Young People’s responses to the Population Wide Act-Belong-Commit Mental Health Promotion Campaign: Implications for Youth Mental Health Interventions

1. Introduction

1.1. Young People and Mental Health

The arrival of COVID stimulated a heightened interest in mental health around the globe, and particularly with respect to the impact of lockdowns on people’s mental health. This COVID-stimulated focus on mental health included studies on the general population [1,2], the elderly [3], vulnerable population sub-groups [4], and young people [5,6,7]. These COVID-stimulated studies have served to not only increase attention on mental health in general, but to also draw attention to the different needs of specific sub-groups in the population. It is clear that the factors impacting negatively on mental health will vary across various socio-demographics, and particularly across the life span [8], and hence specific interventions at the secondary and tertiary prevention levels are required to target these specific factors (e.g., child abuse, racism, exposure to violence, substance abuse, etc).

However, for the promotion of good mental health and for primary prevention, it appears that the factors and behaviours that build resilience and positive mental health are generally consistent across the lifespan [9]. Hence it may well be that a universal messaging approach could apply across all or most population sub-groups, with the articulation of the messaging tailored for the different sub-groups (e.g., age; gender; socio-demographic groups), and/or within specific settings (e.g., schools, worksites, retirement villages, etc).

Given that the mental health of young people has received increasing attention in the past decade [7,10], and was described over 15 years ago as a ‘global crisis’ [11], there have been an increasing number of interventions across the globe targeting youth across a variety of settings, including schools, universities and sporting organisations [12]. However, many of these interventions have been concerned primarily with early detection and help-seeking, and focus on risk factors (e.g., substance use; bullying; social media; etc see [13,14], with fewer focussing on enhancing positive mental health [15]. Further, these interventions appear to be having limited impact at population levels; for example Mohr et al. point to the deteriorating mental health of young people in Nordic countries [10], the World Health Organisation points to increasing rates of suicide and depression amongst young people across the globe [16], and the mental health of young Australians has recently described as a ‘public health crisis’ [17]. Maidment & Carbone also concluded that ‘Australia is experiencing a youth mental health crisis’ and called for a new approach to build a mental health promotion system for young people [18].

This paper is concerned with mental health promotion/primary prevention, although the Act-Belong-Commit mental health promotion campaign has also been shown to contribute to both secondary and tertiary prevention [19,20].

1.2. The ‘Act-Belong-Commit’—‘ABCs of Mental Health’ Campaign

Act-Belong-Commit is an evidence-based mental health promotion program that aims to build the mental health and wellbeing of both individuals and communities [9]. The program follows the WHO definition of mental health as “a state of wellbeing in which the individual realises his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to contribute to his or her community” [21], p. 1. The campaign was first launched statewide in Western Australia in 2008 after extensive qualitative and quantitative research with persons 18 years and older, an extensive literature review of relevant research, and after a two-year pilot campaign in six regional towns. The campaign is now diffusing around the globe, primarily in Denmark, the Faroe Islands, Norway, Sweden, and Finland, where it is titled ‘the ABCs of Mental Health’ [22]. It has also been culturally adapted for First Nations people in Australia [23] and for children in Japan post the tsunami [24].

In the tradition of Aristotle’s saying that ‘virtue is cultivated by practice’ [25], Act-Belong-Commit encourages people to engage in behaviours that research has found to enhance and maintain good mental health and resilience. The three verbs ‘act’, ‘belong’ and ‘commit’ represent the three major behavioural domains that both the literature and people in general (including younger people) believe contribute to good mental health [9,26,27,28,29]. Hence, as in the Scandinavian articulation, the words ‘act’, ‘belong’ and ‘commit’ can also be considered to provide a colloquial ‘ABCs of mental health’. The domains are articulated as follows:

Act: Keep mentally, socially, spiritually, and physically active: Do Something.

Belong: Develop a strong sense of identity and belonging by keeping up family relationships and friendships, joining groups, participating in community activities and inviting others to do so: Do Something with Someone.

Commit: Do things that provide meaning and purpose in life, such as taking up challenges, supporting causes and helping others: Do Something Meaningful—Something that Matters.

Act-Belong-Commit/the ABCs of Mental Health targets individuals to engage in behaviours that enhance and maintain good mental health, and, via a social franchising approach partners with organisations that offer mentally healthy activities to promote the messages internally to their staff and/or externally to their clients or local communities. The campaign in Western Australia receives funding from the state government and is housed in a state university. The campaign is supported by a mass and targeted media presence (paid advertising and publicity), and has partnerships with local municipalities, primary and secondary schools, workplaces, state and community health services, state government departments, a range of non-government organisations (NGOs), local community organisations, and sporting and recreational clubs. A central hub and partnership model has also been adopted by other countries that are implementing the campaign [30].

