
positive attitudes towards mentally ill people rose from
the presentation. Most of the studies used instruments
1.2 to 2.8 after the intervention (P < 0.0001). Watson et al.
which had been used previously; they had thus been tested
(2004) found that summary negative attitude scores
before and could provide reliable results. The items
decreased significantly from 22.57 to 21.99 (P = 0.005). In
included issues on knowledge about mental health and
addition, the results of the study by Spagnolo et al. (2008)
illness, stigmatization, stereotypes, behaviours, opinions
indicate that the attitudes of adolescents towards people
and attitudes.
with mental illness were significantly affected (P ⱕ 0.000).
Furthermore, Esters et al. (1998) found a statistically dis-
Outcomes of mental health educational interventions
cernible difference concerning opinions about mental
According to the findings of the 12 studies, the overall view illness, where the pupils’ scores rose after the intervention,
of the impact of the mental health educational interven- and the results of the study by Petchers et al. (1988)

172 © 2010 Blackwell Publishing


demonstrate a significant short-term impact on the partici-
pants’ opinions.
Moreover, studies indicated improvements in stigmati-
zation. Rickwood et al. (2004) found that the experimental
group had lower mean stigma scores on the post-test than
the control group, which show a moderate effect size, as
indicated by a partial eta squared of 6.7%. In addition, Ng
& Chan (2002) found significant differences (P < 0.001)
between the two groups in stigmatization factor of the
OMICC scale with mean scores of 4.88 for the experimen-
tal group and 5.72 for the control group (the lower score
means more disagreement with stigmatization). Schulze
et al. (2003) showed positive effects on dispelling negative
stereotypes (P = 0.01) within the experimental group,
whereas they estimated changes in stereotypes over time to
be negative in the control group. In order to present stigma
reduction, Bronwyn & Dale (1993) provide representative
comments from the participants’ questionnaires, which
reflect their changing impressions of mental illness. In the
same way, participants felt that the intervention created an
awareness of the stigma of mental illness, provided new
information and new thinking was stimulated (Petchers
et al. 1988).
Furthermore, participants were less socially distanced
after the intervention. In the study by Stuart (2006), scores
improved to 52.1% (n = 169) compared with 41.5% (n =
100) during the pre-test (P = 0.02). Changes in social
distance were also reported in the study by Pinfold et al.
(2003), which stated that the cumulative proportion of
pupils expressing no social distance across four items
changed marginally, from 8% (n = 421) before the interven-
tion to 13% (n = 434) after the intervention. In the study by
Schulze et al. (2003) feelings of social distance decreased
to the point not being statistically significant (P = 0.11)
between the experimental and the control group. The results
in the study by Ng & Chan (2002) described significant
differences in the post-test totals of the separatism factor (P
< 0.005), while there was no reinforcement of benevolence.
Finally, Bronwyn & Dale (1993) claim that, although it is
difficult to demonstrate that education can prevent mental
illness, their programme facilitated early identification and
intervention because participants received accurate infor-
mation which will be useful in the future and that, having
confronted their negative stereotypes, they might be encour-
aged to confront and deal with their personal problems.
To summarize, the outcomes of the studies measured by
several instruments and, thus, presented differently showed
a positive impact regarding the increase of knowledge
about mental health and mental illness, and also showed
that stigmatization and opinions or attitudes towards
mental illness improved as a result of the mental health
educational interventions.
© 2010 Blackwell Publishing
School mental health education
Discussion
The EU Green paper on mental health proposes establish-
ing a strategy on mental health. Among other things, it
stresses the promotion of mental health as high priority and
tackling stigmatization of and discrimination against
people with mental health problems as policy objectives
(European Commission 2005). In addition, the European
Pact for Mental Health and Well-being (2008) includes the
mental health of young people, education and combating
stigma and social exclusion as key priorities for mental
health. Moreover, one of the WHO’s most important
recommendations for the development of mental health
policies and the organization of such policies is the dein-
stitutionalization of mental health care (WHO 2009).
Therefore, attitudes towards mentally ill people should be
positive to promote their social inclusion. Furthermore, the
Mental Health Declaration and Action Plan for Europe
(WHO 2005b) encourages the WHO’s European Member
States to address the challenges posed by stigmatization of,
and discrimination against, people with mental health
problems. In addition, the WHO has developed a mental
health policy and service guidance package, which also
includes a focus on child and adolescent mental health
(WHO 2005c).
Despite the aforementioned efforts to define areas of
action, the current systematic literature review demon-
strates that there have not been many studies conducted
among adolescents on efforts to raise awareness about
mental health issues. Hence, there is a gap that should be
filled by future interventions in order to share information
and expertise on effective practice development.
This systematic review included studies from three data-
bases. Twelve studies satisfied the inclusion criteria for
this review. However, following a systematic approach, we
focused primarily on finding and presenting educational
interventions regarding mental illness among secondary
education pupils. The research methods as well as the
inclusion criteria have been described in this paper. We
conducted the systematic literature review by focusing on a
very limited, specific topic in order to identify the educa-
tional interventions implemented among adolescents, and
it can be concluded that it is not a popular subject. Thus,
the 12 studies included here illustrate only the specific
research questions addressed in this review.
Overall, research on mental health educational interven-
tions is very limited worldwide. In general, among studies
on health educational interventions, mental health has not
been emphasized. There have been studies exploring atti-
tudes towards mentally ill people and mental illness or the
knowledge and understanding of mental health and illness
among young people (e.g. Weiss 1986, Shek 1990, Spitzer
173
E. Sakellari et al.
& Cameron 1995, Chu et al. 1996, Adler & Wahl 1998;
Secker et al. 1999; Ng & Chan 2000, Dogra et al. 2005,
Schulze 2005). However, research on the effectiveness of
educational interventions among secondary school pupils
has not been widely developed. The studies identified in
this review were conducted in various countries throughout
the world; the use of different methodologies although it
provides results, which can be used in the future, cannot
provide results for generalization. Only one study included
a large number of participants.
Furthermore, the studies were not always reported in a
very detailed manner. For example, they did not always
provide the information needed for fully answering the
research questions set out at the beginning. More recent
publications presented their studies better in contrast to
earlier ones, which provided a brief description of the study
without supporting their findings.
The challenge will be to identify promising mental
health educational interventions based on the research
findings. Hence, not only should properly designed studies
be implemented, but the same interventions and method-
ology should also be followed in order to be able to make
generalizations based on the results and, thus, achieve
effective mental health educational practices.
The instruments used in the studies were not the always
the same, which makes comparison of the results difficult
and general conclusions are not possible. It can be indi-
cated, however, that all studies resulted in positive changes;
for example, they resulted in positive changes in the aware-
ness, knowledge and attitudes towards mental illness, stig-
matization and social distance among secondary school
pupils. Concerning the outcomes, it can be said that some
studies reported their results very well and clearly, while
others did not. However, no negative results were found.
This means that all of the educational interventions had
positive attributes. Therefore, mental health education pro-
vides positive outcomes.
The results of this systematic review suggest that mental
health education can be a form of an intervention which
may influence the knowledge and attitudes that secondary
school pupils have about mental health and illness. Even
though the studies reported positive outcomes the tests
scores after the mental health educational interventions
were still not as high as they could have been. As the
evidence base for mental health promotion needs strength-
ening, better-reported studies, which evaluate the effec-
tiveness of mental health educational interventions, may
provide more conclusions that can be shared in order to
encourage further effective development and implementa-
tion of such interventions. In other words, dissemination of
the knowledge obtained from studies has important future
implications.
174
Special consideration should be given to appropriate
mental health interventions by mental health professionals
working in the community and to adequately implementing
programmes that promote mental health. Nurses need to
invest in mental health educational interventions for pro-
moting mental health in society. The educational interven-
tions can be expanded to several implementations in
secondary education. Since this review included a wide
range of different types of educational intervention
methods, a reliable representation of the most effective
method is difficult to provide.
In conclusion, it is clear that further research should be
conducted. This is particularly important due to the fact
that there will be a growing number of mental health
problems in the future. According to the estimates by the
WHO (2005a) 15% of the total disease burden worldwide
will be attributed to mental and behavioural disorders by
the year 2020. The studies under consideration have pro-
duced encouraging results with regard to increasing ado-
lescents’ knowledge about mental health and illness and
reducing their negative attitudes towards people with
mental health problems. However, there is a need for
implementing the same educational interventions, in addi-
tion to using the same standardized evaluation instrument
in order to obtain comparable results and draw conclusions
that would have future implications for mental health pro-
motion and investment in mental health policies.
Integrating mental health aspects within all health pro-
motion programmes has been a key priority emphasized by
the report on the Framework for Promoting Mental Health
in Europe, as well as including the topic of mental health in
school health education (Lahtinen et al. 1999). Therefore,
mental health within the context of school health interven-
tions is an issue that nurses should be concerned with, as
adolescents will soon become active members of the adult
community who, through participation, can have an
impact on the whole community. School health interven-
tions aiming at promoting health will play an essential role
in mental health as well, and the attitudes which school
pupils have towards people with mental health problems
will influence the quality of their lives and community
health in general. Thus, nurses should implement mental
health promotion interventions aimed at reducing or pre-
venting negative attitudes linked to mental illness, because
the better the adolescents are educated, the healthier the
community will be.
Limitations
This systematic review revealed 12 studies that dealt with a
specific population, that is, adolescents. If the age range
had been broader or if the review had not only focused on
© 2010 Blackwell Publishing

