Aims
This study aimed to examine the impact of mental illness related stigma training on third year medical students' knowledge, attitudes and behaviour related to people with mental illness.
Study design
The study was a non-randomised controlled trial with three conditions:
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A.
Control Condition (CC): none of the intervention elements below.
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B.
Experimental Condition 1 (EC1): A presentation on mental illness related stigma which included the social and personal impacts of stigma against people with mental illness together with personal testimonies from a mental health service user and a caregiver of a person with mental illness.
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C.
Experimental Condition 2 (EC2): As B above plus a role-play training session in a class room setting with mental health service user and caregiver feedback.
We hypothesised that there would be greater, more favourable change in the knowledge, attitudes and behaviour of the experimental conditions (EC1 and EC2) combined, compared to the control condition (CC). Furthermore, a greater change would be detected in the intervention condition that had the factual content, personal testimonies and role-play training compared to the condition with just the factual content and personal testimonies alone.
Sample
Students were recruited before the beginning of their third year of medicine, which began with a two week introductory course. All students were given the same standard training during this two-week course by the medical school. Material relating to psychiatry and mental illness during this course was minimal and consisted of a brief introduction without any contact from service users or caregivers. Third year medical students were chosen because at this particular medical school their psychiatry rotation/clerkship took place in the third year hence we did not want them to have had clinical contact with patients which could confound the results.
Students were recruited by e-mail. Each student was sent an email introducing the study and what it would entail if they chose to participate. A brief presentation was also given to students at the start of the two-week course telling them about the study. Students were told that their participation in the study was entirely voluntary and their grades would not be affected in any way if they chose not to participate. Students who chose to participate were told that their responses would be kept anonymous and would not affect their grades or course work.
At the end of the academic year, data pertaining to the Psychiatry assessment grades of participants and non-participants were obtained from the registrar of the University to which the medical school belonged. Global scores on the medical school Psychiatry assessments of the participants and non-participants were used to estimate the representativeness of the sample.
Inclusion/exclusion criteria
Students were included in the trial if they were registered for their third year of medicine at the medical school and they: (i) had a valid e-mail address that was on the list provided by the registrar to the researcher; (ii) were attending the two week introductory session. Participants were recruited two weeks prior to the intervention. The recruitment period was short because the introductory timetable and list of registered students was not finalised until the start of the two week introductory period. Students began their psychiatry rotation immediately after the two week introductory period.
Allocation
Allocation into the trial conditions was done by an administrator at the medical school blind to the proposed intervention and independent from the research team. Each trial condition consisted of clusters of firms which were put together pseudo-randomly by the office of the registrar. This meant that student groups of six to ten students were placed together for learning purposes within the medical school curriculum and remained together throughout the year. The basis for allocation was whether the clusters of firms had space in their timetable at the same time when the experimental condition could take place due to logistical issues at the medical school. The nature of allocation of students by the medical school administration, allowing for the preferences of individual students, was not compatible with randomisation.
For the evaluation component of knowledge and attitudes, students were contacted by e-mail. For the evaluation component of behaviour, a role-play assessment of communication skills was allocated by the administrator to a subset from each of the conditions (CC, EC1, EC2) to be examined when they had spaces in their timetable.
Training intervention
The training intervention was developed separately from the evaluation team and was developed by a mental health charity. The interventions were designed to address the knowledge, attitudes and behaviour model with the factual component targeting knowledge, personal testimonies from service users and caregivers targeting attitudes and role-play training targeting behaviour. The intervention in EC1 consisted of a 1-hour time slot including: (i) a 15 minute factual component presentation from the mental health promotion officer of the charity on the social impacts of stigma and discrimination against people with mental illness including themes such as healthcare, employment, civil society participation, personal relationships, medication, media and aggressive behaviour; (ii) a 15 minute personal testimony from a mental health service user who was taking medication for schizoaffective disorder describing their personal perspectives and experiences of having a mental illness, stigma and discrimination; and (iii) a 15 minute personal testimony from a caregiver of a person with schizophrenia discussing their personal perspectives and experiences of caring for a person with a mental illness, stigma and discrimination; (iv) a 10 minute question and answer session between the students and the mental service user and caregiver; (v) a 5 minute allotment to complete a short satisfaction questionnaire about the entire lecture (factual component and personal testimonies).