1.3. Act-Belong-Commit Interventions Specifically Targeting Young People

In addition to the broad-based media-based campaign targeting all members of the general population, during the period 2015–2019 there were two Act-Belong-Commit interventions specifically targeting young people: a peer-educator workshops program for 14–25-year-olds (Youth Connectors) and a schools intervention for 11–14 year olds (Mentally Healthy Schools Framework).

1.3.1. The Act-Belong-Commit Youth Connector Workshops

The Youth Connectors peer-education program was developed in response to requests from young people wanting to become actively involved in the campaign, and particularly in terms of disseminating the message amongst their peers. Hence, with funding from an Australian Health Promotion Association graduate scholarship, author DM conducted a consultation with 35 young Western Australians across metropolitan and regional areas in 2016 to confirm interest in, and to inform the development of, a youth peer-education component for Act-Belong-Commit. This consultation indicated substantial support amongst community youth for such a program, and specifically in the format of a formal training workshop for peer-educators. Hence, a two-hour workshop was developed for young people aged 14 to 25 with an expressed interest in mental health and wellbeing.

The two-hour peer educator workshop introduces and elaborates the Act-Belong-Commit constructs and encourages attendees to become volunteer ‘Act-Belong-Commit Connectors’. The workshop uses educational and interactive activities to teach participants about the Act-Belong-Commit constructs and to build their capacity to assist and encourage their peers to engage in mentally healthy activities. As for the Mentally Healthy Schools Program, the articulation of the basic campaign constructs, both in terms of language/terminology and recommended activities, was tailored to resonate with and be relevant to this age group.

The overall goals of the Youth Connectors program were to increase young people’s awareness of mental health and the factors that affect mental health, and to change young people’s behaviour and attitudes relating to mental health in general, mental illness, and keeping mentally healthy. In particular, the overall aims were to increase young people’s knowledge of behaviours that protect and promote mental health, to increase their ability to engage and participate in mentally healthy behaviours and activities, and to increase their self-efficacy in communicating their knowledge to their peers.

1.3.2. The Act-Belong-Commit Mentally Healthy Schools Framework

The Act-Belong-Commit Mentally Healthy Schools Framework (MHSF) is based on the WHO’s Health Promoting Schools Framework [31]. Unlike many school interventions that target only students [32], and that emphasise mental illness detection and treatment rather than positive mental health [33], the Act-Belong-Commit Mentally Healthy Schools Framework targets both students and staff to enhance their mental health. Overall, the MHSF encourages a whole-of-school approach to mental health promotion by increasing the capacity of all school staff (both teachers and non-teachers) to create mentally healthy school environments. The overall objectives are to change both staff and student behaviour and attitudes with respect to mental health (and mental illness), and to increase student connectedness to, and teacher morale within, the school see [34,35].

Staff within the schools that sign up as Act-Belong-Commit partners receive formal training by Act-Belong-Commit officers, along with case study resources, promotional strategies, signage, and merchandise to assist with the delivery of the Framework. The program is self-sustaining and complements areas of the Australian Curriculum, allowing schools to tailor the Framework to school priorities and needs [34]. Articulation of the basic Act-Belong-Commit domains is tailored for both primary and secondary schoolchildren in terms of language and specific activities.

The aim of this paper is to summarise data obtained during the period 2015–2019 indicating the acceptance and adoption of the Act-Belong-Commit campaign messages by younger people from the above three sources:

(1) impact on 14–25-year-old participants of the peer-educator workshop program;

(2) impact on 11–14-year-old students of the adaptation of the campaign in secondary schools;

(3) impact of the population-wide media-based campaign on 18-24- and 25–34-year-olds (versus 35+ years).

2. Materials and Methods

2.1. Youth Connector Workshops

The Youth Connectors Program was conducted in the period 2017–2019, with 35 workshops held across the state with a total of 272 participants aged 14-25 years. Participants were recruited through secondary schools (28%), community organisations (31%) and universities (41%).

Participants completed pre- and post-questionnaires to assess the delivery of the workshop and to measure the impact of the workshop on their knowledge about how to keep mentally healthy and their self-efficacy in educating their peers about the Act-Belong-Commit messages and materials. The pre-questionnaire also obtained participant demographics (see [36] for details on the recruitment process, workshop content, pre- and post-questionnaires, and further detailed results).

