BOTI Report Better Out Than In 2017

beyondblue & AFLPA

Australian Football League Players’ Association

Address: Level 2, 170 Bridport Street, Albert Park, Melbourne, Victoria 3206

1 Acknowledgements Better Out Than In 2017

ACKNOWLEDGEMENTS

On behalf of the lead agency, the AFL Players’ Association, I would like to express my sincere appreciation and thanks to all who assisted in the Better Out Than In Project. First and foremost, I would like to express my gratitude to beyondblue, particularly Andrew Thorp, for the opportunity and support that was critical in bringing this project to life. I would like to extend a special thank you to Brent Hedley who managed and oversaw the majority of the project with proficiency and innovation. Paul O’Halloran, our Latrobe University research partner, whose tireless effort, support and passion delivered across the project and report was remarkable. Scott Ruddock and Mandy Ruddock- Hudson, also part of the research team, worked to an extremely high standard. John Brady (Operations Manager) and Jorgen Gullestrup (CEO) of our industry project partner Mates In Construction provided an expansive skillset to connect with our target audience, ensuring that we applied language that would influence and inform. Mates In Construction have trained over 70,000 workers nationally in suicide prevention and stigma reduction for depression and mental illness. Mark Brayshaw, CEO AFL Coaches Association, gave a wealth of insight and access to AFL coaches. These coaches are connected to men who may be viewed as role models or leaders in society, and engaging these men provided an invaluable opportunity to create awareness and shift the norms in communities of men. Thanks and appreciation must also go to my colleagues at the AFL Players’ Association. Brad Fisher’s guidance, willingness to assist and encouragement as the Past Player Alumni manager was second to none. Brett Johnson’s support and input to the project was much valued, as was Rebecca Chitty’s commercial acumen and extensive experience in strategic communications. Bonnie Berridge and Deirdre Ryan, who have worked with our research partner to produce this report, brought essential academic rigour and experience. Special mention to Jo Mitchell, who led the STRIDE project funding application and stigma research. Your expansive knowledge of and expertise in the mental health sector provided the project team with a well-equipped road map.

2 Acknowledgements Better Out Than In 2017

ACKNOWLEDGEMENTS

The Construction Forest Mining and Energy Union provided us with great insight and access to their union members. Cummins and Partners executed an innovative digital strategy after picking up the reins from an earlier digital agency. They provided us with great collateral with utmost professionalism. The abilities and creative flair of Adrian Brown and Kirsty Brown at Whooska Media to understand the core aims of the project, as well as the look, feel and tone, enabled us to produce powerful and inspiring stories. Last, and certainly not least, a huge thank you to the brave young people who shared their story with us. It’s the story sharers and listeners, those who want to make a change, who inspire change. Those who undertook the surveys may, at times, have been uncomfortable or challenged, but the result is that together we are working towards creating a culture that fosters openness, acceptance and hope, and for this, we are grateful.

James Polkinghorne - AFLPA

3 Overview Better Out Than In 2017

OVERVIEW

An overview of beyondblue’s STRIDE Initiative. Following an open, competitive process, beyondblue with donations from the Movember Foundation, commissioned six action research partnerships to answer a key question: “Can digital interventions, implemented at a local population level, promote change across the knowledge, attitudinal and/or behavioural components of stigma experienced and/or exhibited by men aged 30 to 64 years?”.

The partnerships were all required to involve multiple perspectives – local community, academics, evaluators and designers – each contributing to an integrated innovative digital project. The Stigma Reduction Interventions: Digital Environments (STRIDE) Initiative investigated the ‘real world’ effectiveness of evidence-informed interventions and prioritised research partnerships between the community and academics.

The six commissioned projects were: • Better Out Than In, led by the AFL Players’ Association • Contact+Connect, led by Incolink • Out of the Blue: Pete & Dale, led by VAC • Tell Your Story, led by UNSW Refugee Trauma & Recovery Program • The Ripple Effect, led by National Centre for Farmer Health • Y Fronts, led by CGA Consulting

beyondblue received results of the six projects in mid-2017. These results provided us with insights into how to best use digital channels to promote behaviour change in men in their middle years so they report less stigma around mental health and/or suicide. More information on the STRIDE Initiative, including detailed results of the research, is available at: beyondblue.org.au/stigma. The STRIDE Initiative is a beyondblue project funded with donations from the Movember Foundation.

4 Executive Summary Better Out Than In 2017

EXECUTIVE SUMMARY

The Better Out Than In campaign, was a digital campaign directed towards men where masculine ideologies prevail: Construction workers; AFL past players and AFL coaches.

The Better Out Than In campaign aimed to reframe the conversation of men’s depression from one of shame, stigma, and secrecy to one of openness, acceptance and hope by focusing on changing both attitude and behaviour. Better Out Than In was a joint initiative between AFL Players’ Association, LaTrobe University, AFL Coaches Association and Mates In Construction.

Better Out Than In released ten digital stories, delivered in the format of ‘mini-campaigns’, featuring a diverse range of past and present AFL players, coaches and construction workers. The integrated, online digital campaign aimed to reframe the conversation about mens depression from one of shame, stigma and secrecy to one of openness, acceptance and hope. Additionally, the project was based on the premise that sharing and hearing real-life stories about depression and seeking help for depression is one of the most powerful ways of reducing self and personal stigma.

The digital stories were home to various perspectives, demographics, experience and people and at the core of the video was messaging to change the conversation of depression and anxiety. More than 1000 men from the three communities of interest and a mining comparison group were recruited to evaluate the effectiveness of the depression stigma reduction campaign via an online survey. This contained attitudinal measures of self-stigma, personal stigma, intentions of seeking help and actual self-reports of behaviour pertaining to men offering help to others.

5 Executive Summary Better Out Than In 2017

EXECUTIVE SUMMARY

More than 1000 men from three communities & a mining comparison group were recruited. Analysis revealed solid online engagement with the Better Out Than In campaign.

One of the strongest elements of our campaign has been in There were positive communications which has driven very significant attention shifts on stigma towards our campaign. We are pleased to report that an estimated for those that audience of 1.7 million viewers engaged with project related media engaged with the communications. Better Out Than In website. 50% of Video Views: men reported ‘doing • The video engagement was strong, with over 384 hours of story it tough’ over the content viewed, with an average of 01min:25sec session duration. last month.

• More than 40,000 Better Out Than In video views (combined Facebook, website, YouTube)

6 Table of Contents Better Out Than In 2017

CONTENTS

Acknowledgements Executive Summary 5 Table Of Contents 7 1. Introduction 8 2. Project governance 15 2.1 The Better Out Than In Campaign: Rationale, Design and Description 16 Stigma Reduction Rationale for Better Out Than In Campaign Research Objectives Communities of Interest 2.2 Participatory Design 22 3. The Intervention 24 3.1 Description and Delivery of Better Out Than In Campaign 3.2 Digital Technologies 3.3 Web Design 4. Marketing and Promotion 36 4.1 Potential impact campaign 5. Evaluation 44 5.1 Overview of methodology Research Design Description of stigma measures on the online survey 6. Results 49 6.1 Phase One - Baseline Report 6.2 Phase Two - Follow-up one Report 6.3 Phase Three - Follow up two 6.4 Key Findings 154 7. Discussion 157 7.1 Objective One 7.3 Objective Three 7.4 Objective Four 7.5 Objective Five 7.6 Objective Six 7.7 Key learning’s 8. Conclusion 180 Bibliography and References 182 APPENDICES 189 Appendix One: Media Coverage Appendix Two: Activity Schedule Appendix Three: Background Information Appendix Four: SSDS-DSS Item Percentages

7 1. Introduction Better Out Than In 2017 1. INTRODUCTION

8 1. Introduction Better Out Than In 2017

1.1 BACKGROUND INFORMATION

Existing Interventions Aimed at Engaging Men in Help Seeking and Reducing Stigma

A range of programs and interventions aimed at reducing stigma and increasing access to support for depression in males have been developed in the last number of years. Griffiths, Carron-Arthur, Parsons, and Reid (2014), explored the impact of programs aimed at reducing personal or self-stigma (See Appendix three for further information on stigma). The findings from their study suggested that in addition to delivering broad-based programs to reduce personal stigma, there is potential value in targeting and tailoring programs to reduce personal stigma among men, older people, and those with lower educational levels and those born overseas.

They also suggested that further attention should be paid to developing interventions with a focus of destigmatisation and mental health literacy aimed at individuals with potential symptoms of early psychological distress. Their study determined that perceived stigma is high both in individuals with depression and the general public, which may impact on help seeking. Hence, it is suggested that interventions at all levels (national and clinically targeted) should be designed to reduce perceived stigma (Griffiths, Carron-Arthur, Parsons, & Reid, 2014).

9 1. Introduction Better Out Than In 2017

1.1 BACKGROUND INFORMATION

A recent large scale Australian study evaluated a workplace- based suicide prevention and early intervention program (Gullestrup, Lequertier, & Martin, 2011). The program was delivered to more than 9000 construction workers on building sites across Queensland. The intervention was developed to include universal ‘General Awareness Training (GAT)’; general mental health training with a focus on suicide prevention; gatekeeper training provided to construction worker volunteers; Suicide First Aid training offered to key workers; outreach support provided by trained and supervised staff; a state- wide suicide prevention hotline; case management service; and postvention support provided in the event of a suicide.

An evaluation into the effectiveness of the program demonstrated that the program improved attitudes to suicide prevention and knowledge in both GAT and gatekeeper training participants. It was also determined that employees regularly utilised the after- hours crisis support phone line and case management service. The authors of the study concluded that there is currently a poor body of research into exploring evidence for the effectiveness of workplace anti-stigma interventions in improving help seeking in those with mental helath difficulties, particularly in the case of Mental Health First Aid. More research in this area is needed to identify effective interventions, which will improve outcome and uptake of the range of professional services available (Reavley & Jorm, 2014).

More research in this area is needed to identify effective interventions, which will improve outcome and uptake of the range of professional services available (Reavley & Jorm, 2014). The study also highlighted an important opportunity to utilise the workplace as a potential forum to introduce interventions targeting people with mental health difficulties in a large-scale way. In recent years, many work places are introducing mental health promotion programs and identifying this as an important area of investment and preventative care.

10 1. Introduction Better Out Than In 2017

1.1 BACKGROUND INFORMATION

An increase in empirical studies evaluating the effectiveness of such programs would be beneficial in increased implementation. Increasing awareness, particularly in management, of the importance of reducing stigma is essential to the implementation of such initiatives.

A recent systematic review and meta-analysis of 27 relevant papers was undertaken to investigate the effectiveness of existing programs targeting depression in males. Of the 27 papers studied they found that interventions targeting personal stigma or social distance yielded significant reductions in stigma for depression. Educational interventions were also effective in reducing personal stigma as were interventions incorporating consumer contact. They also found that internet programs were at least as effective in reducing personal stigma as face-to-face delivery. The study concluded that there was an evidence base to inform the roll out of programs for improving personal stigma among male members of the community (Griffiths, Carron-Arthur, Parsons, & Reid, 2014). (For further literature on depression in males refer to Appendix three).

In regards to virtual web-based and internet services and supports, these provide an important access point for mental health resources to enable men to be adopt a self-directed approach to accessing relevant information and providing a potential gateway to treatment. It also allows the individual to explore treatment options whilst maintaining anonymity. In recent years several online programs targeted at supporting individuals with depression have been developed. These programs include the Australian-based site called the MoodGYM (Calear, Christensen, Mackinnon, Griffiths, & O’Kearney, 2009). MoodGYM is an online self-directed program, which adopts a Cognitive Behavioural Therapy approach to reducing and preventing depression in young people.

11 1. Introduction Better Out Than In 2017

1.1 BACKGROUND INFORMATION

The program includes five modules, a workbook and a range of interactive tools, which includes an online game. The aim of the program is to increase the individuals self-enquiry and for them to gain a deeper understanding of their inner experience. This is assisted through the use of self-report questionnaires on depression and anxiety as well as improving awareness into the persons triggers for unhelpful feelings and patterns of behaviour, including, parental and peer relationships.

The program adopts a primary and secondary prevention model and aims to support the individual with strategies to identifying and reducing depressive symptoms. A randomised control study evaluating the effectiveness of MoodGYM on a university sample demonstrated that in comparison to a control group, participants completing the MoodGYM program had significantly decreased scores on measures of anxiety, distress and frequency of automatic negative thoughts (Calear et al, 2009).

Another Australian based program is a website developed by, the not-for-profit national Australian depression initiative, ‘beyondblue’. The program named ‘Man Therapy’ is aimed at males with mental health difficulties. This online resource provides a range of depression self-help resources, videos and access points for men experiencing a mental health condition. It also includes mental health ‘quizzes’ and utilises a user-friendly site appealing to stereotypical male representations of masculinity.

An evaluation into the effectiveness of the campaign determined that users of the website largely indicated that they found the resource useful. They reported that eighty per cent of all participants in the survey indicated that the website provided information that was useful to them, and fifty five per cent felt that the information on the website was new to them. The impact of the website on visitors’ behaviour determined that participants were more likely to discuss their experiences with others (either friends and family or health professionals), or to search for further information.

12 1. Introduction Better Out Than In 2017

1.1 BACKGROUND INFORMATION

The study also found that in the fortnight following their visit to the website: thirty six per cent had spoken to family or friends, twenty nine per cent had visited a GP, twenty three per cent had visited a psychologist or psychiatrist and twenty one per cent had looked for further information (Hall, 2012).

A similar digital campaign introduced in America was that of the ‘Real Men, Real Depression’ (RMRD) campaign developed by National Institute of Mental Health [NIMH]. This site followed the experiences of five men who suffered depression and chronicled their respective journeys from identification, help seeking and treatment. The site highlighted the relationship between traditional masculine ideals and mental health, and included audios from males with a range of different backgrounds, including; a policeman, an air force sergeant and a diving champion.

The aim of the site was to emphasise the strength of character it takes to seek help and reduce public stigma and attitudes towards help seeking in males with depression (Rochlen, Whilde & Hoyer, 2005). (For further literature related to depression and stigma in males please refer to Appendix three).

With the aforementioned literature and interventions taken into consideration the present project aimed to build on previous research and contribute to an important area in need of exploration.

13 1. Introduction Better Out Than In 2017

1.1 BACKGROUND INFORMATION

beyondblue Project Partners

beyondblue, aimed to invest in an integrated innovative project which included the development, acceptance testing and trial of digital interventions that had, as one of their central and explicit aims, the reduction of stigma associated with anxiety, depression and/or suicide amongst Australian men aged 30 to 64 years. The successful action research partnerships were advised to demonstrate whether digital platforms realise their proposed potential in achieving stigma reduction goals. The hope was that the results would provide insights into the most effective ways of utilising digital media/platforms in engaging men in stigma reduction interventions as has been described by previous studies above.

With the utility and benefits of previous digital interventions in mind (see above literature), beyondblue aimed to invest in a new intervention that focused on stigma reduction explicitly. This digital intervention was to include, websites, mobile applications and social media initiatives with a focus on the stigma associated with anxiety, depression and/or suicide in a specific community of men (see Appendix three for further background literature).

Taking the direction from beyondblue and previous literature into consideration, the key question guiding the current project was ‘Can digital interventions, implemented at a local population level, prompt change across the knowledge, attitudinal and behavioural components of stigma experienced and/or exhibited by men aged 30 to 64 years?’

14 2. Project Governance Better Out Than In 2017 2. PROJECT GOVERNANCE

15 2. Project Governance Better Out Than In 2017

2.1 THE BETTER OUT THAN IN CAMPAIGN: RATIONALE, DESIGN AND DESCRIPTION

Stigma Reduction Rationale for Better Out Than In Campaign

The extant stigma reduction research formed the basis for the design of all components of the Better Out Than In campaign. This research-included findings pertaining to masculinity and how this impacts on help seeking behaviour (Addis & Mahalik, 2003), principles of effective stigma reducing social marketing campaigns (Corrigan, 2011), and reviews of community and population based stigma reduction interventions (Corrigan et al., 2012; Reavley & Jorm, 2013). The overall design and methodology of the Better Out Than In campaign was guided by several core principles that were directly derived from the stigma research. These principles are as follows: (i) The concept of masculinity is paramount in the overall design of the project; (ii) The overall design ought to align with best practice guidelines for effective social marketing campaigns to reduce stigma and quality evidence from systematic reviews of effective stigma reduction campaigns; and (iii) The methodology ought to address core identified gaps in the extant stigma reduction research.

(i) The concept of masculinity is paramount to the Better Out Than In campaign. As previously highlighted, the adoption of masculinity norms and stereotypes has the potential to negatively impact on stigma related to depression. For instance, many men internalise a belief that they should avoid emotional expression, be tough and avoid asking for help (Addis & Mahalik, 2003). These types of masculinity ideologies place men at greater risk of depression (Courtenay, 2003) and is thought to underlie the well documented finding that men are less likely to seek help when experiencing mental health problems such as depression (see Addis & Mahalik, 2003). Given the potential impact of this negative side of masculinity on both self and personal stigma related to depression, the concept of masculinity influenced both the choice of the targeted communities and the design of the intervention.

16 2. Project Governance Better Out Than In 2017

2.1 THE BETTER OUT THAN IN CAMPAIGN: RATIONALE, DESIGN AND DESCRIPTION

The choice of the targeted communities was influenced by two core considerations. Men in all three communities are likely to be experiencing transitions, which place them at risk of mental health problems like depression. The second is that these men all come from communities where being masculine typically implies being tough, competitive, emotionally contained (other than ‘appropriate’ expressions of anger) and where seeking help is a sign of weakness. For instance, Tim Corney, in a 2011 project regarding help seeking behaviours in apprentices and young workers in the construction industry, noted that beliefs males should be self-reliant and where it was not considered masculine to seek help, were identified as major barriers to seeking help for depression in younger workers in the industry. It is likely that such beliefs are also prevalent amongst older workers (i.e. those aged 30-64). Masculinity is also a major issue in sport, particularly all male impact sports such as Australian Rules Football. As noted by Addis and Mahalik (2003), male athletes are rewarded for being stoic and tough and not expressing physical pain in the face of physical injury, which is likely to impact on willingness to seek help for mental health problems. Whilst negative constructions of masculinity in these populations suggest that they are ideal target communities for stigma reduction campaigns, they have the potential to impact on project outcomes through the willingness of participants to engage in the project. These considerations were core to the design of the present methodology in several ways. First the focus of the intervention draws on the desire to be masculine by changing the narrative about seeking help and talking about problems and depression from a sign of vulnerability and weakness to a sign of strength. This is achieved via a combination of high profile past AFL footballers and coaches and construction workers sharing their stories of when they talked about their problems with others, sought help for their condition, and/or discussed how they helped others with depression. An emphasis on building trust in these communities is also designed to counter against potential negative impacts of masculinity on participation in the program.

17 2. Project Governance Better Out Than In 2017

2.1 THE BETTER OUT THAN IN CAMPAIGN: RATIONALE, DESIGN AND DESCRIPTION

(ii) The overall design of the Better Out Than In campaign aligns with best practice guidelines. Best practice guidelines, based on 10 years of work from the National Consortium on Stigma and Empowerment, a research group working to promote recovery by understanding stigma and promoting empowerment, recommend that social marketing campaigns adhere to five principles to reduce stigma associated with mental health conditions such as depression (Corrigan, 2011). Stigma change in adults is more likely to derive from interventions that emphasise contact with people who have or had a mental health condition rather than education (Corrigan et al., 2012). Integral to this project is people sharing their experiences of depression. Whilst sharing of experiences in a digital format are not as powerful as real life contact they have the capacity to reach greater numbers are have been demonstrated to be effective (Corrigan et al., 2012). The focus on stigma related to depression was based on evidence that focusing on a single specific condition is more effective than programs focused on numerous conditions or mental health generally (Reavley & Jorm, 2013) and that almost one-quarter of surveyed Australians report they would not tell anyone if they had depression (Reavley & Jorm, 2012). In line with the principle of using contacts that are credible, Better Out Than In involved credible leaders in these communities (e.g. The AFL Players Association and AFL Coaches Association) and participating community members were male, aged 30- 64, and represent the diversity within these communities with respect to factors such as ethnicity and employment. Consistent with the principle that contact ought to be continuous and dynamic and evidence that campaigns are more likely to be effective when participants receive an adequate ‘dose’ of the intervention (Reavley & Jorm, 2013), Better Out Than In involved a concentrated burst of different messages, delivered sequentially over the course of the four month campaign, of courage and hope delivered in multiple formats (e.g. online videos, collecting, photographing, and sharing anonymous, hand written stories).

18 2. Project Governance Better Out Than In 2017

2.1 THE BETTER OUT THAN IN CAMPAIGN: RATIONALE, DESIGN AND DESCRIPTION

(iii) The Better Out Than In methodology ought to address core identified gaps in the extant stigma reduction research. A recent meta-analysis identified that there is a lack of research examining the effect of stigma reduction campaigns on self-stigma (Griffiths et al., 2014). To this end, Better Out Than In also focuses on reducing self-stigma related to depression. As well, several recent reviews of stigma reduction programs have identified that there is a lack of evidence of programs impacting on stigma related behaviours, rather than attitudes and intended behaviours per se (Corrigan et al., 2012; Reavley & Jorm, 2013). This is important because changes in attitudes and intended behaviour do not always translate into behaviour change. This project focused specifically on changing behaviour related to personal and self-stigma involved in depression and as such one of the primary intended outcomes was behaviour change in these areas (see evaluation section).

Research Objectives • The first objective of this project was to generate information on what works in terms of stigma reduction for depression in men aged 30-64.

• A second objective was the successful development and implementation of an online digital intervention for self-stigma for depression. The aim was to create a digital intervention that was innovative, user-friendly, engaging, and meaningful. The success of this objective was measured through a comprehensive data- analytics strategy, which provided concrete data on the reach of the intervention as well as information on how users are engaged with the digital interface.

• A third objective was to promote the effective use of participatory design and user experience aspects throughout the project. A strategic approach to user experience and participatory design enabled this project to yield valuable data in terms of how men ‘opt-in’ to mental health interventions and what might encourage/ challenge engagement in digital stigma-reduction campaigns.

19 2. Project Governance Better Out Than In 2017

2.1 THE BETTER OUT THAN IN CAMPAIGN: RATIONALE, DESIGN AND DESCRIPTION

• A fourth objective was to achieve measureable reductions in self-stigma and personal stigma for depression (in terms of both attitudes and behaviour) within the communities of interest. The aim was for men who engaged with this intervention to think differently about depression and mental health after engaging with this project—to view seeking help for depression as an act of openness, acceptance and hope; to engage in positive behaviours such as sharing their experiences with others and seeking help; and to build their capacity to support other men who are experiencing depression. These outcomes were measured via rigorous, evidence-based measures and methods and through interviews with men who engaged with the campaign.

• The fifth objective was the development and implementation of a strategic and comprehensive knowledge translation strategy so that the findings of this project have real-life impact. This strategy includes participatory design, meaningful participation in the knowledge community and communication of key outcomes to academic, industry, and community stakeholders.

• The sixth objective was to conduct a review and make recommendations for the sustainability of the digital campaign beyond the two-year grant period.

Communities of Interest

The Better Out Than In Campaign targeted three communities of interest. • AFL Past Players: Total domestic participation in the game at a community level throughout Australia reached 1,247,575 (AFL, 2015). In terms of AFL PA membership, 5300 men are past players, meaning they have played and transitioned out of AFL senior ranks. The age of these men ranges from 20s to over 90, the majority (66%) of these men fall within the 30 to 64-year-old age range. AFL Players is in direct contact with approximately 2,500 past players currently, and actively seeking contact with the rest.

20 2. Project Governance Better Out Than In 2017

2.1 THE BETTER OUT THAN IN CAMPAIGN: RATIONALE, DESIGN AND DESCRIPTION

• AFL Coaches: The total number of currently accredited coaches at all levels of the game in Australia is approximately 27,000 (AFL, 2015). At the most senior level, AFL CA, has 180 members, averaging ten members at each of the AFL’s 18 clubs. The average age of the AFL’s Senior Coaches is 43 years. • Construction Workers: the construction industry employs over 1 million people (ABS, 2012), and is predominately a male industry (98%) covering ages from 15 through to 70 years of age. Construction workers are identified as a high-risk group for depression and suicide (AISRP 2006; Battams et al. 2014). Mates in Construction estimate their direct reach at approximately 400,000 workers.

Integration of Communities of Interest: Men within the communities of interest were engaged at three levels:

• A diverse user reference group took place, user experience interviews and focus groups to ensure that the digital intervention is content relevant, visually appealing, and engaging to use.

• Men in the communities of interest provided the content for the digital campaign, with the understanding that hearing real-life experiences of other men is a powerful pathway to reducing stigma for depression.

• Ambassadors from the three communities of interest helped to create trust, momentum, and appeal for the campaign through sharing it with others.

21 2. Project Governance Better Out Than In 2017

2.2 PARTICIPATORY DESIGN

The project was fortunate to partner with organisations who hold close relationships and a very intimate understanding of the distinct needs and preferences of their respective members. Recognising this key element and coupling it with focus on evidence-based best practices, including credible research and publications, our project team engaged in a process of stakeholder driven workshops led by specialist UX team members. These workshops, delivered in varied formats, featured an eclectic mix of mental health specialists, industry representatives who operated at the ‘coal face’, creative directors with agency specialisation, ‘everyday people’, and people with a lived experience of depression who had sought professional help. Furthermore, these sessions were largely structured around and informed by the analysis of data collected from within our specific target audiences. Most notably, target audience audio interviews conducted by our research team, paired with pre­-delivered digital content, served as the early foundations. We were incredibly mindful of the strengths that each project partner brought to the process and was disciplined in our focus to centre all design elements on the practicalities of end- user engagement in the context of our target audience. An example of this can be found in the simplistic, mobile optimised layout of our intervention with a core focus on three main elements; ­ stories, tactics, actions. While this sequence is again simplistic in nature, the inter­relationship between these elements is transactional. That is, the stories inform the tactics, which drive the actions, and vice versa. We acknowledge that the user experience hinges on redirection from social media channels and will, in most cases be for a very limited period of time, sandwiched somewhere between competing featured content. With this in mind, we placed principal emphasis on engaging video storytelling and short, sharp content. Throughout many project knowledge gatherings and focus group interviews we were able to refine the project tone, feel and language. We were mindful to steer clear of words and associations that were heavy and depressing and focused more on creating language and tone that was more about hope and possibility.

22 2. Project Governance Better Out Than In 2017

2.2 PARTICIPATORY DESIGN

Our project partners provided great insight to their respective member bases, and provided keyword associations that would be well received by our target audience. Along the way we committed to a campaign that would not reflect a medical model, but rather a relatable platform that used earthy and gritty plain language. Through great discussions and workshops, we agreed that the campaign needed to be about blokes/mates relating to each other and talking about things that are going on with them. We were also mindful that the telling of the stories has a safety component, ensuring that the stories are not doing harm to themselves or others. Through this process we relied heavily on existing relationships and echoing other aspects in this report, of trust and open communication. Mates In Construction have access to over 500 people called “connectors” who are based throughout the country. The connectors act a mate that can keep you safe while connecting you to help - these were the people we wanted to be interviewing rather than the Speaker Bureau. As a project team, we relied heavily on our existing and healthy membership bases. This provided a real advantage in that we could lean on our target audience to refine the campaign and seek feedback as various times throughout the development. We didn’t have to approach big construction groups to gain access to construction workers, as Mates In Construction had that all covered with their healthy, existing relationships. Easy access to our respective members meant we could easily conduct measured and randomised focus group and advisory group meetings and voxpop’s to evolve the initial concept of ‘real courage’.

23 3. The Intervention Better Out Than In 2017 3. THE INTERVENTION

24 3. The Intervention Better Out Than In 2017

3.1 DESCRIPTION AND DELIVERY OF BETTER OUT THAN IN CAMPAIGN

This project released ten digital stories, delivered in the format of ‘mini-campaigns’, featuring a diverse range of present and past AFL players and coaches and construction workers. The underlying elements of the project included the presentation of diverse stories, perspectives, demographics, experience and people. Whilst, we did not relinquish in our commitment to this, it did provide some challenges in our planning and delivery of the mini-campaigns. Equal to this, we committed to an ‘organic’ recruitment process whereby we aimed to leverage existing personal relationships and use the Better Out Than In digital platform as a promotional tool. Through our ongoing commitment to collect and reflect on digital and traditional analytics, we have gained a deeper appreciation and knowledge of the ‘soft data’, as evidenced by the feedback received from story sharers, their friends and family and the wider community. Also, resulting from our reach was the significant interest that was drawn from the grassroots communities, who sought to engage and support. Whilst these requests weren’t anticipated or resourced, we chose to include them. Through this we discovered a great initiative to engage with the community to further develop Better Out Than In through the story sharing and help-seeking platform. The public response and support for our work, both from our target audience and the greater community was overwhelming. It has given us great confidence to continue the story-sharing platform in a similar fashion. An important facet to facilitating the story-sharing platform was to continue to highlight the importance of developing strong relationships, and more specifically, connection and trust. We consider ourselves very fortunate to have developed these relationships in a way that allowed eleven incredibly brave storytellers, to share their story to a global audience. A constant theme identified throughout the feedback we received from this group has been a sincere sense of appreciation for being allowed to contribute to the project. We partnered with an external producer who held an intimate understanding of the project objectives and possessed a unique skill for crafting stories based on the project’s taglines. These included; openness, acceptance and hope.

25 3. The Intervention Better Out Than In 2017

3.1 DESCRIPTION AND DELIVERY OF BETTER OUT THAN IN CAMPAIGN

Hence, this enabled us to adopt a singularly focused, time sequential and thematic method for participant engagement and content development. This allowed us to build genuine relationships with each participant and leverage our previous participant experiences. So, when members of the wider community chose to digitally interact with our participants, as opposed to engaging via the platform itself, we felt confident in the fact that we were supporting participants to act as campaign ambassadors and direct this communication through to the appropriate channels.

