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Lets Talk Colorado

State: CO Type: Promising Practice Year: 2020

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Metro Denver Partnership for Health (Boulder County Public Health, Broomfield County Department of Health and Human Services, Denver Department of Public Health and Environment, Denver Public Health, Jefferson County Public Health, and Tri-County Health D
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Lets Talk Colorado

The Metro Denver Partnership for Health (MDPH) is a regional public health collaboration previously recognized as a NACCHO Model Practice which is led by the six Local Health Departments (LHDs) serving the seven-county Denver Metro area, including Adams, Arapahoe, Boulder, Broomfield, Denver, Douglas and Jefferson counties.  Participants include Boulder County Public Health, Broomfield County Department of Health and Human Services, Denver Department of Public Health and Environment, Denver Public Health, Jefferson County Public Health, and Tri-County Health Department.  The region includes nearly 3 million Coloradans, 60% of the state's population, with substantial diversity:  52% White, 22% Hispanic, 10% Black and 3% Asian (2015 census).    The Partnership collaborates regionally on a range of shared public health priorities, one of which is addressing mental health stigma.

Research indicates that stigma is a significant barrier to early intervention and treatment for mental health concerns.  Even when services are available, they may not be accessed due to fear and stigma. According to the Colorado Health Access Survey, talking with a health professional about mental health concerns has consistently remained a barrier for about a third or more of Coloradans living in the seven county metro region (2015: 39.3%; 2017:      30.8%; 2019: 37.4%). Coloradans living in the Metro area reporting concern about someone finding out they had a mental health problem has increased since 2015 (2015: 24. 3%; 2017:      21.1%; 2019: 31.6%), illustrating growing discomfort talking about mental health concerns. Research conducted by the Frameworks Institute found that while participants agree it is wrong to stigmatize people with mental health issues, they nevertheless engaged in patterns of talk that othered” people, such as defining people with mental health challenges as abnormal” and blaming individuals for their own mental health issues.

MDPH's overarching goal for our practice was to improve mental health by reducing stigma and fear associated with mental health and seeking care for behavioral health issues. The objectives of the project were 1) To develop a messaging campaign , 2) To collaborate with partners to disseminate, and 3) To modify the campaign over time to keep the message novel and timely.

Initiated in 2017, the campaign, Let's Talk Colorado”, is focused on beginning the conversation to reduce stigma of behavioral health issues and increase openness to help-seeking attitudes and behaviors in low-income populations in the Metro region. MDPH convened a Message Action Team representing multiple regional partners to develop messaging and strategies to promote a mental-health conversation. The team began with Minnesota's Make It Ok” campaign and focus-group tested it with a Colorado adult audience. Focus group data guided the development of Let's Talk Colorado.” The materials and website were then trans-created into Spanish (Hablemos Colorado”) and tested with Spanish-speaking audiences. TCHD also engaged the FrameWorks Institute to study perceptions around mental health in Colorado adults, and messages were reframed based on findings. Additionally, due to limited existing work targeting boys and men, additional messages were framed and tested with men-only focus groups.

A communication agency assisted with creation and testing of messages and development of collateral materials.  The partners included LHDs, community mental health, FQHCs, healthcare organizations, caregiver organizations, etc.  About 400 partners helped share the message using resources from https://letstalkco.org/toolkit/.   Paid media was purchased using grant funds, and many partners shared the message through a variety of paid and free channels. Additionally, Colorado Community Media committed to publishing 6 segments in local newspapers on mental health, with attention to getting the messages in frame”.

All objectives were met, including a successful campaign, broad dissemination by a large number of partners, and continual testing and updating of the messaging over time. The combination of the marketing and grassroots efforts resulted in the following media impressions: year 1 - 45,617,882; year 2 55,729,056; year 3 48,303,603.  Over the three years, there were over 23,000 website visits.

Key to success was the wide variety of partners participating, including local public health, healthcare systems/hospitals, schools, and local media partners. By creating a non-branded resource open to all, more partners were willing to share. For example, hospitals shared messaging because it was not branded with a competing health system's logo. The use of sound research to develop the message also improved message uptake and campaign success.