2.2. Mentally Healthy Schools Framework

In 2016 and 2017, surveys of staff and secondary school students (aged 11-14 years) in participating schools were undertaken using structured self-completion questionnaires. ‘Baseline’ questionnaires were completed by N = 90 students from two schools that had recently signed up to the program but had not yet conducted many activities under the Framework, and ‘Follow-up’ questionnaires were completed by N = 50 students from three schools that had been implementing the Framework for 17 months or more. The baseline questionnaire data indicate the impact on students of the population wide campaign and the follow-up questionnaire data indicate the additional impact of the school intervention. The procedures and methods are described in [37]. The student results are reported in full in [37] and summarised below. (The results for staff are reported in [35]).

Both baseline and follow-up students were asked the following questions:

(a) whether they had heard of the Act-Belong-Commit campaign (campaign awareness);

(b) whether they had done or tried to do something as a result of becoming aware of the Act–Belong–Commit message (campaign behavioural impact); and

(c) what they believed the campaign was trying to do (campaign understanding).

2.3. The General Population Campaign

As stated above, the Act-Belong-Commit campaign is supported by a substantial mass and targeted media campaign using paid advertising and unpaid publicity across both traditional and digital media. State-wide surveys of the 18+ years population were undertaken annually in the years 2015 to 2019 via computer-assisted telephone interviews (CATI). In total, N = 3000 respondents took part in the CATI surveys in the years 2015–2019 (n = 600 in each year). Quotas were set such that 50% were female and 50% were male and all age groups were represented (16% were 18-24 years, 20% were 25-34 years; 28% were 35-54 years, and 36% were 55+ years). For details of the questionnaire and survey methods, see [19].

As for the above student surveys, respondents were asked the following questions:

(a) whether they had heard of the Act-Belong-Commit campaign (campaign awareness);

(b) whether they had done or tried to do something as a result of becoming aware of the Act–Belong–Commit message (campaign behavioural impact); and

(c) what they believed the campaign was trying to do (campaign understanding).

These general population impact data have been published for overall sample results (e.g., [19]), but have not previously been reported by age.

3. Results

3.1. Impact of the Youth Connectors Program

Of the 272 workshop participants, n = 198 completed both the pre and post workshop questionnaires, n = 37 completed only the pre and n = 37 completed only the post questionnaire. Sample demographics of the n = 235 who completed the pre-questionnaire were: Sex: female 67%, male 33%; Age: 14-17 years 36%, 18-25 years 64%; Geographic location: metropolitan 51%, regional 49%.

Table 1 shows the impact of these workshops on participants’ pre-post understanding of the main messages of the Act-Belong-Commit campaign. Table 2 shows participants’ pre-post confidence in doing the following: (i) applying the Act-Belong-Commit messages for their own mental health; (ii) explaining the Act-Belong-Commit messages to others; (iii) talking to others about mental health; and (iv) assisting others to get more involved in the community (see [36] in-house report for details on the recruitment process, workshop content, pre- and post-questionnaires, and further detailed results]. Where relevant, chi square analyses have been used here and below to assess the significance of differences (with p < .05 considered ‘significant’).

Table 1 shows that participants’ understanding of the Act-Belong-Commit main messages in terms of being able to nominate relevant actions under each of the three act, belong and commit domains increased significantly across all three constructs: Act: 24% to 44%; Belong: 34% to 47%; Commit: 20% to 38% (p < .05 for each comparison).

With respect to increasing confidence in participants’ ability to engage in various actions, Table 2 shows that the percent stating they were ‘very confident’ in doing each of the following increased significantly as a result of participating in the workshop: (i) applying the Act-Belong-Commit message to their own mental health: 36% to 73%; (ii) explaining the Act-Belong-Commit message to others: 26% to 72%; (iii) talking to others about being mentally healthy: 34% to 73%; and (iv) assisting others to get more involved in the community: 22% to 69% (p < .001 for each comparison).

Overall, these results indicate that young people who participated in the Youth Connectors Workshops not only reported an increased understanding of the Act-Belong-Commit message in terms of their knowledge of activities to keep themselves mentally healthy, but also reported increased efficacy in being able to engage in such activities. They also reported being more confident in their ability to engage with other young people about keeping mentally healthy and Act-Belong-Commit messaging, and to assist other young people to get more involved in community activities.

