Reducing College Student's Stigma Toward People With Schizophrenia: A Pilot Trial

Abstract

Purpose: A new 1-day intervention grounded on the inter-group contact theory was developed and implemented to reduce college students’ stigma toward people with schizophrenia (PWS). We hypothesized that the stigmatizing situation could be alleviated by different levels of contact. Method: A pilot trial was conducted in Hong Kong with 41 college students participating in the intervention. Participants’ perception, stigmatizing attitudes, and social distance toward PWS were measured pre-, post, and 1-month after the intervention. Results: Significant changes were found in all outcome variables with moderate to high effect sizes. Knowledge session without direct contact contributed most to participants’ knowledge improvement, and higher levels of contact led to an obvious improvement in stigmatizing attitudes and social distance changes. Discussion:The current study provided evidence supporting the efficacy of the new intervention based on inter-group contact theory and practical experience for future stigma research.

Keywords

public stigma intervention inter-group contact schizophrenia

One of the commonest targets of public stigma is mental illness, especially severe mental illness. As the illness remains surrounded in mystery for many in the general public (Read et al., 2006), it is not unusual for people with severe mental illness to face exclusion even when they are in remission or have recovered. As severe mental illness is a rather large category, one of the most devalued illnesses—schizophrenia—is addressed in the current study. When we turn our attention to Hong Kong where the current study took place, the total number of psychiatric patients receiving treatment in Hong Kong was about 271,700 by the end of 2020, of which about 50,400, or 18.5%, were diagnosed with the schizophrenia spectrum disorders (Food and Health Bureau, 2021). Comparing with people with other types of mental illnesses, people with schizophrenia (PWS) or diagnosed with schizophrenia previously are most likely to anticipate stigma from friends, family members, health professionals, and the general public (Lee et al., 2006, 2016). According to a research in Hong Kong (Lee et al., 2005), over a third of PWS were treated or commented negatively when their employers became aware of their symptoms. Over half of the participants were viewed as violent or bad by their partners after marriage, particularly during relapse. To protect themselves from the threats of public stigma, PWS often choose to conceal their diagnosis and even reject to obtain professional help (Lee et al., 2016).

Harmful consequences of public stigma may direct act on PWS, threatening their prognosis and chances of reintegration in society. As social workers are one of the key roles in providing rehabilitation and social services to PWS especially in the remission stage (Ma, 1999; Scheyett, 2005), growing attention and discussion have been given to reduce public stigma toward PWS in the social work field. In other words, to better assist PWS's rehabilitation in both health condition and social functions, the stigma issue which is considered as a second illness beside psychotic symptoms (Link & Stuart, 2017) needs to be considered in the first place in social work practice.

Existing literature in stigma research has demonstrated three components that should be tackled to alleviate the problem of stigma—cognitive knowledge, attitude, and behavior (Corrigan et al., 2003; Link et al., 2004). On one hand, correct and comprehensive knowledge of the stigmatized group should be provided (Lo et al., 2021). On the other hand, the public's prejudicial attitude and discriminative behavior should be reduced (Choe et al., 2008; Corrigan & Miller, 2004; Jenkins & Carpenter-Song, 2009; Schomerus et al., 2015). Previous intervention for stigma reduction has covered one or two of the three components, either focusing on knowledge provision only or combining knowledge and attitude change together (Mehta et al., 2015; Thornicroft et al., 2016; Yamaguchi et al., 2013). Although studies have tested the effectiveness of using indirect contact to improve the stigmatizing condition (Amsalem et al., 2021; Morgan et al., 2018), previous research suggested that direct social contact was still the most effective method in achieving stigma reduction (Chan et al., 2009; Fung et al., 2016; Koike et al., 2018; Thornicroft et al., 2016; Yamaguchi et al., 2011). For the target group selection, college students were prioritized by researchers worldwide (Morgan et al., 2018; Nikolaou & Petkari, 2021; Pingani et al., 2016; Thornicroft et al., 2016). Research has found that this target group often has less accurate knowledge about mental illness but is more likely to be threatened by consequential stigma, including delay of early intervention and reject of help-seeking (Lally et al., 2018; Pinto-Foltz & Logsdon, 2009; Wahl et al., 2012; Yang et al., 2013). They are also the most at-risk group influenced by severe mental illness like schizophrenia, as the onset age is just around 20s. Thus, anti-stigma interventions toward mental illness and people with mental illness provided for the college student group become researchers’ priority.