secondary education, but on primary and tertiary educa-
tion as well, more studies would thus have been found.
However, the target population of this systematic review
was adolescents because they are at a critical stage of
human development and will soon help shape communities
of the future. Furthermore, four of the included studies are
quite old and the extent to which their findings can be
generalized in practice today might be questioned.
The analysis of the methods used for the interventions
was difficult since not all the studies provided a detailed
description. Nonetheless, we have presented the informa-
tion as it was given, even though it cannot be compared.
Thus, due to the different methodologies used in each study,
it was not possible to make a comparative analysis and draw
conclusions about the most effective intervention. However,
this review highlights the lack of mental health education
interventions among adolescents and the need for an evalu-
ation of the same intervention in order to produce findings
which will guide future practice on an essential topic such as
this. Moreover, the absence of a universal instrument used in
the studies makes it difficult to interpret and compare the
study findings. Nevertheless, this systematic review provides
a description of previous studies which can aid future
researchers with the development of a properly designed
study to be implemented in several places, as the lack of
studies points out that for such interventions.
Although positive outcomes were found in the current
studies, it might be possible that negative impact was not
reported or that studies which showed negative results
were never published. However, the use of different instru-
ments, in addition to the different methods used for the
interventions, does not enable us to suggest clear implica-
tions for mental health nursing practice.
Acknowledgments
The authors wish to thank the South-Western Hospital
District of Finland for the financial support for this study.
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