Design and setting
This study featured a quasi-experimental pre- and post-test design and did not include a comparison group. It was conducted at Aino University, Japan, from October 2019 to January 2020.
Participants
The participants were university students majoring in health-science and community-dwelling people with mental illness. The student participating in this study were second-year students who attended a series of lectures on basic psychiatry and occupational therapy, but only had limited contact with people with mental illness. We did not recruit first-year students because their present level of education was regarded as similar to that of the general public. Third- and fourth-year students were excluded from this study because they had contact with patients with mental illness during their preclinical practice.
A class of 40 students is the general size in an occupational therapy department in Japanese universities. We recruited 40 students from a second-year occupational therapy class. Before enrolling in this study, the students received 15 90-minute lectures on basic knowledge of psychiatry (psychiatric illness, symptoms, etiology, and psychiatric treatments) as basic subjects for occupational therapy. With an estimated participation rate of 80−90% among students, the number of students would result in 3−4 participants per group. In general, the optimal number of group members is 3 to 8 for group work [24]. Thus, we aimed to recruit 20 people with mental illness living in the community, so that two people with mental illness would be placed in each group. We created flyers for participation in the CPD-RS in collaboration with an institute of Support for Continuous Employment (Type B service) and a psychiatric clinic, and asked the staff at each facility to post these flyers to solicit participation. The people with mental illness had diagnoses of either F2 (schizophrenia) or F3 (mood disorder) in the International Classification of Diseases (ICD-10); all of them were receiving Support for Continuous Employment (Type B services) or engaging in a psychiatric daycare treatment program associated with a psychiatric clinic. Interviews were conducted to confirm that the participants had no communication-related difficulties and understood the purpose of the study.
Intervention
We designed and implemented the CPD-RS with the aim of promoting mutual understanding between the people with mental illness and the students through co-production with dialogue; we also aimed to reduce the students’ stigma toward the people with mental illness and the self-stigma of the people with mental illness. In the CPD-RS, the students and people with mental illness worked in groups to create posters concerning a specific theme. Figure 1 presents an overview of the CPD-RS. The themes for the co-production with dialogue were as follows: (1) coping with daily life and personal problems, (2) problems encountered in interpersonal relationships and means of dealing with them, and (3) how to have fun in daily life. The first author (EN) and co-authors (TH and MT), who each have over 10 years of experience in medical and/or rehabilitation practice and/or education, determined the themes, using the principles of recovery-oriented mental health practice [25] and the recovery’s conceptual framework for personal recovery [26, 27] as base material. The appropriateness of these themes was confirmed by two health-science education professionals who were not involved in this study.
For each of the three themes, the students and people with mental illness wrote their opinions on sticky notes and created posters while engaging in co-production with dialogue. The three principles of co-production with dialogue were: (1) listen to the other person until the end, (2) speak from your own experience, and (3) do not criticize others’ opinions. In the poster-production phase, which was based on co-production, participants considered the experiences and opinions they had written on the sticky notes and sought to identify similar opinions as well as the relationships between their opinions and those of the other members. In the co-production with dialogue process, the students and the people with mental illness shared their life experiences and tips on interpersonal relationships and life problems. Co-production with dialogue was conducted for 90 minutes. Two weeks later, each group presented their posters to the other groups. After the presentation, the group members reflected on the posters and their presentations. These group presentations were conducted over a 90-minute period.
Data collection
The participants’ demographic data (age, gender, diagnosis) were obtained through a questionnaire. The Devaluation Discrimination Scale (DDS), which is a 12-item, self-administered questionnaire developed by Link [28], was used to assess the students’ stigma-related perceptions of mental illness and the self-stigma of the people with mental illness. The DDS assesses respondents’ levels of stigma-related attitudes by inquiring into their attitudes toward and discrimination against people who have received psychiatric treatment. Respondents are initially presented with a description of the tool, after which they report their level of agreement with each of 12 statements concerning discrimination and prejudice regarding mental disorders. Responses are given using a four-point scale (Japanese version; 1 = “strongly disagree,” 2 = “slightly disagree,” 3 = “slightly agree,” and 4 = “strongly agree”). Some statements in the questionnaire are reverse-scored (R). The 12 statements relate to social intimacy, assessments of intellectual ability, and acceptance of employment for people with mental disabilities. The DDS can also be used to assess the self-stigma of people with mental illness [29, 30]. The Japanese version of the DDS has been reported to be reliable and valid (Cronbach’s α = 0.85, θ = 0.85) [31].
The DDS was administered to the participants on four occasions: one month before the intervention (“baseline”; October 2019), immediately before the intervention (“pre-intervention”; November 2019), immediately after the intervention (“post-intervention”; December 2019), and one month after the intervention (“one month after intervention”; January 2020). To ensure that participants’ responses were anonymous, identification numbers were used for all questionnaires rather than names. Participants were also administered a post-intervention questionnaire that aimed to assess their experience of participating in the program. This questionnaire contained six items (focusing on enjoyment of the program, the level of self-expression and mutual interaction in the program, similarities and differences among participants’ life experiences and tips, influences of one’s own experiences, influences of others’ experiences, and willingness to tell others about one’s experience of the program) that were answered using a five-point Likert scale (1 = “very negative,” 5 = “very positive”), and also contained an open-ended question (“How did you feel about participating in the program?”).
Statistical analysis
Statistical tests were performed by comparing the total DDS scores at four time points (October 2019, November 2019, December 2019, and January 2020). The Shapiro–Wilk test was used to examine whether the acquired data were normally distributed. The comparisons of the four sets of DDS scores, from October to January, were conducted by applying a repeated-measures analysis of variance (ANOVA). Tukey’s multiple comparison test was performed when cases of significant differences emerged through this comparison. Nonparametric tests were performed if the data were not normally distributed. Bonferroni corrections were performed for the results of multiple comparisons and for comparisons of DDS sub-items. For the post-intervention questionnaire, the medians and interquartile ranges were calculated for each item (except the open-ended question). IBM SPSS Statistics for Windows, version 26 (IBM Corp., Armonk, NY, USA) was used to perform statistical analyses. The free text provided in the responses to the open-ended question was summarized.
Ethics and consent
This study was conducted in accordance with the stipulations of the Declaration of Helsinki. Approval was obtained from the Research Ethics Committee of Aino University (approval no. 2018-21). Individuals who expressed a wish to participate were informed that participation was voluntary and that they could cancel their participation at any time. The research commenced after written consent was obtained from all participants.