By reviewing the existing literature, we found that the component of the stigma that could be improved by contact was not clearly explained, nor was the type of contact specifically illustrated. In other words, whether contact could improve the knowledge level or the prejudicial attitude toward PWS, and whether the stigma reduction was brought about by general conversation or intimate interaction between the two sides needed to be further explored. To fill the above research gaps, a new contact-based intervention grounded on the inter-group contact theory to reduce stigma toward PWS in Hong Kong was designed and implemented in the current study. Specifically, we separated the contact into three levels, in order to examine how different levels of contact may influence the outcomes of stigma reduction.

Based on previous research, we hypothesize that: (a) participants may report an increased knowledge level, reduced stigma attitudes, and decreased social distance toward the PWS after the intervention. However, (b) different levels of contact may have different functions on the improvement of the three components of public stigma.

Method

In the current study, we conducted a pilot study with pre- and post-intervention measurements to determine if the new intervention with different levels of contact can help improve college students’ stigma toward PWS. No control group was included in the current stage. Consent forms were collected from the participants before the start of the data collection and all participants were informed about the purpose and arrangement of this study. The Human Research Ethics Committee of the University of Hong Kong (EA1903076 and EA1909033) approved this research.

Participants

The research focused on reducing college students’ stigma toward PWS in Hong Kong. The inclusion criteria of participants were current college students aged over 18 who could understand and communicate in Chinese. Online promotion emails and offline posters were distributed to recruit participants in Hong Kong universities. Qualified self-registered participants were then divided into sub-groups with no more than 10 participants in each. PWS were peer specialists recruited from local community mental health service institutions; these were the people that the college students had contact with during the intervention. They were people diagnosed with schizophrenia and currently in remission status, with both experience of the onset of the illness and their own valuable understanding of such experience. Each sub-group included one or two PWS.

Intervention Design

The intervention design was primarily guided by the inter-group contact theory. This argued that successful contact between groups provides opportunities for all group members to understand each other and thus, hostile attitudes may decrease over time (Brophy, 1945; Kephart, 1957). The four conditions (equal status between majority and minority groups, common goals shared by the two groups, institutional supports, and cooperation between the two groups) required in the achievement of successful contact (Allport, 1954) were used to guide the current intervention content. Another new point is that we specifically predicted that different levels of contact may have different influences on the stigma reduction. We set three levels of contact in the study. The first level is zero contact with only knowledge education (no direct contact occurs between the two sides). The second level is moderate contact (limited contact through guided group discussion is introduced with specific instructions). The final and highest level is the intimate level of contact (both sides can have free conversations with each other and have a common task to work together). Each level of contact corresponds to one session of the intervention. In comparison with existing stigma-reduction interventions, the current design only requires 6 hours to finish all three sessions from zero contact to intimate contact level, guaranteeing the efficiency of the project and avoiding a high drop-out rate. The detailed intervention protocol is attached in the Appendix.

Measurements

The current intervention was designed to reduce public stigma toward PSW from three perspectives: knowledge improvement, attitude change, and behavior change. The effectiveness of the intervention was examined in accordance with the three perspectives before and after each session of the intervention. Data collection comprised of participants’ quiz scores and a battery of self-reported scales. Measuring instruments included: a quiz of schizophrenia knowledge to test participants’ knowledge improvement; the shortened Chinese version of the Community Attitudes toward the Mentally Ill (CAMI-SF) scale to measure participants’ change in attitudes, and the Social Distance Scale (SDS) to test participants’ intended behavior change. Specifically, four subscales: authoritarian (AT), benevolence (BN), social restrictiveness (SR), and community mental health ideology (CM) in the CAMI-SF were all included in the measurements. The purpose of measuring participants’ attitudes and intended behavior changes after each session was to examine whether changes occur and how any changes develop during the intervention. Measurements of the three perspectives were also completed a month after the intervention to examine whether improvements in key outcome variables were maintained.

With reference to Hypothesis 1, we assumed that participants’ mean score on the knowledge quiz, BN, and CM subscales will be significantly increased, while participants’ mean score on the AT and SR subscales and the SDS would be reduced post-intervention and at all follow-up points, compared to the mean pre-intervention score. For Hypothesis 2, we may observe the changing trend between each session of the intervention to explore the function of different levels of contact.

