The Effect of Contact-Based Interventions on the Attitudes and Behaviors of Nursing Students towards People with Mental Illness: A Literature Review

Background: 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. 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. Aim: The aim of this literature review was 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. Methods: The relevant literature was extracted by searching electronic databases (MEDLINE, PsycINFO, and CINAHL) and by hand checking reference lists of past similar reviews. Results: Eleven studies were retrieved and included in this review. The included studies in this review either have employed social contact interventions, vid-eo-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 (includ-ing behavioral intentions and social distance). No studies have targeted behavioral outcomes solely. Conclusions: From the available literature, gredients of contact-based interventions among nursing students, as previous literature has large variations. No consistency was found in the previous studies regarding the types or contents of effective contact-based interventions. 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.


Introduction
Worldwide, people with mental illness suffer from the stigma associated with their illness [1] [2] [3]. 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) [4] [5] [6]. Stigmatizing attitudes and behaviors endorsed by the public towards people with mental illness are broad [7] [8] [9] and extend to all populations including university students [10].
University students from different schools and disciplines such as health (medicine [11], nursing [12], dentistry [13] [14], and pharmacy [15]), humanities [16] [17], engineering [16], and business [18] 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 [19] [20]. Yet, when they have been compared to the general public, they have shown more negative attitudes and behaviors towards those people [21] [22], such as the beliefs of dangerousness and unpredictability as well as the desire to social distance [20].
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 [23]. 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 [24]. This would, in turn, limit the access of those people to mental healthcare services [25]. Their negative attitudes and behaviors could further negatively impact therapeutic nurse-patient relationships, and eventually might lead to negative ramifications Open Journal of Nursing of these negative attitudes and behaviors on those patients [22].
However, little is known on effective approaches to correct these negative attitudes and behaviors [10] [23], despite the previous reviews [10] [23] [26]- [36] 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 [26] 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 [27]

Methods
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 [39]. 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 [34].
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 [41] [42]. Furthermore, checking the reference lists of past similar reviews [10] [23] [26]- [36] 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 [43] was excluded due to targeting medical students, two studies [44] [45] were excluded due to employing educational intervention, and one study [46] 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.

Results
Eleven studies [41] [42] [47]- [55] 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 [10] reviewed the interventions that have been developed to improve the attitudes and behaviors of university students (including Open Journal of Nursing 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.  To compare the impact of a DVD-based contact, a live contact, and a lecture control on decreasing the stigma of mental illness.
Nursing students, who were randomly assigned to the DVD-based contact group, watched a DVD of people with mental illness and their informal care providers telling their first-hand experiences about mental illness and associated stigma. The DVD lasted for 71 minutes and followed by discussion. On the other hand, student nurses who were assigned to the live intervention group attended a presentation primarily delivered by a person with mental illness and informal care provider in which they provided personal testimonies about their experiences of mental illness and its stigma. The presentation followed by factual information delivered by one of the researchers regarding to the key points discussed by the presenters. Finally, questions-answers session was took place in which the presenters answered student nurses' concerns.
Both live and DVD-based contact groups had more positive attitudes and behaviors than the control group (lecture).
Coleman (2007)  To measure the impact of a course delivered by an individual with mental illness on nursing students' attitudes towards people with mental illness as well as their intentions to a pursue a career in psychiatric mental health nursing in the future.
The course delivered by a person with mental illness continued for 12 weeks with a primary focus on recovery. The contents included understanding of the recovery in mental health context, the role of nurses in the recovery process, and the importance of collaboration with patients with mental illness to promote recovery.
Nursing students who attended the course delivered by the individual with mental illness showed positive changes in their intentions to pursue a future career in psychiatric mental health nursing and a decrease in their negative stereotypes towards people with mental illness.
To assess the effect of a filmed-contact intervention delivered to student nurses on minimizing their stigmatizing attitudes towards people with mental illness.
The filmed-contact intervention video was a TED Talks video in which a woman talked about successfully managing her schizophrenia; currently holding a doctorate degree in law and teaching in a reputable university.
Reduction in stigmatizing attitudes of nursing students towards people with mental illness.
To assess the effect of module on psychiatric mental health nursing, clinical practice, and anti-stigma program on the attitudes of student nurses towards mental illness. To assess the effect of a direct contact with people with mental illness on the stigma of nursing students towards those people.
A 90-minutes session in which a mental health care provider, an individual with mental illness, and a family member telling their experiences about the mental illness. Then, a 30-minute questions and answers' session was held.
A decrease in fear, perceived danger, avoidance, segregation, and coercive attitudes were noticed after the intervention as well as increase in positive feelings (help and compassion) among nursing students.
To investigate the impact of nursing students' exposure to personal messages delivered by an individual with mental illness in recovery on decreasing stigmatizing attitudes of nursing students towards people with mental illness.
Nursing students in the intervention group attended 3 presentations delivered by different individuals with mental illness in the recovery phase.
Decreasing in stigmatizing attitudes of student nurses towards people with mental illness.
To compare the impact of a contact-based education with the impact of a commitment and acceptance-based training on empathy of student nurses towards people with mental illness.
In the contact-based education; 3 patients with stable mental illness (one had schizophrenia, one had bipolar type 1, and one had major depression) talked about their illness' experiences. Each patient talked for one-hour session.
Both the contact-based education and the acceptance and commitment-based therapy were successful in increasing the level of empathy towards mental illness among student nurses. No significant differences were found between these two methods.
To investigate the effect of short videos on reducing stigmatizing attitudes and behaviors of student nurses' towards people with mental illness as well as compared the effect of short videos with other methods (seminar and informational leaflet).
One of the experimental groups attended a 45-minute seminar was developed by the cooperation of the authors, persons with mental illness, and mental health professionals. The seminar was presented by both a mental health professional and a person with mental illness as well. On the other hand, the other experimental group watched 3 short videos (each of them were 2 -3 minutes).
Seminar had the strongest and the most stable positive impact on student nurses' attitudes and behaviors towards people with mental illness. Also, short videos were effective and stable over time.
The included studies in this review either have employed social contact inter-

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 [41] [47] [49]. Imperio [41] 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 [47] 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 [49] 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.

Studies that Have Employed Both Social Contact and Video-Based Social Contact Interventions
Four studies have employed both types of contact-based intervention (social Two studies have employed the both types in order to combine them in one intervention [51] [52]. Inan and colleagues [51] 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 On the other hand, two studies have employed the both types to make a comparison between them in term of effectiveness [42] [48]. Winkler and colleagues [42] 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 [48] 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 in- formal 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.

Conclusions
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 [10] [23] [29]. 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 [56]. 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.