A list of the project’s core elements was developed and can be seen below. These evidence-based elements also form the core themes relevant to the project’s marketing and communication strategy. This includes:

• Promoting normalisation and acceptance of depression and more broadly, mental illness • Reframing hyper-masculine stereotypes connected to courage, hope and strength, emphasising the importance of friendships, acceptance, love and support • Community-focused approach to storytelling, featuring a range of varied perspectives in connection to the stigma associated with depression (e.g. family, friends, colleagues) • Using light-humor to engage, where and when appropriate • Target audience stories represent real-world situations, circumstances and people (including settings, language and appearance), without over-playing stereotypes • Providing website users with simple design, interface and navigation • Targets wider-community engagement via user-stories/ contributions • Pushing the boundaries set by past mental health digital campaigns (while acknowledging the target audience’s need for simple messaging and functionality) • Memorable tagline provides an opportunity for a good depth of engagement

26 3. The Intervention Better Out Than In 2017

3.1 DESCRIPTION AND DELIVERY OF BETTER OUT THAN IN CAMPAIGN

At a higher level, the digital platform at the centre of this intervention formed a pivotal hub for discussing the campaign. The digital platform was designed with a core focus on participatory design principles, ensuring that the intervention was successful in terms of engaging the communities of interest, ensuring suitable language is applied and a story-sharing platform is developed to encourage others.

27 3. The Intervention Better Out Than In 2017

3.2 DIGITAL TECHNOLOGIES

The Better Out Than In campaign was delivered through a Wordpress website. This was supported by embedded video content housed on a Better Out Than In playlist within the AFLPA YouTube channel. The project content was digitally promoted via three main social media platforms, relevant to the demographic and digital preferences of our target audience. These mediums included; Twitter, Instagram and Facebook. While we established stand-alone @betteroutthanin accounts on both Twitter and Instagram, we elected to leverage the large following that the AFLPA Facebook account had already amassed and use this account to reach the target audience via Facebook. Additional digital technologies activated within this project included; the qualtrics platform to perform the evaluation data collection, an SMS communication service to reach survey participants, ‘Basecamp’ to communicate with other STRIDE projects and an e-newsletter platform to promote new content directly with an online membership base.

28 3. The Intervention Better Out Than In 2017

3.3 WEB DESIGN

A priority for the web design included increased ease of navigation and a minimised need to scroll (particularly on a mobile device). A design including “collapsible” sections was proposed to easily demonstrate and conceal the Talk Tactics and Take Action steps. In addition to this, the selected images/icons were chosen to maintain the designs clean yet appropriate tone and personality of the overall campaign. It was optimised so it could be easily accessed from a mobile device. Video content for Better Out Than In was structured to produce two content streams: ‘Better Out Than In’ stories and ‘Terry Talks Tactics’ videos. The ‘stories’ segments intent was to normalise the act of ‘letting things out’ by sharing personal stories of credible spokespersons. Viewing it should give participants confidence and reassurance that anxiety and depression are commonly occurring amongst men and aimed to lead them to the ‘Talk Tactics’ to assist them with any personal distress.

Talk Tactics- Talk Tactics aimed to provide men with a “game plan” for how to ‘let it out’ and start a conversation about mental health conditions, as well as how to keep the conversation going. Terry Talks Tactics are a series of online videos that follow ‘Terry’, a man who has no difficulty with letting things out . He is a jovial character who belches on the construction site and farts with his peers for fun when they’re watching the footy. However, as time progresses Terry’s head gradually starts inflating, getting larger and larger. His peers notice, but say nothing. Terry continues to try to act normally – belching, farting, etc. – but it’s clear he’s holding something else in. Eventually a peer enquires if he’s holding anything back. Terry admits he is having problems, and as they discuss them, his head shrinks back to normal. In light of the campaign’s attempt to normalise conversations around mental health, our playful Terry videos present a terrific opportunity to balance our approach, particularly against the real-life stories component.

29 3. The Intervention Better Out Than In 2017

3.3 WEB DESIGN

While Terry’s Talk Tactic videos will also have a place on the website, its primary objective is to build awareness of the campaign (i.e. externally) and drive traffic to the website. Terry, in essence, represents someone who may find it difficult to “let it out” and at some point in the video(s) we see Terry or one of his mates refer to Talk Tactics to help address the issue. Using humour in these videos will help us break down some of these barriers.

Take action: Compiles important reference and resource links as well as suggestions for finding out more or getting help with letting it out.

The websites operation was initially designed to have an offline period, which ran between October 2016 and March 2017. This was to allow our research partners to capture accurate follow-up data. After several project team discussions and based on advice from our industry partner, this changed on ethical grounds, and we decided to keep the website operational due to the potential for Christmas to be an increasingly stressful time for many. We were of the view it would be unethical to withdraw a platform for help seeking in a time of potential need. However, the campaign essentially ceased from promotional activities during this period.

We were mindful of the strengths that each project partner brought to the process and were disciplined in our focus to centre all design elements on the practicalities of end-user engagement in the context of our target audience. An example of this can be found in the simplistic, mobile optimised layout of our intervention with a core focus on three main elements - stories, tactics, actions which are housed on the Better Out Than In website (http://betteroutthanin. com.au).

30 3. The Intervention Better Out Than In 2017

3.3 WEB DESIGN

Stories include:

• John Longmire – AFL past player, Sydney Swans senior coach. • Jake Edwards – AFL past player • Lukas Webb – Current AFL player • Russell and Angie Greene – AFL past player, Angie daughter to Russell and CEO of Stand-Up Events. • Luke Gibson – construction worker and union delegate • Justin Geange - Plumber • Cameron Wight- AFL past player • Caine Ansell – construction worker and union delegate • Andrew Crowell – AFL past player

Tactics section included subheadings with further guidance and advice:

• Blokes talk best when they’re... • Things you or your mate might be dealing with • Signs something’s not OK • How letting it out helps • 6 ways to support a mate • Terry Talks Tactics videos; 5 quirky videos were developed to visualise the above advice and tactics.

Take Action

• Help seeking advice and tips.

Whilst this sequence is simplistic in nature, the inter-relationship between these elements is transactional. That is, the stories inform the tactics, which drive the actions, and vice versa. We acknowledge that the user experience hinges on redirection from social media channels and will, in most cases be for a very limited period of time, sandwiched somewhere between competing featured content. With this in mind, we placed principal emphasis on engaging video storytelling and short, sharp content.

31 3. The Intervention Better Out Than In 2017

3.3 WEB DESIGN

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3.3 WEB DESIGN

We have identified that grassroots initiatives are interested in attaching themselves to the story-sharing platform. We aim to explore the opportunities of a ‘community stories’ section as a subsection to stories, which effectively shines a light on community, based initiatives. We feel that by granting each of these stories a dedicated page to demonstrate their own Better Out Than In community activities we can;

a) Support them b) Grow our campaign brand c) Use their communities to spread greater awareness of the Better Out Than In platform.

BETTER THAN OUT IN

TALK TAKE STORIES TACTICS ACTION

Simihic onfertatume nonsu con No topic is out of bounds here. Firmande oca; nem sentea num maio, vilintus, quasdac te nemum intimmo Verfecen trobsen dionerem ute, denterum Patum publina, sedeliu ratifec oenius, non sena, nemnincles- verbi etieraelut imperum esciorum vercerit, stis auceps, scrit, comne sa nes! Ibuscre, fi rmande oca; nem audeessa que facchuid iam porum faciacide notam faudemquam ia nia sentea num maio, ute, patraet; issuppl. mene vit.

19 33 3. The Intervention Better Out Than In 2017

3.3 WEB DESIGN

BETTER THAN OUT IN

TALK TAKE STORIES TACTICS ACTION

Simihic onfertatume nonsu con No topic is out of bounds here. Firmande oca; nem sentea num maio, vilintus, quasdac te nemum intimmo Verfecen trobsen dionerem ute, denterum Patum publina, sedeliu ratifec oenius, non sena, nemnincles- verbi etieraelut imperum esciorum vercerit, stis auceps, scrit, comne sa nes! Ibuscre, fi rmande oca; nem audeessa que facchuid iam porum faciacide notam faudemquam ia nia sentea num maio, ute, patraet; issuppl. mene vit.

19

34 3. The Intervention Better Out Than In 2017

STORIES

John Longmire

Luke Gibson

Lucas Webb

35 4. Marketing & Promotion Better Out Than In 2017 4. MARKETING & PROMOTION

36 4. Marketing and Promotion Better Out Than In 2017

4.1 POTENTIAL IMPACT CAMPAIGN

One of the strongest elements of our campaign has been in communications which has driven very significant attention towards our campaign. We are pleased to report that an estimated audience of 1.7 million viewers engaged with project related media communications (see appendix one for further information). Outside of this, 200,000 members of the construction industry, through Mates In Construction, have received targeted communications driving awareness of the project. We’ve also received extensive anecdotal ‘soft data’. Examples include: Help seeking members of our target community who’ve been exposed to our campaign, reached out to us personally and subsequently received the professional support they required. In one case, this included an individual who was experiencing suicidal tendencies. Project participants stated that work colleagues had approached them on their worksite and outside of work to discuss one of the campaign clips and to share that they were struggling. These participants were then connected to professional help. They also reported having had numerous peers discuss the clip at work, which opened up good focused discussions. Video’s shown at the Construction Forest Mining and Energy Union (CFMEU) delegates’ convention (over 300) received a standing ovation from those attending and stimulated conversation. Help seekers being directed to professional services as a result of storyteller’s courage to share their story.

Social media (Audience views) • Twitter (combined @AFLPlayers & @betteroutthanin): Over 323,000 impressions. • Instagram (combined @AFLPlayers & @betteroutthanin): Over 5,500 promo video views • Story video full length views (combined BOTI website & Facebook): 27,817 views • Videos with 30 second video snippets by far recorded our highest engagement numbers, similarly ‘who could this be’ posts, with a link - recorded the good engagement numbers.

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Video Views: • The video engagement was incredibly reassuring, with over 384 hours of story content viewed, with an average of 01min:25sec session duration.

Highlights • Lukas Webb’s story drew terrific engagement from the likes of Marcus Bontempelli and other teammates on Twitter. • Facebook reach - 15,729, 3.6k views, 72 likes, 20 shares. • Instagram - 1045 view, 162 likes. • Twitter - 45,771 impressions, 1966 engagements, 129 likes, 25 AFL Players tweeting in response retweets, 7 tweets. to Lucas Webb’s story. • Hours watched: 96 hours (4 days)

• Andrew Crowell’s story resonated with a large audience. Crowell’s received a substantial amount of Facebook views with - 32,386 reach, 10,000 views, 260 likes, 65 shares, 33 comments. • Instagram- 1046 video views, 130 likes. Additionally, had a great impact on Twitter with 41,133 impressions, 1618 engagements, 71 likes, 23 retweets (6 tweets) • Hours watched: 2 days (48 hours)

• Jake Edwards (AFL Past player) • Facebook – 6,309 reach, 1.3k video views, 29 likes, 13 shares • Instagram – 117 likes, 686 video views • Twitter – 27139 impressions, 305 engagements, 32 likes, 17 retweets (4 Tweets) • Hours watched: 3 days (72 hours)

• John Longmire (AFL Past Player, Sydney Swans coach) • Facebook – 5820 reach, 1k video views, 24 likes, 2 shares • Instagram – 1072 views, 162 likes • Twitter – 40,474 impressions, 389 engagements, 41 likes, 18 retweets (6 Tweets) Hours watched: 30 hours

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4.1 POTENTIAL IMPACT CAMPAIGN

• Mark Eustice (AFL past player) • Facebook – 3648 reach, 802 video views, 13 likes, 4 comments • Twitter – 15,144 impressions, 162 engagements, 4 likes, 1 retweet (2 Tweets) • Hours watched: 18 hours

• Cameron Wight (AFL Past player) • Facebook – 5134 reach, 1k views, 13 likes, 1 share, 1 comment • Instagram – 1288 video views, 127 likes • Twitter – 12,448 impressions, 169 engagements, 4 likes, 2 retweets (2 Tweets) • Hours watched: 3 days (72 hours)

• Angie/Russell Greene (Russell AFL past player, Angie; daughter) • Facebook – 4374 reach, 20 likes, 1 share • Instagram – 118 likes, • Twitter – 13,934 impressions, 444 engagements, 13 likes, 4 retweets (2 Tweets) • Hours watched: 14 hours

• Justin Geange Plumber: • 300 views • Website: 173 • Youtube: 127 • Hours watched: 5 hours

• Luke Gibson: Construction worker and union delegate • 10,075 views • Facebook: 9444 views, 2.8k video views, 68 likes, 57 shares, 7 comments • Website: 357, • Youtube: 274 • Hours watched: 7 hours

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4.1 POTENTIAL IMPACT CAMPAIGN

• Caine Ansell: Construction worker and union delegate, 9,439 views • Facebook: 8215 reach, 1.6k video views, 32 likes, 27 shares • Website: 438 views • Youtube: 786 views • Twitter: 1992 impressions • Hours watched: 29 hours

Website Highlights • Website hits – over 40,000 Better Out Than In video views (combined Facebook, Website and YouTube) • Unique page views: over 16,000 • Average time on page: 00:01:25 • Bounce rate: 70.17% • % exit: 51.88% • Terry Talks Tactics - 1,540 page views • 1,124 people spent 1min34sec on the Take action page.

Demographics • 18-24 sessions: 13.94% • 25-34 sessions: 31.78 % • 35-44 sessions: 22.40 % • 45-54 sessions: 18.53 % • 55-64 sessions: 9.88 % • 65+ sessions: 3.46 %

Sessions total gender break down: Male: 66.1% Female: 33.9%

Amongst some really positive and reassuring website data, it was also evident that traditional media is still a powerful tool. Using the ‘mini-campaign’ model for each of our stories, we approached relevant media outlets to assist in publicity opportunities and have generally been granted good support, especially in circumstances where the profile of the individual or the nature of the personal story is likely to draw public interest.

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4.1 POTENTIAL IMPACT CAMPAIGN

Given traditional media such as newspaper and radio also generate digital content promotions, we’ve witnessed a positive spike in public engagement with stories as a result. This allowed us to get out stories out to over 1.7million eyes and ears.

Social media posts that featured a video snippet or release info were found to be the most successful in terms of engagement not only through social media, but and also website visits. Site visitation would spike when a teaser of the video was posted through social media, in particularly when it was shared or promoted through our existing social media channels and network at the AFL Players’ Association. The below information outlines a particular Instagram post and the corresponding website traffic.

John Longmire video: Instagram post on AFLPA channel (26.1k followers): July 12, 2016 Instagram post on Better Out Than In Handle (237 followers): July 11, 2016 Website spike: July 11: 261 page views July 12: 100 page views July 13: 32 page views

Jack Edwards video: Instagram post on AFLPA channel (26.1k followers): July 27 Instagram post on Better Out Than In channel (237 followers): July 26 Website spike: July 26: 159 page views July 27: 105 page views

Luke Gibson video: Instagram post on AFLPA channel (26.1k followers): August 5, 2016 Instagram post on Better Out Than In channel (237 followers): Aug 4, 2016 Website spike: August 4: 112 page views August 5: 51 page views

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Cups for good campaign

The aim of the two-three week activation is to use coffee cup messaging to Inspire, Influence and Inform of Better Out Than In message and campaign. We encouraged engagement through the #betteroutthanin hashtag with the call to action to share your coffee experience. We strategically placed 50,000 branded coffee cups around Melbourne cafes that were frequented to by our target audience and demographic. The front of the cup read “Hey Don’t Bottle Things Up” with social media and one liner info on the back.

The awareness of the campaign was to start a conversation with the activation being to share a selfie with a mate over coffee. We developed the concept based on the popularity of coffee in Melbourne where Melbournians on average consume fourteen coffees a week, just shy of one million a week. It was estimated that it takes between five and twenty minutes to consume a cup of coffee, hence, we identified a good opportunity to leave a lasting impression. There was also an element of intimacy in that the individual will have the opportunity to hold the message in their hand.

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4.1 POTENTIAL IMPACT CAMPAIGN

Pre cups - Web analytics During cups - Web analytics Feb 6 2017-Mar 6 2017: Mar 6 2017- Apr 12 2017: Page views: 407 Page views: 1,268 Unique page views: 330 Unique page views: 1,003 Avg. time on page: 00:02:02 Avg. time on page: 00:01:21 Bounce rate: 68.16% Bounce rate: 54.30% % exit: 49.39% % exit: 38.49%

There was a significant increase in web traffic during the cups for good campaign. The main call to action was to engage on social media with the hashtag #betteroutthanin. It was pleasing to note that the design and messaging on the cup, created intrigue to find out more about the Better Out Than In campaign without actually putting the website URL on the cups.

• Instagram- cup shares: 66 photo shares • Twitter- cup shares: 11 photo shares

The cups for good campaign generated some great engagement and was received extremely well throughout the community. We thought it would be another positive way to get the message in front of people and continue to encourage people to talk.

43 5. Evaluation Better Out Than In 2017 5. EVALUATION

44 5. Evaluation Better Out Than In 2017

5.1 OVERVIEW OF METHODOLOGY

Research Design

A mixed-methods evaluation of the program was conducted over an 8-month period. Although randomised control trials are often not appropriate or practical when evaluating population-based health interventions, designs such as repeated cross-sectional population surveys make it difficult to attribute change in stigmatising attitudes and behaviours to the intervention alone, due to the absence of a comparison group (Reavely & Jorm, 2013). Thus, in line with recommendations of the Cochrane EPOC group (2007) a controlled before and after design was used to examine the efficacy of the intervention. An age-appropriate group of workers in the mining industry (another male dominated profession) served as the control condition.

Quantitative methods: A confidential online survey was used to evaluate the efficacy of the campaign in reducing stigma pertaining to depression in the targeted communities of men (construction workers, ex-AFL players, and AFL coaches). The survey was administered on three occasions at baseline and then at two follow-ups:

• Prior to the commencement of the campaign (between late April 2016 to June 2016)- see report below • 4 months after commencement of the campaign (November 2016 to December 2016) – see report below • Eight months after the commencement of the campaign – see report below

The items on this survey are described below. Qualitative methods: following the final online survey a subset of participants who did engage with the campaign were asked via an individual interview about what they liked about the Better Out Than In campaign, how they engaged with it and how they think it could be improved. As well, a subset of participants who did not engage with the campaign were asked about why this was the case and what would have encouraged them to engage.

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Specifically a total of 27 participants were interviewed, 14 who had reported engaging with the Better Out Than In campaign and 13 that did not. These data are reported after the final follow-up survey data.

Description of stigma measures on the online survey

Overview measurement of stigma: The goal of the evaluation was to assess change on multiple components of self and personal stigma and self-report behaviour and behavioural intentions related to help seeking behaviour using a survey delivered via an online platform (Qualtrics) on three occasions: baseline and two follow up assessments. Specifically, the focus was on measuring attitudes, behavioural intentions and actual behaviour using psychometrically sound measures including the 16- item Self-stigma of Depression Scale (Barney et al., 2010); the 9-item Depression Stigma Scale (Griffiths et al., 2004); and an adaptation of the help seeking likelihood scale (Barney et al., 2010). Actual behaviour change in terms of help seeking behaviour and offering support to others experiencing problems was measured by items produced by the research team in consultation with other social researchers and representatives from the targeted communities. For these measures respondents were asked about times when they or others were doing it tough. The decision to use the term doing it tough rather than depression was based on extensive engagement with our industry partners who had extensive experience talking with men of this age and construction workers about their mental health. As well, the goal was to promote an early intervention approach. That is, to encourage men to discuss what was troubling them or others and engage them in help seeking as early as possible, before these troubles resulted in a considerable deterioration in their condition and placing them at risk of developing clinical depression.

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5.1 OVERVIEW OF METHODOLOGY

Measurement of self-stigma: Self stigma was assessed by the 16-item Self-stigma of Depression Scale (SSDS: Barney et al., 2010). This scale asks participants to rate their level of agreement to a number of statements regarding if they were to have depression like a person described in a short vignette (e.g. If I had depression like the person described above I would feel inadequate around other people) on a 5-point scale from strongly agree to strongly disagree. Items are scored so that higher scores = greater stigma (minimum score 16 to maximum 80) and the scale contains four subscales: Shame (range 4-20); Self Blame (range 4-20); Social Inadequacy (range 4-20) and Help Seeking Inhibition (range 4-20). The SSDS has been used previously in large national surveys in Australia and has sound psychometric properties (Reavley & Jorm, 2012). Measurement of personal stigma: Personal stigma was assessed by the 9-item Depression Stigma Scale (DSS: Griffiths et al., 2004). This scale asks respondents to rate their level of agreement to a number of statements about other people with depression (e.g. People with depression could snap out of it if they wanted) on a 5-point scale from strongly agree to strongly disagree. Item scores form a single measure of personal stigma ranging from 9 to 36, with higher scores providing an indicator of higher personal stigma. The DSS has sound psychometric properties and has been used previously in in large national surveys in Australia (e.g. Reavley & Jorm, 2012) Measurement of help providing behaviour: Participants were asked about whether they had regular contact with people (i.e., a workmate, family member, friend, and partner) who had been doing it tough over the last month. For the people that responded yes they were then asked about the frequency in which they spoke to these people about their problem during the last month. For example if they responded yes about a workmate they were asked how frequently they spoke to their workmate about what is troubling them on a 5 point scale ranging from 1= not at all to 5 = every day I have contact with them.

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Measurement of help seeking behaviour: Participants were asked about whether they themselves had had been doing it tough over the last month. If they responded yes they were then asked about the frequency in which they spoke to specific people in their community (i.e. family member/friend/GP/partner) about their problem during the last month. For example, they were asked how frequently they spoke to their GP about what is troubling them on a 5 point scale ranging from 1 = not at all to 5 = every day I have contact with them. Measurement of help seeking likelihood: If participants responded with no to the questions about whether they themselves had been doing it tough over the last month they were then asked to complete a modified version of the help seeking likelihood scale (Barney et al., 2010) in which respondents were asked about how likely they would be to seek help from their partner of close workmate, friend, family member and GP if they were doing it tough/ depressed on a 5 point scale ranging from 1 = extremely unlikely to 5 = extremely likely.

48 6. Results Better Out Than In 2017 6. RESULTS

49 6. Results Better Out Than In 2017

6.1 PHASE ONE – BASELINE REPORT

Number of participants recruited and time frame The baseline recruitment campaign was conducted between late April 2016 and June 2016. Invitations to complete the survey were distributed using electronic communication channels (i.e., email) from the AFL Players Association, AFL Coaches Association, MATES in Construction, CFMEU, and several mining organisations. A target of 1500 participants was set to obtain responses from men working in construction or mining industries, past AFL football players and coaches, to complete an online survey about questions around depression in men. A total of 1350 responses were received before exclusion criteria were applied. The final baseline sample group comprised 1054 participants who were past AFL players (204); current AFL coaches (50); Construction workers from NSW, QLD or SA (547), Victoria Construction workers (88); and men working in the mining Industry (165).

Reasons for exclusion ( general) Participants were excluded from the final sample if they met any of the following criteria:

• Were not male • Were not between 30-65 years of age • Were not currently employed (this was applied to avoid potential overlap in recruitment pools with another Stride project that was specially targeting unemployed men of the same age in the construction industry) • Had engaged with MATES in Construction mental health awareness programs within the previous 2 years

Overall evaluation group – description and demographics Table 1 provides the total number of participants who were eligible to be included in study at baseline. The sample includes men from the Construction Industry, past AFL Players and AFL Coaches, and men from the Mining Industry. Figure 1 displays the state participants were recruited from.

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Table 1 Age of total evaluation participants at baseline

Total Sample

N 1052

Age in years (SD) 44.57 (9.88)

NT 0% TAS 1% WA 8%

SA 10% NSW 19%

VIC 23%

QLD 39%

Figure 1. Breakdown of state where participants who responded to the survey reside

As can be seen in Figure 1, the majority of baseline participants resided in Queensland, followed by Victoria and then New South Wales. The data in Table 2 show the breakdown of participants in the campaign group (i.e., individuals targeted for the STRIDE campaign).

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Table 2 Average age of construction industry workers, past AFL players and AFL coaches in the treatment group at baseline

Construction Construction Past AFL Players AFL Coaches Industry (other Industry (Victoria) states)

N 547 88 202 77

Age in years (SD) 44.59 (9.43) 43.42 (10.26) 45.29 (11.50) 43.52 (9.81)

As noted in Table 2, the largest group was construction workers from states other than Victoria and smallest coaches. The average age of mid 40s was comparable across the four groups of men in the Better Out Than In campaign group.

Overall control group - Description and Demographics The values in Table 3 represent the number of participants recruited for the study who are from the Mining Industry and represent the control group and were not targeted during the Better Out Than In digital campaign.

Table 3 Age of the control group at baseline

Mining Industry

N 165

Age in years (SD) 44.54 (9.02)

The average age of the miners was comparable to the four groups of men from the Better Out Than In campaign group.

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Reports on measures

Psychometrics of measurements used for the survey (internal consistency) on baseline sample

For the baseline sample, internal consistency estimates were generated on the SSDS and DSS. The SSDS is a 16-item scale which contains 4 subscales. The DSS is a 9-item scale. Reliability estimates for both measures are provided in Table 4.

Table 4 Internal consistency estimates for Self-Stigma of Depression Scale (SSDS) and Depression Stigma Scale (DSS)

Scale Reliability Coefficient (Cronbach’s alpha)

SSDS Total .89

SSDS Shame .85

SSDS Self Blame .80

SSDS Social Inadequacy .74

SSDS Help-seeking Inhibition .81

DSS .81

Note. N= 1054

As can be observed in Table 4 Cronbach alpha values on the SSDS total, all SSDS subscales and the DSS were all above .7, which suggests acceptable levels of internal consistency of the scale when administered at the baseline assessment. The values for the SSDS are comparable to those reported in an Australian study by Barney et al. (2010) and Reavley et al. (2014) for the DSS.

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Descriptives of total baseline sample and campaign groups

Self-stigma and personal stigma data Descriptive data of the averages for the self-stigma personal stigma scales of the total baseline sample are contained in Table 5a

Table 5a Descriptive statistics of the Self-Stigma of Depression Scale (SSDS) and Depression Stigma Scale (DSS) for the total sample at baseline

Total Sample

M (SD) Possible Range

SSDS Total Score 53.16 (10.06) 20 – 80

SSDS Shame 12.59 (3.60) 4 – 20

SSDS Self Blame 13.34 (3.24) 4 – 20

SSDS Social Inadequacy 14.61 (2.57) 4 – 20

SSDS Help-seeking Inhibition 12.62 (3.53) 4 – 20

DSS 20.30 (5.24) 9 – 35

Note. N = 1052 In order to ascertain the areas where stigma was highest the percentage of men agreeing or strongly agreeing with each item was calculated. These data are presented in Tables 1-5 in Appendix 4. Inspection of Table 1 columns 2 and 3, revealed the top five most strongly endorsed items (highest percentages of men either agreeing or strongly agreeing with the item) which were indicative of highest rates of self- stigma according to the SDSS. These were: I think I should be able to ‘pull myself together’; I would feel like I was good company (reverse scored); I would feel like a burden to other people; I would feel inadequate around other people; and I would feel like I could not contribute much socially.

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The rate of men agreeing or strongly agreeing to these items were between 65-75%. In terms of personal stigma highest rates of stigma related to people with depression being dangerous (17% either agreeing or strongly agreeing), not telling anyone if they had depression (32%), and the belief that people with depression are unpredictable.

A cohort breakdown of the campaign group of scale averages for the SSDS and DSS are provided in Table 5b and for the overall campaign group versus the mining control group are provided in Table 5c. Also included are descriptives of the researcher developed behavioural questions in Table 5d, 5e, 5f and 5g for the total sample.

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Table 5b Descriptive statistics of the Self-Stigma of Depression Scale (SSDS) and Depression Stigma Scale (DSS) for Better Out Than In campaign cohorts at baseline

Past AFL Players AFL Coaches Construction Workers Construction Workers (other) (VIC)

M (SD) Range M (SD) Range M (SD) Range M (SD) Range

SSDS Total 52.51 29-73 50.32 26-73 53.05 20-80 53.43 34-78 (8.89) (10.46) (10.52) (9.99)

SSDS 12.33 4-19 12.02 4-20 12.52 4-20 12.71 (3.63) 5-20 Shame (3.29) (3.52) (3.74)

SSDS Self 13.58 6-20 12.96 4-2 13.15 4-20 13.92 5-20 Blame (2.88) (3.34) (3.32) (3.20)

SSDS 14.31 4-20 13.81 9-19 14.77 (2.51) 6-20 14.19 6-19 Social (2.59) (2.36) (2.77) Inadequacy SSDS Help- 12.29 4-20 19.11 (3.23) 5-18 12.60 4-20 12.61 5-20 seeking (3.38) (3.57) (3.49) Inhibition DSS 20.51 9-36 19.11 (4.41) 11-28 20.11 (5.15) 21.02 12-32 (5.15) 9-35 (5.45)

As can be observed from Table 5b baseline scores on the SSDS and DSS were relatively comparable across the different campaign occupational groups. The one exception was a tendency for lower SSDS scores for the AFL coaches relative to other occupations. The breakdown of stigma according to agreement on each item on the SSDS was consistent with this pattern of lower stigma in coaches and similarity between past players and construction workers (see Appendix 4, Table 2). There was also relative consistency across groups of men with respect to rates of agreement on individual items of the DSS. One exception was that more construction workers from Victoria agreed that depression was a sign of weakness (see Appendix 4, Table 2). These values on the SSDS total and subscales were slightly lower (indicating less stigma) than those reported by Australian men in the study by Barney et al. (2010).

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Comparison campaign group v mining controls Baseline measures were recorded for the campaign and control group (i.e., men who work in the mining industry). There were 165 valid cases for the control group and 889 valid cases for the campaign treatment group. Table 5c provides comparative measures on SSDS and DSS scales.

Table 5c Descriptive statistics of the Self-Stigma of Depression Scale (SSDS) and Depression Stigma Scale (DSS) for Better Out Than In campaign group and mining industry control group at baseline

Campaign Group Control Group

M (SD) Range M(SD) Range

SSDS Total 52.81 (10.10) 20-80 55.01 (9.67) 24-75

SSDS Shame 12.47 (3.61) 4-20 13.26 (3.50) 4-20

SSDS Self Blame 13.31 (3.22) 4-20 13.47 (3.36) 4-20

SSDS Social 14.55 (2.56) 4-20 14.91 (2.59) 8-20 Inadequacy

SSDS Help-seeking 12.47 (3.50) 4-20 13.37 (3.58) 4-20 Inhibition

DSS 20.24 (5.15) 9-36 20.62 (5.69) 9-36

As can be observed in Table 5c men from the campaign group had comparable scores on personal stigma (DSS) to men from the construction industry. There was a tendency for men in the control group (miners) to score slightly higher on self-stigma (SSDS) relative to men from the campaign group. In terms of individual self stigma items, men in the control group had higher rates of agreement by 10% or more (see Appendix 4, Table 5 columns 2-5) on two items both relating to feeling embarrassed (‘I would feel embarrassed’ and ‘I would feel embarrassed about seeking professional help’).