Demographic Characteristics

Self-reported demographic characteristics including age, gender, education level, marital status, religion, and previous diagnosis of mental illnesses were collected before the intervention.

Previous Level of Contact

The Level-of-Contact Report (Holmes et al., 1999) was used to ask participants about any previous contact experience with the mentally ill. Specific instruction was given, providing a concrete description of the mentally ill as PWS. There were 12 descriptions of previous contact experience representing 12 levels of contact. Higher levels of contact referred to closer contact with PWS. The participants’ level of contact was determined by the behavior with the highest contact level.

Knowledge of Schizophrenia

A knowledge quiz with 12 true-or-false items was developed before the intervention to test the participants’ understanding of schizophrenia. The total score of the quiz was 12. The quiz covered diagnosis, symptoms, treatment, prevalence, and common misunderstandings of schizophrenia. Participants choosing the correct answer could obtain one point, while choosing the wrong answer would have a point deducted. No point would be gained if the option Unsure was chosen. This scoring method was used to discourage random guessing.

Public Stigma

A validated short-form Chinese version of the Community Attitudes toward the Mentally Ill (CAMI-SF) scale was used to examine the participants’ attitude toward PWS. The revised 5-point Likert scale (Taylor & Dear, 1981) included 17 items with four subscales measuring four perspectives of stigma attitudes: AT, BN, SR, and CM. The total score of each subscale is 25, 15, 20, and 25 accordingly. Specific instruction is given in the scale, providing a concrete description of the mentally ill as PWS. Higher scores of AT and SR subscales indicate a more stigmatizing attitude, while higher scores of BN and CM subscales indicate a less stigmatizing attitude. The validation was conducted by the author before application in the current study (Gao & Ng, 2021). The reliability of the short-form Chinese version of the CAMI scale yielded alpha coefficients from 0.58 to 0.75.

Intended Behavior

The Social Distance Scale (Link et al., 1987) was used to examine the participants’ intended behavior toward PWS. The 4-point Likert scale includes seven items asking about participants’ attitudes to different social contexts (e.g., living next door to the mentally ill). Specific instruction is given in the scale, providing a concrete description of the mentally ill as PWS. The score range of the SDS is 0–3. Higher scores indicate a greater distance from PWS. The reliability of the SDS yielded Cronbach's alpha coefficients of 0.75 to 0.76 among college samples (Corrigan et al., 2002; Kosyluk et al., 2016; Penn et al., 1994). The Chinese version of the Social Distance Scale was used, and the reliability coefficients ranged from .81 to .98 (Wong et al., 2017).

Data Analysis

Analysis was conducted using SPSS version 23. Paired-sample t-tests were conducted to compare participants’ knowledge, attitude, and intended behavior change before and after the intervention. The size of the effect was estimated using Cohen's d. With reference to the standard proposed by Cohen (1969), three thresholds of the d value were set as 0.2, 0.5, and 0.8 to describe small, medium, and large effect sizes, respectively (Goulet-Pelletier & Cousineau, 2018). Repeated-measures ANOVA was used to compare changes before the intervention, after each session, and a month after the intervention. One-way ANOVA was performed to check the predictability of different demographic groups on the outcome variables.

Results

Demographic Characteristics

Forty-nine participants joined the intervention and eight of them dropped out amid the three sessions. Thus, 41 participants in total finished all sessions of the intervention, and 34 participants were approached in the 1-month follow-up test. All were current college students with a mean age of 26.24 years (SD = 6.76). Of the 41 participants, there were 35 female students and 6 male, none of whom had a previous diagnosis of mental illnesses. The majority were in master programs (N = 26) and were currently single (N = 32). Over half of them had no religious faith (N = 24) and most of the other half were Christian (N = 13). Half of them had low contact levels with PWS (N = 20, contact level ranking under 4), as shown in Table 1. Participants in different demographic groups presented no significant difference in the scores of the outcome variables at T0; however, the scores of the knowledge of schizophrenia presented a significant difference between participants with different previous contact levels—F(2, 38) = 3.42, p = .043. Participants with high contact level (scores between 9 and 12) reported significantly higher knowledge scores than those with low contact level (scores between 0 and 4; p = .03; Table 2).

Table 1.
Demographic Characteristics of Participants at Baseline (T₀).

