Worldwide, people with mental illness suffer from the stigma associated with their illness   . The stigma of mental illness is best defined as a construct of interrelated components of poor knowledge (stereotypes), negative attitudes (prejudice), and negative behaviors (discrimination)   . Stigmatizing attitudes and behaviors endorsed by the public towards people with mental illness are broad    and extend to all populations including university students .
University students from different schools and disciplines such as health (medicine , nursing , dentistry  , and pharmacy ), humanities  , engineering , and business  frequently hold negative stigmatizing attitudes and behaviors towards people with mental illness. Nursing students, when having been compared to other university students, have reported more positive attitudes and behaviors towards people with mental illness  . Yet, when they have been compared to the general public, they have shown more negative attitudes and behaviors towards those people  , such as the beliefs of dangerousness and unpredictability as well as the desire to social distance .
It is important to carefully assess the attitudes and behaviors of nursing students towards people with mental illness and to correct negative ones before their first contact in psychiatric training to ensure that students have more positive experiences . Furthermore, student nurses and other healthcare students are the future mental health professionals and have the potential for changing the future of mental healthcare. Therefore, their negative attitudes and behaviors should be screened and corrected by effective anti-stigma interventions. Otherwise, they would likely withhold some health services and practice coercive treatments once planning care to people with mental illness . This would, in turn, limit the access of those people to mental healthcare services . Their negative attitudes and behaviors could further negatively impact therapeutic nurse-patient relationships, and eventually might lead to negative ramifications of these negative attitudes and behaviors on those patients .
However, little is known on effective approaches to correct these negative attitudes and behaviors  , despite the previous reviews    -  that have shown that contact-based interventions have demonstrated positive attitudinal and behavioral changes for nursing students towards people with mental illness. The following is a brief description of the aim and focus of these previous reviews. Corrigan and colleagues  meta-analyzed the previous literature that have assessed the effect of anti-stigma strategies (including protest, education, and contact) on public stigma of mental illness among young adults and adolescents. Couture and Penn  reviewed the previous literature on the relationship between contact and stigma reduction. They reviewed both retrospective and prospective contact studies. Griffiths and colleagues  performed a meta-analysis of previous randomized controlled trials that have examined the effect of different anti-stigma programs on personal and perceived stigma, self-stigma, and social distance. Gronholm and colleagues  conducted a narrative synthesis of previous literature that has discussed interventions to reduce discrimination and stigma among the general public and key target groups (including healthcare professionals, police officers, and students). Heim and colleagues’  systematic review collected the previously available evidence on anti-stigma interventions among medical and nursing students in Low- and Middle-Income Countries (LMICs). Kolodziej and Johnson  conducted a meta-analytic review on the effect of interpersonal contact between mental healthcare professionals or students and people with mental illness on the attitudes and behaviors of the former group towards the latter group. Mehta and colleagues  synthesized the previous global literature on interventions shown effectiveness on reducing the stigma of mental illness and discrimination in the medium and long terms. They also synthesized similar literature but in LMICs only. Morgan and colleagues  reviewed and evaluated the previous evidence in regard to effective interventions on public stigma towards people with severe mental illness only (schizophrenia, psychosis, and bipolar disorders only). Pinto-Foltz and Logsdon  summarized the previously available evidence of mental illness stigma-reducing interventions in the disciplines of nursing, psychology, and psychiatry. Stubbs  examined the effect of anti-stigma interventions among healthcare students and professionals in the previous literature. Thornicroft and colleagues , in their narrative review, summarized the previous global literature (both in high-income and LMICs) that has focused on effective interventions for the general public, school and college students, healthcare professionals, and other populations; that have targeted their stigma towards and discrimination against people with mental illness. Yamaguchi and colleagues  narratively reviewed the previous literature that has examined the effect of anti-stigma interventions (educational and contact interventions) on reducing the stigma of mental illness and improving the awareness of mental health problems among young people. Yamaguchi and colleagues , in another a review, systematically reviewed previous intervention studies that have employed short-time anti-stigma interventions in order to reduce the stigma of mental illness among university and college students.
In Jordan, only two studies   have assessed the attitudes of Jordanian nursing students towards people with mental illness. Abuhammad and colleagues  found that Jordanian nursing students had negative attitudes towards people with mental illness while Hamaideh and Mudallal  found that Jordanian nursing students had positive attitudes towards people with mental illness. No study has employed a contact-based intervention of any type among a sample of nursing students was conducted in Jordan.
The current review attempted to provide what is somewhat different than the previous ones, with the aim to compile the available research evidence on contact-based interventions that have targeted the attitudes and behaviors of nursing students towards people with mental illness. No prior review is identical to our review in terms of the intervention of interest (only contact-based interventions of both types), the population of interest (only nursing students), and the outcomes of interest (only attitudes and behaviors towards people with mental illness).