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Help providing and help seeking behaviour

Data in Table 5d report on the number of men responding with a yes or no to the questions about whether they have known other people who have been doing it tough over the last month. People who responded yes in a particular category were then asked about the frequency with which they spoke to the people about what was troubling them (see below).

Table 5d Frequency of responses to researcher developed behaviour towards other screening questions for the total baseline sample

Question Yes No

Interacting with others. In the past month…

do you know of a workmate who has been doing it tough? 591 420

do you know of a family member who has been doing it tough? 593 417

do you know of a friend who has been doing it tough? 515 495

have you thought that your partner was doing it tough? 420 489

As can be observed in Table 5d more than 50% of the baseline sample had interacted in the past month with a workmate, family member, or friend they identified as doing it tough. The one exception was in the partner category where this was 46%.

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Table 5e reports on data on the researcher developed behaviour towards other questions for the campaign and mining groups

Table 5e Frequency of responses to researcher developed behaviour towards other questions for the campaign and mining groups. Thinking of the people listed, how often have you spoken to them about what is troubling them when you thought they were doing it tough?

Not at all Hardly at all Some of the Most of the Every day I have days I have had days I have had had contact with contact with contact with them them them Campaign Group Workmate 16 43 187 162 63

Family 18 58 142 147 113

Friend 21 50 136 140 71

Partner 3 27 65 84 154

Mining Group

Workmate 11 14 53 29 12

Family 6 13 37 34 25

Friend 4 10 34 33 16

Partner 0 6 23 19 38

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For the purposes of interpretation the 5 categories in Table 5e can be collapsed into 3 categories based on frequency of asking people about what is troubling them:

• Low frequency = not at all and hardly at all • Moderate frequency = some of the days I have had contact with them • High frequency = most of the days/every day I have had contact with them

As can be observed from Table 5e there were a larger number of responses in higher frequency categories (most of the days I had contact with them and every day I had contact with them) than in the lower frequency categories (not at all and hardly at all) for all categories of people that were perceived as doing it tough. For instance, when the men in the campaign group were asked about how often they had spoken to a friend about what was troubling them when they thought had been doing it tough, 211 of the 418 men (50.5%) reported either speaking to them most of the days they had contact with them or all of the days they had contact with them over the last month and only 71 of the men (17%) reported either not speaking to them at all, or hardly at all about what was troubling them over that period. This pattern was apparent for both respondents in the campaign group and people in the mining group. The social group that the men in the campaign group spoke to least about what was troubling them with when they were doing it tough were friends (71 of 418 or 17% of the men scored either not at all or hardly at all) and the group they spoke to most about what was troubling them was partners (238 of 333 or 71.5% of men scored either most of the time or every time). Consistent with the campaign group, the group that men in the mining group also asked about what was troubling them most was partners (57 of 86 or 66.3% of men scored either most of the time or every time). However unlike the campaign group the social group that the men in the mining group spoke to least about what was troubling them with when they were doing it tough were workmates (25 of 119 or 21% of the men scored either not at all or hardly at all).

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Table 5f reports on data on the researcher developed behaviour towards themselves questions for the campaign and mining groups.

Table 5f Frequency of responses to researcher developed behaviour towards themselves questions for the campaign and mining groups. In the past month how often have you spoken to a family member/friend/GP/partner about what is troubling you when you were doing it tough?

Not at all Hardly at all Some of the Most of the Every day I have days I have had days I have had had contact with contact with contact with them them them Campaign Group Workmate 183 90 102 29 11

Family 96 109 132 49 29

Friend 143 111 117 35 9

GP (Doctor) 306 36 32 27 14

Partner 57 74 104 65 66

Mining Group

Workmate 0 45 28 6 3

Family 28 32 26 15 7

Friend 38 31 25 10 4

GP (Doctor) 77 7 14 4 6

Partner 13 22 26 13 20

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As can be observed in Table 5f when men were asked about how often they spoke to selected people over the last month about what was troubling them when they (themselves) were doing it tough there were a larger number of responses in the lower frequency categories (not at all and hardly at all) than in the higher frequency categories (most of the days I had contact with them and every day I had contact with them). This was apparent for 4 of the 5 categories of people: the exception was partners where numbers were comparable. For instance, when the campaign group were asked about how often they spoken to a friend about what was troubling them when they (themselves) had been doing it tough, only 44 of the 415 men (10.6%) reported either speaking to them about this most of the days they had contact with them or all of the days they had contact with them over the last month. Conversely 254 of the men (61.2%) reported either not speaking to a friend or hardly at all about what was troubling them. This overall pattern was apparent for both respondents in the campaign group and people in the mining group. The group that the men in the campaign group spoke to least about what was troubling them when they (themselves) were doing it tough were GPs where 342 of the 415 men (82.4%) scored either not at all or hardly at all. The group they spoke to most about what was troubling them most was partners where 131 of the 366 (35.8%) of men scored either most of the time or every time. This pattern was also apparent for men in the mining group.

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Table 5g contains data from men who reported not doing it tough themselves over the last month. These men were asked about their likelihood of seeking help from others if they were doing it tough/ depressed. Table 5g Frequency of responses from men in the campaign and mining groups to the modified version of the help seeking likelihood scale (Barney et al., 2010) in which respondents were asked about how likely they would be to seek help from their partner of close workmate, friend.

Extremely Unlikely Somewhat Likely Extremely likely unlikely unlikely

Campaign Group Workmate 72 159 101 74 21

Family 16 60 95 173 83

GP (Doctor) 16 59 93 160 99

Partner or close 7 43 82 155 140 mate

Mining Group

Workmate 6 25 14 9 2

Family 1 11 13 24 7

GP (Doctor) 5 10 12 21 8

Partner or close 3 6 14 19 14 mate

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Findings in Table 5g show the number of men rating themselves as either likely or extremely likely to seek help from family; GP (doctor), partner or close mate exceeded those who selected the unlikely or extremely unlikely categories. This pattern was consistent across both men in the campaign and mining groups. For instance, amongst men in the campaign group 259 of 427 men (60.6%) reported that they would be either likely or extremely likely to seek help from a GP if they were doing it tough/depressed and only 75 (17.6%) reported that they would be unlikely or extremely unlikely to seek help from a GP in this situation. However the pattern was reversed when asked about seeking help from a workmate. In the campaign group 231 of the 427 (54%) men reported that they would either be unlikely or extremely unlikely to seek help from a workmate if they themselves were doing it tough/ depressed.

Key findings • Baseline scores on self-stigma (SSDS) and personal stigma (DSS) were relatively comparable across the different campaign occupational groups, however men in the mining group had slightly higher self-stigma scores relative to the campaign group.

• Both the campaign and control groups had slightly lower self- stigma scores relative to Australian men in the study by Barney et al. (2010).

• Approximately 50% of the total sample of 1054 reported they perceived a workmate, family member or friend had been doing it tough over the last month.

• There were higher rates of self-reported help providing/offering support for others than there was for personal help seeking when the men reported they themselves were doing it tough.

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• More men in both the campaign and mining groups reported high frequencies than low frequencies of speaking to core other people in their lives when they perceived these people were doing it tough.

• In contrast when the men in both the campaign and mining groups had been doing it tough themselves they were more likely to report not speaking/or hardly speaking to a workmate, family member or friend. This was the opposite with partners where the men in both groups were more likely to report speaking to their partners about what was troubling them either most or all of the time they had contact with them.

• Most men did not speak to a GP or friend about what was troubling them when they (themselves) were doing it tough.

• Men in both groups reported that they were would be more likely than unlikely to seek help from family, a GP, partner or close mate. when asked to image they were doing it tough or depressed. However this pattern was reversed when asked the same question about seeking help from workmates.

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Number of participants recruited over what time Participants who responded to the baseline evaluation survey were invited to participate in the follow-up survey (termed ‘Follow- up 1 survey’). Follow-up 1 survey contained the same questions and scales as reported in the baseline survey (i.e., SSDS, DSS, behavioural questions towards others and self, and intended help seeking behaviour). The recruitment period spanned November to December 2016 and 440 participants responded to the survey. After data screening and exclusion criteria were applied, there was 319 valid responses comprising of men from AFL players, AFL coaches, construction workers and the mining industry – a 30.3% retention rate.

Reasons for exclusion In accordance with the exclusion protocol mandated at baseline, participants who responded to Follow-up 1 survey were excluded from data analysis if they:

• Were not in active employment (to again ensure that no men might be drawn from the other project Stride research that targeted unemployed men) • Were not male • Were not between 30-65 years of age

Retention rates Breakdown of participant retention for each evaluation group is reported in Table 6. Tables 7 and 8 provide descriptive data for total sample and evaluation groups in Follow-up Survey 1.

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Table 6 Retention rates from baseline to follow-up survey 1

Cohort group Baseline Follow-up 1 Survey Percentage retention

Past AFL Players 202 64 31.7%

AFL Coaches 77 11 14.2%

Construction Industry 547 157 28.7% (Other)

Construction Industry 88 38 43.2% (VIC)

Mining Industry 165 49 29.7%

Note. N = 319

Table 6 shows that the retention rates were highest in men from the construction industry in Victoria and lowest from AFL coaches. The retention rate in men from the mining industry was relatively comparable to the retention rates of AFL past players, and construction workers from locations other than Victoria.

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Overall Evaluation Group (including treatment & control cohorts) – Description & Demographics

Table 7 Average age of evaluation cohorts who completed follow-up survey 1

Average Age in Years (SD)

Total Sample 45.91 (10.54)

Evaluation Cohort

Past AFL Players 47.75 (12.87)

AFL Coaches 45.82 (7.74)

Construction Industry (Other) 45.30 (9.99)

Construction Industry (VIC) 44.67 (8.80)

Mining Industry 44.64 (8.80)

Note. N = 319

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Table 8 Breakdown of state location where survey respondents resided

State AFL Players AFL Coaches Construction Construction Mining Workers (other) Workers (vic) NT 0 0 0 0 1

NSW 6 6 47 0 1

Victoria 42 42 0 38 1

Queensland 6 6 71 0 42

SA 3 3 23 0 2

WA 6 6 15 0 2

Tasmania 1 1 1 0 0

Reports on Measures: Psychometrics The statistical properties of the survey instruments included in Follow-up Survey 1 were examined to ensure that the measures were psychometrically sounds and that they displayed comparable reliability coefficients to the baseline survey (see Table 9).

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Table 9 Internal consistency estimates for Self-Stigma of Depression Scale (SSDS) and Depression Stigma Scale (DSS) used in follow-up survey 1

Scale Cronbach’s alpha

SSDS Total .90

SSDS Shame .85

SSDS Self Blame .80

SSDS Social Inadequacy .77

SSDS Help-seeking Inhibition .82

DSS .82

Note. N= 319

The internal consistency on all scales for participants completing the follow up survey were above .7 which is the criteria used for acceptability and were consistent with the values reported for the men at baseline.

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Descriptives of measures of overall group at follow-up Descriptive data of the psychometric measures used in Follow-up survey 1 are provided in Table 10.

Table 10 Descriptive statistics of the Self-Stigma of Depression Scale (SSDS) and Depression Stigma Scale (DSS) for the total sample for follow-up 1 survey

Total Sample

M (SD) Range

SSDS Total Score 51.74 (10.53) 18 – 77

SSDS Shame 12.20 (3.51) 4 – 20

SSDS Self Blame 13.05 (3.25) 4 – 20

SSDS Social Inadequacy 14.24 (2.77) 5 – 20

SSDS Help-seeking Inhibition 12.26 (3.53 4 – 20

DSS 19.62 (5.22) 9 – 35

As with baseline data, in order to ascertain the areas where stigma was highest the percentage of men agreeing or strongly agreeing with each item was calculated. These data are presented in Tables 1-5 in the Appendix 4. Inspection of Table 1 columns 4 and 5, revealed the top five most strongly endorsed items (highest percentages of men either agreeing or strongly agreeing with the item) which were indicative of highest rates of self-stigma according to the SDSS at follow up for the total sample. These were: I would think I should be stronger ‘; I would feel like I was good company (reverse scored); I would feel like a burden to other people; I would feel inadequate around other people; and I wouldn’t want people to know I was not coping. The rate of men agreeing or strongly agreeing to these items was between 60-70%. Consistent with baseline data, in terms of personal stigma highest rates of stigma related to people with depression being dangerous (13% either agreeing or strongly agreeing), not telling anyone if they had depression (27%), and the belief that people with depression are unpredictable (34%).

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Descriptives of Measures by Occupation in Campaign Group A cohort breakdown of the campaign group of scale averages for the SSDS and DSS are provided in Table 11a and a comparison of the campaign and mining groups in Table 11b. Also included are descriptives of the researcher developed behavioural questions in Table 11d, 11e and 11f.

Table 11a Descriptive statistics of the Self-Stigma of Depression Scale (SSDS) and Depression Stigma Scale (DSS) for campaign cohorts for follow-up 1 survey

Past AFL Players AFL Coaches Construction Construction Workers Workers (other) (VIC)

M (SD) Range M (SD) Range M (SD) Range M (SD) Range

SSDS Total 49.67 33 - 67 50.09 35 - 65 51.72 18 - 75 53.24 33 - 77 (7.70) (10.88) (11.78) (11.11)

SSDS Shame 11.47 4 - 18 12.36 8 - 16 12.22 4 - 20 12.42 5 - 20 (3.02) (3.11) (3.67) (3.74)

SSDS Self Blame 12.82 5 - 18 12.55 7 - 18 12.82 8 - 20 13.82 7 - 19 (2.90) (3.83) (3.58) (2.96)

SSDS Social 13.80 7 - 20 13.45 9 - 17 14.37 7 - 20 14.21 8 - 20 Inadequacy (2.69) (2.66) (2.74) (2.89)

SSDS Help-seeking 11.58 6 - 17 11.73 8 - 17 12.30 6 - 20 12.79 6 - 20 Inhibition (2.79) (3.32) (3.78) (4.01)

DSS 18.93 11 - 27 19.64 12 - 28 19.95 10 - 29 19.61 11 - 35 (4.14) 5.24) (5.79) (5.78)

As can be observed in Table 11a there was a tendency for the Past AFL players and coaches to score lower on self-stigma (SSDS) than the construction workers (particularly those from Victoria). The breakdown of stigma according to agreement on each item on the SSDS revealed lower levels of agreement (by 13% or more) in AFL Past Players relative to men from other groups with items related to taking antidepressants as being a sign of weakness, feeling embarrassed about seeking help and feeling ashamed (see Appendix 4, Table 3). As well, AFL Past players and coaches scored lower than men from the construction industry (by more than 10%) in relation to feeling inadequate around others. There was relative consistency across groups of men with respect to rates of agreement on individual items of the DSS (see Appendix 4, Table 3).

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Comparison Overall Campaign Group V Miners Of the 319 respondents who completed Follow-up 1 Survey, 270 participants from the past AFL players, AFL coaches and construction workers formed the campaign group while 49 miners comprised the control group. Table 11b displays the scores of the SSDS and DSS between campaign and control group.

Table 11b Means and standard Deviations of SSDS and DSS for the Better Out Than In campaign and control groups

Campaign Group (Players, Coaches, Control Group (Miners) Construction Workers)

M (SD) Range M (SD) Range

SSDS Total 51.40 (10.3) 18 - 77 53.60 (8.62) 34-73

SSDS Shame 12.08 (3.52) 4 - 20 12.83 (3.47) 4-20

SSDS Self Blame 12.96 (3.36) 4 - 20 13.54 (2.58) 8-20

SSDS Social 14.18 (2.75) 5 - 20 14.56 (2.99) 7-20 Inadequacy

SSDS Help-seeking 12.18 (3.59) 4 - 20 12.67 3.20) 6-20 Inhibition

DSS 19.65 (5.41) 9 - 35 19.48 (4.06) 10-29

Note. N = 319 Consistent with baseline data while both the campaign group and mining group had comparable mean scores on personal stigma (DSS), mean self-stigma scores (SSDS) were slightly elevated in the mining group relative to the campaign group. Consistent with baseline data, in terms of individual self stigma items, men in the control group had higher rates of agreement by 10% or more (see Appendix 4, Table 5 columns 6-9) on two items both relating to feeling embarrassed (‘I would feel embarrassed’ and ‘I would feel embarrassed about seeking professional help’).

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Data in Table 11c report on the number of men responding with a yes or no to the questions about whether they have known selected other people who have been doing it tough over the last month.

Table 11c Frequency of responses to researcher developed behaviour towards other questions for the total sample at follow-up 1 survey

Question Yes No

Interacting with others. In the past month…

do you know of a workmate who has been doing it tough? 174 131

do you know of a family member who has been doing it tough? 158 146

do you know of a friend who has been doing it tough? 152 152

have you thought that your partner was doing it tough? 114 153

As can be observed in Table 11c more than 50% of the follow- up sample had interacted in the past month with someone they identified as doing it tough. Consistent with data from baseline the one exception was in the partner category where this was 43%

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Table 11d to 11f report on the behavioural measures developed by the research team for the campaign and mining groups separately.

Table 11d Frequency of responses to researcher developed behaviour towards other questions for campaign and mining groups at follow-up 1 survey. Thinking of the people listed, how often have you spoken to them about what is troubling them when you thought they were doing it tough?

Not at all Hardly at all Some of the Most of the Every day I have days I have had days I have had had contact with contact with contact with them them them Campaign Group Workmate 1 11 67 48 15

Family 2 2 11 12 4

Friend 0 6 9 8 2

Partner 0 0 6 6 8

Mining Group

Workmate 1 5 12 8 6

Family 5 18 31 37 36

Friend 2 17 47 37 23

Partner 0 5 18 31 40

Consistent with baseline data there were a larger number of responses in higher frequency categories (most of the days I had contact with them and every day I had contact with them) than in the lower frequency categories (not at all and hardly at all) for all categories of people that were perceived as doing it tough.

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Table 11e Frequency of responses to researcher developed behaviour towards themselves questions for campaign and mining groups at follow-up 1 survey. In the past month how often have you spoken to a family member/friend/GP/partner about what is troubling you when you were doing it tough?

Not at all Hardly at all Some of the Most of the Every day I have days I have had days I have had had contact with contact with contact with them them them Campaign Group Workmate 56 22 32 12 5

Family 37 30 31 22 7

Friend 43 33 38 8 5

GP (Doctor) 93 4 20 2 8

Partner 16 19 31 22 16

Mining Group

Workmate 11 10 5 3 1

Family 13 8 4 1 4

Friend 10 11 8 0 1

GP (Doctor) 19 4 3 3 1

Partner 7 3 8 1 3

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When men at the first follow up were asked about how often they spoke to selected people over the last month about what was troubling them when they (themselves) were doing it tough there were a larger number of responses in the lower frequency categories (not at all and hardly at all) than in the higher frequency categories (most of the days I had contact with them and every day I had contact with them). This was apparent for all 5 categories of people in the mining group and for 4 of the 5 categories for the campaign group: the exception was partners (where the reverse pattern was exhibited). This was typically consistent with the pattern exhibited at the baseline assessment.

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Table 11f contains data from men who reported not doing it tough themselves over the last month. These men were asked about their likelihood of seeking help from others if they were doing it tough/ depressed. Table 11f Frequency of responses to researcher developed behaviour towards themselves questions for the campaign and mining groups at follow-up 1 survey. Imagine you were doing it tough / feeling depressed. How likely would you seek help?

Extremely Unlikely Somewhat Likely Extremely likely unlikely unlikely Campaign Group Workmate 24 41 27 30 7

Family 2 24 30 49 24

GP (Doctor) 1 14 15 67 32

Partner or close 2 11 31 47 38 mate Mining Group

Workmate 1 6 4 5 16

Family 1 6 8 1 16

GP (Doctor) 0 0 5 7 4

Partner or close 1 5 7 3 16 mate

Consistent with data reported at baseline the number of men in both the campaign and mining groups rating themselves as either likely or extremely likely to seek help from family, GP (doctor), partner or close mate exceeded those who selected the unlikely or extremely unlikely categories.

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Comparison Campaign Group Engaging in Website V Those Not V Miners The Better Out Than In campaign was delivered as a digital campaign via several forms of media, social media (Facebook, Instagram and Twitter) which were used to either promote the campaign and/or provide short key campaign messages or brief videos. The core campaign resources, core messages and video segments of men’s stories were housed on the Better Out Than In website (http://betteroutthanin.com.au). We therefore asked participants if they had engaged with the website during the campaign in order to form three comparison groups at follow up: those who had been targeted in the campaign but did not access the website; those who had been targeted in the campaign and did access the website; and those who were not targeted by the campaign (the mining group), Tables 12 and 13 show the frequency and descriptives of campaign participants who indicated that they did access the website, campaign participants who indicated that they did not access the website, and the number of miners who were used as a control condition.

Table 12 Number of campaign participants who did and did not access the Better Out Than In Website

Group Did access the website Did not access the website

Campaign Cohort 72 198

Mining 0 49

As noted in Table 12 only participants from the campaign group accessed the Better Out Than In website prior to the first follow up. Specifically of the 270 participants in the campaign group with follow up data 72 (26.7%) had accessed the campaign website.

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Table 13 Descriptive statistics of SSDS and DSS of campaign participants who did and did not access the Better Out Than In Website

Campaign Group Campaign Group (no Mining Group (website engagement) website engagement)

M (SD) Range M (SD) Range M (SD) Range

SSDS Total 49.47 18-77 52.09 (9.82) 24-75 53.60 (8.62) 34-73 (13.18)

SSDS Shame 11.75 4-20 12.20 (3.38) 4-19 12.83 (3.47) 4-20 (3.87)

SSDS Self Blame 12.31 4-20 13.19 (3.17) 4-20 13.54 (2.58) 8-20 (3.79)

SSDS Social Inadequacy 13.82 5-20 14.30 (2.47) 8-20 14.56 (2.99) 7-20 (3.39)

SSDS Help-seeking 11.59 4-20 12.40 (3.36) 5-20 12.67 (3.20) 6-20 Inhibition (4.14)

DSS 17.90 9-30 20.28 (5.30) 9-35 19.48 (4.06) 10-29 (5.40)

Note. N = 319

As can be observed in Table 13 whilst the self-stigma (SSDS) and personal stigma (DSS) mean scores are comparable across the campaign group who did not engage with the website and the mining group, there was a tendency for men in the campaign group who did engage with the website to have lower mean self-stigma (SSDS) and personal stigma (DSS) mean scores at the first follow up assessment. Using planned contrasts, SSDS total stigma was significantly lower for campaign website engagement group than the mining group, p = .04. SSDS self-blame stigma was also significantly lower in the campaign website engagement group than the mining group, p = .04. No other differences on the SSDS were significant. Analysis of the differences between DSS scores across groups at the follow-up revealed that the group that did not access the campaign website had significantly higher DSS scores than those men in the campaign group that did access the website, p =.001. No other differences on the DSS were significant.

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Changes over time in campaign group overall (i.e. v their baseline scores), website group and mining control group

Self-stigma and personal stigma We also measured the change in scores of the campaign group between the first (baseline) and Follow-up Survey 1. Tables 14a, 14b, 14c and 15d provide indicators of possible change between survey administrations for the campaign group, for participants who accessed the website, those who did not access the website and for the mining control group on the SSDS and DSS.

Table 14a Change in SSDS and DSS scores between baseline survey and follow-up Survey 1 for campaign and mining control group.

Campaign Group (Players, Coaches, Control Group (Miners) Construction Workers)

Baseline Follow-up Baseline Follow-up

SSDS Total 51.88 (10.86) 51.40 (10.83) 53.00 (10.50) 53.60 (8.62)

SSDS Shame 12.15 (3.91) 12.08 (3.52) 12.97 (3.66) 12.83 (3.47)

SSDS Self Blame 13.11 (3.26) 12.96 (3.39) 12.65 (3.57) 13.54 (2.58)

SSDS Social 14.44 (2.74) 14.18 (2.75) 14.65 (2.99) 14.56 (2.99) Inadequacy

SSDS Help-seeking 12.19 (3.67) 12.18 (3.59) 12.73 (3.63) 12.67 3.20) Inhibition

DSS 19.05 (5.17) 19.65 (5.41) 19.03 (4.72) 19.48 (4.06)

Note. N = 319

Data in Table 14a indicate relative stability in self-stigma (SSDS) and personal stigma (DSS) across assessment periods for both men in the campaign and mining groups.

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Data in Table 14b below report on baseline and follow-up data for both self-stigma (SSDS) and personal stigma (DSS) scales for the campaign group that is further categorised into men who were in the targeted campaign group who did not engage with the website and those who did engage with the campaign website.

Table 14b Change in SSDS and DSS scores between baseline survey and follow-up survey 1 for campaign group who did engage with website, campaign group who did not engage with the website and mining control group

Website engagement No website engagement Mining Group

Baseline Follow-up Baseline Follow-up Baseline Follow-up

SSDS Total 52.50 49.47 51.68 (10.59) 52.09 53.00 53.60 (11.79) (13.14) (9.81) (10.50) (8.62)

SSDS Shame 12.54 11.75 12.03 (3.91) 12.20 12.97 (3.66) 12.83 (3.93) (3.87) (3.38) (3.47)

SSDS Self Blame 12.81 12.31 (3.79) 13.20 (3.23) 13.19 (3.17) 12.65 (3.57) 13.54 (3.37) (2.58)

SSDS Social Inadequacy 14.90 13.82 14.30 (2.73) 14.30 14.65 (2.99) 14.56 (2.76) (3.39) (2.47) (2.99)

SSDS Help-seeking 12.25 11.59 (4.14) 12.16 (3.59) 12.40 12.73 (3.63) 12.67 3.20) Inhibition (3.99) (3.36)

DSS 18.44 17.90 19.24 (5.24) 20.28 19.03 (4.72) 19.48 (4.92) (5.40) (5.30) (4.06)

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Table 14b shows a relative stability over assessments for the men on both self-stigma (SSDS) mean scores and personal stigma (DSS) mean scores for men in the mining group. However for men who were exposed to the campaign, both personal stigma (DSS) mean scores and self-stigma (SSDS) mean scores were slightly lower at the follow- up assessment relative to the baseline assessment.

One way of accessing whether these changes were statistically significant was to examine differences between these means once the baseline values were controlled for. This revealed that both campaign groups (website and no website exposure) had significantly lower overall SSDS scores at follow-up (suggestive of greater improvements relative to baseline) relative to the men in the mining group. No other differences reached significance.

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Stigma behaviour and stigma behavioural intentions We also assessed possible shifts in stigma related behaviour and stigma behavioural intentions in the campaign group between the first (baseline) and Follow-up Survey 1. Tables 15a, 15b, 15c. 15d, 15e, and 15f provide indicators of possible change between survey administrations for the total campaign group, for men in the campaign group further subcategorised into participants who accessed the Better Out Than In website and those who did not access the website and for men in the mining control group. In order to best assess change in self-reported behaviour from baseline to the first follow-up assessments on behaviour and behavioural intentions related to stigma we adopted the following processes

1. We obtained the total number of people at follow-up in both the campaign and mining groups who had answered yes to questions relating to knowing different people who had been doing it tough over the last month. 2. We then followed the same process for people who had acknowledged doing it tough themselves over the last month. 3. We then matched these people with their own baseline data on each of these assessments. For instance, as can be observed in Table 15a below 107 men in the campaign group at follow-up had answering yes to knowing a workmate who had been doing it tough over the last month also answered yes at baseline on this question – this enabled us to compare if there had been a shift in frequency categories across the two assessment periods for these same people.

This process was also followed for behavioural intention data for the people answering no about doing it tough themselves over the last month.

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One negative consequence of this process is data loss due to people answering yes about knowing different people who were doing it tough/ or doing it tough themselves at follow-up not having baseline data on the question on account of answering no to these questions at the earlier assessment. As such, some of the cell sizes in each category in Tables 15a to 15f were very small, particularly in the mining group and as such some changes based on low frequency shifts need to be interpreted with care. Given the modest sizes per category, frequency data are presented in 3 categories in each Table: Not at all and hardly at all were grouped (representing low frequency); some of the days I had contact with them (representing moderate frequency); and most of the days and every day I have had contact with them were grouped (representing high frequency). To aid interpretation of the data in these tables – changes of 5% or more between baseline and follow-up data are highlighted. Reductions over time are highlighted by italicised text and increases over time are highlighted as bold text.

Data in Table 15a below report on baseline and follow-up data for the overall campaign group and mining group for the researcher developed behavioural questions about how frequently men reported speaking to other people about what was troubling them when they thought that person had been doing it tough.

Table 15a Change in frequency of researcher developed behavioural measures between baseline survey and follow-up survey 1 for the campaign and mining control group. Thinking of the people listed, how often have you spoken to them about what is troubling them when you thought they were doing it tough?

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Table 15a

Campaign Group Mining Group

Baseline Follow-up Baseline Follow-up

Workmate

Not at all/Hardly at all 15 (14%) 10 (9%) 6 (22%) 7 (26%)

Some of the days I have had contact with them 51 (48%) 47 (44%) 11 (41%) 10 (37%)

Most of the days/Every day I have had contact with 41 (38%) 50 (47%) 10 (37%) 10 (37%) them Family Member

Not at all/Hardly at all 14 (12%) 20 (18%) 3 (11%) 4 (14%)

Some of the days I have had contact with them 34 (30%) 25 (22%) 10 (36%) 10 (36%)

Most of the days/Every day I have had contact with 66 (58%) 69 (60%) 15 (54%) 14 (50%) them Friend

Not at all/Hardly at all 15 (16%) 12 (13%) 3 (16%) 4 (21%)

Some of the days I have had contact with them 31 (34%) 37 (40%) 7 (37%) 5 (26%)

Most of the days/Every day I have had contact with 46 (50%) 43 (47%) 9 (47%) 10 (53%) them Partner

Not at all/Hardly at all 7 (9%) 5 (6%) 2 (10%) 0 (0%)

Some of the days I have had contact with them 13 (16%) 13 (16%) 5 (24%) 8 (38%)

Most of the days/Every day I have had contact with 59 (75%) 61 (77%) 14 (66%) 13 (62%) them

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As can be observed in Table 15a above there were changes of 5% or more across both the campaign and control conditions. For the mining group there was one increase from baseline to the first follow up in the high frequency category (i.e. most of the days/everyday…) of speaking to people about what was troubling them when they were doing it tough. This occurred with respect to friends who were doing it tough, although it should be noted that the increase of 6% (47% to 53%) was due to an increase of one person only. The remainder of changes in the mining group related to increases in the lower frequency speaking or changes in the middle frequency category.