Baseline Characteristic n

Age Under 25 19

25–30 13

Over 30 7

Missing 2

Gender Female 35

Male 6

Education Undergraduate 10

Master 26

Doctor 3

Others 1

Missing 1

Marital Status Single 32

Married 9

Religion None 24

Christian 13

Buddhism 1

Others 3

Diagnosis of MI None 41

Level of Contact Report 0–4 20

4–8 7

8–12 14

Table 2.
Changes Between Different Previous Contact Levels: Means and SD Pre- and Post-Intervention (N_T0 = 41, N_T3 = 34).

Low Contact Level (0–4) Moderate Contact Level (5–8) High Contact Level (9–12)

Mean SD t p Mean SD t p Mean SD t p

Quiz T0 4.3 2.43 −5.90 <.001 6.29 2.69 −1.81 .12 6.07 1.73 −2.52 .03

T3 8.4 2.44 7.86 2.48 8.43 3.06

CAMI-AT T0 10.5 2.16 2.65 .016 10.14 1.57 1.19 .28 10.64 3 1.71 .11

T3 9.4 1.79 9.57 1.9 9 2.96

CAMI-BN T0 12.35 1.31 −1.99 .061 12.29 1.8 −2.52 .045 12.79 1.53 −3.37 .005

T3 13 1.97 13.14 1.77 13.79 1.63

CAMI-SR T0 8.2 2.59 3.94 .001 7 2.16 0.56 .60 7.5 2.14 2.92 .01

T3 6.25 2 6.43 2.94 6.64 2.53

CAMI-CM T0 19.35 2.06 −4.23 <.001 20.43 2.07 −1.11 .31 19.93 2.46 −4.84 <.001

T3 21.3 2.64 21.14 2.27 22.07 2.43

SDS T0 1.13 0.44 7.05 <.001 1.08 0.56 3.42 .01 1.11 0.69 3.97 .002

T3 0.64 0.42 0.71 0.49 0.88 0.74

Knowledge, Attitude, and Intended Behavior Toward PWS

Paired-sample t-tests were conducted to compare participants’ knowledge, attitude, and intended behavior change pre- and post-intervention. The results supported hypothesis 1, indicating that the participants’ knowledge level of schizophrenia was significantly increased after the intervention, and the stigmatizing attitude and social distance toward PWS were both significantly reduced (Table 3). There was a significant increase in scores for knowledge of schizophrenia pre- and post-intervention—t(40) = −6.08, p < .001. The score remained significantly increased—t(33) = −5.31, p < .001—a month after the intervention (T4). For the mean scores of the four subscales in the CAMI-SF scale, they also presented significant changes after the intervention. There was a significant reduction in scores of the AT subscale—t(40) = 3.26, p = .002—and the SR subscale—t(40) = 4.20, p < .001. And significant increase was obtained from the BN subscale—t(40) = −4.13, p < .001—and the CM subscale—t(40) = −6.08, p < .001. A month after the intervention, significant changes could still be found in the mean scores of BN—t(3) = −2.19, p = .04. The scores of the SDS again indicated a significant reduction before and after the intervention—t(40) = 8.26, p < .001. Also, a significant reduction could still be found a month after the intervention—t(33) = 2.04, p = .049.

Table 3.
Within-Group Changes: Means and Effect Sizes at Different Measuring Points (N = 41).

T0 (Pre) T1 (After Session 1) T2 (After Session 2) T3 (Post) T4 (1-month N = 34) t p Cohen's d (T0–T3)

Mean SD Mean SD Mean SD Mean SD Mean SD (Pre-Post)