There is a vast literature on the topic of this review, wherefore; a search strategy was used to include only pieces of literature that have focused on the population, the intervention, and the outcomes of interest. Also, clear search strategy is crucial for ensuring the rigor of literature reviews, because ill-defined search strategy might yield inaccurate and incomplete results .
The relevant literature was extracted by searching electronic databases and by hand checking reference lists of past similar reviews    - . Two different strategies were used to retrieve the maximum number of relevant materials . These search strategies were adapted from a previous similar review . The following electronic databases were exhaustively searched to extract the relevant literature: MEDLINE, PsycINFO, and the Cumulative Index to Nursing and Allied Health Literature (CINAHL). These databases were particularly searched because they were the most frequent searched databases in previous similar reviews        . No time limit was set in order to retrieve the maximum number of relevant materials.
Initially, the search was conducted using the following keywords separately: 1) keywords that relate to attitudes (which include attitude and prejudice), 2) Keywords that relate to behaviors (which include behavior, behavioral intentions, discrimination, and social distance), 3) Keywords that relate to mental illness, e.g., mental illness or its synonymous, psychiatric disorder or its synonymous, 4) Keywords that relate to contact-based intervention including contact, contact intervention, contact-based intervention, and anti-stigma contact intervention, 5) Keywords that relate to nursing students including nursing students and student nurses. Then, the Boolean operators (AND, OR) were used between these keywords to retrieve relevant materials only.
The inclusion criteria for considering relevant materials in this review were: 1) published in English language only, 2) articles employed contact-based interventions in both forms (live or video-based) alone or in combination with other anti-stigma interventions such as educational interventions, 3) targeted nursing students only as participants or targeted also other students for the aim of comparison with nursing students, and 4) targeted at least one of the attitudinal outcomes (including prejudice) or the behavioral outcomes (including behavioral intentions, discrimination, or social distance) or both outcomes. On the other hand, incomplete reports, editorial papers, conference proceedings, opinion papers, abstracts, posters, unpublished materials, and grey literature were excluded from this review. Further exclusion of materials discussed the effect of student-patient contact in nursing curricula’s psychiatric clinical trainings, rotations, placements, clerkships, secondments, or affiliations were done, as excluded by previous similar review .
At first, searching for each of the abovementioned keywords was performed separately for each one by using the selected electronic databases. This search yielded the following results: attitudes (582,290 records), behaviors (1,514,394 records), mental illness (276,998 records), contact-based intervention (342,896 records), and nursing students (58,282 records). Then, as shown in Figure 1, searching for the combination of these keywords using the same electronic databases came back with 21 articles. Then, removing duplicates resulted in 8 articles only. After that, screening of the titles of those articles resulted in exclusion of 6 articles, as the titles were not relevant to this review; 2 articles left  . Furthermore, checking the reference lists of past similar reviews    -  yielded 21 articles. Eight of these articles were excluded due to employing nursing curricula’s psychiatric clinical trainings, rotations, placements, clerkships, secondments, or affiliations, one study  was excluded due to targeting medical students, two studies   were excluded due to employing educational intervention, and one study  was excluded due to targeting outcomes other than attitudes and behaviors; 9 articles left. Therefore, the sum of resulted articles from those two different searching strategies became 11 articles.
Eleven studies    -  were reviewed carefully and included in this review. In Table 1, each included study in this review was summarized and described in terms of: authors, year of publication, aim, intervention, and main results. These descriptions were particularly reported because they were the most frequent reported in similar tables included in previous similar reviews       .
Yamaguchi and colleagues  reviewed the interventions that have been developed to improve the attitudes and behaviors of university students (including
Figure 1. Search strategy and outcomes.
nursing students) towards people with mental illness and classified these interventions into eight categories; two of these categories were contact-based interventions (social contact and video-based social contact). Social contact is any face-to-face interaction between people with mental illness and university students; in which people sharing their lived experiences of having such illness. Video-based social contact is any media that shows people with mental illness talking about their own illness’ experiences. Both types have shown effectiveness in improving the attitudes and behaviors of university students generally and nursing students particularly towards people with mental illness.
Table 1. Summary of studies included in this review.
The included studies in this review either have employed social contact interventions    , video-based social contact interventions   , or both types for the aim of combining   or comparing  . Furthermore, the included studies either have targeted the attitudes of nursing students towards people with mental illness (including prejudice)    , or a combination of attitudinal and behavioral outcomes (including behavioral intentions and social distance)       . No studies have targeted behavioral outcomes solely.