For the overall campaign group there were two notable shifts from baseline to follow-up. First, there was a 6% (12% to 18%) increase in men either not speaking to or hardly speaking to a family member about what was troubling them when they were doing it tough. However, in terms of positive shifts there was a 9% (38% to 47%) increase in men from baseline to follow-up who reported speaking to workmates about what was troubling them most or all of the time they had contact with them. Data in Table 15b below report on baseline and follow-up data for the campaign group categorised by whether they reported engaging with the Better Out Than In website and mining group for the researcher developed behavioural questions about how frequently men reported speaking to other people about what was troubling them when they thought that person had been doing it tough.

Table 15b Change in frequency of researcher developed behavioural measures between baseline survey and follow-up survey 1 for the campaign group who did engage with the website, the campaign group who did not engage with the website and the mining control group. Thinking of the people listed, how often have you spoken to them about what is troubling them when you thought they were doing it tough?

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Table 15b

Website Engagement No Website Mining Group Group Engagement Group Baseline Follow- Baseline Follow-up Baseline Follow-up up Workmate

Not at all/Hardly at all 3 (10%) 3 (10%) 13 (16%) 7 (9%) 6 (22%) 7 (26%)

Some of the days I have had contact with 15 (52%) 12 (41%) 36 (46%) 35 (44%) 11 (41%) 10 (37%) them Most of the days/Every day I have had 11 (38%) 14 (48%) 30 (38%) 37 (49%) 10 (37%) 10 (37%) contact with them Family Member

Not at all/Hardly at all 4 (14%) 4 (14%) 10 (12%) 16 (19%) 3 (11%) 4 (14%)

Some of the days I have had contact with 5 (17%) 3 (10%) 29 (34%) 34 (40%) 10 (36%) 10 (36%) them Most of the days/Every day I have had 20 (69%) 22 (76%) 46 (54%) 35 (41%) 15 (54%) 14 (50%) contact with them Friend

Not at all/Hardly at all 5 (18%) 4 (14%) 10 (14%) 16 (23%) 3 (16%) 4 (21%)

Some of the days I have had contact with 8 (29%) 3 (11%) 23 (33%) 18 (26%) 7 (37%) 5 (26%) them Most of the days/Every day I have had 15 (54%) 21 (75%) 36 (52%) 35 (51%) 9 (47%) 10 (53%) contact with them Partner

Not at all/Hardly at all 4 (17%) 3 (13%) 3 (5%) 2 (4%) 2 (10%) 0 (0%)

Some of the days I have had contact with 3 (13%) 3 (13%) 10 (18%) 13 (23%) 5 (24%) 8 (38%) them Most of the days/Every day I have had 16 (70%) 17 (74%) 43 (77%) 41 (73%) 14 (66%) 13 (62%) contact with them

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Mining data in Table 15b are identical to that reported in 15a and are here for comparison purposes only.

For men in the campaign group who did not engage with the website there were two shifts of 5% or more in the low frequency category of speaking to people about what was troubling them when they were doing it tough and one in the high frequency category. There was a 9% increase from baseline to follow up (14% to 23%) in the number of men reporting low frequencies of speaking to friends about what was troubling them. Conversely there was a 7% reduction over time (16% to 9%) in men reporting low frequencies (i.e. not at all or hardly at all) of speaking to workmates about what was troubling them which was coupled by a 11% increase from baseline to follow up (38% to 49%) in the number of men reporting speaking to their workmates about what was troubling them either most or all of time they had contact with them. For the men in the campaign group who did engage with the Better Out Than In campaign website between the baseline and follow up assessments there were 3 notable changes of 5% or more in the high frequency category of speaking to people about what was troubling them when they were doing it tough. Specifically, the number of men speaking to others about what was troubling them most or all of the time they had contact with them increased by 21% (54% to 75%) for friends, 10% for workmates (38% to 48%) and 7% for family members (69% to 76%) Data in Table 15c below report on baseline and follow-up data for the overall campaign group and mining group for the researcher developed behavioural questions about how frequently men reported speaking to other people about what was troubling them when they themselves had been had been doing it tough during the past month.

Table 15c Change in frequency of researcher developed behavioural measures between baseline survey and follow-up survey 1 for the campaign and mining control group. Thinking of the people listed, how often have you spoken to them about what is troubling you when you were doing it tough?

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Table 15c

Campaign Group Mining Group

Baseline Follow-up Baseline Follow-up

Workmate

Not at all/Hardly at all 64 (65%) 58 (58%) 11 (42%) 16 (62%)

Some of the days I have had contact with them 21 (21%) 25 (25%) 13 (50%) 6 (23%)

Most of the days/Every day I have had contact with 15 (15%) 17 (17%) 2 (8%) 4 (15%) them Family Member

Not at all/Hardly at all 54 (59%) 48 (52%) 10 (40%) 15 (60%)

Some of the days I have had contact with them 27 (29%) 20 (23%) 9 (36%) 3 (12%)

Most of the days/Every day I have had contact with 11 (12%) 23 (25%) 6 (24%) 7 (28%) them Friend

Not at all/Hardly at all 60 (65%) 57 (62%) 17 (65%) 16 (62%)

Some of the days I have had contact with them 23 (25%) 24 (27%) 6 (23%) 8 (31%)

Most of the days/Every day I have had contact with 9 (10%) 10 (11%) 3 (12%) 2 (7%) them GP (Doctor)

Not at all/Hardly at all 78 (85%) 76 (83%) 19 (73%) 20 (76%)

Some of the days I have had contact with them 5 (5%) 9 (10%) 4 (15%) 3 (12%)

Most of the days/Every day I have had contact with 9 (10%) 6 (7%) 3 (12%) 3 (12%) them Partner

Not at all/Hardly at all 30 (33%) 32 (35%) 5 (22%) 7 (33%)

Some of the days I have had contact with them 21 (24%) 27 (30%) 4 (18%) 7 (33%)

Most of the days/Every day I have had contact with 30 (33%) 32 (35%) 13 (60%) 7 (33%) them

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As can be observed in Table 15c above there were changes of 5% or more across both the campaign and control conditions.

For the mining group shifts from baseline to follow-up were typically in the negative direction. For instance, there were 20% increases in the number of men reporting either not speaking or hardly at all speaking about what was troubling them to either their workmates (from 42% to 62%) or family members (from 40% to 60%). As well, there was an 11% (22% to 33%) increase in the number of miners either not speaking or hardly speaking to their partners about what was troubling them. However, one positive shift with respect to partners was a 15% (18% to 33%) increase in the number of men who identified as doing it tough speaking to their partners about what was troubling them some of the time they had contact with them. The other notable shift was that 27% less men reported speaking to their partners (from 60% to 33%) about what was troubling them either most or all of the days they had contact with them. For the overall campaign group there were three notable shifts from baseline to follow-up in terms of men who identified as doing it tough speaking to other people about what was troubling them. All three shifts were in the positive direction. First, 7% fewer men at follow up relative to baseline reported not speaking or hardly speaking to a family member (from 59% to 52%) or workmate (65% to 58%) about what was troubling them when they were doing it tough. Second, 13% more men in the campaign group reported speaking to a family member most of the days/every day I have had contact with them about was troubling them at follow-up relative to baseline. Data in Table 15d below report on baseline and follow-up data for the campaign group categorised by whether they reported engaging with the Better Out Than In website and mining group for the researcher developed behavioural questions about how frequently how frequently men reported speaking to other people about what was troubling them when they themselves had been had been doing it tough during the past month.

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15d Change in frequency of researcher developed behavioural measures between baseline survey and follow-up survey 1 for the campaign group who did engage with the website, the campaign group who did not engage with the website and the mining control group. Thinking of the people listed, how often have you spoken to them about what is troubling you when you were doing it tough?

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Table 15d

Website Engagement No Website Mining Group Group Engagement Group Baseline Follow- Baseline Follow-up Baseline Follow-up up Workmate

Not at all/Hardly at all 12 (60%) 12 (60%) 52 (72%) 46 (64%) 11 (42%) 16 (62%)

Some of the days I have had contact with 5 (25%) 4 (20%) 16 (22%) 20 (28%) 13 (50%) 6 (23%) them Most of the days/Every day I have had 3 (15%) 4 (20%) 4 (6%) 6 (8%) 2 (8%) 4 (15%) contact with them Family Member

Not at all/Hardly at all 10 (50%) 8 (32%) 44 (61%) 42 (58%) 10 (40%) 15 (60%)

Some of the days I have had contact with 7 (35%) 7 (35%) 20 (28%) 15 (21%) 9 (36%) 3 (12%) them Most of the days/Every day I have had 3 (15%) 5 (32%) 8 (11%) 15 (21%) 6 (24%) 7 (28%) contact with them Friend

Not at all/Hardly at all 16 (80%) 11 (55%) 44 (61%) 47 (68%) 17 (65%) 16 (62%)

Some of the days I have had contact with 2 (10%) 7 (35%) 21 (29%) 19 (26%) 6 (23%) 8 (31%) them Most of the days/Every day I have had 2 (10%) 2 (10%) 7 (10%) 6 (8%) 3 (12%) 2 (7%) contact with them GP (Doctor)

Not at all/Hardly at all 14 (70%) 16 (75%) 64 (89%) 60 (83%) 19 (73%) 20 (76%)

Some of the days I have had contact with 3 (15%) 1 (10%) 2 (3%) 8 (11%) 4 (15%) 3 (12%) them Most of the days/Every day I have had 3 (15%) 3 (15%) 6 (8%) 4 (6%) 3 (12%) 3 (12%) contact with them Partner

Not at all/Hardly at all 4 (22%) 5 (29%) 26 (41%) 26 (41%) 5 (22%) 7 (33%)

Some of the days I have had contact with 5 (28%) 3 (18%) 16 (25%) 24 (38%) 4 (18%) 7 (33%) them Most of the days/Every day I have had 9 (50%) 10 (53%) 21 (34%) 13 (21%) 13 (60%) 7 (33%) contact with them

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Mining data in Table 15d are identical to that reported in 15c and are here for comparison purposes only.

For men in the campaign group who did not engage with the website there were shifts of 5% or more in frequency of speaking to others about what was troubling them (personally) with respect to all categories of people other than workmates. Changes with respect to family were mixed. Whilst 10% (11% to 21%) more men at follow up reported speaking to a family member about what was troubling them all or most of the time they had contact with them, 7% (28% to 21%) less men reported speaking to family members about this in the some of the time category. Negative changes over time were reported with respect to both speaking to their friends and partner about what was troubling them when they were doing it tough. For instance there was a 13% (34% to 21%) reduction in the number of men reporting speaking to partners most or all of the days they had contact with them and 7% (61% to 68%) more men reported either not speaking to or hardly speaking to friends about what was troubling them personally at the follow up assessment. For men in the campaign group who did not respond to the website there were several positive shifts in terms of the men reporting speaking to GPs when they were doing it tough. Specifically, 6 % (89% to 83%) less men at follow up relative to baseline reported not speaking or hardly speaking to a GP about what was troubling them when they were doing it tough. It ought to be noted that these figures remained very high. Second, 8% (3% to 11%) more men in the campaign group reported speaking to a GP some of the time they had contact with them. However despite the shift this overall percentage remains low. For the men in the campaign group who did engage with the Better Out Than In campaign website between the baseline and follow up assessments changes of 5% or more were typically in the positive direction. The one exception was for speaking to GPs where 5% (70% to 75%) more men either did not speak to GPs at all or hardly spoke to then about what was troubling them when they identified as doing it tough over the last month.

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For men who did engage with the website, positive shifts over time did occur with respect to speaking with friends, workmates and family members. For instance, as can be observed in Table 15d 17% (15% to 32%) more men who identified as doing it tough reported speaking about what was troubling them to family members most or all of the time they had contact with them. The comparable increase for workmates was 5% across the assessment periods (15% to 20%). Data in Table 15e below report on baseline and follow-up data for the overall campaign group and mining group for the modified version of the help seeking likelihood scale (Barney et al., 2010) in which men were asked about how likely they would be to seek help from other people if they were depressed/doing it tough.

15e Frequency of responses from men in the campaign and mining groups to the modified version of the help seeking likelihood scale (Barney et al., 2010) in which respondents were asked about how likely they would be to seek help from other people if they were depressed/doing it tough

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Table 15e

Campaign Group Mining Group

Baseline Follow-up Baseline Follow-up

Workmate

Extremely Unlikely/Unlikely 61 (57%) 52 (50%) 4 (34%) 5 (42%)

Somewhat likely 19 (18%) 20 (19%) 6 (50%) 5 (42%)

Likely/Extremely Likely 24 (23%) 32 (31%) 2 (16%) 2 (16%)

Family Member

Extremely Unlikely/Unlikely 22 (26%) 22 (26%) 2 (17%) 4 (33%)

Somewhat likely 17 (20%) 20 (24%) 3 (25%) 6 (50%)

Likely/Extremely Likely 46 (54%) 43 (50%) 7 (58%) 2 (17%)

GP (Doctor)

Extremely Unlikely/Unlikely 20 (17%) 13 (13%) 2 (16%) 2 (16%)

Somewhat likely 22 (20%) 17 (16%) 5 (42%) 7 (58%)

Likely/Extremely Likely 70 (62%) 84 (81%) 5 (42%) 3 (25%)

Partner / Close Mate

Extremely Unlikely/Unlikely 14 (13%) 11 (11%) 3 (25%) 4 (33%)

Somewhat likely 15 (15%) 20 (19%) 2 (16%) 6 (50%)

Likely/Extremely Likely 75 (72%) 73 (70%) 7 (59%) 2 (17%)

As can be observed in Table 15e there were 5% shifts from the baseline to follow up assessment for both men in the campaign and mining groups.

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For men in the mining groups there were several positive shifts over time in the number of men reporting being somewhat likely to seek help from family members (25% to 50%), a GP (42% to 58%) and partner/close mate (16% to 50%) in the event that they were doing it tough/depressed. However the majority of shifts were negative. For instance there were increases in the number of men reporting been extremely unlikely or unlikely to seek help from a partner/close mate (25% to 33%), family member (17% to 33%) or workmate (33% to 42%) when they were asked what they would do if depressed/doing it tough. For men in the campaign group there were no negative shifts over time and positive shifts with respect to reporting been more likely to seek help their workmates or GP when they were asked what they would do if depressed/doing it tough. For instance, 7% (57% to 50%) less men at follow up relative to baseline reported been unlikely or extremely unlikely to seek help from a workmate and 8% (23% to 31%) more men reported been likely or extremely likely to seek help from a workmate. With respect to GPs, 19% (62% to 81%) more men at follow–up reported been likely or extremely likely to seek help from GPs if they were depressed/doing it tough. Data in Table 15f below report on baseline and follow-up data for the campaign group categorised by whether they reported engaging with the Better Out Than In website and mining group for the modified version of the help seeking likelihood scale (Barney et al., 2010) in which men were asked about how likely they would be to seek help from other people if they were depressed/doing it tough.

15f Frequency of responses from men who engaged with the website, who did not engage with the website and mining groups to the modified version of the help seeking likelihood scale (Barney et al., 2010) in which respondents were asked about how likely they would be to seek help from their other people if they were depressed/doing it tough.

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Table 15f

Website Engagement No Website Mining Group Group Engagement Group Baseline Follow- Baseline Follow-up Baseline Follow-up up Workmate

Extremely Unlikely/Unlikely 18 (64%) 13 (46%) 43 (57%) 40 (52%) 4 (34%) 5 (42%)

Somewhat likely 5 (18%) 5 (18%) 14 (18%) 18 (24%) 6 (50%) 5 (42%)

Likely/Extremely Likely 5 (18%) 10 (36%) 19 (25%) 18 (24%) 2 (16%) 2 (16%)

Family Member

Extremely Unlikely/Unlikely 5 (18%) 2 (7%) 17 (20%) 20 (23%) 2 (17%) 4 (33%)

Somewhat likely 3 (11%) 9 (32%) 14 (16%) 26 (30%) 3 (25%) 6 (50%)

Likely/Extremely Likely 20 (71%) 17 (61%) 55 (64%) 40 (47%) 7 (58%) 2 (17%)

GP (Doctor)

Extremely Unlikely/Unlikely 4 (14%) 5 (18%) 18 (21%) 11 (13%) 2 (16%) 2 (16%)

Somewhat likely 2 (7%) 2 (7%) 18 (21%) 10 (12%) 5 (42%) 7 (58%)

Likely/Extremely Likely 22 (79%) 21 (75%) 48 (58%) 63 (75%) 5 (42%) 3 (25%)

Partner

Extremely Unlikely/Unlikely 3 (11%) 0 (0%) 15 (18%) 11 (13%) 3 (25%) 4 (33%)

Somewhat likely 2 (7%) 6 (21%) 17 (20%) 22 (26%) 2 (16%) 6 (50%)

Likely/Extremely Likely 23 (82%) 22 (79%) 52 (62%) 51 (61%) 7 (59%) 2 (17%)

Mining data in Table 15f are identical to that reported in 15e and are here for comparison purposes only.

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For men in the campaign group who did not engage with the Better Out Than In website over the course of the campaign there were reductions over time in the percentage of men reporting that they would be unlikely or extremely unlikely to seek help from partners/close mates (18% to 13%), GPs (21% to 13%), and workmates (57% to 52%). Other positive shifts from the assessment at baseline to first follow up period included a 17% (58% to 75%) increase in the number of men reporting being likely or extremely likely to seek help from their GP if they were to be depressed or doing it tough and somewhat more likely to seek help from workmates (18% to 24%) and partners/close mates (20% to 26%). For men in the campaign group who did engage with the Better Out Than In website over the course of the campaign, consistent with the men who did not engage with the website there were reductions over time in the percentage of men reporting that they would be unlikely or extremely unlikely to seek help from partners/ close mates (18% to 7%) and workmates (64% to 46%). With respect to workmates there as a further 18% (18% to 36%) increase across assessments in the amount of men reporting that they would be either likely or extremely likely to seek help from a workmate if feeling depressed/doing it tough. However in contrast to the men who did not access the website there were no positive shifts in the likelihood of seeking help from GPs and several positive shifts in the likelihood of contacting a family member. Specifically, positive changes were recorded across all three categories for family member. There was a 10% (71% to 61%) reduction in the amount of men reporting they would be either likely or extremely likely to seek help from a family member, a 11% (21% to 10%) reduction in the amount of men reporting that they would be unlikely or extremely unlikely to seek help from a family member and a 21% (11% to 32%) increase in men endorsing the somewhat likely category.

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Follow up one key findings • There were data for 317 participants at follow-up, which represented a little over a 30% retention rate .

• Of the 270 participants in the campaign group with follow up data 72 (26.7%) had accessed the Better Out Than In campaign website. On the basis of the website containing the full complement of campaign resources (a more potent dose of the intervention than social media alone) the campaign group was subdivided into those who did engage with the website and those that did not between baseline and follow-up assessments. This resulted in some small cell sizes in categories and data need to be interpreted in light of this.

• Analysis of self-stigma and personal stigma data suggested that for men who reported engaging with the Better Out Than In campaign website, both personal stigma (DSS) mean scores and self-stigma (SSDS) mean scores were slightly lower at the follow-up assessment relative to the baseline assessment. The self- stigma scores were significantly lower in men exposed to the campaign relative to men from the mining group.

• Men that reported engaging with the website reported the most favourable shifts on the self-report behavioural measures of how frequently they spoke to others about was troubling these people when they were doing it tough. For instance more men in this group reported speaking to their friends, workmates and family members about what was troubling them most or all of the time they had contact with them.

• Data on the behavioural measure concerning the frequency with which men who identified as doing it tough speak to others about what is personally troubling them revealed that men in the campaign group reported some positive shifts over the campaign period, particularly with respect to speaking about what was troubling them more often to family members. This was in contrast to the mining group which primarily reported negative shifts from baseline to the first follow-up.

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• Consistent with finding regarding frequencies with which men spoke to other who were doing it tough, it was men that reported engaging in with the website who reported the most favourable shifts in frequency of speaking to others when they themselves were doing it tough. This was particularly evident for more frequently speaking about what was troubling them with friends and workmates.

• Whilst improvements were reported across some categories of people for the campaign group it is still concerning that with the exception of the frequency of contact with partners and the improvement recorded for the family member category for people who engaged in the website over 50% of men in the campaign groups still reported either not speaking or hardly speaking about their own problems with other people when they were doing it tough. Indeed over 70% of the men at the follow up assessment reported either not or hardly speaking to GPs about what was troubling them.

• The campaign group who did not identify as doing it tough over the last month reported being more likely to seek help at the follow up assessment relative to baseline if they were to imagine they were depressed/doing it tough. This was particularly evident with respect to being more likely to seek help from GPs and workmates. Positive shifts in favour of the group that engaged with the website relative to those not engaging with the website were less pronounced than with other stigma measures. In contrast to the campaign group the mining group typically reported being less likely over time to seek help from people if they were to be doing it tough or depressed.

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6.3 PHASE THREE – FOLLOW UP TWO

This data collection phase which ran from March-April 2017 involved following up the men in the campaign and mining control group who responded to the first follow up survey. The 317 men were invited to complete the full survey for the third and final time. Men in the campaign group were also invited to participate in individual telephone interviews. Specifically, participants who did engage with the campaign were asked via an individual interview about what they liked about the Better Out Than In campaign, how they engaged with it and how they think it could be improved. As well, a subset of participants who did not engage with the campaign were asked about why this was the case and what would have encouraged them to engage with the campaign.

Phase 3 – Follow-up Two Survey data

Number of participants recruited over what time Participants who responded to first follow-up survey were invited to participate in the second follow-up survey (termed ‘Follow-up 2 survey’). Follow-up 2 survey contained the same questions and scales as reported in the baseline survey and follow-up one surveys (i.e., SSDS, DSS, behavioural questions towards others and self, and intended help seeking behaviour). The recruitment period spanned March to April 2017. After data screening and exclusion criteria were applied, there were 103 valid responses comprising of men from AFL players, AFL coaches, construction workers and the mining industry – a 33.8% retention rate.

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Table 16 Retention rates from baseline to follow-up survey 1 to follow- up survey 2

Cohort group Baseline Follow-up 1 Survey Follow-up 2 Survey % retention at Follow-up 2

Past AFL Players 202 64 18 28.1%

AFL Coaches 77 11 5 45.5%

Construction 547 157 50 31.8% Industry (Other)

Construction 88 38 11 28.9% Industry (VIC)

Mining Industry 165 49 19 38.7%

Note. N for follow-up survey = 103

Table 16 shows that the retention rates were highest in men from the from AFL coaches and lowest from the past AFL players. The retention rate in men from the mining industry was slightly higher than all other groups except AFL coaches.

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Overall Evaluation Group (including treatment & control cohorts) – Description & Demographics

Table 17 contains the average ages of people responding to the follow-up survey broken down by industry.

Table 17 Average age of evaluation cohorts who completed follow-up survey 2

Average Age in Years (SD)

Total Sample 47.73 (10.19)

Evaluation Cohort

Past AFL Players 49.75 (12.05)

AFL Coaches 46.80 (7.40)

Construction Industry (Other) 47.44 (10.15)

Construction Industry (VIC) 48.20 (11.25)

Mining Industry 46.72 (9.38)

Note. N = 103

As can be observed in Table 17 average age, despite a tendency to be higher in the past AFL players was relatively consistent across industry groups. As with all previous assessments, the statistical properties of the survey instruments included in Follow-up Survey 2 were examined to ensure that the measures were psychometrically sounds and that they displayed comparable reliability coefficients to the previous survey administrations (see Tables 4 & 9).

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Table 18 Internal consistency estimates for Self-Stigma of Depression Scale (SSDS) and Depression Stigma Scale (DSS) used in follow-up survey 2

Scale Cronbach’s alpha (FU2)

SSDS Total .91

SSDS Shame .86

SSDS Self Blame .82

SSDS Social Inadequacy .77

SSDS Help-seeking Inhibition .85

DSS .63

Note. N = 103

The internal consistency on the majority of scales for participants completing the follow up survey were above .7, which is the criteria used for acceptability these were consistent with the values reported for the men at baseline. The one exception was the DSS where this fell slightly below .7.

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Descriptives of measures of overall group at follow-up

Descriptive data for the validated stigma measures used In Follow- up survey 2 are presented in Table 19

Table 19 Descriptive statistics of the Self-Stigma of Depression Scale (SSDS) and Depression Stigma Scale (DSS) for the total sample for follow-up 2 survey

Total Sample

M (SD) Range

SSDS Total Score 50.96 (11.14) 22-76

SSDS Shame 12.20 (3.61) 4-20

SSDS Self Blame 12.71 (3.37) 4-20

SSDS Social Inadequacy 14.17 (2.74) 8-20

SSDS Help-seeking Inhibition 11.87 (3.73) 5-20

DSS 21.42 (4.21) 13-33

Note. N = 103 As with baseline and follow-up assessments the rate of agreement with individual SSDS items were calculated to ascertain where self-stigma was highest (see Appendix 4, Table 1 columns 6 and 7). The top five most strongly endorsed items (highest percentages of men either agreeing or strongly agreeing with the item) which were indicative of highest rates of self-stigma according to the SDSS at follow up 2 for the total sample were: I would think I should be stronger ‘; I would feel like I was good company (reverse scored); I would feel like a burden to other people; I would feel inadequate around other people; and I wouldn’t want people to know I was not coping. These were identical to those at follow-up one. The rate of men agreeing or strongly agreeing to these items were between 61-70%.

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Descriptives of Measures by Occupation in Campaign Group

A cohort breakdown of the campaign group of scale averages for the SSDS and DSS are provided in Table 20a and a comparison of the campaign and mining groups in Table 20b. Also included are descriptives of the researcher developed behavioural questions in Tables 20c, 20d, 20e and 20f

Table 20a Descriptive statistics of the Self-Stigma of Depression Scale (SSDS) and Depression Stigma Scale (DSS) for campaign cohorts for follow-up 2 survey

Past AFL Players AFL Coaches Construction Construction Workers Workers (other) (VIC)

M (SD) Range M (SD) Range M (SD) Range M (SD) Range

SSDS Total 48.22 31-68 50.40 38-58 51.10 24-73 50.00 22-75 (8.38) (8.08) (11.90) (13.83)

SSDS Shame 11.39 8-16 13.20 7-16 12.26 4-20 11.82 4-19 (2.50) (3.83) (3.77) (4.14)

SSDS Self Blame 12.06 8-17 12.80 11-15 12.52 4-20 12.82 4-20 (2.58) (1.64) (3.76) (4.02)

SSDS Social 13.72 9-17 13.20 8-19 14.46 8-20 13.00 8-17 Inadequacy (2.37) (3.96) (2.61) (3.07)

SSDS Help-seeking 11.06 5-18 11.20 7-14 11.86 5-20 12.36 6-19 Inhibition (3.49) (2.59) (4.00) (3.88)

DSS 20.28 13-27 21.80 19-29 21.48 13-33 22.55 18-32 (4.10) (4.21) (4.37) (4.01)

Note. N = 84

Consistent with data from Follow-up 1 survey there was a tendency for past AFL players to score lower on self-stigma (SSDS) and personal stigma (DSS) relative to construction workers.

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The breakdown of stigma according to agreement on each item on the SSDS revealed lower levels of agreement (by 16% or more) in AFL Past Players relative to men from other groups with items related to feeling ashamed and feeling embarrassed if others knew they were seeking professional help (see Appendix 4, Table 4). However, AFL past players had higher levels of agreement relative to men from other groups with items related to not feeling like good company and feeling like a burden to others (see Appendix 4,Table 4).

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Comparison Overall Campaign Group vs Miners

Table 20b Means and standard Deviations of SSDS and DSS for the Better Out Than In campaign and control groups

Campaign Group (Players, Coaches, Control Group (Miners) Construction Workers)

M (SD) Range M (SD) Range

SSDS Total 50.30 (11.20) 22-75 53.89 (10.66) 34-76

SSDS Shame 12.07 (3.56) 4-20 12.79 (3.90) 6-20

SSDS Self Blame 12.48 (3.44) 4-20 13.74 (2.90) 8-19

SSDS Social 14.04 (2.71) 8-20 14.79 (2.60) 10-20 Inadequacy

SSDS Help-seeking 11.71 (3.77) 5-20 12.58 (3.55) 7-20 Inhibition

DSS 21.38 (4.23) 13-33 21.58 (4.18) 13-27

Note. N = 103

Consistent with data from both baseline and follow-up survey 1, whilst personal stigma data (DSS) were comparable across the campaign and mining groups, mean self-stigma scores (SSDS) were slightly higher in the mining group compared to the campaign group. In terms of individual self stigma items, men in the control group had higher rates of agreement by 10% or more (see Appendix 4, Table 5 columns 10-13) on eight items. The five highest related to feeling ashamed about feeling depressed, feeling like they should be able to cope, feeling like they should be stronger, feeling like a burden to other people, and feeling inadequate around others.

Data in Table 20c report on the number of men responding with a yes or no to questions about whether they have known selected other people who have been doing it tough over the last month.

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Table 20c Frequency of responses to researcher developed behaviour towards other questions for the total sample at follow-up 2 survey

Question Yes No

Interacting with others. In the past month…

do you know of a workmate who has been doing it tough? 51 52

do you know of a family member who has been doing it tough? 68 35

do you know of a friend who has been doing it tough? 41 62

have you thought that your partner was doing it tough? 34 55

Note. N = 103

Between 38% (in relation to partner) and 66% (in relation to a family member) of the follow-up sample had interacted in the past month with someone who had been doing it tough.

Tables 20d to 20f report on behavioural measures developed by the research team for the campaign and mining groups separately.

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Table 20d Frequency of responses to researcher developed behaviour towards other questions for campaign and mining groups at follow-up 2 survey. Thinking of the people listed, how often have you spoken to them about what is troubling them when you thought they were doing it tough?

Not at all Hardly at all Some of the Most of the Every day I have days I have had days I have had had contact with contact with contact with them them them Campaign Group Workmate 3 1 15 10 10

Family 4 9 12 16 12

Friend 3 3 6 12 2

Partner 0 3 4 7 1

Mining Group

Workmate 1 1 4 5 1

Family 1 1 3 7 3

Friend 0 1 1 8 1

Partner 0 0 3 4 2

Note. N = 103

Consistent with data from the two previous surveys (baseline and follow-up 1) there were a larger number of responses in higher frequency categories (most of the days I had contact with them and every day I had contact with them) than in the lower frequency categories (not at all and hardly at all) for all categories of people that were perceived as doing it tough.