Quiz 5.24 2.40 8.42 2.61 8.68 2.56 8.32 2.40 8.26 2.43 −6.08 <.001 1.08

CAMI-AT 10.44 2.36 9.75 2.49 9.90 2.32 9.46 2.22 10.12 2.24 3.26 .002 −0.50

CAMI-BN 12.49 1.45 12.33 1.66 13.08 1.60 13.29 1.82 12.65 1.81 −4.13 <.001 0.75

CAMI-SR 7.76 2.36 7.68 2.41 6.87 2.29 6.41 2.30 7.26 2.12 4.20 <.001 −0.65

CAMI-CM 19.73 2.19 20.70 2.41 21.13 2.54 21.54 2.48 20.71 2.55 −6.08 <.001 1.03

SDS 1.11 0.54 0.98 0.56 0.80 0.57 0.73 0.55 0.95 0.52 8.26 <.001 −1.30

As for hypothesis 2, by examining the changing trends between each measuring point, we found that different levels of contact may bring about different improvement on the three perspectives of public stigma. The mean score of participants’ knowledge of schizophrenia increased significantly after session 1 (p < .001). However, there was only a slight increase in scores between T1 and T2 (p = 1), and between T2 and T3 (p = 1), neither of which were significant. When analyzing participants’ attitude, the SR score of T2 was significantly lower than that of T1 (p = .009) while the BN score of T2 was significantly higher than that of T1 (p = .002). For participants’ mean score of SDS, though there were only slight changes between the four time points, the results still showed significant differences between T1 and T2(0 < 0.001). All these findings echoed with our hypothesis that attitude changes may mainly result from direct contact sessions (T2 or T3) with the PWS, and knowledge increase may result primarily from the knowledge session (T1).

No statistically significant difference was found in different demographic groups after the intervention. Although participants in high previous contact level group reported higher knowledge scores before the intervention, such difference did not remain. Results suggested that mean knowledge scores for all three contact levels were nearly the same after the intervention (Table 2). And the mean scores were all higher compared with the baseline level.

Discussion and Applications to Practice

The pilot study findings offered preliminary evidence that a 1-day contact-based intervention with different levels of inter-group contact can improve knowledge of schizophrenia and discriminative attitudes toward PWS. The results indicated a significant improvement in knowledge, stigmatizing attitudes and social distance after the intervention (T3) with medium to large effect sizes, echoing our first assumption.

In terms of knowledge, the mean score of the knowledge quiz increased from 5.24 to 8.32, yielding a large effect size (d = 1.08). After watching the knowledge video, which introduced core knowledge about schizophrenia such as diagnosis, symptoms, treatment, etc., the quiz score at T1 indicated a great increase compared with T0 (p < .001). Although improvement in knowledge was still found at T2 and T3, the results were not statistically significant, indicating that the participants’ knowledge increase mainly resulted from the knowledge session. The presence of contact may not be necessary for knowledge increase, in line with previous findings that contact might not directly bring about knowledge improvement. Thus, education was still the primary method in achieving information distribution.

The four subscales of the CAMI-SF scale measure the four important perspectives of public stigma attitudes. Although the results indicated significant changes after intervention (T3), and the magnitude of this finding was medium to high (d ranging from 0.50 to 1.03), it still showed the process of fluctuating and incremental attitude change (Figure 1). For CM subscale, it measures the extent participants could understand the therapeutic effects of community and the principle of deinstitutionalization (Taylor & Dear, 1981). After the knowledge session, we could observe a significant improvement on this perspective and the positive change maintained with the help of following contact sessions. However, for the other three subscales which discuss more about the attitude dimensions, our hypothesized outcome did not occur easily. For the BN subscale, the knowledge session even provided opposite effect, as the mean score decreased at T1, which may indicate that the tolerant and sympathetic attitude reduced when more knowledge was introduced. Only after the two contact sessions, we could find substantial changes in the positive attitude toward PWS (Figure 1). This may help support the view that education may improve knowledge of schizophrenia but may not influence negative attitudes effectively (Högberg et al., 2008). Also, the function of contact sessions reflected in the improvement of negative attitudes—control and restrictiveness—from the AT and SR scores as well. But we need to pay attention that moderate contact may not be enough sometimes, as the AT scores still increased after the short discussion session and finally decreased significantly when the cooperative session was finished. This phenomenon was in line with our second assumption that stigmatizing attitudes are more likely to be reduced with increasing levels of contact with PWS. In other words, attitude change could not be achieved immediately from inter-group contact, and was rather a cumulative process where the degree of familiarity and understanding ascended step by step.

Figure 1.
Mean scores of knowledge quiz, CAMI-SF scale, and SDS at five time points.

The results of the BN and CM subscales—testing participants’ benevolence and willingness to provide help for PWS—presented high scores before the intervention. The results of the AT and SR subscales—asking about participants’ control and restrictiveness toward PWS—both presented low scores at T0. The slight though significant changes between pre- and post-intervention scores for all four subscales may be attributed to a social desirability bias, especially for self-reported scales. This finding indicated the necessity to add a scale to test the participants’ intended behavior. When faced with practical contexts such as living next door to or marrying someone with schizophrenia, it may be harder for participants to hide their implicit attitudes.

