A total of 29 psychiatric trainees (26.3%) participated, 17 males and 12 females, with a mean age of 28.2 years (SD 2.22). There were trainees from every academic year, seven (24.1%) from 1st year, nine (31%) from 2nd year, five (17.2%) from 3rd year, seven (24.1%) from 4th year and one (3.4%) from 5th year. All 29 trainees attended at least one of the two sessions delivered, but only 12 completed both sessions.

Table 2 shows the mean pre- and post-intervention (3-month follow-up) scores and SD for all outcomes. The pre-post comparison OMI-MV scale scores, showed no evidence for improvement in the attitudes of assessed trainees, only one subscale, stereotypes, showed a significant improvement with a medium effect size. The comparison of the MHPSI total scores, showed a significant reduction in the scores of those trainees at follow-up, with a medium effect size. However, only the influence of co-workers’ subscale showed a significant reduction at follow-up. The comparison of the mean pre and post scores for each diagnosis in the ‘Changing Minds’ campaign questionnaire showed that there was a significant improvement, with medium effect sizes, in the attitudes towards all, but one, of the eight psychiatric disorders assessed.

Table 2 Pre and post scores of outcome measures

Feasibility

Demand

About a quarter (26.4%) of trainees participated in this intervention, so, it was not possible to establish the actual intentions of all the trainees from the target population. However, some residents who did not take part in the study, expressed that they wanted to participate but were unable to join any session because of their duties. Therefore, it is possible that the actual demand for the intervention was higher than the reach.

Results from the evaluation questionnaire and from individual interviews suggested that trainees’ main motivation to participate in the intervention was personal interest, as they recognised learning more about the subject or learning a new skill, were the main reasons behind their decision to attend the intervention sessions. Although these results account only for trainees that participated in the intervention, when participants were questioned about what they considered were the reasons why other trainees did not participate in the study, they suggested that lack of interest was one of the main factors associated with this (Table 3).

Acceptability

This element corresponds to participants’ opinions towards the intervention, which is covered below (see Participants’ response).

Implementation

According to our fidelity checklist, every element of the proposed intervention was delivered. However, only half of the proposed elements were delivered as originally intended, the other half was partially covered or had elements missing. The elements that were not delivered as intended, were the live presentation of a mental health service user; opportunity to ask questions to the service user; disconfirmation of stereotypes by the service user and history of personal recovery by the service user. These elements were not included as planned, because they were only included in the second session, rather than in both sessions.

This intervention was originally intended to include two sessions of two hours each. However, both sessions last around 1:45 min. The first one was shorter because the live presentation by a service user was not delivered, and the second because most participants arrived late.

As few participants, who attended session 1, were not able to attend session 2, another date for session 2 was scheduled, so interested participants could complete both sessions. Although this new session was aimed to include participants from session 1 who were not able to complete the course, there were seven new participants who did not attend the first one.

The proportion of individuals that came into contact with the intervention from the target population was 26.3%, as 29 out of all the 110 trainees registered at the host institution attended at least one session. However, only 12 (10.9%) trainees completed all the elements of the intervention.

Practicality

Some characteristics of the host institution were considered to have influenced the intervention, as some participants considered that conflicting schedules or lack of support from their direct supervisors stopped them from attending both sessions. Although this intervention was supported by the education and clinical directors, as they agreed to reduce the activities of those trainees interested in participating, results from the questionnaires suggested that not all participants felt their activities were reduced or that they did not receive encouragement from their supervisors or direct managers to participate in the intervention (Table 3).

Adaptation

There were two major adaptations implemented for this intervention. The inclusion of a service user from a different psychiatric hospital, and the inclusion of an extra date to deliver the second session.

Integration

The results showed participant of this study considered that the content of this intervention should be included as part of their psychiatric training (Table 3).

Expansion

Most trainees interviewed suggested that the intervention should be implemented in the host organisation, as it could potentially help them improve their attitudes. However, some participants considered that they did not receive enough support, and some others perceived that there might be some barriers to implement this intervention. The barriers identified were a possible lack of support from authorities, lack of interest from other trainees and work overload.

Potential effectiveness and mechanisms of impact

All 29 participants completed the initial assessment; 21 completed the assessment at the end of the second session and 18 at follow-up. Therefore, the estimation of the effect size was calculated using only the results of those trainees that were assessed at follow-up. Fourteen trainees participated in either a focus group or an individual interview. The main scores of all the scales and subscales showed a reduction at follow-up. All the scores that showed a significant change had medium effect sizes.

In order to assess which were the mechanisms associated with any possible effect on participants, qualitative and quantitative data were integrated to assess the three different elements included in the evaluation of mechanism of impact: participants’ response, mediators and unintended pathways.

Participants’ response

All participants completing questionnaire reported that they were satisfied (28.6%) or very satisfied (66.7%) with the course, all found that the information provided was at least very useful and most considered that the course facilitator had expertise in the field. Over three quarters considered the intervention was better (52.4%) or much better (23.8%) than expected, only five (23.8%) considered the intervention was as expected; no trainee considered it was below their expectations. Most participants also reported the content of the intervention should be included within their routine training, and that they would recommend the course to their colleagues.

Trainees considered this intervention would lead to positive benefits for their patients, as they considered this would help them improve their empathy, reduce the use of labels and the therapeutic pessimism they have towards their patients (see Table 3).

Overall, participants responded positively to the intervention. They considered the intervention was well structured and planned, and although many commented the length of the course was adequate, they also mentioned the course should be longer, or include more sessions. Regarding course content, participants considered that the elements included in the intervention were comprehensive and included useful information. The last elements related to participants’ satisfaction with the course, was the course facilitator, who was considered to be knowledgeable, approachable and non-judgemental (Table 3).

Mediators

There were three main mediators identified which seemed to be related to possible changes on participants’ attitudes and behaviours: recognition of negative attitudes; reflection about the impact of stigma and ability to make a change. Moreover, these mediators seemed to have been triggered by the inclusion of the following elements in the intervention: the videos of service users; the challenge of myths/stereotypes and awareness of the results of two other studies conducted in the same hospital.

Recognition of negative attitudes, in themselves or other colleagues, and reflection about the impact of stigma seemed to be important mediators of change. As most trainees mentioned that attending the intervention help them realise the great impact stigma has on their patients, and recognise that they could be considered a source of stigma (Table 3).

A further sub-theme recognised as a possible mediator was the ability to make a change. Overall, most participants mentioned that realising they could change their attitudes or that they can contribute to change this problem, was considered an important factor for them to modify their attitudes and behaviours (Table 3).

Results from the questionnaires also support that having learnt about the attitudes psychiatric trainees have towards psychiatric patients in the host organisation (a pre-existing contextual factor) was considered one of the most influential factors linked to a possible change of attitudes from participant trainees.

Unintended pathways

The main unanticipated outcome recognised as consequence of this intervention was the organisation of a group of psychiatric trainees to create an anti-stigma campaign at the host institution. Two trainees that participated in the intervention, created an online anti-stigma campaign called enlazando mentes (connecting minds) (https://es-la.facebook.com/enlazandomentes/), which aims to reduce mental health-related stigma through education. The creation of this campaign seems to have been triggered by this intervention, as formal and informal talks with the developers suggested that, although they were already interested in creating some kind of programme to target mental health-related stigma, they were motivated to finally develop an online campaign after they both participated in this study (Table 3). Additionally, these trainees have started delivering talks focused on stigma to the newly accepted trainees, as they were interested in improving the attitudes of these residents before they started their formal psychiatric training.

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