Let's Talk Colorado” continues to be utilized and promoted even after grant funding ended. Partners are continuing to utilize all materials, MDPH has committed to maintaining the website, and several stakeholders have committed funds to promote throughout the year, especially during Mental Health Month in May.

Websites: https://www.coloradohealthinstitute.org/research/metro-denver-partnership-health, letstalkco.org, and hablemosco.org.

Let's Talk Colorado” is focused on beginning the conversation to 1) reduce stigma of behavioral health issues and 2) increase openness to help-seeking attitudes and behaviors in low-income populations in the seven-county Denver Metro region. Research indicates that stigma is a significant barrier to early intervention and treatment for mental health concerns. 

Even when services are available, they may not be accessed due to fear and stigma according to the Colorado Health Access Survey. Conducted every other year, this survey measures why people are not getting needed care. Not feeling comfortable talking with a health professional about your mental health concerns has consistently remained a barrier for about a third or more of Coloradans living in the metro area (2015: 39.3%; 2017: 30.8%; 2019: 37.4%). The proportion of Metro area Coloradans  reporting concern about what would happen to them if someone found out they had a problem has increased by 30 %  since 2015 (2015: 24.3%; 2017: 21.1%; 2019: 31.6%). These data illustrate growing discomfort talking about mental health concerns. Research conducted by the Frameworks Institute found that while participants agree it is wrong to stigmatize people with mental health issues, they nevertheless engaged in patterns of talk that othered” people, such as defining people with mental health challenges as abnormal” and blaming individuals for their own mental health issues.

This practice reflects an innovative use of an existing tool. The team began with messaging from Minnesota's Make It Ok” campaign and focus-group tested it with a Colorado adult audience. Focus group data guided the development of Let's Talk Colorado.” The materials and website were then trans-created into Spanish (Hablemos Colorado”) and tested with Spanish-speaking audiences. MDPH also engaged the FrameWorks Institute to study perceptions around mental health in Colorado adults and messages were reframed based on findings. Additionally, due to limited existing work targeting boys and men, additional messages were framed and tested with men-only focus groups (eg, men from the following categories:  Spanish-speakers, Re-entry and recovery, members of South Metro Denver Chamber of Commerce, LGBTQI men, Veterans).

Mental health stigma affects all populations. This project originally was focused on the general adult population. Males were added as a more specific target audience after an environmental scan conducted by Colorado's State Innovation Model (SIM) program determined that strategies to address the mental health issues of boys and men were disproportionately lagging behind the rest of the population.

One of our key innovations was the recognition that existing message development processes were not sufficient and that public health was in a strategic position to influence the mental health conversation.  We identified the need for social science research to support and inform our messaging efforts to reduce stigma associated with mental health and found a funder (Colorado Health Foundation) to support it.  The result was the Frameworks Institute's research Beyond Awareness of Stigma: Moving Public Understanding to the Next Level”  https://www.frameworksinstitute.org/mental-health.html  which identifies existing cultural models and provides guidance for message framing.”  The report generated a number of important recommendations, among them the following:  (1) define mental health and reframe it in positive terms, (2) use values to help people see mental health as a collective issue, (3) avoid crisis messaging (which can reinforce a sense of fatalism), (4) use social math” to increase understanding of the scope of the problem (eg, adults are more likely to die from suicide than opiate overdoses), (5) use inclusive positive language to overcome stigma, and (6) fight fatalism by explaining solutions. This type of research had not been done before for adult mental health. The definition of innovation includes changing your practice and adapting to your environment to deliver a better product.  Let's Talk Colorado” is about how to frame a conversation to be better understood.

MDPH's overarching goal for Let's Talk Colorado  was to improve mental health by reducing stigma and fear associated with mental health and seeking care for behavioral health issues. The objectives were 1) To develop a messaging campaign, 2) To collaborate with partners to disseminate, and 3) To modify the campaign over time to keep the message novel and timely. This was accomplished through the use of a multidisciplinary Message Action Team and numerous partners disseminating the message.

This work was aligned with the Public Health Improvement Plans (PHIP) of several of the LHDs within the MDPH which were created in 2013-14 just prior to initiating Let's Talk Colorado. The PHIP Leadership Teams consisted of a broad cross-section of community partner representatives, including community mental health, parks and recreation, non-profit community organizations, county government, Colorado Department of Public Health and the Environment, Colorado Office of Behavioral Health, school districts, Federally Qualified Health Centers (FQHC), safety net clinics, Mental Health Colorado, and an early childhood council.