As a result, in order to provide deeper understanding to the possible behavioral intention to PWS, we tried to use the SDS to reveal the fact. With reference to the results, though the social distance was reduced gradually after each session and we obtained significant improvement at both T1 and T2, the biggest change occurred after session 2. This could help strengthen the view that educational programs alone may not directly motivate change in personal attitude and behavior (Högberg et al., 2008), as in this study, adding contact induced the major change. The reduction of social distance maintained till the end of the intervention a month later which further proved the effectiveness of inter-group contact on reducing attitudes of stigma and encouraging positive behavior toward PWS.

Moreover, we also analyzed feedback from participants with different previous contact levels with PWS, as the knowledge level of schizophrenia and PWS showed significant difference between participants with low contact level and high contact level before the intervention. Although we found that participants with high contact level reported higher knowledge level of schizophrenia and PWS, their attitude toward PWS did not present significant difference compared with the others. This echoed us with the assumption of inter-group contact theory that having contact might be inadequate, while successful contact with more empathy and mutual understanding is the key (Allport, 1954). After further exploring participants’ feedback in the high contact level group, significant improvement could still be found in all measured perspectives except the AT subscale. This may indicate that though previous contact could have impact on participants’ perception, prejudicial attitudes and intended social distance, our intervention could further introduce positive changes to people with existing perception toward the stigmatized group. For participants in low and moderate previous contact group, the effectiveness of the current intervention also presented substantial changes (Table 2).

Based on the findings of the current intervention study, we could summarize the following points for future social work practice targeting at stigma reduction toward PWS. In line with our hypotheses, different levels of contact may present different functions on improving the three components of public stigma. Existing anti-stigma interventions toward PWS or people with severe mental illness usually advocate the educational method, while we suggest that knowledge education programs only may be inadequate. We propose that all three levels of contact need to be combined together in the anti-stigma intervention in order to improvement of all aspects of public stigma. Second, the current intervention could be finished within 1 day and positive changes in knowledge, attitudes, and social distance maintained 1-month after the intervention. It introduced successful experience for interventions guaranteeing both efficiency and effectiveness. Moreover, as this new intervention design was based on the inter-group contact theory, it emphasized the direct interaction between two groups. The design of incremental levels of contact could assist the successful contact and positive group dynamic. In this way, this intervention model could be extended to other stigma issues or just two groups with misunderstandings.

In the current study, there are also several important limitations to note. First, female participants accounts for the majority of the participants and no participant has diagnosis of mental illness previously. The diversity of participants included in the intervention should be expanded. Also, the targeted group is college students only. It is interesting and meaningful to include more diversified participants to further investigate the effectiveness of the intervention design. Second, as we proposed to examine the effectiveness and the protocol of the new intervention design, we only provided pre-post tests in the pilot trial. A larger sample size with a randomized controlled trial design and participants with different demographic backgrounds should be recruited to examine the generalizability of the intervention. Third, we only examined the content validity of the Level of contact scale and the knowledge quiz, robust validation should be added before future use in the intervention. Lastly, based on the findings from the quantitative data, we could describe the changing trend between different levels of contact during the intervention. However, the moment or issue triggering such changes is still unrevealed. A qualitative study may need to be added to explore the mechanism of attitude change during the intervention process.

Conclusion

The pilot study provided preliminary findings that different levels of contact with PWS have different functions in the reduction of public stigma toward PWS. And it provided quantitative evidence supporting the feasibility and effectiveness of a 1-day intervention for stigma reduction toward PWS with positive changes maintained 1-month after. Based on our findings, though direct contact is considered the better way to reduce public stigma, the establishment of successful contact is crucial. More knowledge and interaction did not necessarily bring more acceptance and understanding toward the stigmatized group. And we also noticed that providing knowledge only may even introduce negative outcomes. With reference to the inter-group contact theory and the design of incremental contact levels in the current intervention, the research provided practical experience for future anti-stigma intervention design.