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Table 20e Frequency of responses to researcher developed behaviour towards themselves questions for campaign and mining groups at follow-up 2 survey. In the past month how often have you spoken to a family member/friend/GP/partner about what is troubling you when you were doing it tough?

Not at all Hardly at all Some of the Most of the Every day I have days I have had days I have had had contact with contact with contact with them them them Campaign Group Workmate 21 4 9 7 2

Family 9 11 13 6 4

Friend 15 13 7 5 3

GP (Doctor) 32 3 6 0 2

Partner 2 11 10 7 6

Mining Group

Workmate 6 3 2 2 0

Family 4 5 0 1 3

Friend 6 4 1 2 0

GP (Doctor) 9 1 1 1 1

Partner 2 4 3 1 1

Note. N = 103

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In contrast to the data reported in Table 20d, when men at the second follow up were asked about how often they spoke to selected people over the last month about what was troubling them when they (themselves) were doing it tough there were a larger number of responses in the lower frequency categories (not at all and hardly at all) than in the higher frequency categories (most of the days I had contact with them and every day I had contact with them). This was consistent across both the campaign and mining groups.

Table 20f contains data from men who reported not doing it tough themselves over the last month. These men were asked about the likelihood of seeking help from others if they were doing it tough/ depressed.

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Table 20f Frequency of responses to researcher developed behaviour towards themselves questions for the campaign and mining groups at follow-up 2 survey. Imagine you were doing it tough / feeling depressed. How likely would you seek help?

Extremely Unlikely Somewhat Likely Extremely likely unlikely unlikely Campaign Group Workmate 10 14 11 4 2

Family 3 6 9 16 7

GP (Doctor) 2 7 6 14 12

Partner or close 1 6 7 15 12 mate Mining Group

Workmate 0 2 1 3 0

Family 0 0 3 3 6

GP (Doctor) 0 0 2 2 2

Partner or close 0 0 2 1 3 mate

Note. N = 103

Consistent with data reported at both baseline and follow-up 1 surveys, the number of men in both groups rating themselves as either either likely or extremely likely to seek help from family, GP (doctor), partner or close mate exceeded those who selected the unlikely or extremely unlikely categories. The one exception to this pattern in the campaign group was with workmates where the opposite pattern was evident.

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Comparison Campaign Group Engaging in Website V Those Not V Miners Tables 21 and 22 display the frequencies and descriptives of the campaign participants who reported engaging with the campaign website, campaign participants who reported not engaging with the website and the miners who participated in the control condition.

Table 21 Number of campaign participants who did and did not access the Better Out Than In website reported in follow-up 2 survey

Group Did access the website Did not access the website

Campaign Cohort 28 56

Mining 0 19

Note. N = 103

As noted in Table 21, 28 (33%) of the 84 campaign participants had reported accessing the Better Out Than in website prior to the second follow-up. This was a slight increase relative to the first follow-up. Consistent with follow-up 1 data no men from the comparison group (i.e. miners) had reported accessing the website.

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Table 22 Descriptive statistics of SSDS and DSS of campaign participants who did and did not access the Better Out Than In website for follow-up 2 survey

Campaign Group Campaign Group (no Mining Group (website engagement) website engagement)

M (SD) Range M (SD) Range M (SD) Range

SSDS Total 48.39 26-75 51.25 (10.40) 22-73 53.89 34-76 (12.71) (10.66)

SSDS Shame 11.18 (3.81) 4-20 12.52 (3.37) 4-20 12.79 (3.90) 6-20

SSDS Self Blame 11.96 4-20 12.73 (3.25) 4-20 13.74 (2.90) 8-19 (3.81)

SSDS Social Inadequacy 14.14 9-20 13.98 (2.75) 8-20 14.79 (2.60) 10-20 (2.67)

SSDS Help-seeking 11.11 (4.24) 5-20 12.02 (3.52) 5-20 12.58 (3.55) 7-20 Inhibition

DSS 19.93 13-27 22.11 (4.17) 1-33 21.58 (4.18) 13-27 (4.11)

Note. N = 103

As can be observed in Table 22 there was a tendency for self- stigma (SSDS) total scores and personal stigma (DSS) scores to be lower for participants who engaged in with the campaign website relative to those who did not and the mining group. However, based on group comparisons using planned contrasts, no significant differences were detected on the SSDS total score, SSDS sub-scales and DSS scale, p > .05.

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Changes over time in campaign group overall (i.e. vs their baseline scores and follow-up 1), website group and mining control group

Self-stigma and personal stigma We also measured the change in scores of the campaign group between the first (baseline) and Follow-up survey 1 and Follow- up survey 2. Tables 23a and 23b provide indicators of possible change between survey administrations for the campaign group, for participants who accessed the website, those who did not access the website and for the mining control group on the SSDS and DSS. Data in Table 23a and 23b refer to data from participants who completed all surveys at all three assessment points.

Table 23a Change in SSDS and DSS scores between baseline survey, follow-up 1 survey and follow-up 2 survey for campaign and mining control group.

Campaign Group (n=84) Mining Group (n=19)

Baseline Follow-up 1 Follow-up 2 Baseline Follow-up 1 Follow-up 2

1 52.48 (11.17) 52.28 (11.27) 50.30 (11.20) 54.63 (11.78) 50.50 (9.20) 53.89 (10.66)

2 12.80 (3.83) 12.55 (3.47) 12.07 (3.56) 13.00 (3.48) 12.11 (3.64) 12.79 (3.90)

3 12.51 (3.23) 12.86 (3.60) 12.48 (3.44) 13.05 (4.05) 12.61 (3.03) 13.74 (2.90)

4 14.68 (2.65) 14.57 (2.69) 14.04 (2.71) 15.53 (3.06) 14.44 (3.31) 14.79 (2.86)

5 12.48 (3.79) 12.30 (3.72) 11.71 (3.77) 13.05 (3.64) 11.33 (3.33) 12.58 (3.55)

6 19.59 (5.45) 19.61 (5.79) 21.38 (4.24) 18.68 (4.90) 19.28 (4.85) 21.58 (4.18)

Note. N = 103. 1 = SSDS Total, 2 = SSDS Shame, 3 = SSDS Self Blame, 4 = SSDS Social Inadequacy, 5 = SSDS Help-seeking Inhibition, 6 = DSS

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Data in Table 23a indicate relative stability over time for both groups across the three surveys. The exceptions were a slight decrease in the campaign group from baseline and follow-up 1 surveys to the follow-up 2 survey for SSDS total and a slight decrease in SSDS total at follow-up survey 1 for the mining group and some slight fluctuations over time in DSS score for both groups.

Table 23b Change in SSDS and DSS scores between baseline survey, follow-up 1 survey and follow-up 2 survey for campaign group who did engage with website, campaign group who did not engage with the website and mining control group

Website Engagement No Website Engagement Mining Group (n=28) (n=56) (n=19)

Baseline FU1 FU2 Baseline FU1 FU2 Baseline FU1 FU2

1 51.96 50.76 48.39 52.73 53.02 51.25 54.63 50.50 53.89 (13.85) (14.38) (12.71) (9.72) (9.46) (10.36) (11.78) (9.20) (10.66)

2 12.81 12.52 11.18 12.80 12.57 12.52 13.00 12.11 12.79 (4.16) (3.60) (3.81) (3.69) (3.44) (3.37) (3.48) (3.64) (3.90)

3 11.96 12.28 11.96 12.78 13.14 12.73 13.05 12.61 13.74 (4.01) (4.16) (3.81) (2.77) (3.30) (3.25) (4.05) (3.03) (2.90)

4 14.74 14.04 14.14 14.65 14.82 13.98 15.53 14.44 14.79 (3.10) (3.60) (2.68) (2.47) (2.10) (2.75) (3.06) (3.31) (2.86)

5 12.44 11.92 11.11 12.49 12.49 12.02 13.05 11.33 12.58 (4.20) (4.65) (4.24) (3.62) (3.20) (3.52) (3.64) (3.33) (3.55)

6 17.89 18.04 19.93 20.42 20.37 22.11 18.68 19.28 21.58 (5.67) (5.92) (4.11) (5.18) (5.63) (4.15) (4.90) (4.85) (4.18)

Note. N = 103. 1 = SSDS Total, 2 = SSDS Shame, 3 = SSDS Self Blame, 4 = SSDS Social Inadequacy, 5 = SSDS Help-seeking Inhibition, 6 = DSS

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Table 23b shows a relative stability over survey assessments for the majority of scales across all groups. The exceptions were for self- stigma (SSDS) total for the website engagement group where there was a tendency for lower total self-stigma scores over time and for the mining group between baseline and time 1 and higher personal stigma (DSS) scores for the mining group at follow-up two relative to other assessments. We tested to see if the change in stigma scores between follow-up survey 1 and 2 differed statistically. This was achieved by controlling for the scores obtained at follow-up survey 1. The analyses revealed that both campaign groups (website and no website exposure) had significantly lower overall SSDS scores at follow-up 2 survey relative to the men in the mining group, indicating a positive shift over time. No other differences reached significance.

Stigma behaviour and stigma behavioural intentions We also assessed possible shifts in stigma related behaviour and stigma behavioural intentions in the campaign group between the follow-up survey 1 and follow-up survey 2. Tables 24a, 24b, and 24c provide indicators of possible change between survey administrations for the total campaign group, and for men in the mining control group. However data in these tables need to be interpreted in light of the fact that due to the very low number of men who reported interacting with others who were doing it tough or doing it tough themselves over the last month, follow-up 1 and 2 data are not entirely comparable (i.e. some men at follow –up 1 were not matched at follow-up 2 as men did not always report that they knew someone who was doing it tough during both survey administrations). As well, due to the reduced number of men in the campaign group at follow-up 2, data for this cohort was not split into those who engaged with the website and those that did not. Further given the very small numbers of participants across categories in the mining group changes in this group need to be interpreted with caution. As per follow-up one, to aid interpretation of the data in these tables – changes of 5% or more between baseline and follow-up data are highlighted. Reductions over time are highlighted by italicised text and increases over time are highlighted as bold text.

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Data in Table 23c below report on Follow-up 1 and Follow-up 2 data for the overall campaign group and mining group for the researcher developed behavioural questions about how frequently men reported speaking to other people about what was troubling them when they thought that person had been doing it tough.

Campaign Group Mining Group

Follow-up 1 Follow-up 2 Follow-up 1 Follow-up 2

Workmate

Not at all/Hardly at all 7 (16%) 4 (11%) 2 (17%) 2 (17%)

Some of the days I have had contact with them 15 (35%) 15 (38%) 6 (50%) 4 (33%)

Most of the days/Every day I have had contact 21 (49%) 20 (51%) 4 (33%) 6 (50%) with them Family Member

Not at all/Hardly at all 10 (27%) 13 (24%) 1 (7%) 2 (13%)

Some of the days I have had contact with them 9 (24%) 12 (23%) 1 (7%) 3 (20%)

Most of the days/Every day I have had contact 18 (49%) 28 (53%) 12 (86%) 10 (67%) with them Friend

Not at all/Hardly at all 7 (20%) 6 (20%) 2 (20%) 1 (9%)

Some of the days I have had contact with them 16 (46%) 6 (20%) 1 (10%) 1 (9%)

Most of the days/Every day I have had contact 12 (34%) 18 (60%) 7 (70%) 9 (82%) with them Partner

Not at all/Hardly at all 2 (9%) 3 (12%) 0 (0%) 0 (0%)

Some of the days I have had contact with them 4 (17%) 4 (16%) 1 (11%) 3 (33%)

Most of the days/Every day I have had contact 17 (74%) 18 (72%) 8 (89%) 6 (64%) with them

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For the campaign group there was relative stability across the follow-up 1 and follow-up 2 assessments with respect to how frequently these men were talking to others about what was troubling them when they were perceived as doing it tough. There were however two positive shifts over time: with respect to workmates who were doing it tough there was a reduction of 5% (16% to 11% reduction) in men speaking to them not at all or hardly at all and there was a 26% increase (34% to 60%) in men reporting speaking to friends who they perceived as doing it tough either most or all of the days they had contact with them. With respect to the mining group the shifts were both positive and negative but difficult to interpret given they represented shifts of just 1 or 2 people.

Data in Table 23d report on Follow-up 1 and Follow-up 2 data for the overall campaign group and mining group for the researcher developed behavioural questions about how frequently men reported speaking to other people about what was troubling them when they themselves had been doing it tough during the past month.

Table 23d Change in frequency of researcher developed behavioural measures between follow-up 1 survey and follow-up 2 survey for the campaign and mining control group. Thinking of the people listed, how often have you spoken to them about what is troubling you when you were doing it tough?

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Table 23d

Campaign Group Mining Group

Follow-up 1 Follow-up 2 Follow-up 1 Follow-up 2

Workmate

Not at all/Hardly at all 22 (67%) 25 (58%) 8 (66%) 9 (70%)

Some of the days I have had contact with them 9 (27%) 9 (21%) 2 (17%) 2 (15%)

Most of the days/Every day I have had contact 2 (6%) 9 (21%) 2 (17%) 2 (15%) with them Family Member

Not at all/Hardly at all 20 (60%) 20 (60%) 7 (58%) 9 (69%)

Some of the days I have had contact with them 7 (20%) 3 (9%) 2 (17%) 0 (0%)

Most of the days/Every day I have had contact 6 (20%) 10 (31%) 3 (25%) 4 (31%) with them Friend

Not at all/Hardly at all 23 (70%) 28 (65%) 9 (75%) 10 (76%)

Some of the days I have had contact with them 8 (24%) 7 (16%) 2 (17%) 1 (8%)

Most of the days/Every day I have had contact 2 (6%) 8 (19%) 1 (8%) 2 (16%) with them GP (Doctor)

Not at all/Hardly at all 24 (73%) 35 (81%) 9 (75%) 10 (77%)

Some of the days I have had contact with them 7 (21%) 6 (14%) 2 (17%) 1 (8%)

Most of the days/Every day I have had contact 2 (6%) 2 (5%) 1 (8%) 2 (15%) with them Partner

Not at all/Hardly at all 10 (36%) 13 (36%) 4 (33%) 6 (55%)

Some of the days I have had contact with them 8 (28%) 10 (28%) 4 (33%) 3 (27%)

Most of the days/Every day I have had contact 10 (36%) 13 (36%) 4 (33%) 2 (18%) with them

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For the campaign group there was stability in the frequency of contact with partners when they themselves had reported doing it tough during the past month. However there were positive shifts of 5% or more for the highest category (most of the days or every day that they had contact with them) of speaking to workmates (15%), Family members (11%) and friends (13%) when they were themselves doing it tough. As with the data in Table 23 c there were positive and negative shifts over time for the mining group but these were difficult to interpret given they represented shifts of just 1 or 2 people.

Data in Table 23e below report on baseline and follow-up data for the overall campaign group and mining group for the modified version of the help seeking likelihood scale (Barney et al., 2010) in which men were asked about how likely they would be to seek help from other people if they were depressed/doing it tough.

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Table 23e Frequency of responses from men in the campaign and mining groups to the modified version of the help seeking likelihood scale (Barney et al., 2010) in which respondents were asked about how likely they would be to seek help from other people if they were depressed/doing it tough

Campaign Group Mining Group

Follow-up 1 Follow-up 2 Follow-up 1 Follow-up 2

Workmate

Extremely Unlikely/Unlikely 24 (57%) 24 (59%) 1 (17%) 2 (33%)

Somewhat likely 7 (17%) 11 (27%) 1 (17%) 1 (17%)

Likely/Extremely Likely 11 (26%) 6 (14%) 4 (66%) 3 (50%)

Family Member

Extremely Unlikely/Unlikely 10 (24%) 9 (22%) 0 (0%) 0 (0%)

Somewhat likely 15 (36%) 9 (22%) 1 (17%) 3 (50%)

Likely/Extremely Likely 17 (40%) 23 (56%) 5 (83%) 3 (50%)

GP (Doctor)

Extremely Unlikely/Unlikely 9 (21%) 9 (22%) 0 (0%) 0 (0%)

Somewhat likely 4 (9%) 6 (15%) 1 (17%) 2 (33%)

Likely/Extremely Likely 29 (70%) 26 (63%) 5 (83%) 4 (67%)

Partner / Close Mate

Extremely Unlikely/Unlikely 4 (9%) 7 (17%) 0 (0%) 0 (0%)

Somewhat likely 13 (31%) 7 (17%) 2 (33%) 2 (33%)

Likely/Extremely Likely 25 (60%) 27 (66%) 4 (67%) 4 (67%)

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Changes over time for the campaign group between follow-up 1 and 2 were mixed. There were positive shifts over time with respect to reporting been more likely to seek from a family member (40% to 56%) in the event that they were doing it tough/depressed. However, there were also several negative shifts related to the likelihood of making contact with a GP, partner or workmate in the event that they themselves were doing it tough/depressed.

Follow up two key findings

• There were data for 103 participants at follow-up, which represented a little over a 33% retention rate from the first follow- up. This retention rate was comparable to that between baseline and follow-up 1 surveys. Numbers in the mining comparison group were modest and ought to be interpreted with care.

• Of the 103 participants in the campaign group with follow up data at the second follow up survey 28 of the 84 in the campaign group (33%) had accessed the Better Out Than In campaign website. On the basis of the website containing the full complement of campaign resources (a more potent dose of the intervention than social media alone) the campaign group was subdivided for analysis of change on the self-stigma (SSDS) and personal stigma (DSS) scales into those who did engage with the website and those that did not between baseline and the two follow-up assessments. This resulted in some small cell sizes in categories and data need to be interpreted in light of this.

• Analysis of self-stigma data suggested that for there had been an improvement in self-stigma (SSDS) mean scores between the first and second follow-up surveys for the men exposed to the Better Out Than In campaign relative to mining control group. Personal stigma scores increased slightly between the first and second follow-up surveys in both groups.

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• Given the modest number of men per campaign group and the impact this would have on cell sizes, analysis of the behavioural data were based on a comparison between men in the campaign group and those in the mining control group- there was no subdivision between those who engaged and did not engage with the campaign website. As well, given the very low numbers per category in the mining group these data cannot be interpreted with any clarity.

• There was relative stability across the follow-up 1 and follow-up 2 assessments with respect to how frequently men in the campaign group were talking to others about what was troubling them when they were perceived as doing it tough. This is suggestive that the positive shifts between baseline and follow up were maintained at the second follow-up assessment. There were however further positive shifts over time with respect to the frequency with which they spoke to workmates and friends who were perceived as doing it tough.

• Data on the behavioural measure concerning the frequency with which men speak to others about what is personally troubling them revealed that men in the campaign group reported some further positive shifts over the campaign period, particularly with respect to speaking about what was troubling them more often to family members, workmates and friends. As with data from the first follow-up survey few men reported speaking to GPs with high frequency about what was troubling them.

• Consistent with data from the first follow-up survey with the exception of speaking to partners over 50% of men in the campaign group still reported either not speaking or hardly speaking about their own problems with other people when they were personally doing it tough.

• Changes across the follow-up assessments for the campaign group who did not report doing it tough over the last month with respect to how likely they would be to talk to someone if they were depressed/doing it tough were mixed.

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Phase 3 evaluation interviews

At the second follow-up survey men exposed to the campaign group were invited to participate in a one-on-one telephone interview typically lasting between 20-30 minutes. A total of 27 of the 84 men who completed the final survey were interviewed about the Better Out Than In campaign. Fourteen men who had reported engaging with the Better Out Than In campaign were asked about were asked about issues such as what they liked about the Better Out Than In campaign, how they engaged with it, if it impacted their thinking or behaviour and how they think it could be improved. As well, 13 participants who reported not engaging with the campaign were asked about why this was the case and what would have encouraged them to engage. Demographic characteristics for these men are reported in Table 32 below. Interview data were analysed separately for each group of men and these are reported below.

Table 32 Average age and profession from men who participated in a telephone interview about whether they engaged with the Better Out Than In website

Campaign engagement No campaign engagement

Average age 46.75 (11.14) 43.53 (11.50)

Industry

Past AFL player 2 3

AFL coach 0 0

Construction (other) 10 12

Construction (VIC) 0 0

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Men who reported engaging with the Better Out Than In Campaign

Three core themes emerged from the analysis of interview data from 14 men who had reported engaging with the Better Out Than In Campaign. These themes related to: • their perceptions of how the campaign was promoted (Low key promotion); • what motivated them to engage with the campaign (Motivation for campaign engagement: helping others); • and their perceptions of the value of the campaign, which contained information regarding the need for campaigns like this (Stigma still high in the industries and advantages of players with construction workers), what they liked about the campaign (Stories we could relate to and Accessible Information: digital platform) and the perceived impact of the campaign (Perceived effect of campaign: reaching out when doing it tough).

Low key promotion. » “It seems to be The majority of men who had engaged with the campaign reported fairly low key I guess. first hearing about the Better Out Than In Campaign through either With mental health Mates in Construction (for construction workers) or the AFL Players I guess pretty much Association (past AFL players). This was through avenues like all discussions start organisational Facebook pages, emails and to a lesser extent tweets initially very low-key sent by these organisations. Men from both industries were highly i s h …”. complementary of the work organisations like Mates in Construction do in terms of raising awareness of mental health issues amongst workers and how responsive they were in the case of workplace incidents like suicide. Few men reported hearing about the Better Out Than In Campaign through traditional media sources such as print media, television or radio. The perceived approach was described by many as low key or a soft approach and was perceived as appropriate for an issue like mental health, where it was acknowledged that you don’t want to be seen to be forcing the message down people’s throats. As noted by one of the men in response to a question about their thoughts about the promotion of the campaign »

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Whilst this approach to promotion was seen as appropriate by the men, most men thought the campaign would have benefitted from being promoted slightly more widely to reach a wider audience. Suggestions included the use of traditional media such as TV, radio, billboards, posters, and co-promotion through organisations like unions or the AFL where it can be promoted at the grass roots level.

Motivation for Campaign engagement: helping others » “Look, I think it The men who reported engaging with the Better Out Than In really runs deep within website were motivated by multiple reasons including interest in our industry. We work how the campaign provided information about mental health and really long hours. We whether that was consistent with what they already knew and general spend a lot of time at interest in mental health. However the two most common reasons work, and we as blokes for accessing the campaign given by the men who were interviewed on sites and with the was an overwhelming desire to help others and a personal interest in workers we work with, mental health based on their own experiences and other significant we probably spend more people in their lives such as friends, partners and family. time with them than we The men recognised that mental health was a major issue in both do with our families at the construction industry and football: depression was seen as a home. So to ensure that silent threat to the health and wellbeing of their mates and your workmate is in a colleagues and they wanted to be part of the solution. This belief good place, it’s like was illustrated in the comments of a participant working in the ensuring that your wife construction industry» or your children are in a good place as well. The men also commented on a motivation to engage with You just feel like we’ve the Better Out Than In website based on personal histories of got an obligation or depression which at times had previously resulted in thoughts and responsibility to look attempts at suicide. This motivated the men to want to understand after each other”. as much as possible about depression to both protect themselves and to ensure that they could help others who had been in similar situations to themselves.

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Value of the Better Out Than In Campaign The interviewed men all believed that the Better Out Than In was highly valuable as a tool to fight depression in men and the overall satisfaction with the campaign was very high. Indeed, when asked about how the campaign could be improved the only comments were that more audio on the website would have been useful and it would have bene useful to include rugby players telling their stories given some states were more interested in rugby than AFL. The value that the men placed on the Better Out Than In Campaign are represented under the following four subthemes which relate to the need for campaigns like this, what the men valued most about the campaign and the perceived impact of the campaign on their attitudes and behaviour.

Stigma still high in the industries and advantages of players with construction workers One thing the majority of men referred to was that the culture of the football and construction industries with respect to mental health was slowly improving. This was illustrated in the following comment »

» “Men are starting to talk about their issues, their brokenness a lot more. I think there is a lot more transparency, and I think there’s a lot more freedom to and a lot more agencies that are easily accessible as to non-recent times”

However the men believed that this was just the beginning and there was still a long way to go before the stigma of having a mental health condition in either the football or construction industry was removed and the Better Out than In campaign was well suited to address this stigma.

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This is illustrated by the following comment about the AFL industry »

» “ I’m pretty sure it’s been through football and that’s one thing, it’s such a macho environment, you grow up with this stigma attached that you have to be tough and by being a man you don’t whinge or you don’t complain. So being a male and being in that football environment you know that it’s not really an environment where guys openly talk about their feelings because it’s, I wouldn’t say frowned upon but it’s just not promoted that guys talk about their emotions and they talk about their feelings.

So I certainly think they’re [The Better Out Than In Campaign] targeting the right areas because those are the type of guys that need it the most, they need to be made comfortable enough to feel that hang on, if I am feeling a bit off or I’m not feeling myself or I’m feeling a little bit down then talking about it doesn’t make me weak or there’s no stigma attached to it to say that I’m any less of a man, and it’s perfectly fine to reach out and ask for help.”

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This was also echoed by men in the construction industry »

» “I think people, well » “So generally blokes it’s mainly men work in keep to themselves and our industry, they’re too only reach out for help proud to admit they’ve when they feel they’ve got problems”. got no other option”

Another general comment about the value of the Better Out Than In campaign related to the perceived value of targeting the campaign to both the football and construction industries. The reasons for this related to perceived commonalities across the industries and it can facilitate the misconception that elite sports people are immune from conditions like depression. This perceived similarities across industries was illustrated by the following comment »

» “Mixing the sport and the construction is probably a good idea because you do get cross over there with people looking to maintain a level of fitness and get together with mates. I think it’s a good opportunity there for people to have conversations about it, so I thought that was, I guess, unique in its way”.

Consistent with this were the comments that illustrated the perceived benefit of having elite footballers share their stories with construction workers »

» “But also the fact they’ve put construction workers in there. I found that very humbling to have – you have your ex-players who someone who might be going through depression looks at that and goes well you’ve got guys that they watched and adored, next to guys like themselves. I really like that. It removes that barrier that these people are a million feet tall and bullet-proof. They go through the same things as everyone”.

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Stories we could relate to When asked about what section of the Better Out Than In website the men valued most, they all mentioned it was the videos of the men from both the construction and football industries telling their own stories of depression. Whilst the men acknowledged that the Talking tactics and Taking action sections of the website were incredibly valuable as a resource they could refer others to who were doing it tough or could use personally if needed, the Stories section really stood out for the men. These stories, the cornerstone of Better Out Than In campaign, were seen as talking to the men in their own language. They were perceived as personal and highly relatable to the target population of men who may have been going through similar issues to themselves»

» “Just reading those stories and knowing that they’re not bullshitting, that these stories are real, they’re not using it as a means to excuse their behaviour or where they ended up or why their careers never progressed and why they’ve spiralled into some of the problems that they are trying to get themselves out of”.

As well, when discussing the value of the stories one participant commented »

» “For sure, definitely because it’s more real. They’re not made up, they’re not character actors, they’re real people. It’s not an ad, it’s real life situations and real life stories and I think people should appreciate that fact”.

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Consistent with this were comments about how stories can empower others to share their troubles with others »

» “Look, I think it was just the vulnerability to share their own struggles and their own pain and their own broken-ness. I think that when guys are able to do that I think it empowers others to be able to do the same that are struggling themselves, and that was sort of a key right through all of the different videos”.

The men also commented that the stories provided a sense of solidarity with men »

» “It’s learning that you’re not – well you probably know you’re not the only one that feels like this but hearing other people’s stories, I think that certainly gives you that much more confidence that you’re not alone and you’re not the only one like that and you don’t feel like you’re the only person feeling like that. I think it’s almost like a strength in numbers mindset”.

These stories were perceived as a valuable resource to both the men personally and also as a core resource for others who were perceived as doing it tough, as a way of starting the conversation. The men also appreciated the diversity of the stories both in relation to the industry that the men worked in but also with respect to their ages and life experiences.

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Accessible information: digital platform A further comment about what the men valued about the Better Out Than In Campaign was the overall quality of the website with respect to the content of the information, how it was presented and ease of access and layout of the material. One participant noted how valuable it was that the focus was exclusively on men »

» “I think only men can heal men and I think because it was about blokes, the men could relate to that”.

The men noted that the information on the website was easy to navigate, was clear and simple and was presented in a way that was not too forceful. This is illustrated in the following comment of one of the participants who noted »

» “...look I think the information there is good. It’s not in your face. It’s not – it’s just a resource that is there. It’s clear, it’s simple. I think it’s relevant, so I think it’s pretty good really in terms of improvement. I like the simplicity of it and how it talks in a probably more blokey language than a posh language. I think for blokes to receive help is always a hard thing to do and I think it serves its purpose well”.

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The accessibility of the website and utility as a resource was noted as a clear positive by the men »

» “...I think it’s a fantastic website. Whoever designed it must know what they’re doing. It’s got all the links there for people to call these numbers or whatnot, Lifeline and things like that, where you need to. Beyondblue, things like that, so I think that’s probably the most important thing is to have access to those or quick direction to that information”.

Another clear positive noted by the men was given that the information was presented on a digital platform that could be accessed by computer or smartphone it was easily accessible at all times. This was seen as a huge advantage when trying to help others when they were perceived to be depressed or doing it tough »

» “a little flip card thing [about mental health], and that’s handy but if you don’t have it you need something to be able to get to it really quickly, and something like this, this site, it’s like the flip card but got a lot more information. You can also show these guys that they’re not alone by showing them some of these videos or trying to use that to help draw out some of the information that might be getting to them at their core”.

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Perceived effect of campaign: reaching out when doing it tough When asked about the perceived impact of the Better Out Than In campaign the men noted that the campaign had a small to minimal effect on the way they viewed depression. For most of the men who chose to be interviewed the campaign reinforced what they had previously thought in relation to depression as being something that can happen to anyone, it does not discriminate, it is not a sign of weakness and it is an illness like anything else. This was illustrated by the following participant when asked about whether the campaign impacted on the way he viewed depression »

» “It just reaffirmed the position that I already held I guess, which is you’ve got to keep – at any stage, mental health doesn’t discriminate. It can happen to anyone, and like the campaign says, Better Out Than In. That it can help talking, and use people there. For mine, like I said it’s not necessarily a weakness. I think that’s where mental health can sometimes get a bit lost, is by saying that it’s a weakness. For me it’s just a part of what we do, a part of ups and downs of life, and I think to normalise it that way instead of saying it’s more of a condition, I think that’s more beneficial”.