Work to begin the campaign was initiated in 2016 and the campaign kicked off in 2017.  Our first step was to convene a Message Action Team representing multiple partners across the region tasked with creating messaging to promote a mental health conversation. The team began with messaging from Minnesota's Make It Ok” campaign and focus-group tested it with a Colorado adult audience. Focus group data guided the development of Let's Talk Colorado.” The materials and website were then trans-created into Spanish (Hablemos Colorado”) and tested with Spanish-speaking audiences. TCHD also engaged the FrameWorks Institute to study perceptions around mental health in Colorado adults, and messages were reframed based on findings. Additionally, due to limited existing work targeting boys and men, additional messages were framed and tested with men-only focus groups (eg, Spanish-speakers, Re-entry and recovery, Members of South Metro Denver Chamber of Commerce, LGBTQI, Veterans).

A communication agency assisted with the creation and testing of messages and development of collateral materials.  The partners included LHDs, community mental health centers, FQHCs, healthcare organizations, caregiver organizations, etc.  Additional grassroots partners (400+) collaborated in disseminating the common messages through a variety of channels (e.g. current programming, existing communication channels, and social media) which maximized our reach across a fairly broad geographic area on a low budget.  In addition, paid media was purchased using grant funds, and many partners shared the message through additional paid and free channels. Importantly, Colorado Community Media committed to publishing 6 segments on mental health in local newspapers with a strong commitment by the reporter to getting the messages in frame.”  Since its inception, the campaign was targeted to the broad general population, although refinements over time have been added to take advantage of insights from the FrameWorks research and to increase relevance to boys and men.

In 2016, funding from the Colorado State Innovation Model (SIM) to the MDPH created support for development of our collaboration on Let's Talk Colorado”.  With the creation of the campaign, several local hospitals also joined the effort. Many of these non-profit hospitals had identified behavioral health as a community health need through their community health needs assessments.  The MDPH LHDs, along with hospital partners and other participants collaborated together on message development, campaign creation, and dissemination. Of critical importance, the fact that the campaign was not branded or owned by any one agency allowed for greater uptake of the materials and messaging by a wider variety of partners. This was key for a successful regional campaign.  Partners took a regional approach to the work - acknowledging that residents in the metro area may live, work, access care, and more in multiple counties. Consistent messaging and coordinated efforts can boost efficiency and increase likelihood of success.

Initial funding for this project included approximately $430,000 from the SIM grant over three years for the communications agency contractor to support message development and testing and creation of collateral materials and the website. A separate $98,000 grant was received from the Colorado Health Foundation to support the Frameworks Institute research. Finally, hospital partners contributed a combined $40,000 for paid media placement.  Although the SIM grant ended in July, 2019, MDPH and community partner efforts will allow it to continue for the forseeable future.

The objectives were 1) Develop a messaging campaign , 2) Collaborate with partners to disseminate, and 3) Modify the campaign over time to keep the message novel and timely. All objectives were achieved.

Let's Talk Colorado” is a research-based messaging campaign, with a website with a toolkit and print materials available to use. A collaborative team of 400+ partners worked together to disseminate the campaign through paid, free, and earned media; formative research throughout the process allowed the campaign to evolve, with each year's messaging building upon the previous one. The first year of the campaign was based on adaptations to the Minnesota Make It OK” campaign based on testing with a general adult audience. The second year built on the initial messaging with updates to the messaging based on research conducted by nationally-renowned social research and communications firm FrameWorks Institute. The third year of the campaign allowed for updated messaging targeting men and boys based on further message testing with this target audience.

The budget did not allow for in-depth evaluation; however, we collected media impressions of known paid and earned media through our communications agency. Also, it is clear from user behavior on both the Spanish and English websites that people were very engaged in seeking more information on how to talk to people about mental health and use the toolkit that was  provided on the website. The majority of the promotion efforts occurred during May of each year for Mental Health Month. These promotion efforts included several local stories both in print and television as well as several national stories.