Baseline Characteristic		n
Age	Under 25	19
25–30	13
Over 30	7
Missing	2
Gender	Female	35
Male	6
Education	Undergraduate	10
Master	26
Doctor	3
Others	1
Missing		1
Marital Status	Single	32
Married	9
Religion	None	24
Christian	13
Buddhism	1
Others	3
Diagnosis of MI	None	41
Level of Contact Report	0–4	20
4–8	7
8–12	14

	Low Contact Level (0–4)	Moderate Contact Level (5–8)	High Contact Level (9–12)
Quiz	T0	4.3	2.43	−5.90	<.001	6.29	2.69	−1.81	.12	6.07	1.73	−2.52	.03
T3	8.4	2.44	7.86	2.48	8.43	3.06
CAMI-AT	T0	10.5	2.16	2.65	.016	10.14	1.57	1.19	.28	10.64	3	1.71	.11
T3	9.4	1.79	9.57	1.9	9	2.96
CAMI-BN	T0	12.35	1.31	−1.99	.061	12.29	1.8	−2.52	.045	12.79	1.53	−3.37	.005
T3	13	1.97	13.14	1.77	13.79	1.63
CAMI-SR	T0	8.2	2.59	3.94	.001	7	2.16	0.56	.60	7.5	2.14	2.92	.01
T3	6.25	2	6.43	2.94	6.64	2.53
CAMI-CM	T0	19.35	2.06	−4.23	<.001	20.43	2.07	−1.11	.31	19.93	2.46	−4.84	<.001
T3	21.3	2.64	21.14	2.27	22.07	2.43
SDS	T0	1.13	0.44	7.05	<.001	1.08	0.56	3.42	.01	1.11	0.69	3.97	.002
T3	0.64	0.42	0.71	0.49	0.88	0.74

	T0 (Pre)	T1 (After Session 1)	T2 (After Session 2)	T3 (Post)	T4 (1-month N = 34)	t	p	Cohen's d (T0–T3)
Quiz	5.24	2.40	8.42	2.61	8.68	2.56	8.32	2.40	8.26	2.43	−6.08	<.001	1.08
CAMI-AT	10.44	2.36	9.75	2.49	9.90	2.32	9.46	2.22	10.12	2.24	3.26	.002	−0.50
CAMI-BN	12.49	1.45	12.33	1.66	13.08	1.60	13.29	1.82	12.65	1.81	−4.13	<.001	0.75
CAMI-SR	7.76	2.36	7.68	2.41	6.87	2.29	6.41	2.30	7.26	2.12	4.20	<.001	−0.65
CAMI-CM	19.73	2.19	20.70	2.41	21.13	2.54	21.54	2.48	20.71	2.55	−6.08	<.001	1.03
SDS	1.11	0.54	0.98	0.56	0.80	0.57	0.73	0.55	0.95	0.52	8.26	<.001	−1.30

Footnotes

Appendix

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

SiYu Gao

Siu-Man Ng

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		Low Contact Level (0–4)				Moderate Contact Level (5–8)				High Contact Level (9–12)
		Mean	SD	t	p	Mean	SD	t	p	Mean	SD	t	p
Quiz	T0	4.3	2.43	−5.90	<.001	6.29	2.69	−1.81	.12	6.07	1.73	−2.52	.03
Quiz	T3	8.4	2.44	−5.90	<.001	7.86	2.48	−1.81	.12	8.43	3.06	−2.52	.03
CAMI-AT	T0	10.5	2.16	2.65	.016	10.14	1.57	1.19	.28	10.64	3	1.71	.11
CAMI-AT	T3	9.4	1.79	2.65	.016	9.57	1.9	1.19	.28	9	2.96	1.71	.11
CAMI-BN	T0	12.35	1.31	−1.99	.061	12.29	1.8	−2.52	.045	12.79	1.53	−3.37	.005
CAMI-BN	T3	13	1.97	−1.99	.061	13.14	1.77	−2.52	.045	13.79	1.63	−3.37	.005
CAMI-SR	T0	8.2	2.59	3.94	.001	7	2.16	0.56	.60	7.5	2.14	2.92	.01
CAMI-SR	T3	6.25	2	3.94	.001	6.43	2.94	0.56	.60	6.64	2.53	2.92	.01
CAMI-CM	T0	19.35	2.06	−4.23	<.001	20.43	2.07	−1.11	.31	19.93	2.46	−4.84	<.001
CAMI-CM	T3	21.3	2.64	−4.23	<.001	21.14	2.27	−1.11	.31	22.07	2.43	−4.84	<.001
SDS	T0	1.13	0.44	7.05	<.001	1.08	0.56	3.42	.01	1.11	0.69	3.97	.002
SDS	T3	0.64	0.42	7.05	<.001	0.71	0.49	3.42	.01	0.88	0.74	3.97	.002