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The most notable impact of the campaign was on their behaviour towards others who were doing it tough and at times themselves when they were doing it tough. The men perceived the Better Out Than In website as a wonderful and effective resource for approaching others when they thought they may have been doing it tough. The men commented that they were more likely to now approach others because they now had a non-threatening way to start the conversation about doing it tough. As one of the men commented »

» “I think for mine, it’s more of a you’d have a conversation. Part of the conversation would be hey, I want you to check out this website, just to once again stimulate conversation for follow-up. I think that’s how I intend to use it going forward, is have a chat, oh here’s a really good resource. Have a look at it, check it out, do a bit in your own time. That’s how I see myself using it going f o r w a r d ”.

Another comment made by many of the men was that the information and stories on the campaign website helped them become attuned to some of the signs that someone was doing it tough and gave them confidence to ask questions. This was evident in the following comment »

» “Attuned to things you were hearing and stuff like that, and thinking oh maybe something’s going on here and maybe I need to dig a bit more. Is that what you’re saying? Have I got it right?”

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Consistent with this other participants commented on how they now felt better equipped and had more confidence to approach others they perceived as doing it tough as a result of gaining skills from the campaign website »

» “I think I’m a lot better equipped maybe to ask someone if they’re alright. Fortunately I haven’t had anyone in my close circle who have been showing behaviours of that kind or have been acting a little bit different in a way to what they normally are.

But yeah I would certainly have no hesitation if a mate was showing signs of depression or just showing signs of not being himself, I wouldn’t have any issue in approaching them and just asking if they’re alright and even just saying, “Mate if you’re not alright it’s perfectly okay.” He might be hesitant to ask and maybe I could give him a spiel about what I went through or what I’m still going through and how I’m dealing with it.

For them they might think hang on, he’s going through the same thing, I’m not alone, I’m not isolated. I haven’t had to do it yet but I certainly wouldn’t have any issue in asking a mate if they’re okay if they’re acting like they w e r e n’t.”

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Whilst most of the men commented on the impact of the campaign on their actual or likely behaviour in terms of approaching others who were perceived as doing it tough some of the men commented that it changed the way they either viewed depression in themselves or behaved when they were doing it tough. Some men described how they now have opened up more to family and friends when they themselves have been doing it tough as a result of visiting the campaign website. Whilst this was still acknowledged as being difficult they now felt more comfortable and confident about doing so. This is illustrated by the following participant’s response to a question about the impact of the Better Out Than In campaign »

» “...it certainly gave me the confidence to go and speak to someone about it”

Some of the men also commented on how the campaign not only made them feel more comfortable about sharing their story when they were doing it tough but made them feel less guilty about being burden »

» “I’ve never been good at is talking about myself or talking about my feelings. I just bottled everything up and it was just so counterproductive and I’m only starting to see the real benefits of talking about my issues and being open and honest with people close to me about those issues and not feeling guilty about it and not feeling like I’m a burden about it”

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Men who reported NOT engaging with the Better Out Than In Campaign

Eleven themes emerged under four core categories following the analysis of data from the 12 interviews with men in the campaign group who did not report engaging with the Better Out Than In campaign. The four core categories were: knowledge and access of the campaign; importance of campaigns such a Better Out Than In; overcoming obstacles to engagement; and best way to hear about these campaigns.

Knowledge and access of the campaign

Just a guess: Limited knowledge of the campaign Participants reported having minimal, to no knowledge, of the Better Out Than In Campaign. Thirty five percent of participants indicated they were aware of the campaign, however they had minimal knowledge of its aims and content. These participants reported that their minimal understanding of campaign focused on concepts including awareness of mental illness, depression, and the discussion of feelings and emotions. For example, one man related:

“Not a great deal, to be honest. Only what I sort of read on the email to be honest, also about depression and… Oh, I’d say just from what I gather it’s more so being able to talk about issues with people and whatnot and ways about being able to do t h a t ”. And:

“I know only really by name more than anything. Well, it’s similar to a couple of other campaigns that we sort of use in our workplace…So they can talk more about feelings and issues in the workplace, home and whatnot rather than just keeping it bottled up. We have a large suicide rate in construction, so it’s one of those main pushes that we try and get.”

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These participants also explained that they became aware of the campaign through their work place, in association with Mates In Construction (participants in the construction industry), or the AFLPA Alumni (past AFL players).

No engagement: absence of need and lack of time

When participants were asked why in fact they did not access the Better Out Than In Campaign, two distinct reasons emerged among the men. The majority of the participants explained that the reason for not accessing the campaign was simply because they felt as though they did not have a need to do so. This was expressed by one participant that said:

“I just seem to go on relatively well, I haven’t had any issues since leaving the game… I’ve never been much of a type to get too down, I didn’t get too down, but you do see mates who come out of the system and they’re finding it a little bit tougher, but yeah, probably that’s more of the reason why I never accessed it. I felt like it wasn’t needed for m e.”

The second reason identified by participants for not accessing the campaign was time/convenience »

» “My email is my source of truth; my work email, so that’s the thing ... So I don’t think I had my work email attached… Anything that’s got a link to it in a work email, that’s the best chance of getting me to stop, look and then disperse out to the right people. So it would probably come down to that. If it doesn’t fall into that then it usually depends on me having lots of free time, which doesn’t happen enough.”

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No knowledge of the Better Out Than In Campaign:

The majority (65%) of participants indicated that they had no specific knowledge of the Better Out Than In Campaign, only that they assumed the campaign might be associated with Mates In Construction:

“No idea. I don’t even know how I stumbled across it. I think maybe it’s affiliated with Mates In Construction.”

Similarly another participant said:

“I didn’t really hear about it. I didn’t know if it was run in conjunction or put out through Mates in Construction…Okay, so I guess for myself nothing specific in relation to that campaign other than maybe as a slogan via Mates in Construction.”

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Thirst for knowledge: Positive consideration of accessing the campaign

As these participants had no knowledge of the campaign, the interviewer provided a brief overview of the Better Out Than In Campaign. Once participants had this information, they were asked if it would be something they would be interested in accessing. All participants indicated that they would be interested in accessing the campaign. Participants explained that they would do so in order to gain more information and awareness of the content, especially as mental illness is such a wide spread area of concern:

“Oh definitely. Definitely. Yeah, definitely. Just to have an awareness that you’re not going through it alone, to get an understanding that- for me it’s always finding out if someone else is going through it, similar things or similar feelings…If you’re asking, probably awareness for me more than anything. Again, curiosity, because I’ve had issues of depression and suicide, so it definitely would have led me to it to see what it was all about.”

The interest in gaining more information from the campaign was echoed by another participant:

“ I think mental illness is very common. If we don't go through it at some point in our lives I’d be very surprised, or if we didn't know somebody that was going through it. So I think it’s really important to know that there is information available… So I think the more educated we are, the more likely we are to seek out help and to get that help to make ourselves feel better. I’ve done a lot of work on myself over the years and I’m very open about that.”

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Importance of campaigns such as Better Out Than In

Statistics speak for themselves: Awareness and attention is required Participants explained that there is a significant need in the construction industry for campaigns such as Better Out Than In. This need was directly associated with the concerning statistics relating to mental illness and suicide in the industry. Participants highlighted that the importance of these campaigns was to directly raise awareness, and to promote resources available to individuals in the industry. For example, one participant explained:

“Oh definitely. It’s an epidemic at the moment, it’s getting- there is a crisis happening and it’s not spoken about. It is being spoken now, which is great, but we need more information, we need more resources, especially for men; we need to get over that stigma, if that makes sense. So the more the merrier, the more the better, I’m for it d e f i nit ely.”

And:

“I think it’s an awareness of how depression can affect us but also people around us…Certainly so, because attending a Mates in Construction briefing, the size of the problem or that- it’s been enlightening, I guess”.

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Macho Mentality: Breaking down barriers A number of participants reported that campaigns such a Better Out Than In have the ability to reduce stigma surrounding men’s mental illness and suicide in the ‘macho world’ that is the construction industry:

“I think if no-one’s aware of it that adds to the problem that people may not talk about it, especially in such a male-dominated industry. It certainly brings it to the surface.”

Consistent with this, another participant noted:

“The statistics [in the construction industry] show it would, but I know a lot of the reason of these campaigns is to breakdown that male macho mentality and things like that which yeah, a lot of people would never show it and you’d never pick up on that specifically for that reason which is why further knowledge is needed by everyone.”

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Delisted or Retired: Lack of support when departing the AFL system Past AFL player participants discussed the challenges associated with becoming delisted, or retiring from the AFL system. Participants reported that having a lack of support often led to experiencing some depressive feelings. It was highlighted that having resources available, such as the Better Out Than In campaign, to deal with these feelings is of great importance to ease some the challenges related with the transition phase. One participant relayed:

“As I said, I’ve seen a lot of lads come out of the AFL system and it is pretty tough, and yeah, a lot of them do get pretty down and out and more time goes past and things don’t get better. Yeah, I think it’s very important…If it’s all laid down or something like that, it’s not going to hurt to have resources or not going to hurt to have programs in place or people available to sort of help you out. That’s my gut feel”.

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Overcoming obstacles to engagement

The Construction Industry: It’s a ‘Macho’ World A key theme that emerged from the interviews was that the majority of participants identified a clear barrier to engaging with campaigns such as Better Out Than In. This barrier was attributed to the ‘male dominated’ and ‘macho’ characteristics of the construction industry. These characteristics lead to a stigma being associated with males discussing their feelings and emotions: A participant explained one of the challenges he has encountered in the construction industry:

“And if you do approach that sort of thing in a group session you always have a negative voice come in like, “Go and eat some cement sort of thing, harden up”, that sort of style that really annoys m e ”.

This was supported by another participant who reported:

“I think even in talking about it, being comfortable talking about it, I reckon that would be as much of an issue as anything. You know, that macho personality around the construction site; as much as you try not to fall into it it’s part of the nature, like if you’re going to be listened to on-site you don’t want to sort of show any signs of weakness or anything like that. It is a tough one, that’s for sure, especially in construction.”

And:

“I reckon there’d be mates on a construction site that are prepared to listen but they don't know how to talk, they don't know how to open up to a mate and go, “You know what I’m really struggling.” It shows a sign of weakness and men aren't good at that”.

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Breaking Ground: GENY Y’s are changing the face of construction In contrast to highlighting the negative stigma surrounding men’s mental health in the construction industry, participants reported that the younger generation are slowly altering this perception of stigma. One participant discussed this change by reporting:

“It’s definitely much better received, and I think that’s an age scenario as well; we’ve got more and more Gen Y workforce guys coming through the ranks, and they’re more willing to listen and respond to this, and they’re bringing along some of the older guys as well to get in, and even then, some of the older guys have been through it as well, so I see a lot less resistance to this stuff than when I started doing it 11 years ago to now.”

Another participant echoed this sentiment by explaining:

“Well, it’s definitely changing, I think, for all men over the time. You see the older generation and what they sort of say compared to the younger ones, who are more willing to talk about their - how would you say - feelings, as such, which is a great thing.”

And:

“I think the stigma’s still there, but I don't think it’s as bad with younger people compared to those that have been in the industry for a long time. In other generations like our parents and our parent’s parents it was very unlikely spoken of”

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Best way to hear about these campaigns

That Social Media Effect: Instant, easy and accessible When participants were asked about the most effective ways of hearing about campaigns such as Better Out than In, the majority reported that social media was an effective tool to use. Participants reported that this method resonated mostly with the younger generation, and that it’s ‘instant’ effect was key to its success: The following three participants expressed why they believe the use of social media to build awareness of these campaigns is key:

“... I think social media is quite large now, like everyone’s got Facebook, everyone’s got Instagram, those sort of things, and they all sit on their phones all lunch and smoko going through it. Even after work they’re sitting on their phones. Things like that, by my gut feel, is a pretty good way of getting across to them”.

Similarly this participant reported:

“I think social media you can never underestimate how good that is at getting into people’s heads. I think a combined strategy where we can be talking about something and the guys can relate to actually ‘I saw that thing on YouTube/Facebook/Twitter’ or whatever it might be, and I think the most important thing is it’s got to be engaging.”

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And:

“Through social media, I think, would be the way to go - especially with pop-ups and especially through Facebook and stuff like that, advertising, which when you’re going through your feed it comes through, so that’ll catch your eye. I suppose it’s more visual… Especially with social media, it’s the internet, it’s instant gratification, so people can quickly Google it or go see, so it’s just creating another way so people know it’s there for them.”

The Real Deal: Face-to-Face Communication A number of participants expressed that another effective tool in raising awareness of campaigns such as Better Out Than In was through Face-to-Face communication. This was supported by participants sharing their own experiences of its effectiveness. One participant explained:

“I’ve had stuff through work and that, spoken to about drug abuse and alcohol abuse and depression as well. You get all the blokes in one room, they all listen… You’re better off face-to-face. That’s the only thing that opened my eyes to it, being spoken to about it, to be honest with you.”

And:

“As I was saying before, when the guy came out onto the site and we had a meeting, there was probably 1,000 people onsite at that stage that went to that site meeting that would have heard that story and walked away from that probably with a bit more awareness, I suppose, anyway…Yeah. To actually hear them from somebody that’s lived and breathed it. You can relate that to a real person then.”

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Case Studies and the inclusion of Role Models: The final key theme that emerged regarding effective ways of growing awareness around campaigns such as Better Out Than In, was the use of role models or high profile individuals to create awareness through a relatable approach. Participants reported the effectiveness of having high-profile individuals share their own stories stemmed from a case study format:

“I think media’s always good, especially when you’ve got people that they can see, anyone like a sportsperson, like a role model to people, that have been through and had those issues. I think people relate to those people, especially- there’s a lot of males who would relate to those types of people better, so media, general TV”.

Consistent with this »

» “So I think there’s a lot more we need to do to get the messages across, and it’s good that there’s been a lot of case studies role models if I can use that term in other areas, particularly high profile people that have made their circumstances public. I think that’s been of great help. But we need to constantly keep the message out there”.

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And:

“We’ve done a few similar type of things, and I guess the connection between sports people, as well, and construction is a really good link. We’ve had some great wins of being able to get former football players to come and talk with the guys, and particularly those that have been through tough times, and the guys idolise these people and they start- they help to break the ice quicker than somebody who’d come in as an average Joe off the street or a psychologist or something else. They’re great, and I think more and more we’ve pushed them”.

153 6. Results Better Out Than In 2017

6.4 KEY FINDINGS

• Of the 84 men who completed the final survey 27 (32%) were interviewed about the Better Out Than In campaign. Fourteen men who had reported engaging with the Better Out Than In campaign were asked about were asked about issues such as what they liked about the campaign, how they engaged with it, if it impacted their thinking or behaviour and how they think it could be improved. As well, thirteen participants who reported not engaging with the campaign were asked about why this was the case and what would have encouraged them to engage.

• Men who reported engaging with the campaign thought the promotion of the campaign was subtle but many thought it was appropriate for a topic like mental health. Both men who did and those who did not engage in the campaign thought the campaign could have been promoted more at both the grassroots level (on construction sites etc) and through social media.

• Both groups of men (those who did and those who did not engage with the campaign) thought anti-stigma campaigns like Better Out Than In are required in both the construction and AFL industries where a culture of not complaining and not sharing problems due to wanting to maintain the mucho ideal still prevailed. The thinking amongst men as that there had been some improvement over time but there was still a long way to go.

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6.4 KEY FINDINGS

• Men who reported engaging with the campaign were motivated to interact with the campaign primarily to help others, with some motivated to learn more based on their own personal experience.

• There was a high level of satisfaction with the Better Out Than In campaign amongst men who had accessed it over the campaign period. The men thought that it was ideally pitched to the target audience and thought it was highly appropriate that people in the AFL industry were paired with workers in the construction industry. The men valued all sections of the website but thought the stories were the most valuable as they were highly relatable and spoke to men in their own language

• In terms of the perceived impact of the campaign amongst men who had accessed it over the campaign period, men acknowledged that it had just a small effect on the way they viewed depression, primarily reinforcing what they already knew. This was consistent with the modest improvements in attitudes about depression (i.e. SSDS data) reported over time in the surveys.

• Consistent with data from the surveys, the most noticeable impact reported by the men was with respect to their behaviour both in terms of approaching others when they were perceived as doing it tough and speaking to others when they themselves were doing it tough.

155 6. Results Better Out Than In 2017

6.4 KEY FINDINGS

• The men reported how accessing the Better Out Than In campaign had given them a resource they could use to approach others when they perceived that others were doing it tough. Men commented that the website could be used to get the conversation started in a non-confronting way and gave them the skills and confidence to approach others.

• Some of the men that were interviewed also commented on how the Better Out Than In campaign made them feel that it was OK to be feeling down and gave them the courage and motivation to speak to others.

• Even though scores were relatively high to begin with, there was considerable evidence that the Better Out Than In campaign had a positive impact on the frequency of providing/offering support to others over the course of the campaign period.

• The men reported increasing the frequency with which they approached others when they perceived them as doing it tough because they now felt better equipped to do so. As well, the men reported increasing the frequency with which they shared their problems with others as a result of feeling more confident and comfortable about doing so.

156 7. Discussion Better Out Than In 2017 7. DISCUSSION The discussion will be framed around the six objectives of the Better Out Than In campaign.

157 7. Discussion Better Out Than In 2017

7.1 OBJECTIVE ONE

The first objective of this project was to generate information on what works in terms of stigma reduction for depression in men aged 30-64. The Better Out Than In digital campaign, as discussed in the evaluation findings above, was able to generate a comprehensive data set pertaining to the potential effectiveness of a targeted digital campaign designed to reduce stigma related to depression in three populations of men aged 30-64: Construction workers; Past AFL players and AFL coaches. This data set included three comprehensive administrations of a survey that included measures of attitudes related to self- stigma of depression (SSDS), personal stigma of depression (DSS), and behavioural intentions to seek help if troubled or depressed and actual frequency of offering support to others when the men perceived that others were doing it tough or help seeking they were doing it tough themselves. This inclusion of measures of stigma related behaviour was important in terms of determining what works to reduce stigma as changes in attitude do not always translate to changes in behaviour. The importance of measuring behavioural changes has been widely recognised by stigma reduction researchers (see Evan-Lacko et al., 2011). These data were obtained from three populations of men for whom the campaign was targeted and a control condition of miners which enabled us to determine that any observed reductions were not simply due to the passage of time or other campaigns operating during the evaluation period. We were thus able to generate information on what works to reduce stigma from a survey of over 1000 men prior to the campaign beginning (baseline data) and then at two follow ups consisting of over 300 men at follow-up 1 and 100 men at follow-up 2. We also interviewed 27 men after follow-up 2 about their thoughts and experiences of the campaign and the potential impact of the campaign on their aptitudes and help seeking behaviour related to stigma. The specifics about the extent to which the Better Out Than In campaign worked in reducing stigma are discussed under objective four.

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7.2 OBJECTIVE TWO

A second objective was the successful development and implementation of an online digital intervention for self-stigma for depression. The aim was to create a digital intervention that was innovative, user-friendly, engaging, and meaningful. The success of this objective was measured through a comprehensive data- analytics strategy, which provided concrete data on the reach of the intervention as well as information on how users are engaging with the digital interface. Through comprehensive engagement with men from the three targeted populations, based on a participatory design (see discussion under objective three), we were able to create a digital platform that gave men access to their peers telling their own stories of their experiences of depression (stories), information about how to approach other men who they perceive as doing it tough or approaching others to talk when they themselves are doing it tough (talking tactics) and suggestions for taking action (taking action). There were several indicators that the Better Out Than In digital platform was user-friendly, engaging and meaningful to the men from these populations. For instance, one of the core themes to emerge from interviews with men who accessed the campaign was the accessibility of information on the campaign website. The men reported that the website was easy to navigate and highly meaningful to them. Typical of responses from these men »

» “look I think the information there is good. It’s not in your face. It’s not – it’s just a resource that is there. It’s clear, it’s simple. I think it’s relevant, so I think it’s pretty good really in terms of improvement. I like the simplicity of it and how it talks in a probably more blokey language than a posh language. I think for blokes to receive help is always a hard thing to do and I think it serves its purpose well.”

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7.2 OBJECTIVE TWO

As well, another core theme to emerge from the interviews with these men was their high degree of satisfaction with the section of the Better Out Than In website that contained the men’s personal stories of depression. The men reported that these stories were inspiring and highly relatable and gave them a sense that they were not alone with their own struggles. This is illustrated by the following quote »

» “It’s learning that you’re not – well you probably know you’re not the only one that feels like this but hearing other people’s stories, I think that certainly gives you that much more confidence that you’re not alone and you’re not the only one like that and you don’t feel like you’re the only person feeling like that. I think it’s almost like a strength in numbers mindset”

Another indicator of that the men engaged with the campaign and found it meaningful were the data analytics. Whilst we experienced some powerful numbers and engagement in the website and social media as reported on earlier in this report, what sat alongside this reassuring data, was the anecdotal evidence and qualitative findings to suggest there was meaningful impact for those who engaged with Better Out Than In. Our videos were unique in their own way and all represented openness, acceptance and hope, thus with over 16 days of video viewing time we can feel comfortable that those who engaged, would have experienced a range of influential and inspiring stories to ignite a behaviour change.

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7.3 OBJECTIVE THREE

A third objective was to promote the effective use of participatory design and user experience aspects throughout the project. A strategic approach to user experience and participatory design enabled this project to yield valuable data in terms of how men ‘opt-in’ to mental health interventions and what might encourage/ challenge engagement in digital stigma-reduction campaigns. We considered ourselves very fortunate to have had partnered with organisations who hold close relationships and a very intimate understanding of the distinct needs and preferences of their respective members. Recognising this key element and coupling it with focus on evidence-based best practices, including credible research and publications, our project team engaged in a process of stakeholder driven workshops led by specialist UX team members. These workshops, delivered in varied formats, featured an eclectic mix of mental health specialists, industry representatives who operated at the ‘coal face’, creative directors with agency specialisation, ‘everyday people’, depression help seekers with personal experience.

161 7. Discussion Better Out Than In 2017

7.4 OBJECTIVE FOUR

A fourth objective was to achieve measureable reductions in self- stigma and personal stigma for depression (in terms of both attitudes and behaviour) within the communities of interest. The aim was for men who engaged with this intervention to think differently about depression and mental health after engaging with this project—to view seeking help for depression as an act of openness, acceptance and hope; to engage in positive behaviours such as sharing their experiences with others and seeking help; and to build their capacity to support other men who are experiencing depression. These outcomes were measured via rigorous, evidence- based measures and methods and through interviews with men who engaged with the campaign. This objective relates to the effectiveness of the campaign to reduce the impact of both self- stigma and personal stigma for depression. The aim of the campaign was to produce meaningful positive change in both attitudes and help seeking behaviour related to depression.

Impact of the campaign on stigma related attitudes: Stigma related attitudes were assessed by two evidence based measures with psychometric support: the 16-item Self-stigma of Depression Scale (SSDS: Barney et al., 2010) and the the 9-item Depression Stigma Scale (DSS: Griffiths et al., 2004). The evidence regarding the impact of the Better Out Than In campaign on stigma related attitudes about depression was mixed. Whilst there was a tendency for personal stigma scores to be lower at the first follow-up assessment relative to the pre campaign period in the men exposed to the Better Out Than In campaign this difference did not reach statistical significance. However, there was a statistically significant reduction in total self-stigma for the men exposed to the Better Out Than In campaign at the follow-up assessment 1 (4-5 months following the commencement of the campaign) and some evidence of further reductions in self-stigma for these men between the first and second follow up assessments (the second follow-up assessment was undertaken 4-5 months later). There were few meaningful reductions on any of the specific self-stigma subscales.

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7.4 OBJECTIVE FOUR

It was of note that there was no change in self-stigma or personal stigma for the mining group that was not exposed to the Better Out Than In campaign. Whilst the reductions in depression related self- stigma reported over time were statistically significant they were relatively modest in size. This was consistent with the interview data obtained from men who had engaged with the campaign. Whilst a couple of the men commented that they had positively changed the way they viewed their own depression in terms of seeing themselves as being less of a burden on others and as depression as being almost normative for many men at some point in time, most men specifically commented that the campaign had little impact on the way they viewed depression. Most of the men commented that their attitudes about depression in others (personal stigma) and themselves (self-stigma) had been positively shaped by previous exposure to either industry based mental health campaigns or those available more widely to the general community. They reported that the Better Out Than In campaign was useful in terms of reinforcing this earlier information they had been exposed to. Thus the modest impact of the campaign on stigma related attitudes may have been due to the men’s relatively low levels of stigma related attitudes prior to the campaign. There was some support for this given that the campaign group prior to the intervention had slightly lower self-stigma scores relative to Australian men in the study by Barney et al. (2010).

Impact of the campaign on stigma related behaviour: The impact of the campaign on stigma related behaviour was assessed by two measures developed by the researchers designed to assess help providing behaviour and help seeking behaviour. These measures were developed in consultation with mental health experts. The first measure was administered to the men who had reported one or more of the following workmate, family member, friend, or partner had been doing it tough during the last month.

163 7. Discussion Better Out Than In 2017

7.4 OBJECTIVE FOUR

The measures assessed the frequency with which the surveyed men reported speaking with the selected people about what was troubling them during that time- help providing/offering support to others behaviour. The second measure was administered to the men who reported doing it tough themselves during the last month. This measure asked men to rate the frequency with which they reported speaking to selected others (e.g. workmate, family member, friend, GP, or partner) about what was troubling them personally when they themselves were doing it tough – help seeking behaviour. For both measures frequencies were classified as low frequency, moderate frequency or high frequency. Men who did not report doing it tough themselves during the past month were administered a modified version of the help seeking likelihood scale (Barney et al., 2010) – help seeking likelihood. Impact of the campaign on help providing/offering support to others behaviour: Data from all participants prior to the beginning of the campaign indicated that men typically spoke to others about what was troubling them at a reasonably high frequency. The men in these populations had a desire to want to help others when they thought others such as their workmates and friends and families were perceived as doing it tough. The interview data revealed that the desire to help others was the main motivation for men to engage in the Better Out Than In website. Even though scores were relatively high to begin with, there was considerable evidence that the Better Out Than In campaign had a positive impact on the frequency of help providing/offering support to others behaviour over the course of the campaign period. For instance, there were self-reported increases in the frequency of providing help to others in men exposed to the campaign between the pre-campaign survey and the first follow-up survey. What was interesting was that it was the men exposed to the higher dose of the Better Out Than In campaign (the men who had accessed the website rather than just information on social media) that showed the largest improvement.

164 7. Discussion Better Out Than In 2017

7.4 OBJECTIVE FOUR

Specifically, more men in this high exposure website group reported speaking to their friends, workmates and family members about what was troubling them most or all of the time they had contact with them relative to the low exposure campaign group. The mining group remained relatively stable over this period. Although the sample size at the second follow-up survey was too small to divide into low and high exposure groups there was evidence that the improvements in the campaign group in terms of speaking to other about what was troubling them tended to persist to the second assessment. Interview data were highly consistent with these increases in attempting to provide help to others perceived as doing it tough over the course of the campaign. The interviewed men perceived the Better Out Than In website as a wonderful and effective resource for approaching others when they thought they may have been doing it tough. They commented that they were now more likely to approach others because they had access to a resource that provided a non-threatening way to start the conversation about doing it tough. The men also noted that the campaign website helped them become more attuned to signs that people were doing it tough/depressed and they now had the confidence to ask these people questions. Impact of the campaign on help seeking behaviour: Data from the instrument designed to measure the frequency of seeking help (through talking to others about what is concerning them when they themselves were doing it tough) revealed that men in these populations were typically much kinder to others than they were to themselves when doing it tough. That is, in contrast to when they perceived others as doing it tough, men who were doing it tough themselves were typically more likely to speak to other people about what was troubling them at a lower rather than high frequency (the one exception to this was with their partners). As well, it was somewhat of a concern that men reported speaking to their GP about what was troubling them at a very low rate across all of the survey assessments.

165 7. Discussion Better Out Than In 2017

7.4 OBJECTIVE FOUR

However, there was evidence that the Better Out Than In campaign resulted in improvements in the frequency with which the men in the campaign group spoke to others about what was troubling them when they themselves were doing it tough. For instance, between the pre-campaign and first follow–up assessment the frequency with which men who identified as doing it tough spoke to others about what was personally troubling them revealed that men in the campaign group reported some positive shifts particularly with family members. Although data at the second follow-up was not subdivided into high and low exposure groups it suggested that men in the campaign group reported some further positive shifts over the campaign period, particularly with respect to speaking about what was troubling them more often to family members, workmates and friends. This was in contrast to the mining group which primarily reported negative shifts from baseline to the first follow-up. Consistent with finding regarding frequencies with which men spoke to others who were doing it tough, it was men in the high exposure campaign group (that reported engaging in with the website) who reported the most favourable shifts in frequency of speaking to others when they themselves were doing it tough. This was particularly evident for more frequently speaking about what was troubling them with friends and workmates. The interview data supported this positive impact of the campaign on the men speaking to others about what was troubling them. For instance, some men described how they now have opened up more to family and friends when they themselves have been doing it tough as a result of visiting the campaign website. Whilst this was still acknowledged as being difficult they now felt more comfortable and confident about doing so.

166 7. Discussion Better Out Than In 2017

7.4 OBJECTIVE FOUR

Impact of the campaign on the likelihood of help seeking behaviour: Data from the instrument that was utilised to measure the likelihood of seeking help if depressed or doing it tough (the modified version of the help seeking likelihood scale (Barney et al., 2010)) revealed that men may be more likely to report a high likelihood of speaking to others when depressed or troubled than they actually do when feeling like they are doing it tough based on comparisons with data from the help seeking behaviour described above. However, it should be noted that the descriptors and response options in these scales differ slightly and this may account for the difference. Nevertheless, as with findings from measures of actual behaviour, results from the likelihood scale revealed several improvements over the course of the campaign in men exposed to the Better Out Than In campaign. This was particularly evident with respect to men reporting being more likely to seek help from GPs and workmates. However, positive shifts in favour of the high exposure group relative to low exposure group were less pronounced than with other behavioural stigma measures. Further, there was less evidence of sustained improvement, as assessed by changes between the first and second follow-up survey, on this measure relative to other behavioural measures. In contrast to the campaign group the mining group typically reported being less likely over time to seek help from people if they were to be doing it tough or depressed. As with the survey improvements on other behavioural measures, there was some support from the interview data. Some interviewed men commented on the fact that since exposure to the Better Out Than In campaign they would not be more likely to seek help than previously for many of the same reasons as those stated above (feeling more comfortable and confident about approaching others). Summary: Whilst there was some evidence that the Better Out Than In campaign resulted in men thinking differently about depression there was considerable support from both survey and interview data that the greatest impact of the Better Out Than In campaign was on the men’s actual behaviour.