Media impressions were analyzed and the totals over the three years were as follows: 2017 - 45,617,882; 2018 55,729,056; 2019 48,303,603.  In addition, website visits were as follows:  2017--English 6,659, Spanish: 1,836; 2018-English 6,760, Spanish 962;  and 2019-- English 6,721, Spanish 706 These estimates do not include additional reach of regional, state, and national partners. For example, several other jurisdictions outside of the Denver Metro area began to use and disseminate the campaign through their local media markets.  In addition, national exposure includes American Communities Project (https://www.americancommunities.org/on-child-well-being-colorado-moving-beyond-family-bubble-to-village-model/), Authority Magazine (https://medium.com/authority-magazine/historically-when-we-hear-the-words-mental-health-we-automatically-think-of-mental-illness-75ce3fc532b2), and the Public Good Projects (https://downloadcenter.actionminded.org/).

We also continue to track perceptions of stigma as a barrier to care in the community although our ability to link them to the impact of the campaign is limited. According to the Colorado Health Access Survey, not feeling comfortable talking with a health professional about your mental health concerns decreased slightly statewide from 2015 (39.3%) to 2019 (37.4%) among Coloradans in the Metro area. Also, an increasing number of Coloradans in the Metro area are reporting poor mental health according to the same survey (2015: 9.2%; 2017: 11. 1%; 2019: 15. 5%). This could be due to greater willingness to recognize mental health concerns and open up about them rather than an actual increase in poor mental health in the population over such a short time period.  In addition, MDPH used grant funding to add mental health stigma questions to the Colorado Behavioral Risk Factor Surveillance System in 2017 and 2019. Data from 2017 have been analyzed for the state and for our region, and we are awaiting release of the 2019 data to determine areas of possible progress.

Through the process, MDPH and our partners learned many lessons. The Frameworks Institute research highlighted the awareness of the unproductive patterns in public thinking and that knowing this is crucial for the development of communication strategies.  This research showed that it is necessary to go beyond communicating that stigma is wrong or undesirable and utilize framing recommendations to shift public thinking at a deeper level.  Framing helps build understanding with more productive values and narratives. The Message Action Team discovered that the implementation of recommendations from social science research was very challenging.  The messaging must tackle the underlying understandings that continue to perpetuate the stigmatization of mental health issues within our culture. 

We have also learned lessons in relation to partner collaboration.  Particularly important was the observation by our health systems partners that partnership in an area of general interest (eg, mental health) was much more likely to result in aligned work across the community if public health took the lead in identifying specific examples of collaboration (e.g., help us test messages for our campaign, help us disseminate the campaign through your communication channels and modest contributions to paid media, etc).   Such efforts helped our partners more authentically own” the effort and in fact was instrumental in many of them seeking to continue the campaign once our grant funding ended.  It also provided an example of an early win” on collaboration with public health agencies and has enhanced the interest of our health system partners in working with MDPH on current rounds of Community Benefit Plans.

The nature of our campaign did not lend itself to a cost/benefit analysis.

MDPH is committed to maintaining the campaign and making it available to all interested in using it. An MDPH work group of health systems and LHD partners focused on addressing behavioral health regionally has named addressing mental and behavioral health stigma as one its key priorities, with utilizing best practices such as Let's Talk Colorado” as a main strategy. One of our members, Tri-County Health Department (TCHD), has committed funds to maintain the website and will be doing another paid media push in May, 2020.  TCHD has also included Let's Talk Colorado,” proper framing, and stigma-reduction messaging in its 2019-2025 Public Health Improvement Plan (PHIP).

And, very gratifyingly, the perceived value of the campaign by many partners means that it will be sustained through a range of efforts. For example, several healthcare partners have already committed funds to run the campaign even after the original grant ended. The Douglas County Mental Health Initiative, a county-wide collaboration focused on improving mental health outcomes in one of the Metro counties, has prioritized stigma reduction as a direct result of this work and will be utilizing Let's Talk Colorado” in their efforts moving forward.  As noted above, the campaign has also been utilized by counties outside of the Denver Metro area, including both urban and rural counties across the state. Additionally, campaign messaging has been utilized in several national forums, expanding reach even beyond the State of Colorado. We are hopeful that the national exposure mentioned above may alert others to the use of the Let's Talk” campaign in particular as well as to the general importance of addressing mental health stigma.

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