The additional intervention for EC2 was also developed by the charity. This consisted of two 10-minute role-play scenarios (a parent and daughter seeking help for their daughter's mental health problems and a service user who had a physical health complaint). Role-players were recruited from the role-player company used by the medical school and were instructed about the scenario by the researcher. Students were divided into groups of 8 to 10 and systematically allocated to different classrooms. A facilitator and either a service user or caregiver observer were present among the students. A student was asked to volunteer for the first role-play scenario and the role-players were asked to enter the room by the facilitator. After the role-play, the medical students gave their feedback on how they felt they performed and what they found challenging. This was followed by the role-players, observing service user or caregiver and fellow students sharing their feedback regarding the communication skills used by the medical student with the role-player(s) in the scenario. This process was repeated for the second role-play with a different student volunteer. A satisfaction questionnaire was completed after the role-play training.
Assessments
At baseline the students were asked a number of demographic factors, social contact of someone with mental illness and intended area of specialisation after medical school and had their knowledge and attitudes towards mental illness evaluated. Students were asked to complete the assessments online two weeks before the intervention (baseline) and were sent reminder e-mails from the researcher. On the day of, but prior to, the intervention, students also had the opportunity of completing the instruments in hardcopy. One week after all of the interventions and role-play assessments were completed, students were reassessed using baseline measures, either online or through hard copy. Primary knowledge and attitude outcome data were obtained from the Knowledge Quiz and the Mental Illness: Clinicians' Attitudes (MICA) scale [31]. The secondary outcome measure was a role-play assessment carried out by the role-players of which there were no baseline data.
Measures
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a)
Knowledge: The Knowledge Quiz was designed by the study team to assess knowledge regarding information on stigma and discrimination against people with mental illness. This consists of 10 true or false items based on key information from current literature and legislation on areas of prevalence, violence, serving the community, media, employment, black minority ethnic (BME) issues, access to healthcare, cost of mental healthcare and the importance of social networks for people affected by mental illness. Items generated for the Knowledge Quiz were reviewed by key researchers in the field of stigma and mental illness. Although not formally validated it has both face and content validity with items derived from sources related to stigma and discrimination in people with mental illness. The knowledge quiz is scored in a manner in which a high total score represents more knowledge about people with mental illness, stigma and discrimination.
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b)
Attitudes: Mental Illness: Clinicians' Attitudes (MICA) scale The development and validation of the MICA scale has been described elsewhere [31]. It is comprised of 16 items with a (1-6) Likert scale. A low total score (16 minimum) represents less stigmatising attitudes towards mental illness and psychiatry. The maximum score on the MICA is 96 showing very stigmatising attitudes. The MICA scale has satisfactory internal consistency with a Cronbach's alpha coefficient of 0.79 and a test-retest reliability of 0.80.
We felt that meaningful change in knowledge and attitudes corresponds to at least 10% change in the total mean score although this is somewhat arbitrary given the nature of this study which was exploratory. In order to detect a 10% change in the total MICA scale scores before and after the intervention with 80% power using a two-tailed test, a minimum of 31 students would be required at an alpha level of 0.01.
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c)
Role Play Behaviour: Role play does not necessarily equate to behaviour. However in medical education, role-play is often used as a teaching method that is valued by students in the acquisition of communication skills. Furthermore, role play promotes active learning [32]. The role play assessment constituted a list of fifteen items pertaining to behaviours (both verbal and non verbal) that could be interpreted as discriminating by a person with mental illness or their caregiver. Each of these items is scored either with a 0, 1 or 2; a higher score indicating more positive communication behaviour and comprised the component score. There was also a global score for the checklist which was used to indicate the rater's overall impression of how the student performed. The global score categories were Excellent = 5, Very good, 4 = Good, 3 = Pass, 2 = Borderline Fail, 1 = Fail. The development and validation of the role-play assessment was based on an actual observed structured clinical examination (OSCE) station checklist, tailored to issues of stigma with input from service users and caregivers and is described elsewhere [33].
Statistical analysis
Analyses were carried out using only data from students who completed instruments at both baseline and post-intervention. Non-completer data were compared to completers to assess bias. Baseline scores were compared between the arms of the trial, and an analyses of covariance (ANCOVA) controlling for baseline scores, gender, and psychiatry assessment grades (from the medical school at the end of the academic year) was conducted to estimate differences across the three conditions regarding knowledge and attitudes. For behaviour, only a post intervention assessment was available. Analysis was carried out using regression in STATA version 10. Residuals from the regressions were examined for normality. Two pre-specified contrasts were tested: 1) to compare the two interventions combined with the control condition, and 2) to compare the two intervention arms with each other.
Ethics
This project was approved by the Local Research Ethics Committee of Bexley and Greenwich (06/Q0707/56) for the National Health Service in the UK.