167 7. Discussion Better Out Than In 2017

7.4 OBJECTIVE FOUR

The men reported increasing the frequency with which they approached others when they perceived them as doing it tough because they now felt better equipped to do so. As well, the men reported increasing the frequency with which they shared their problems with others as a result of feeling more confident and comfortable about doing so. Considerations when interpreting the data: Although the evaluation data consistently demonstrated that the campaign led to positive changes in the men’s behaviour both with respect to talking to others about their problems and their own help seeking behaviour several considerations ought to be taken into account when interpreting the data. First, the retention rate between survey assessments was just a little over 30%. Although retention rates as low as 20% have been reported in mental health stigma studies with just a 6 week gap between assessments (Evans-Lacko et al, 2012), a 30% retention rate even over 5-6 months needs to be considered when interpreting data. Second although improvements as measured on the behavioural measures were highly consistent with interview data, the behavioural measures were developed specifically for the purpose of this study and have yet to be validated against other measures.

168 7. Discussion Better Out Than In 2017

7.5 OBJECTIVE FIVE

The fifth objective was the development and implementation of a strategic and comprehensive knowledge translation strategy so that the findings of this project have real-life impact. This strategy includes participatory design, meaningful participation in the knowledge community and communication of key outcomes to academic, industry, and community stakeholders Our key findings coincide with the knowledge synthesis piece that will combine the research findings with the broader body of anecdotal evidence which we’ve accumulated from this project. The dissemination of research results will vary on audience, as will the need to tailor the message and medium. We plan to exchange our knowledge with knowledge users and see the completion of this final report as a terrific opportunity to act upon this, along with various upcoming conferences and speaking opportunities. We are hopeful for the opportunity to act on our knowledge in the form of a continuation of the Better Out Than In project, understanding that these learning can present opportunities to evolve the project to better itself going forward. Please refer to appendix two for the detailed knowledge transfer strategy and activity.

169 7. Discussion Better Out Than In 2017

7.6 OBJECTIVE SIX

The sixth objective was to conduct a review and make recommendations for the sustainability of the digital campaign beyond the two-year grant period. We look to maintain our easy to navigate digital platform that is clear and talks to our target audience. Aside from the video content and stories, we recognise the language and offering of the Talk Tactics section has positively affected behavioural changes in the men engaging in the platform, so we can maintain this for at least five years before revisiting. To continue to develop stories we will be entertaining commercial partnerships to sustain this core element of the platform. Partnership proposals will coincide with the key findings and learnings of this report. The adaptation of men in other communities will be explored, in line with the qualitative key informant interviews. These findings will help us identify ways to improve Better Out Than In and more specifically explore what users considered the core elements of the program, what pieces of information they used, how they shared this information with other people, and any changes they recommended for future roll out of the project. Please refer to key learnings for further comment on sustainability.

170 7. Discussion Better Out Than In 2017

7.7 KEY LEARNING’S

We committed to an ‘organic’ recruitment process whereby we aimed to leverage existing personal relationships and use the Better Out Than In digital platform as a promotional tool. To this point, as outlined in the discussion we ultimately succeeded to achieve desired outcomes, however it was not without regular periods of uncertainty and doubt. These achievements are outlined under the WINS section below.

Wins

Willingness of participating ambassadors One of the core achievements of the Better Out Than In campaign was the participatory nature of each stage of the campaign process. Core stakeholders were not only consulted but were central to the decision making process as the campaign was designed, produced and evaluated. These core stakeholders included the core industry partners with particular knowledge and expertise in this area such as the AFLPA, Mates in Construction, Cummins partners and La Trobe University. But more importantly it involved the participating ambassadors themselves, people who were working alongside these men on a daily basis. The cumulative effect of this participatory design and consultation was a stigma reduction campaign intervention that was described by the men as real, authentic and something that was speaking to them in their own language.

Industry recognition, media and community interest There was evidence that the Better Out Than In campaign changed behaviour in men aged 30-64. Changing stigma related attitudes regarding depression is important. To that end, there were some modest improvements in self-stigma about depression amongst the target population. However the most pleasing outcome was the evidence that the Better Out Than In campaign had a positive impact on the men offering support to others when they were doing it tough and their own help seeking behaviour when they themselves were doing it tough.

171 7. Discussion Better Out Than In 2017

7.7 KEY LEARNING’S

Survey data showed that the men who were exposed to the higher dose of the campaign (the website group) reported contacting other people in their lives such as speaking to their friends, workmates and family members more often than the low exposure campaign group and the mining control group. A similar pattern of results was reported when men had reported doing it tough themselves. The data from interviews was also consistent with these changes and provided some valuable insight into how the campaign assisted these men to change their behaviour. The men spoke about how the campaign, and in particular the stories on the website, provided a strong sense of solidarity with other men. These stories were used by men to as a non-threatening way to start the conversation of doing it tough with other men and gave them greater confidence and skills to ask the right questions. The men also spoke about how other men just like them sharing their stories of going through hard times and depression made them feel like they were not going through things alone and it normalised these feelings they themselves were having. The net effect of this was that the men felt more comfortable about sharing their stories to others when they themselves needed help.

There is value in bespoke industry based stigma reduction campaigns like Better Out Than In One of the core findings from the interviews was that the men valued the fact that the Better Out Than In campaign was targeted to two industries that share much in common. In particular the men felt that both industries have a mucho culture, share a similar language, are both very physical in nature and place considerable importance on mateship and teamwork. The core effect of this targeting was a set of what the men considered to be highly valuable resources that spoke their language and felt real.

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7.7 KEY LEARNING’S

What we learnt about men in these industries A further win was that we were able to ascertain some very useful information about stigma and depression in these populations of men who may be at high risk of depression as a result of their occupations. The first learning relates to the need for stigma reduction campaigns in these populations and the second to the men’s desire to help.

Some improvement but there is still a need for campaigns like this There was some evidence from both the data collected before the intervention commenced and the interviews that there has been some improvement over the last few decades in the way that men in these industries viewed depression in others and themselves. However, the interviewed men were consistent in their beliefs that there was still a long way to go, many men still viewed depression as a weakness and there was evidence from the survey data that whilst the men will check in with others such as friends, family and workmates when they are perceived as doing it tough most men will not do so when they themselves are doing it tough. Although this campaign was able to show evidence of change in help seeking behaviour amongst these men there was still considerable space for improvement.

Men want to help Data from this project showed that the men clearly understood that others around them were being affected by mental health problems and they genuinely wanted to help. As noted by the participants who were interviewed men in these industries have an overwhelming desire and motivation to help others. They felt like they needed to look out for one another given the challenges of working in these industries such as the pressures and long hours. Consistent with this as noted above the largest changes were in men more frequently approaching others who were doing it tough.

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7.7 KEY LEARNING’S

Sustainability of the Better Out Than In campaign We believe that one of the critical consideration of stigma reduction campaigns is that they are potentially sustainable. This was one of the core design considerations of Better Out Than In. This campaign is essentially housed on a website, where participants have access to resources like men sharing their stories, tactics for sharing stories and getting the conversation started and strategies for what to do next. Whilst a small number of these links may require an annual update there is no reason to expect that the website would not remain relevant to the men in these industries as is for a period of at least five years. With the application for some further funding through philanthropic or other relevant funding sources there is no reason why this campaign website could not be maintained for considerably longer.

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7.7 KEY LEARNING’S

Challenges/Lessons learnt

Campaign participants are the true face of the project: We’ve been really pleased to see the wider community digitally engage with our campaign participants to support their involvement and in some cases, share their own stories in return. This, in particular, has been an unforeseen element of the project and certainly raised the importance for our project team to adequately support participants ‘post shoot’. Our understanding of the possible consequences that ‘going public’ can have been elevated and in some anecdotal cases allowed us to witness the very tangible positive impact that the project has had on the lives of individuals.

Grassroots initiatives are interested in attaching themselves The large collective public profile of our partner organisations presents an attractive opportunity for grassroots initiatives to align themselves, as has been evident throughout this campaign. This level of community interest was not planned for within our campaign development, nor were required resources allocated to this, which has ultimately meant that we have not had the capacity to engage in these opportunities. This consideration has been noted for development within the sustainability review process.

Community response a) Ambassadors contacted by public, With over 1.7million people engaging in Better Out Than In related media, we were deeply encouraged by this support. Whilst a great reflection of care and encouragement from the community, we were conscious to ensure the story sharers were managing this attention and sharing their story publicly. Thus, we kept in regular contact with the story sharers, and best tried to manage any media or public contact with them as a result of their story being shared. This stayed true to our objective of developing strong relationships, and more specifically, connection and trust with our video participants, to ensure the courage to share their story didn’t become detrimental.

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7.7 KEY LEARNING’S

b) Critical incident management procedures. “Share your story” was our responsibility once they disclosed their story. We worked with our in house psychologists to manage each story with a best practice approach.

c) Request for resourced support for events, initiatives, partnerships (community piece and opportunities with football clubs to run their own Better Out Than In awareness round.

Promotion of the Campaign Striking the appropriate balance between maintaining a low-key soft approach to promotion and ensuring the campaign reached a sufficient number of men in these populations was a challenge. On the one hand the men who were interviewed specifically commented on how they valued and appreciated the low-key soft approach to promotion and thought this was highly appropriate to the topic of depression in men. However, on the other hand whilst there were certainly some encouraging website analytics it was of note that only approximately 30% of the men who completed the evaluation actually engaged with the campaign website. Resolving whether some more promotion through either grassroots approaches or social of other media, as suggested by some of the men, would be appropriate is an issue that needs resolution.

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7.7 KEY LEARNING’S

Addressing research and evaluation requirement The logistics around the collection of baseline data was well managed by researchers from La Trobe University, despite access issues to construction workers within their home state of Victoria and access to a comparative industry. One challenge which we have grappled with in an ongoing sense, is the conflicting and countering use of language seeming to be required to promote survey participation (e.g. ‘Help us FIGHT depression’). As well, as noted above there were challenges in maintaining a high retention rates between survey assessments despite following best practice strategies such as use of ethically sound incentives.

Conceptual development Our carefully considered approach to project development has been the by-product of consistent consultation and involvement from the AFLPA’s, Mates In Construction and Latrobes’ in house expertise, including: clinical psychologists, marketing and communication specialists, digital content creators, and target audience representatives. Through applying a variety of ‘lens’, we were able to refine our project and ultimately enhance it to better promote openness, acceptance and hope as core themes of a renewed ‘Better Out Than In’ concept.

External content producer appointment The AFLPA seized on an opportunity and modified its approach to content collection through the acquisition of award winning documentary producer, Adrian Brown. Adrian has an impressive body of work is possibly best known for his most recent work ‘Sons of the West’ and holds a comprehensive understanding of the project, including its core aims. Project partners have praised this appointment, which we collectively feel has placed content as the true ‘hero’ of the project and provides a consistent and first class narrative which we know has earned increased attention.

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7.7 KEY LEARNING’S

Greater transparency of partner’s internal processes One of the greatest lessons learnt has been the importance of gaining clearer transparency on the internal processes, timelines and operational details relevant to key project partners. In the case of our original digital partners, we feel that we were completely blindsided, due to secretary and poor management on their end.

Perceived conflict with ‘competing’ STRIDE project La Trobe University, in coordinating their collection of baseline data concerning Victorian construction workers, entered in productive negotiations with MATES in Construction (MIC) to identify opportunities to address this. In short, MIC, while very active in most other Australian states, do not have an ‘active presence’ in Victoria for a range of reasons however used their relationship with the CFMEU to aid in this process. There was a potential issue with two STRIDE project accessing Victorian construction workers, however after meeting with CFMEU Head Frank O’Grady, this issue was resolved and the CFMEU emerged as very supportive of our project. To this point, they appointed a staff member as a central point of contact to enable our project to maximise engagement opportunities which we hope will extend to participation.

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7.7 KEY LEARNING’S

Opportunities that could not be realised a) Funding limitations / payment schedules - agencies generally require 50% payment to commence the job. Additionally, we could have executed more stories with more money, equalling a stronger digital presence through utilising a digital/PR agency to push out more. b) Timeline limitations - The campaign had a short shelf life. c) Resourcing limitations - opportunities to get out there and have a strong presence and showcase Better Out Than In. The Project Managers’ roll was 2.5 days’ p/week so limited the opportunity to promote and strategize, most notably during the filming process which was generally a full day process.

Project launch date The original launch month of May 2016 was jeopardised by the withdrawal of our digital partners, and ultimately set at early July 2016. Project partners were forced to adjust timelines to cater for the recruitment and resourcing of our new digital partners, and thank beyondblue for their support during this unsettling experience.

179 8. Conclusion Better Out Than In 2017 8. CONCLUSION

180 8. Conclusion Better Out Than In 2017

8. CONCLUSION

There were some positive shifts on stigma measures in the campaign group, particularly for those who engaged with the Better Out Than In website. Specifically, these men had reported reductions in self-stigma related to depression and communicated with others who were doing it tough at higher frequencies than they were prior to the campaign. This pattern was also evident when they themselves were doing it tough.

Several self-reports, and behavioural measures of depression related stigma were developed to examine the effectiveness of the Better Out Than In campaign.More than 1000 men from the three communities of interest and a mining comparison group were recruited to evaluate the effectiveness of the depression stigma reduction campaign via an online survey that contained attitudinal measures of self-stigma, personal stigma, intentions of seeking help and actual self-reports of behaviour pertaining to men offering help to others.

Public support for the campaign was overwhelming, both from within the target audience and the wider community, which has fuelled our desire to continue this work into the future. A key recommendation for future targeted campaigns, which emerged consistently in our learnings, was the importance of relationships and, more specifically, connection and trust. The project was fortunate to have had a group of brave and open project participants who were comfortable sharing their personal stories with a global audience.

We recommend a program like Better Out Than In as an ongoing resource for men in masculine communities. Maintaining simple design and informal language would ensure a stigma-reduction campaign could become a powerful resource for men who may be struggling and equip them with the tools you required help a mate who may be struggling. Additionally, continuing to add stories on the premise that sharing and hearing real-life stories about depression and seeking help for depression is one of the most powerful ways to reducing self and personal stigma in communities of men.

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Courtenay, W. H. (2000). Constructions of masculinity and their influence on men’s well-being: a theory of gender and health. Social science & medicine, 50(10), 1385-1401.

Courtenay, W. (2003). Key determinants of the health and well-being of men and boys. International Journal of Men’s Health, 2, 1-30.

Courtenay, W. H. (2004). Best practices for improving college men’s health. New Directions for Student Services, 2004(107), 59-74.

Cramer, H., Horwood, J., Payne, S., Araya, R., Lester, H., & Salisbury, C. (2014). Do depressed and anxious men do groups? What works and what are the barriers to help seeking?. Primary health care research & development, 15(03), 287-301.

Crisp, A. H., Gelder, M. G., Rix, S., Meltzer, H. I., & Rowlands, O. J. (2000). Stigmatisation of people with mental illnesses. The British Journal of Psychiatry, 177(1), 4-7.

Dew, K., Dowell, A., McLeod, D., Collings, S., & Bushnell, J. (2005). “This glorious twilight zone of uncertainty”: Mental health consultations in general practice in New Zealand. Social science & medicine, 61(6), 1189-1200.

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Griffiths, K. M., Carron-Arthur, B., Parsons, A., & Reid, R. (2014). Effectiveness of programs for reducing the stigma associated with mental disorders. A meta-analysis of randomized controlled trials. World Psychiatry, 13(2), 161-175.

Gullestrup, J., Lequertier, B., & Martin, G. (2011). MATES in construction: impact of a multimodal, community-based program for suicide prevention in the construction industry. International journal of environmental research and public health, 8(11), 4180-4196.

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O’Brien, R., Hunt, K., & Hart, G. (2005). ‘It’s caveman stuff, but that is to a certain extent how guys still operate’: men’s accounts of masculinity and help seeking. Social science & medicine, 61(3), 503- 516.

Ogrodniczuk, J., Oliffe, J., Kuhl, D., & Gross, P. A. (2016). Men’s mental health Spaces and places that work for men. Canadian Family Physician, 62(6), 463-464.

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Schrank, B., Amering, M., Hay, A. G., Weber, M., & Sibitz, I. (2014). Insight, positive and negative symptoms, hope, depression and self- stigma: a comprehensive model of mutual influences in schizophrenia spectrum disorders. Epidemiology and psychiatric sciences, 23(03), 271-279.

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Vogel, D. L., Wade, N. G., & Hackler, A. H. (2007). Perceived public stigma and the willingness to seek counseling: The mediating roles of self-stigma and attitudes toward counseling. Journal of Counseling Psychology, 54(1), 40.

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188 Appendices One Better Out Than In 2017 1. APPENDICES

189 Appendices One Better Out Than In 2017

APPENDICES ONE - MEDIA COVERAGE

Date Talent Media Journo Show / Type Audience Topic Summary Audience Outlet Segment

11-Jul John Herald Ash N/A Print Melbourne Better Out Shortened version of 331,715 Longmire Sun Argoon Than In interview with John Longmire about why it's mental illness is Better Out Than In. 11-Jul John Herald Ash N/A Online Melbourne Better Out Full article of 40,000 Longmire Sun Argoon Than In interview with John Longmire about why it's mental illness is Better Out Than In. 11-Jul John Daily Ash N/A Print Melbourne Better Out Shortened version of 241,372 Longmire Telegraph Argoon Than In interview with John Longmire about why it's mental illness is Better Out Than In. This also got picked up on news.com. au and Daily Tele website. 11-Jul John Daily Ash N/A Online Melbourne Better Out Full article of 35,000 Longmire Telegraph Argoon Than In interview with John Longmire about why it's mental illness is Better Out Than In. 12-Jul John Sydney N/A N/A Online Sydney Better Out The Swans ran the 5000 Longmire Swans Than In full press release and video with Longmire on their website. 19-Jul John Preston Harrison N/A Print Melbourne Better Out Article about the 37,382 Longmire Leader Tippet Than In launch of Better Out Than In, focusing on La Trobe's involvement. Includes quotes from John Longmire. 18-Jul Brett SEN Andy Afternoon Radio Melbourne Better Out Interview with Johno 15,000 Johnson Maher Show Than In about the Better Out Than In campaign, what it aims to do and the support provided to players suffering from mental illness

190 Appendices One Better Out Than In 2017

APPENDICES ONE - MEDIA COVERAGE

Date Talent Media Journo Show / Type Audience Topic Summary Audience Outlet Segment

22-Jul John AFL Michael Footy Record Print National Better Out Small blurb 194,000 Longmire Media Lovett Than In announcing Better Out Than In and that John Longmire and Jake Edwards have shared their stories. 27-Jul John Northcote Harrison N/A Print Melbourne Better Out Article about the 22,525 Longmire Leader Tippet Than In launch of Better Out Than In, focusing on La Trobe's involvement. Includes quotes from John Longmire. 26- Jake Fox Drew AFL Tonight TV National Better Out Interview with Jake 40,000 Jul Edwards Footy Jones Than In about his experience with mental illness, how he has overcome it and what the Better Out Than In campaign is about. 27-Jul Jake 3AW Gerard SportsToday Radio Melbourne Better Out Jake told his story 35,000 Edwards Healy and Than In to Dwayne and and Online Gerard and pushed Dwayne the Better Out Russell Than In messaging. The interview then directed people to the website. 26- Jake ESPN Jonno N/A Online National Better Out Jake told his story to 2,000 Jul Edwards Nash Than In Jono and the article directs people to the Better Out Than In website.

10- Lukas Fox Rylie N/A Online National Better Out Rylie spoke with 8,046 Aug Webb Sports Jackson Than In Lukas about his experience and wrote an in-depth article about Better Out Than in and Lukas' story

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APPENDICES ONE - MEDIA COVERAGE

Date Talent Media Journo Show / Type Audience Topic Summary Audience Outlet Segment

11- Lukas Western Tom N/A Online National Better Out The Dogs used the 11,500 Aug Webb Bulldogs Nickson Than In BOTI video of Lukas and wrote an article to accompany the video. The article featured as the main story on the Dogs website and they shared it through their social channels. 13- Jake Triple M Mark DeadSet Radio Melbourne Better Out In-studio interview 50,000 Aug Edwards Howard Legends and Than In with Jake Edwards and Online about his battle Brendan with depression Fevola and what Better Out Than In. Fev also contributed a lot the conversation, discussing his own battle with depression. 27- Andrew Adelaide Jesper N/A Print Adelaide Better Out Article about 167,357 Aug Crowell Advertiser Fjeldstad and Than In Crowelly's struggle Online with anxiety during his playing career and what he's doing now to help players through the AFLPA. Mention of the Better Out Than In platform. 28- Andrew Adelaide Jesper N/A Print Adelaide Better Out Article from 202,567 Aug Crowell Advertiser Fjeldstad Than In Crowelly saying that social media is an added pressure to players in the AFL right now. The article then focused on Better Out Than Than in and what the campaign is all about.

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APPENDICES ONE - MEDIA COVERAGE

Date Talent Media Journo Show / Type Audience Topic Summary Audience Outlet Segment

21- Mark SEN Andy Afternoon Radio Melbourne Better Out Mark spoke to 15,000 Sep Eustace Maher Show Than In Andy about his own experience battling with mental illness, the importance of speaking up and his involvement in Better Out Than In.

1.7 million

193 Appendices Two Better Out Than In 2017 2. APPENDICES

194 Appendices Two Better Out Than In 2017

APPENDICES TWO - ACTIVITY SCHEDULE

Audience Activities Timing / Frequency Knowledge gained from...

Mental Health Community • Sharing key findings in • Presentations and Industry relevant industry applied journals and attendances will be applications/findings. publications once final report reported annually- Mates In Construction – and key findings developed. events, conferences and leading the way conference; • Conference/meeting symposiums to follow in line Discuss how digital presentations and with key findings and final technology can be used attendance at relevant report. to improve mental health wellbeing and mental health • Diverse opportunities and prevent suicide in the related events. will be explored with workplace. It has been • Share key findings at annual collaborations and argued that technology has AFL Players’ Psychology partnerships. created a world where we are Network conference. • Mates In Construction as connected as ever, while • Present on elements of the delegates conference. at the same time being more projects offering. socially disconnected. Academic Community • Share key research and • Annual report – Latrobe • Participatory design; User applied outcomes in peer symposium (July 2017). Experience Testing; Digital reviewed publications. • Mates In Construction – Media impact/reach; User • Conference presentations Leading the way conference feedback; Industry relevant and attendance. March 2017. applications/findings. • The 2017 Conference LEADING THE WAY Workplace Mental Health Conference, will provide an opportunity for workplaces to come together to exchange expertise, learn and collaborate. General Public • Utilising social media • Leveraging with Latrobe’s Promotion of and channels of Better Out Than and Mates In Construction engagement with the Better In partner organisations social network and following Out Than In platform and (twitter, Facebook, • Stories shared on AFLPA stories. Instagram, website). website. • Content on AFL Players • Media released and EDM’s & partner organisations in line story releases. websites. • Print, TV and radio media • Media releases and follow- opportunities. up interviews. • Traditional media opportunities. Community Sporting Groups • Focus group / participatory • Active ongoing engagement Engagement with the design with community in the development. foundation / key messaging sporting groups. of the Better Out Than In platform.

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APPENDICES TWO - ACTIVITY SCHEDULE

Audience Activities Timing / Frequency Knowledge gained from...

Australian Sport Industry • AFL club land presentations • Player development Sharing the platform with • AFL Players is a member managers to share Better other sports of the Australian Athletes Out Than In platform with Industry relevant Alliance, the peak body for transitioning players. applications/findings; Athletes in Australia, which • Quarterly. participation (direct through meets quarterly. presentations and indirect through attendance) at industry events and conferences. AFL Industry • Tailored briefings with AFL, • Twice a year and as required Integration of Better Out AFL Coaches Association, • As requested Than In with AFL Community. AFL Clubs, Player agents etc. • During video • Engagement in implementation stage participatory design and user • Quarterly. experience phases of Better Out Than In project. • Direct email and eNews distribution to industry partners and membership base (AFLPA & MIC). • Quarterly updates with AFL club welfare and wellbeing staff. AFL Players public facing website. AFL Players Association • Direct communication with • Ongoing Participatory design; User key stakeholders (players, • Development phase prior to Experience Testing; agents, player development video roll out - March 2016- Industry relevant staff). July 2016. applications/findings; • Social media Target audience insight; • Engagement in Community and Industry participatory design and user presentations including experience phases of Better promoting the program at Out Than In project. industry events such as: induction camp; Delegates conference, Player Development Manager (PDM) forum; agents conference; club visits. AFLPA internal presentations with sports industry stakeholders (including New Zealand Cricketers Association) and commercial partners.

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APPENDICES TWO - ACTIVITY SCHEDULE

Audience Activities Timing / Frequency Knowledge gained from...

beyondblue • Progress reports • Twice annually Knowledge Translation • Final report • Year 2-Once annually from STRIDE knowledge • Knowledge gatherings gatherings and other STRIDE projects; User feedback; participatory design and basecamp knowledge transfer. Better Out Than In • Project steering group • Quarterly Sharing current project ideas; partner organisations meetings aligning the project and the project aims with associated programs projects and organisations; Industry relevant applications/ findings. Target audience insights/focus group insight

197 Appendices Three Better Out Than In 2017 3. APPENDICES

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APPENDICES THREE - BACKGROUND INFORMATION

Depression in Males

Depression amongst males is a growing public health concern with increasingly risky consequences (Oliffe, Ogrodniczuk, Gordon, Creighton, Kelly, Black & Mackenzie, 2016). Depression is diagnosed when a range of symptoms that interfere with a persons daily functioning and persisting for over two weeks are present. These symptoms include, but are not limited to; diminished interest or pleasure in a range of activities, a sense of hopelessness or loss, poor appetite and disturbed sleep. The individual may experience persistent feelings of worthlessness or inappropriate guilt as well as reduced ability to think or concentrate. A person with depression may also experience recurrent thoughts of death and persistent suicidal ideation (DSM-5, 2016). Research indicates that the rates for diagnosed depression have increased worldwide over the past decade where the World Health Organisation (WHO) reports that globally, more than 300 million people of all ages suffer from depression. The WHO also reports that depression is the leading cause of disability worldwide, and is also a major contributor to the overall global burden of disease (WHO, 2017). Although reported rates of diagnosed depression in males are almost half that of females (Oliffe, & Phillips, 2008), consistently over the past 10 years, the number of suicide deaths in Australia has been approximately 3 times higher in males than females. In 2015, 75.6% of people who died by suicide were male (Australian Bureau of Statistics, 2016). As well as much higher rates of suicidality, rates of drug and alcohol abuse in males is also significantly higher (Ridge, Emslie & White, 2010). This may indicate that males may cope with mental health difficulties and distress differently to women (Cramer, Horwood, Payne, Araya, Lester & Salisbury, 2014). It has been suggested that lower reported rates of men’s depression can be attributed to a range of factors including men’s hesitancy to express their inner experience or concerns about their mental well-being and reluctance to seek professional mental health supports (Oliffe et al, 2016). Some have speculated that men’s depression-related behaviours and beliefs are related to prevailing ideals of masculinity.

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These dominant ideals include cultural norms identifying men as strong, tough and independent where a denial of depression may be ascribed to these masculine stereotypes (Oliffe, et al, 2008). It has also been highlighted in the research that men who deviate from these ‘masculine scripts’ by seeking help or even acknowledging they have depression, were more likely to experience societal and self stigma (Bartlett, 2005). A study in the United Kingdom explored experiences of depression from a range of different perspectives. They found that when studying men’s data and interviews of males with depression, the strategies adopted to sustain a valued sense of self during recovery included identifying ways to fit in as ‘one of the boys’ and re-establishing control (Oliffe et al, 2008). Another study indicated that men with a diagnosis of major depression experienced lack of connectedness with others, and engaged in elaborate secret-keeping for fear of being seen as weak. They also identified feeling out of control and engaged in persistent self-blame as a result of a sense of not being able to ‘overpower’ depression. They also found that most participants aligned to traditional, stereotyped gender roles with delays in treatment seeking being attributed to a desire to avoid the impairment to masculine self- concept (Heifner, 1997). A concerning conflicting relationship of relatively lower rates of diagnosed depression in males and increasingly high rates of suicide, coupled with poor engagement with mental health services, demonstrates an increased need to further identify and explore the range of potential factors that contribute to poor help seeking behaviours (Ogrodniczuk, Oliffe, Kuhl, & Gross, 2016). Although current and past research on depression and its potential causes, symptoms and treatment is vast, our understanding of depression amongst males remains relatively limited (Ramirez & Badger, 2014). There has been found to be a notable lack of evidence describing or exploring male’s experiences of depression. Hence, further exploration of this diagnosis from a male perspective warrants merit, with an urgent need to seek a better understanding and insight into its experiential presentation (Ramirez et al, 2014).

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The consistently higher rates of suicide in males contrasted with lower rates of diagnosed depression, provides a platform through which to explore the potential contributing factors to this phenomenon. This report aims to identify some of the barriers to help seeking in males with depression as well as highlight potential solutions and interventions to overcome these barriers. The connections between depression, masculinity and stigma will be explored and recommendations for future research highlighted.

Masculine Norms in Mental Health

Research demonstrates that men typically display distinctive health and illness behaviours where they tend to risk rather than promote their health (Oliffe & Phillips, 2008). This results in males often relying on performance-based models to confirm health, self-monitor and treat symptoms. This often leads to males denial of illness leading to an avoidance of health care professionals and services (O’Brien, Hunt & Hart, 2005).

Although it has been found that males experience and suffer from depression in much the same ways as females, how they express depression often differs greatly and therefore can be more difficult to detect or identify (Ogrodniczuk et al. 2016). Specifically, Ogrodniczuk and Oliffe (2011) found that in the initial stages, depression in males often manifests as anger, aggression, irritability, hostility, risk taking, and escaping behaviours.

The researchers highlighted that this atypical expression of emotional distress often masked more typical symptoms of depression like sadness, crying, feelings of guilt, and changes in appetite. The authors noted that it is only in recent years that mental health professionals have begun to recognise that these types of signs and symptoms among men can be early indicators of depression (Ogrodniczuk et al. 2011).