3.2. Impact of the Mentally Healthy Schools Program

Table 3 shows that almost two-thirds (62%) of baseline students reported being aware of the campaign, with awareness increasing to almost 90% amongst follow-up students (p < .01), indicating that the schools were successfully implementing the campaign. It is also of note that awareness in the ‘baseline’ schools (62%) was only somewhat lower than in the general adult population at that time (75%). This finding indicates that the population-wide mass media campaign had in fact already attracted the attention of a substantial proportion of schoolchildren.

With respect to a behavioural impact amongst those aware of the campaign, Table 3 shows that significantly more follow-up than baseline respondents reported trying to do something for their mental health as a result of their exposure to the campaign: 25% at baseline vs 30% at follow-up (p < .05).

Although based on small numbers it can be noted that these behavioural impact percentages are considerably higher than in the general population surveys (around 12% in 2016; 10% in 2017) [43].

With respect to campaign understanding amongst those aware of the campaign, both baseline and follow-up students’ responses demonstrated an appropriate understanding of the campaign messages in terms of acting, belonging, and committing activities, as well as interpreting the campaign as delivering positive messages about mental health.

Although based on relatively small numbers of respondents, the above ‘baseline’ findings, indicate that the general population-wide Act-Belong-Commit campaign had already reached and impacted a substantial proportion of the 11-14 years age group, and the ‘follow-up’ findings indicate an intensified impact within the school setting. Overall, these data indicate that the Act-Belong-Campaign appears acceptable to and positively impacts 11–14-year-old young people, both at a population wide level and in the school setting.

3.3. Impact of the General Population Campaign on 18-24- and 25-34-Year Olds vs 35+ Years

Table 4 shows the results for the awareness and behavioural impact variables for the total sample and for the various age categories. Table 4 shows that campaign awareness was equally high for 18–24-year-olds and 25-34 year olds, with 84% of both age groups aware of the campaign, which was significantly higher than amongst those aged 35+ years: 72% (p < .001).

When those aware of the campaign were asked what they ‘thought the Act-Belong-Commit campaign is trying to do’, all age groups showed an equally high level of understanding of the campaign messages, and specifically with respect to acting, belonging, and committing behaviours.

With respect to ‘whether they had done something as a result of their exposure to the campaign’, Table 4 shows that amongst those aware of the campaign, a behavioural response was significantly and substantially higher amongst 18–34-year-olds than amongst older groups: 15% of 18–24-year-olds and 17% of 25–34-year-olds versus 10% of those 55+ years (p < .01 for both comparisons).

Overall, the above results from the statewide general population surveys show that with respect to the different age groups, the Act-Belong-Commit campaign attracts the attention and involvement of 18-24- and 25–34-year-olds at a significantly higher level than that of 35+ years age groups.

4. Discussion

The above findings of the impact of the Act-Belong-Commit campaign constructs delivered at a community ‘workshop/training’ level, a ‘place’ intervention, and a population wide mass media intervention, together indicate that the Act-Belong-Commit campaign is effective in attracting the attention and involvement of individuals from childhood to adolescence to young adulthood, and in fact somewhat more so than that of older members of the population.

In retrospect, these positive findings are perhaps not unexpected as the campaign constructs were based on extensive formative qualitative and quantitative research with participants aged 18 years and older (including focus groups with 18–29-year-olds), and an extensive search of the then literature, which included some data on children’s understanding of keeping mentally healthy. The resulting campaign articulation and messaging was then based on concepts considered applicable across all age groups.

To facilitate a universal approach, the first television commercial featured ageless, animated cartoon characters rather than real persons. Anecdotal feedback indicates that it is likely that the animated cartoon television commercial had special appeal to schoolchildren. This animated cartoon tv commercial was supplemented several years later by three ‘testimonial’ television commercials, two of which featured an early-middle aged adult (one male, one female), and one that featured an 18–25-year-old university student (female).

For future specific adaptations, the basic underlying constructs and messaging of Act-Belong-Commit could undergo further tailoring to even more effectively communicate with younger people across different age groups, gender, socio-demographic characteristics and ethnicity, and within not only primary and secondary schools but also sporting and recreational organisations, religious and spiritual organisations, workplaces and tertiary education institutions. Given the importance of reinforcing and maintaining good mental health at an early age, adoption of the Act-Belong-Commit/WHO Mentally Healthy Schools Framework in primary schools could be a priority for both government and private schools.

In a broader context, the above findings and the universality of the Act-Belong-Commit constructs across cultures around the globe [22,24] suggest that the Act-Belong-Commit framework could provide a substantial contribution not only to answering Maidment & Carbone’s recent call for a comprehensive ‘youth mental health promotion system’ in Australia [18], but also for children, adolescents and young adults around the globe.