3.1. Studies that Have Employed Social Contact Interventions
Four studies have employed social contact interventions among nursing students for the aim of improving their attitudes and behaviors towards people with mental illness    . Martínez-Martínez and colleagues  developed and assessed the impact of a direct contact’s intervention with people with mental illness with the aim to improve the attitudes of student nurses. The intervention was a single 90-minutes session involved a mental health professional, an individual with mental illness, and a family member of another person with mental illness who spoke about their first-hand experiences of having mental illness and recovery after that, and then, they received and answered questions posed by nursing students. After the intervention, a decrease in fear, perceived danger, avoidance, segregation, and coercive attitudes were found among nursing students towards those people, as well as increase in positive feelings (tendency to help and compassion).
Sadow and Ryder  recruited two groups of nursing students to assess the effect of personal messages by a recovered person with mental illness on reducing the student nurses’ stigmatizing attitudes towards people with mental illness. The first group (27 nursing students) received three trainings by a psychologist focused on the psychosocial rehabilitation principles. Then, they asked questions got answered by the psychologist. The second group (30 nursing students) also received the same trainings, in addition to a presentation by an individual with mental illness in recovery who discussed lived experiences of mental illness and answered nursing students’ questions. The results indicated that the second group, who attended the presentation, changed attitudes towards people with mental illness and mental health professionals positively. No such change was found among the first group (who did not attend the presentation).
Happell and colleagues  aimed to determine the effect of a 12-weeks mental health course delivered by an individual with mental illness and focused on recovery, on nursing students’ attitudes towards people with mental illness and intentions to pursue a career in mental health nursing. They further compared its effect with the effect of a 12-weeks length traditional mental health course delivered by a nurse. The results showed that nursing students, who attended the course delivered by a person with mental illness, reported a reduction in negative attitudes towards people with mental illness and a positive change in their intentions to become mental health nurses in the future, that were not reported by nursing students who attended the traditional mental health course.
Vaghee and colleagues  selected 111 nursing students using different samples techniques in Iran and distributed them to 3 groups: contact-based education, acceptance and commitment-based training, and control group. Nursing students who were in group of contact-based education met 3 patients with mental illness (one with schizophrenia, one with bipolar disorder - type 1, and one with major depression) who talked about their experiences of mental illness. Nursing students in the acceptance and commitment-based training’ group, had a workshop held by holders of a masters degree in clinical psychology and psychiatric nursing. The control group received regular psychiatric nursing clerkship. The results showed that both groups of contact-based education and acceptance and commitment-based training, had an improvement in their empathy towards people with mental illness. On the other hand, the control group had no such improvement. Further, no significant difference was noticed between the group of contact-based education and the group of acceptance and commitment-based training; in terms of empathy towards people with mental illness.
3.2. Studies that Have Employed Video-Based Social Contact Interventions
Three studies shave employed video-based social contact interventions to improve the attitudes and behaviors of student nurses towards people with mental illness   . Imperio  investigated the impact of a filmed-contact intervention on stigmatizing attitudes of 37 pre-licensure nursing students towards people with mental illness. The film was one of the TED Talks videos which featured a woman shared her experiences of adaptation with schizophrenia (challenges and successes) that led her to obtain a doctorate degree in law and teach in prestigious university. Nursing students, who watched the film, demonstrated reduction in their stigmatizing attitudes towards people with mental illness.
Brown  evaluated the impact of a faith-based program on the stigma of mental illness and substance abuse as well as the knowledge and skills on community mental health among a sample of nursing students. The faith-based program was a hour and half workshop that involved the following components: 1) a PowerPoint presentation about causes, signs, symptoms, and treatments of mental illness and substance abuse, 2) a brief video presented commentaries from persons with mental illness, their families, and faith communities that support those people, and 3) interactive learning activity or game. After the program, a reduction in mental illness stigma as well as improvement in the knowledge and skills about community mental health, were noticed among nursing students. In contrary, Coleman  determined the effect of video-based educational materials focused on schizophrenia, on the attitudes of 240 student nurses towards people with mental illness. Nursing students who were randomly assigned to the intervention group, viewed a one-hour educational videotape discussed schizophrenia. This video gave information on the causes and treatments of schizophrenia. It further contained interviews with persons with schizophrenia and their families who shared the consequences of illness on their family dynamics, personal relationships, and overall functioning. On the other hand, nursing students, in the control group, watched a videotape about diabetes, in which a discussion of the causes and treatments of diabetes was presented. The results suggested no effect for the schizophrenia’s videotape on the attitudes of nursing students towards people with schizophrenia.