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One Australian study, identified the practices of ‘acting in’ and ‘acting out’ among male teachers and students who described their experiences of low mood and how they managed symptoms (Brownhill, Wilhelm, Barclay & Schmied, 2005). The findings revealed that the process of ‘acting in’ referred to male participants experience of engaging in avoidance behaviours (e.g. drugs and alcohol, distraction techniques) to manage low mood.

They found that repeated attempts to avoid or ‘act in’ often led to an accumulation of unhelpful and distressing inner experiences which often resulted in male participants ‘acting out’. The process of ‘acting out’ included externalising behaviours such as aggression, violence, impulsivity, crime and increased risk taking. The study also identified the concept of ‘stepping over the line’, which highlighted deliberate self-harm and suicide.

The study determined that traditional notions of masculinity were intrinsically linked to how males expressed emotional distress (Brownhill et al. 2005). Courtenay (2000) connected the varying displays of distress amongst males to dominant ideals of masculinity. Specifically they highlighted that men’s health risk- taking and performance of heroic feats are linked to their need to have other men and women grant or acknowledge their manhood (Oliffe et al. 2008).

It has been found that when men disclose emotional problems, they often veer towards describing “functional” problems, such as issues at work or with sex. Sometimes they will discuss existential concerns such as conflicts around what makes them happy or brings them joy. Although, these are not necessarily male-specific issues, as women can also struggle with them, they are found to be more common in men. Ramirez and Badger (2014), identified that masculine gender role socilaisation often promotes stoicism and suppression of emotions.

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As a result these social norms or stereotypes can impact thoughts, feelings and behaviours in men and restrict expression of their inner experience (Cochran & Rabinowitz, 2003; Zamarripa, Wampold & Gregory, 2003). An aforementioned UK based study on depression in males, identified that male participants experienced persistent feelings of isolation, guilt, sadness, detachment, fear and anger (Heifner, 1997).

However, in spite of this, rather than disclose that they had depression to others or seeking help, the male participants preferred to self-monitor and exhibit a range of ‘coping’ behaviours instead. Seeking help or support appeared to be one of the last options for males and indicated a perceived sense of failure. This may be related to the perception that attention and health concerns for others, as well as caring for the health of others, is more related to the feminine ideals of gentleness, fragility and nurturing.

These values often conflict with that of the masculine ideals of self-reliance and aggression (Courtenay, 2004; Robertson, 2003). In regards to the male physique, the male form is often idealised as strong and hardy where health is presumed and displayed through performance indicators such as physical and sexual prowess.

Stigma Associated with Depression in Males

Stigma in mental illness is deep rooted and is often varied in terms of how it is defined and reported. Stigma has been categorised into both self/personal or internal stigma and public stigma (Oliffe et al. 2016). Self-stigma involves the perception of the self as inadequate, due to a mental illness, leading to a loss of self- esteem (Vogel, Wade & Haake, 2006). Often people who have internalised the prejudice of mental illness can experience self-stigma as a result (Boyd, Adler, Otilingam & Peters, 2014).

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In turn self-stigma and diminished self-esteem may exacerbate depression in people with mental illness (Schrank, Amering, Hay, Weber & Sibitz, 2014). Research now suggests that stigma in a range of different forms is a serious cause for concern in people with depression. As such there has been a plethora of research studies conducted in this area specifically investigating stigma associated with depression and various other mental disorders (Griffiths, Carron-Arthur, Parsons, Reid, 2014).

Public stigma is the reaction that the general population has to people with mental illness (Corrigan & Watson, 2002). An Australian study investigating public attitudes toward mental illness reported that stigmatised attitudes were more often attributed to men experiencing mental illness compared to women (Reavley & Jorm, 2014). Hence, when considering public stigma, the medias portrayal of male depression is an important area to explore. Research suggests that media demonstrations of male depression that are not representative of the average man can increase stigma (Scholz, Crabb & Wittert, 2014).

Conversely, media portraying men as being proactive in managing their depression and open to confiding in others can help to de- stigmatise men’s depression (Oliffe et al. 2016). Corrigan, Larson, Michaels, Buchholz, Del Rossi, Fontecchio et al. (2015) found that programs with an anti-stigma focus, including education and cognitive restructuring can be beneficial as research suggests people with mental health difficulties who disclose and seek support for their experiences report reduced self-stigma and greater quality of life (Corrigan, Morris, Larson, Rafacz, Wassel, & Michaels et al. 2010).

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With this in mind, many advocates have reported that it is possible to teach strategic disclosure to people to manage self- stigma (Corrigan et al., 2015). Griffiths et al (2014) identified a pattern of findings for personal stigma that was very similar for the national, community and depressed populations. They found that for each of those populations personal stigma was higher among men, specifically in those who received less education, had greater psychological distress, and lower depression literacy. They also found an association between lower self-reported prior contact with depression and higher stigma in both the national and community samples.

Masculinity and Help Seeking

Although asking for help is difficult for many people, it is well documented that men tend to be more reluctant to seek help in various contexts, including help for mental health concerns (Ogrodniczuk et al. 2016). Researchers have demonstrated that seeking psychological services is consistently less common in men than in women, even when experiencing the same levels of distress (Andrews, Issakidis & Carter, 2001).

It has been estimated that only 15–27% of men with a mental health disorder seek formal help. These types of support include; psychotherapy or psychotropic medication (Oliver, Pearson, Coe, & Gunnell, 2005). Furthermore, research suggests that men are less likely to seek informal help from family and friends (Forchuk et al., 2009). It has been theorised that this may in part be due to a propensity to conform to traditional masculine norms including, but not limited to stoic emotional control and self-reliance (Addis & Mahalik, 2003).

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Further research indicates that males hold more negative attitudes towards help-seeking when they ascribe to these traditional masculine norms in addition to increased stigma, poorer intentions to seek help, and lower rates of formal and informal help-seeking (Syzdek, Addis, Green, Whorley & Berger, 2014). Empirical studies suggest that the correlation between traditional male gender roles and help- seeking behaviours is mediated by factors such as stigma, which has consistently been found to be an important predictor of help seeking for men (Vogel, Bitman, Hammer & Wade, 2013).

Self-stigma in particular is directly correlated to low self- esteem and an increased risk of depression (Vogel et al, 2013). A pattern emerges where an individual may experience shame and embarrassment about having a mental illness. If a person then identifies as someone with a mental illness in need of treatment, often this can lead to a further reduction of self-esteem, which in turn establishes the self-stigma of seeking help.

Conversely, two subgroups of self-stigma have been identified in the literature; one related more directly to experiencing mental illness and the other linked to seeking treatment (Latalova, Kamaradova & Prasko, 2014). Hence, it has been posited that if stigma is related to male’s reduced potential to seek help, it is judicious to predict that stigma may also be associated with men’s reduced willingness to share their experiences of mental health issues and treatment with others (Vogel et al. 2013).

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Barriers to Help-Seeking

One of the main identified barriers to help-seeking behaviour is gender (Vogel, et al, 2011). As a result of unhelpful gender ascribed narratives e.g. “boys don’t cry”, often males internalise messages, which can result in reluctance to express inner distress. The consequences of these often culturally aligned influences are apparent differences between male and female attitudes in how they approach or communicate a request for help. Philips (2005) explored the role of cultural discourse in producing normative and marginalised masculinities in adolescents. They found that a range of practices were related to maintaining status as the hegemonic masculine norm in adolescence. These practices included but were not limited to; heterosexuality, homophobia, athleticism, economic privilege, toughness, and violence. Latalova et al. (2014) suggested that the Western ideal of masculinity is displayed as stoic endurance of suffering, persistent self-reliance, and an unwillingness to seek help. They further reported that this gender role, often acquired and internalised early in life and enhanced by repetition and life experiences, is challenging to alter. Yet the effect of gender role on resistance to help seeking is also potentially facilitated, by self-stigma. Meaning the people with depression may believe themselves to be inferior or weak for needing to seek treatment. However, in spite of the deep-rooted influence of dominant gender roles on men’s attitudes toward seeking help, much less is known about the potential mediating factor of stigma between learned gender roles and perception of help-seeking (Lannin, Vogel, Brenner & Heath, 2015). This has been found to be an important distinction as gender roles are often learned early in life, and as a result are difficult to change. Hence, interventions or prevention programs designed to enhance men’s use of psychological services may take these factors into consideration when identifying a target population. When revisiting the impact of stigma on help seeking, it is helpful to view this as a gender salient barrier, which is potentially more amenable to change.

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As previously identified there are two main types of stigma; public stigma and self-stigma. So how do these pose potential barriers to help seeking in males with depression? Firstly, public stigma has been identified in the literature as an important barrier to seeking psychological support due to males in particular being more vulnerable to internalising public stigma than females (Vogel, Wade, & Hackler, 2007). This internalisation of public stigma then manifests over time as self-stigma. Vogel et al. (2007) reports that, ‘self-stigma is the internalisation of negative views of society toward mental illness and seeking help (e.g., to believe oneself is “inferior” or “weak” for needing to seek counselling)’ pp. Hence, it may be assumed that due to this internalisation, self-stigma has the potential to facilitate the relationship between perceptions of public stigma and help-seeking attitudes (Vogel et al., 2007). Hence, increased public stigma can result in increased self-stigma, which negatively impacts inclination to seek professional support. A recent study conducted by Lannin, Vogel, Brenner and Heath (2015) explored a correlation between stigma and help-seeking found that in individuals experiencing higher levels of distress, those with high self-stigma were nearly half as likely to seek mental health and counselling information than those with low self-stigma. They concluded that self-stigma may obstruct initial decisions to seek mental health and counselling information, which indicated the need for the development of early interventions designed to reduce help- seeking barriers (Lannin et al. 2015). It has also been found that self-stigmatisation for help seeking is more prominent in males than females but there is more potential for individual intervention in this form of stigma than of public stigma and traditional gender roles (Vogel, Wade & Hackler, 2007). When focusing specifically on depression it has been found that this mental disorder is associated with both public stigma as well as self-stigma. A potential personal perception that only ‘weak’ individuals get depressed is often compounded by a public view that depressed individuals are precarious or should ‘push through’ or ‘pull themselves together’ (Latalova, et al 2014; Crisp, Gelder, Rix, Meltzer, & Rowlands, 2000).

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Building on the idea that men are often reluctant to engage in their own health care, Johnson, Oliffe, Kelly, Galdas and Ogrodniczuk (2012), reported that depressed men explained their mental health help seeking in particular ways. Some participants’ accounts challenged dominant ideals of masculinity, instead emphasising the role of help seeking in being understood and having illness validated by a professional. Most accounts, however, included typically masculine explanations of help seeking, such as only engaging with health services out of necessity. It appears that depression impacts on men’s subjectivities about what it means to achieve masculine ideals (Scholz, Crabb & Wittert, 2016). As well as gender norms and stigma, men’s poor health outcomes and barriers to help seeking have also been linked to professional health services (Oliffe, 2008). Several studies have identified specific challenges when men access professional help services. As males often prolong their help seeking until it is at a critical point, they are often met with adverse and judgmental reactions from health professionals. Reports of male unfriendly health environments and past unhelpful experiences of help seeking from professionals, have been found to contribute to reluctance of seeking support. Furthermore, challenges such as health care professionals’ preoccupation with changing men’s behaviours, as well as the anonymity, loss of identity and the subsequent marginalised, subordinate masculinity that can occur when men enter health care institutions have all been identified as barriers (Courtenay, 2000; Watson, 2000). Males have also reported finding it very challenging to articulate their emotional distress and concerns to health professionals where they may minimise their symptoms. Health professionals in turn may then offer inappropriate treatment or neglect suggesting helpful referral options for their patients. This may lead to further avoidance on the individual’s behalf if they feel their needs are not being met (Oliffe, 2008).

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When a male suffering from depression has made the decision to seek help, the most common entry point is through general practice. Unfortunately, there is a large body of evidence suggesting that depression is often undetected and ineffectively treated in these settings (Dew, Dowell, McLeod, Collings & Bushnell, 2005). Reasons for this include; very brief consultation times, which make it challenging for an individual to fully disclose and explore their range of symptoms. Lack of mental health training in medical practitioners is also a persistent challenge, where medical practitioners themselves can be avoidant of exploring mental health difficulties or veer towards medication management rather than referring for ongoing psychotherapeutic support. Lack of continuity of care across health settings has also contributed to fragmented pathways in mental health care (Forster & Wu, 2002). A study conducted in Canada explored health services and access to health care from the perspective of men experiencing persistent suicidal ideation. They concluded that the male participants were more likely to utilise drugs, alcohol and sex as alternatives to professional health care as a result of experiencing challenges securing appropriate referrals and difficulties navigating a complex referral system. They also described challenges in interacting with health care professionals, and a range of humiliations during hospitalisation (Strike, Rhodes, Bergmans & Links, 2006). As a result of such challenges, research consistently demonstrates that many men suffer from depression in silence, rather than engage with professional mental health care services. (Oliffe et al, 2008). Gaining a deeper understanding of the complexities of correlations between men’s help seeking behaviours and access to health services is more pertinent in relation to mental health. This is a result of men with depression often experiencing difficulty accessing appropriate treatment and their needs going unmet.

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Research indicates that this is partly attributable to a range of varying, multi-layered and challenging circumstances which many mental health services face as well as systemic difficulties on a social, financial and individual basis that impede access (Strike et al. 2006).

It has been suggested that that exploring men’s own unique experience of their depression and other mental health distress may be an increasingly successful approach to alter help-seeking attitudes, as opposed to attempts to alter those attitudes directly. Importantly research suggests that the inhibitory effect of traditional masculine gender norms on help-seeking can be counteracted if depressed males feel that a genuine connection has been established with a health care professional, leading to mutual understanding and shared experience being founded (Latalova et al, 2014).

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APPENDICES FOUR - SSDS-DSS ITEM PERCENTAGES

Appendix Table One Percentage of particpants from the total sample who responded ‘agree’ or ‘strongly agree’ with statements about depression from the Self-Stigma Depression Scale and Depression Stigma Scale

Baseline (n=1052) Follow-up one (n=319) Follow-up two

(n=103)

SSDS Agreed Strongly agreed Agreed Strongly agreed Agreed Strongly agreed

1 40% 6% 36% 4% 31% 7%

2 28% 4% 27% 2% 23% 5%

3 48% 12% 48% 9% 45% 12%

4 47% 9% 45% 5% 38% 8%

5 53% 14% 49% 10% 39% 12%

6 53% 7% 48% 7% 46% 6%

7 54% 10% 50% 10% 51% 11%

8 29% 6% 26% 5% 18% 4%

9 51% 21% 53% 17% 56% 14%

10 59% 16% 60% 9% 57% 6%

11 60% 9% 55% 6% 53% 8%

12 56% 9% 53% 6% 46% 9%

13 56% 8% 51% 16% 45% 20%

14 26% 8% 24% 10% 21% 10%

15 28% 5% 25% 5% 19% 4%

16 40% 11% 37% 9% 33% 7%

DSS

1 6% 1% 4% 1% 3% 0%

2 9% 1% 9% 1% 45% 37%

3 3% 1% 2% 1% 2% 2%

4 15% 2% 12% 1% 13% 2%

5 3% 1% 2% 0% 3% 1%

6 32% 2% 33% 1% 24% 7%

7 28% 4% 21% 6% 22% 6%

8 10% 1% 8% 0% 3% 0%

9 11% 2% 8% 2% 8% 0% Notes: Item 9 of the SDSS was reverse coded. A response of ‘disagree’ or ‘strongly disagree’ was reversed to represent high stigma scores

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• SSDS Labels 1= I would feel embarrassed; 2= I would feel ashamed; 3= I would feel disappointed in myself; 4= I would feel inferior to other people; 5= I would think I should be able to ‘pull myself together’; 6= I would think I should be able to cope with things; 7= I would think I should be stronger; 8= I would think I only had myself to blame; 9= I would feel like I was good company; 10= I would feel like a burden to other people; 11= I would feel inadequate around other people; 12= I would feel I couldn’t contribute much socially; 13= I wouldn’t want people to know that I wasn’t coping; 14= I would see myself as weak if I took antidepressants; 15= I would feel embarrassed about seeking professional help for depression; 16= I would feel embarrassed if others knew I was seeking professional help for depression

• DSS Labels 1= People with depression could snap out of it if they wanted; 2= Depression is a sign of personal weakness; 3= Depression is not a real medical illness; 4= People with depression are dangerous; 5= It is best to avoid people with depression so you don’t become depressed yourself; 6= People with depression are unpredictable; 7= If I had depression I would not tell anyone; 8= I would not employ someone if I knew they had been depressed; 9= I would not vote for a politician if I knew they had been depressed

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Appendix Table 2 Percentage of participants from each campaign group at baseline who responded ‘agree’ or ‘strongly agree’ with statements about depression from the Self-Stigma Depression Scale and Depression Stigma Scale

AFL Players AFL Coaches Construction (other) Construction (VIC)

SSDS Agreed Strongly Agreed Strongly Agreed Strongly Agreed Strongly

agreed agreed agreed agreed

1 40% 4% 34% 2% 39% 5% 40% 12%

2 28% 0% 21% 4% 29% 4% 22% 4%

3 51% 7% 40% 9% 47% 13% 42% 15%

4 52% 6% 43% 2% 47% 9% 43% 12%

5 54% 14% 45% 15% 53% 11% 51% 22%

6 57% 5% 43% 6% 53% 5% 48% 16%

7 58% 9% 43% 6% 56% 9% 48% 15%

8 30% 6% 23% 2% 29% 5% 28% 7%

9 59% 16% 57% 4% 60% 18% 58% 10%

10 61% 5% 57% 2% 61% 9% 57% 10%

11 64% 5% 45% 6% 57% 10% 47% 8%

12 53% 6% 45% 4% 59% 9% 61% 6%

13 54% 19% 49% 17% 52% 19% 55% 24%

14 23% 5% 15% 2% 27% 9% 28% 5%

15 27% 4% 19% 2% 26% 6% 28% 4%

16 40% 9% 28% 9% 41% 10% 41% 11%

DSS

1 10% 0% 0% 0% 5% 1% 6% 0%

2 11% 1% 4% 0% 8% 1% 20% 0%

3 5% 2% 0% 2% 2% 1% 2% 2%

4 10% 0% 11% 4% 16% 2% 18% 2%

5 3% 0% 2% 0% 3% 1% 9% 2%

6 32% 0% 26% 2% 34% 2% 32% 4%

7 29% 3% 17% 2% 28% 3% 23% 5%

8 15% 1% 6% 0% 7% 1% 17% 0%

9 13% 1% 11% 0% 9% 2% 20% 0% Notes: N = 1052. Item 9 of the SSDS was reverse coded. A response of ‘disagree’ or ‘strongly disagree’ was reversed to represent high stigma scores

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• SSDS Labels 1= I would feel embarrassed; 2= I would feel ashamed; 3= I would feel disappointed in myself; 4= I would feel inferior to other people; 5= I would think I should be able to ‘pull myself together’; 6= I would think I should be able to cope with things; 7= I would think I should be stronger; 8= I would think I only had myself to blame; 9= I would feel like I was good company; 10= I would feel like a burden to other people; 11= I would feel inadequate around other people; 12= I would feel I couldn’t contribute much socially; 13= I wouldn’t want people to know that I wasn’t coping; 14= I would see myself as weak if I took antidepressants; 15= I would feel embarrassed about seeking professional help for depression; 16= I would feel embarrassed if others knew I was seeking professional help for depression

• DSS Labels 1= People with depression could snap out of it if they wanted; 2= Depression is a sign of personal weakness; 3= Depression is not a real medical illness; 4= People with depression are dangerous; 5= It is best to avoid people with depression so you don’t become depressed yourself; 6= People with depression are unpredictable; 7= If I had depression I would not tell anyone; 8= I would not employ someone if I knew they had been depressed; 9= I would not vote for a politician if I knew they had been depressed

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Appendix Table 3 Percentage of participants from each campaign group at follow-up 1 who responded ‘agree’ or ‘strongly agree’ with statements about depression from the Self-Stigma Depression Scale and Depression Stigma Scale

AFL Players AFL Coaches Construction (other) Construction (VIC)

SSDS Agreed Strongly Agreed Strongly Agreed Strongly Agreed Strongly

agreed agreed agreed agreed

1 30% 2% 36% 0% 38% 3% 34% 5%

2 15% 0% 36% 0% 30% 2% 26% 5%

3 47% 3% 55% 0% 49% 11% 40% 13%

4 38% 3% 55% 0% 47% 3% 45% 11%

5 52% 8% 46% 9% 45% 11% 53% 11%

6 43% 10% 46% 0% 48% 6% 61% 8%

7 50% 7% 46% 9% 51% 12% 55% 13%

8 18% 2% 27% 0% 26% 5% 24% 8%

9 50% 12% 36% 9% 27% 18% 53% 21%

10 62% 7% 55% 0% 66% 7% 50% 13%

11 47% 3% 46% 0% 59% 5% 61% 8%

12 45% 5% 55% 0% 59% 5% 45% 5%

13 58% 5% 46% 9% 48% 18% 50% 21%

14 15% 8% 27% 9% 28% 10% 24% 13%

15 22% 2% 18% 0% 26% 5% 26% 13%

16 27% 0% 55% 0% 37% 10% 34% 18%

DSS

1 5% 0% 9% 0% 2% 1% 11% 8%

2 7% 0% 0% 0% 11% 0% 16% 5%

3 5% 2% 0% 9% 1% 1% 3% 0%

4 0% 2% 0% 0% 18% 0% 8% 2%

5 0% 0% 0% 0% 3% 0% 0% 0%

6 20% 0% 46% 0% 41% 1% 37% 0%

7 15% 2% 27% 0% 21% 8% 26% 5%

8 5% 0% 9% 0% 10% 0% 8% 0%

9 5% 2% 0% 0% 11% 3% 8% 5% Notes: N = 319. Item 9 of the SSDS was reverse coded. A response of ‘disagree’ or ‘strongly disagree’ was reversed to represent high stigma scores

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• SSDS Labels 1= I would feel embarrassed; 2= I would feel ashamed; 3= I would feel disappointed in myself; 4= I would feel inferior to other people; 5= I would think I should be able to ‘pull myself together’; 6= I would think I should be able to cope with things; 7= I would think I should be stronger; 8= I would think I only had myself to blame; 9= I would feel like I was good company; 10= I would feel like a burden to other people; 11= I would feel inadequate around other people; 12= I would feel I couldn’t contribute much socially; 13= I wouldn’t want people to know that I wasn’t coping; 14= I would see myself as weak if I took antidepressants; 15= I would feel embarrassed about seeking professional help for depression; 16= I would feel embarrassed if others knew I was seeking professional help for depression

• DSS Labels 1= People with depression could snap out of it if they wanted; 2= Depression is a sign of personal weakness; 3= Depression is not a real medical illness; 4= People with depression are dangerous; 5= It is best to avoid people with depression so you don’t become depressed yourself; 6= People with depression are unpredictable; 7= If I had depression I would not tell anyone; 8= I would not employ someone if I knew they had been depressed; 9= I would not vote for a politician if I knew they had been depressed

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Appendix Table 4 Percentage of participants from each campaign group at follow-up 2 who responded ‘agree’ or ‘strongly agree’ with statements about depression from the Self-Stigma Depression Scale and Depression Stigma Scale

AFL Players AFL Coaches Construction (other) Construction (VIC)

SSDS Agreed Strongly Agreed Strongly Agreed Strongly Agreed Strongly

agreed agreed agreed agreed

1 28% 0% 40% 20% 36% 6% 27% 9%

2 6% 0% 60% 0% 24% 6% 18% 9%

3 56% 0% 40% 20% 42% 12% 46% 9%

4 50% 0% 20% 0% 36% 8% 46% 0%

5 28% 6% 40% 0% 40% 14% 46% 9%

6 39% 0% 40% 0% 48% 6% 36% 9%

7 44% 6% 60% 0% 46% 14% 46% 9%

8 11% 0% 0% 0% 18% 4% 18% 9%

9 72% 0% 40% 20% 58% 16% 27% 9%

10 72% 0% 20% 20% 56% 6% 46% 0%

11 56% 0% 0% 20% 54% 8% 64% 0%

12 39% 6% 40% 0% 50% 12% 46% 0%

13 44% 17% 60% 20% 34% 26% 64% 9%

14 17% 6% 0% 0% 20% 16% 27% 0%

15 17% 0% 0% 0% 20% 4% 27% 9%

16 22% 0% 40% 0% 30% 8% 46% 9%

DSS

1 0% 0% 0% 0% 4% 0% 9% 0%

2 44% 39% 80% 20% 44% 40% 18% 46%

3 0% 0% 0% 0% 4% 2% 0% 0%

4 33% 6% 0% 20% 10% 0% 27% 0%

5 0% 0% 0% 0% 4% 0% 9% 0%

6 6% 11% 0% 0% 30% 6% 27% 0%

7 17% 0% 20% 0% 22% 8% 27% 9%

8 0% 0% 0% 0% 6% 0% 0% 0%

9 6% 0% 20% 0% 8% 0% 9% 0% Notes: N = 103. Item 9 of the SSDS was reverse coded. A response of ‘disagree’ or ‘strongly disagree’ was reversed to represent high stigma scores

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• SSDS Labels 1= I would feel embarrassed; 2= I would feel ashamed; 3= I would feel disappointed in myself; 4= I would feel inferior to other people; 5= I would think I should be able to ‘pull myself together’; 6= I would think I should be able to cope with things; 7= I would think I should be stronger; 8= I would think I only had myself to blame; 9= I would feel like I was good company; 10= I would feel like a burden to other people; 11= I would feel inadequate around other people; 12= I would feel I couldn’t contribute much socially; 13= I wouldn’t want people to know that I wasn’t coping; 14= I would see myself as weak if I took antidepressants; 15= I would feel embarrassed about seeking professional help for depression; 16= I would feel embarrassed if others knew I was seeking professional help for depression

• DSS Labels 1= People with depression could snap out of it if they wanted; 2= Depression is a sign of personal weakness; 3= Depression is not a real medical illness; 4= People with depression are dangerous; 5= It is best to avoid people with depression so you don’t become depressed yourself; 6= People with depression are unpredictable; 7= If I had depression I would not tell anyone; 8= I would not employ someone if I knew they had been depressed; 9= I would not vote for a politician if I knew they had been depressed

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Appendix Table 5 Percentage of participants from the control and campaign groups who responded ‘agree’ or ‘strongly agree’ with statements about depression from the Self-Stigma Depression Scale and Depression Stigma Scale

Baseline (n = 1052) Follow-up (n = 319) Follow-up 2 (n = 103)

Control Campaign Control Campaign Control Campaign

SSDS Agreed Strongly Agreed Strongly Agreed Strongly Agreed Strongly Agreed Strongly Agreed Strongly

agreed agreed agreed agreed agreed agreed

1 46% 9% 38% 6% 40% 8% 35% 3% 21% 11% 33% 6%

2 29% 7% 28% 3% 29% 2% 27% 2% 32% 5% 21% 5%

3 51% 14% 47% 11% 51% 8% 48% 9% 42% 16% 45% 11%

4 42% 12% 48% 9% 42% 8% 45% 4% 32% 21% 39% 5%

5 53% 17% 53% 13% 56% 8% 48% 10% 42% 16% 38% 11%

6 53% 9% 53% 6% 46% 8% 49% 7% 53% 11% 44% 5%

7 51% 13% 55% 9% 42% 13% 51% 10% 68% 11% 46% 11%

8 28% 7% 29% 5% 33% 6% 24% 4% 26% 5% 16% 4%

9 53% 17% 60% 16% 46% 17% 54% 17% 58% 21% 56% 12%

10 57% 13% 61% 8% 50% 15% 62% 8% 63% 11% 56% 5%

11 52% 15% 57% 8% 52% 10% 56% 5% 58% 16% 52% 6%

12 52% 13% 57% 8% 52% 10% 53% 5% 42% 11% 46% 9%

13 45% 29% 52% 19% 52% 19% 51% 15% 58% 16% 42% 21%

14 32% 10% 25% 8% 21% 6% 25% 10% 32% 5% 19% 11%

15 34% 7% 26% 5% 27% 4% 25% 5% 21% 5% 19% 4%

16 41% 17% 40% 10% 46% 10% 35% 9% 42% 11% 31% 6%

DSS

1 4% 1% 6% 1% 4% 0% 4% 1% 0% 0% 4% 0%

2 7% 2% 10% 1% 4% 2% 9% 1% 5% 1% 8% 0%

3 2% 1% 3% 1% 2% 2% 2% 1% 0% 0% 2% 1%

4 17% 4% 15% 2% 8% 2% 12% 1% 26% 0% 10% 2%

5 7% 1% 8% 3% 4% 0% 2% 0% 0% 5% 4% 0%

6 27% 5% 33% 2% 19% 2% 35% 1% 32% 11% 23% 6%

7 31% 6% 27% 3% 23% 8% 21% 6% 26% 5% 21% 6%

8 10% 2% 10% 1% 9% 0% 9% 0% 0% 0% 4% 0%

9 10% 5% 11% 1% 2% 0% 9% 3% 5% 0% 8% 0% Notes: Item 9 of the SDSS was reverse coded. A response of ‘disagree’ or ‘strongly disagree’ was reversed to represent high stigma scores

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• SSDS Labels 1= I would feel embarrassed; 2= I would feel ashamed; 3= I would feel disappointed in myself; 4= I would feel inferior to other people; 5= I would think I should be able to ‘pull myself together’; 6= I would think I should be able to cope with things; 7= I would think I should be stronger; 8= I would think I only had myself to blame; 9= I would feel like I was good company; 10= I would feel like a burden to other people; 11= I would feel inadequate around other people; 12= I would feel I couldn’t contribute much socially; 13= I wouldn’t want people to know that I wasn’t coping; 14= I would see myself as weak if I took antidepressants; 15= I would feel embarrassed about seeking professional help for depression; 16= I would feel embarrassed if others knew I was seeking professional help for depression

• DSS Labels 1= People with depression could snap out of it if they wanted; 2= Depression is a sign of personal weakness; 3= Depression is not a real medical illness; 4= People with depression are dangerous; 5= It is best to avoid people with depression so you don’t become depressed yourself; 6= People with depression are unpredictable; 7= If I had depression I would not tell anyone; 8= I would not employ someone if I knew they had been depressed; 9= I would not vote for a politician if I knew they had been depressed

222