28 January 2014 by Tania Browne, posted in Epidemiology, Mental Health



Mirrors - how often do you actually think about them, and how they reflect?

I'm prepared to bet that you've already looked in a mirror at least once today, if only as you brushed your teeth or checked your rear view before reversing. We take mirrors for granted. They're always there when we need them, even if it's ensuring your bum doesn't look big in the reflection of a shop window (another kind of checking your rear view).

We make the assumption that mirrors give an honest reflection, even if it's a brutal one. We expect them to tell the truth. Few of us think how easy it would be for mirrors to become distorted. The surface may be tinged to reflect colour differently, or tarnished, or scratched all over. There may be a single, small flaw in the reflective surface so that even if it seems so at a cursory glance, the full picture isn't there. There may be a dent, a wobble which distorts a small part of the big picture.

What if we had mirrors that were capable of reflecting not just us or those close to us, but huge swathes of people, thousands at a time? Would you expect them to be more accurate, or give a more distorted view of the big picture? Well, in a way we do. Epidemiological studies are a little like mirrors, they try to give us information that's a true reflection of what we really are. And like mirrors, we take them for granted and use them every day without even thinking. Know you need to eat five a day? That you should really  exercise 3 or 4 times a week to stave off that impending heart attack? That obesity and diabetes are increasing problems as we get older? Had all your vaccinations, and made sure your children did too?

See? You use epidemiological studies without even thinking about it. You take them for granted. Just like mirrors.

As with mirrors, too, there are different kinds for different jobs. In the same way you wouldn't use a handbag compact to make sure you look a knockout in that dress, some kinds of epidemiological study are unsuitable for what we want to find out. Over the next few posts, I want to look in more detail at the ways we can find out information about people, how we try and make sure the information we glean isn't distorted (either in the first place or by us reporting it), and how particular kinds of study design can be good for answering some questions we ask, but useless for others.

The Time to Change campaign is a good example of this, as it covers several different ways of collecting information. You start with the basic idea: can we make an information campaign that changes people's attitudes to mental illness? Then you start to look at how you can do it.

  • How do we measure that, how do we know if we changed anything?
  • who do we try to measure a changed attitudes in? A few people, or lots? Individuals, employers of people with mental illness, the media?
  • Are numbers or personal stories the best way to glean that information?
  • How do we measure the way people feel about something so personal, and is it possible to quantify at the end?
  • How long do we let the campaign run before we measure again?

These are some of the most basic questions that needed to be asked before they even thought about what kind of study to run. And in the case of Time to Change it was a complicated issue with many branches. First, who do we want to change attitudes in? Who do we measure to see if it was a success? The obvious answer is "well.... everyone."

Think about it for a moment. As a mentally ill person who do I interact with every day? I get up, I make breakfast for my family, but on some days I might be feeling less inclined to get out of bed than others, and my children might think I'm "in one of my moods" when I do. I cancel a night out with the girls at the weekend because I don't think I can face them right now. My husband might ask me if I've taken my medication or remembered to make the appointment with my GP. My children go to school, where I may have struggled with the last parent's evening or not managed to make a costume for the school play in time because I was feeling low. Later in the day I email my course tutor to explain that I might hand in my latest assignment a couple of days late because I've had difficulty concentrating recently and am a little behind. I'm looking for a part time job - if I give permission for my medical records to be disclosed to my employer, or they check my social media pages and see I've had a rough time of it recently, will they assume I can perform well enough and employ me anyway? If they did, would they treat a sick day due to mental illness with as much sympathy as a sick day for a bad back, or the flu? I do my online supermarket shop, idly click on Halloween costumes for trick or treating and find a bloody, battered straight jacket costume for a "Mental Patient". Later on, I read a newspaper and there's a story about a woman who was attacked by a schizophrenic teenager on the tube. When the kids are in bed I switch on my favourite soap, where one of the characters is portrayed as having mental health problems. Do they seem like a sympathetic, or a threatening character?

I think I've made my point. Attitudes to mental health are all around us, on personal levels (my family and friends), social levels (the school PTA) institutional levels (my university, the company I work for) and in the media (news stories and soaps). Pretty big task, huh?

And of course, the method you use to ask my husband how he feels and how we've coped with my illness would not be the same as asking for a company's statistics on sick days taken due to mental illness, or even an employee's experience of explaining that to their manager. We could not use the same method to look at how many stories appear in a newspaper portraying mental illness in a sympathetic light.

So many methods, so little time. And there's the other thing - time. Time to Change is a "longitudinal" campaign, they know that their campaign won't have an effect overnight. How long do you run it for? Do you measure attitudes just at the beginning, the end, intermediate points? Do you do anything to check if those changes in attitude, if you find them, last a long time or are temporary? Is there any evidence that people's attitudes change because they are more educated about mental illness, or does the education part make no difference nd we just know we should be more sympathetic?

If it all sounds a bit headachey and complicated, that's because it is.

But we can take each piece of the puzzle and piece it together. As a child in the 1980s, my parents were very fond of two things: home improvements and mirror tiles. We had a small house, and putting a block of mirror tiles on the wall gave the illusion of more space and light.They were cheap and cheerful, yet effective as a whole.  If the Time to Change campaign is an enormous mirror, then we just have to take each individual tile, make sure it has no flaws, check it over then plan how to piece them together to give the big picture.

We'll start at the very beginning, with the people. People are the building blocks of society, so it seems like a good place to start. But how can we measure what they think, what they feel? Can we make their personal experiences "scientific" and "universal" or is that an impossible task?

Next time we'll look at the power of stories and the use of questionaires.

2 Responses to “Mirrors”

  1. DorrisYThetford Reply | Permalink

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