3.3. Studies that Have Employed Both Social Contact and Video-Based Social Contact Interventions
Four studies have employed both types of contact-based intervention (social contact and video-based social contact) for improving the attitudes and behaviors of nursing students towards people with mental illness    . Two studies have employed the both types in order to combine them in one intervention  . Inan and colleagues  assessed the impact of a psychiatric nursing module, a clinical practice, and an anti-stigma program on a sample of 64 nursing students’ attitudes and behaviors towards mental illness in Turkey. Only the anti-stigma program included contact ingredients. In further details, it included the following parts: 1) information on myths on mental illness, 2) short videos by mental health professionals, 3) documentary films which described the lives of patients with schizophrenia, 4) mental illness stigma articles, 5) visiting one of the associations that concerns about patients with schizophrenia and their families, and 6) visiting persons with mental illness and their families. It continued 8 sessions (2 - 3 hours for each session). After the mental health nursing module, the clinical practice, and the anti-stigma program, a decline in the dangerousness’ perceptions and the desire for social distance were noticed. Itzhaki and colleagues  employed a planned intervention of a mental health course among a convenience sample of 101 third year undergraduate nursing students and assessed its effect on changes in attitudes and intentions to work with patients with mental illness (treat, specialize, or work in mental health field). The intervention (70 hours) was consisted of the following components: 1) A face-to-face meeting with two persons with mental illness (schizophrenia and mood disorder) who shared their experiences of mental illness, 2) a meeting with a woman with a diagnosis of anorexia nervosa from her teens, 3) a film featured the story of well-coping women with mental illness who eventually got a doctoral degree in psychology, 4) two simulations by an actress who played the character of a manic or a depressive patient at psychotic phase, and 5) lectures about mental illness and treatments by a psychiatric nurse. The intervention improved the student nurses’ attitudes towards patients with mental illness. Yet, it did not improve their intentions of working with them.
On the other hand, two studies have employed the both types to make a comparison between them in term of effectiveness  . Winkler and colleagues  investigated the effect of short videos on reducing the mental illness stigma (attitudes and behaviors) among student nurses, as compared with an informational leaflet and a seminar involved a direct contact with a person with a mental illness. Both the short videos and the seminar included contact components. The short videos were of a 2 - 3 minutes long that featured people with mental illness talking about their mental illness. The seminar (45 minutes) was delivered by a mental health professional and a person with mental illness. The results concluded that the seminar was the best intervention in terms of effectiveness and stability over time. However, the effect of short videos was considerable and stable as well. Clement and colleagues  assessed the effect of three different anti-stigma interventions and made a comparison between them in term of effectiveness for improving the attitudes and behaviors of 216 nursing students. The first intervention was a DVD that sowed people with mental illness and their informal caregivers talking about their mental illness’ experiences, followed by a discussion. The second intervention was a live intervention that involved personal stories of a person with mental illness and informal caregiver about their experiences of mental illness and stigma, as well as information provided by the researcher commenting on their stories. The third intervention was a lecture by a mental health nurse on mental illness stigma. The results indicated that both the DVD and the live interventions were more effective than the lecture intervention in improving the attitudes and behaviors of nursing students towards people with mental illness. The results further revealed no differences in effectiveness between the DVD and the live interventions.
In this paper, a review of the literature on contact-based interventions among nursing students that have targeted their attitudes and behaviors towards people with mental illness was undertaken. From the available literature, the current authors cannot draw conclusions on the most effective type, form, or ingredients of contact-based interventions among nursing students, as previous literature has large variations. No consistency was found in the previous studies in regards to the types or contents of effective contact-based interventions. Moreover, we believe that there is no way to meta-analyze the previous literature due to the lack of studies and the differences of these studies in terms of outcomes, data collection methods, and contents of contact-based interventions. However, the compiled evidence in this review, has suggested that contact-based interventions (both social contact and video-based social contact) have been effective in changing the attitudes and behaviors of nursing students favorably, similarly to what previous reviews have found   .
Further research is needed to confirm the findings of this review. Future research is also needed to find out the most effective form and contents of contact-based interventions for nursing students. Also, more studies are needed to understand the process by which contact-based interventions (both types) affect positively the attitudes and behaviors of nursing students towards people with mental illness. Further, time-series and longitudinal studies are needed to measure the effect of contact-based interventions of both types over time, because only a few studies measured long-term effects. Moreover, as no previous study has targeted behavioral outcomes solely in terms of behavioral intentions, social distance, and discrimination, future research should be directed to this area, since the ultimate goal of contact-based interventions and other anti-stigma interventions is to change actual behaviors towards people with mental illness . Finally, as no studies have been found in the Arab world in general and Jordan in particular, nursing researchers, projects, and funding should be focused on this important area.
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