The effects of an educational intervention on reducing stigma among medical students toward patients with psychiatric disorders

Abstract

Background

Stigma surrounding psychiatric disorders persists among medical students, who represent the future of healthcare provision. The reluctance of these students to engage with patients with psychiatric conditions poses challenges in delivering appropriate healthcare services. This study aimed to evaluate the effects of an educational package on reducing stigma and altering attitudes toward patients with mental illnesses among medical students.

Methods

This interventional and quasi-experimental study enrolled medical students who entered in a 4-week clinical post in psychiatry wards from September 2021 to February 2022. Each group of students was randomly assigned to the intervention or control group. All students in the two groups underwent practical training in psychiatry wards. An anti-stigma educational package was provided for the students in the intervention group. This package consisted of three components, including a one-hour virtual training session titled “Stigma, its importance, and coping strategies”, watching three short documentary films on the experiences of successfully treated patients with mental illness, and writing a reflection after a face-to-face interview with a hospitalized patient. The Attitudes Toward Mental Illness (ATMI) questionnaire was used to evaluate the attitudes of all students at the end of the rotation. Additionally, content analysis was performed on the reflection writings of the intervention group.

Results

The intervention group (n = 142) and control group (n = 92) showed slight changes in ATMI. The effect sizes were small. Both the intervention and control groups demonstrated significant improvements in attitudes toward the treatment of mental illness. Content analysis of reflection writings highlighted increased awareness, empathy, and medical students’ need for more educational content on the significance of stigma and how to address it.

Conclusions

The educational intervention did not significantly impact medical students’ attitudes toward patients with psychiatric disorders; however, the standard clinical training and exposure to psychiatric patients may be sufficient to enhance students’ perspectives on the treatability of mental illness. Writing a reflection regarding face-to-face exposure with a patient with mental illness may increase awareness and empathy in medical students. Further investigation is needed to assess the long-term effects of reflection on medical students’ behavior.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12909-024-06189-1.

Introduction

The World Health Organization has highlighted stigma as a manifestation of disgrace and shame, coupled with rejection, discrimination, and the incapacity to engage in various social activities [1]. According to statistics, psychiatric disorders affect 1 in 3 to 4 individuals during their lifetime. In Iran, in terms of disease burden, psychiatric disorders rank second after nonintentional injuries [2]. Despite the prevalence of these disorders, a significant number of affected individuals do not seek or adhere to treatment. One of the fundamental reasons for this is societal, healthcare professional, and individual attitudes toward psychiatric disorders [3]. The consequences of experiencing stigma, such as difficulties in finding housing, loss of employment and educational opportunities, and even deprivation of other health services, discourage patients from seeking treatment [4]. Interventions to reduce stigma can contribute to building a healthier society. Stigma results from three factors: “lack of awareness about the illness,” “issues with attitudes and subsequent inappropriate emotional reactions,” and “problems in behavior”. The relationships among these three components are complex, and improving one of them does not necessarily impact the other two components [5]. Many studies have indicated three methods for reducing stigma [4, 6–8], which include (1) educating the general population about psychiatric illnesses and correcting misconceptions that lead to the public’s fear of individuals with mental disorders; (2) communicating between people and individuals affected by psychiatric disorders, whether through direct or indirect means; and, ultimately, (3) protesting against discriminative public policies targeting mental illnesses. It is better if the communication is face-to-face and continuous and if the patient and the target individual share similar social and economic conditions for maximum impact. Since three groups in society, namely, employers, legislators, and healthcare providers, play a pivotal role in improving the quality of life for patients, it is preferable to initially prioritize these individuals as the target community [7, 9, 10].

Approximately 25% of the stigma experienced by individuals may be attributed to healthcare professionals. Considering that individuals’ experiences from childhood to adulthood significantly influence their attitudes toward issues, solely having a medical degree may not be effective in reducing stigma [11]. The existence of stigma among healthcare professionals can lead to irreparable consequences. For instance, physicians may perceive physical symptoms in this group of patients as signs of psychiatric issues, potentially leading to the misdiagnosis of many physical illnesses, thus preventing affected individuals from receiving appropriate treatment [12]. A substantial body of research was carried out in various cultures delineating attitudes toward mental illness held by medical students. These studies generally indicate that people with mental disorders are perceived as different from patients with medical conditions. The intolerable attitudes of medical students as future doctors toward people with mental disorders might act as a barrier for patients to receive appropriate care. A systematic review carried out by Petkari and colleagues (2018) to evaluate the impact of psychiatry clerkship on the stigma showed a highly significant medium effect size for reducing overall stigma, attitudes and behavioral intentions [13]. This finding highlights the role of clinical rotation as a necessary agent for the battle against stigma. Another review conducted by Gervás and colleagues (2022) indicated that 16 different types of interventions had been used to reduce stigma in students [14]. They found that interventions based on “teaching practices”, and different kinds of direct and indirect contacts generally led to short-term improvements. The inability and reluctance to communicate with this group of patients also serve as additional factors hindering the delivery of appropriate healthcare services to these individuals.

According to the current evidence, addressing the concerns and negative attitudes of healthcare professionals before their initial encounter with this patient population may have a substantial impact on reducing stigma [15]. Given that one of the significant factors influencing the formation of stigma is the age of individuals, interventions conducted at younger ages have a greater impact [16]. As medical students are future physicians, altering their attitudes toward individuals with psychiatric disorders can play a significant role in enhancing the mental health of society in the long term [12].

Previous studies indicate that the use of two methods, namely, education about psychiatric disorders and establishing patient connections, has been effective in reducing negative attitudes and increasing awareness among individuals while having less effect on changing societal behaviors toward these patients. To compare the effectiveness of these two methods, various factors, such as age, should be taken into account. Additionally, when interventions involve a combination of several approaches, their effectiveness is enhanced [10, 17, 18]. Notably, in a limited number of studies conducted in Iran, unlike in many other countries, interventions such as increasing communication with patients with psychiatric illnesses have demonstrated no improvement in students’ attitudes. In explaining this difference, in addition to the limitations of the studies, reference has been given to individual characteristics and the ceiling effect. Furthermore, the conducted studies have exclusively utilized quantitative methods for assessment, neglecting qualitative approaches [19, 20].

In the present study, the effectiveness of a multicomponent educational intervention for reducing stigma among medical students toward patients with psychiatric disorders was investigated, and the experience of the intervention group students was analyzed through reflection writing.

Method

Participants and context

The present study was interventional and quasi-experimental. The study population consisted of all medical students who attended Roozbeh Hospital, a psychiatric teaching center in Tehran, Iran, from September 2021 to March 2022 for their 4-week clerkships or internships. Each student group was randomly assigned to an intervention or control group. The only criterion for individuals’ exclusion was dissatisfaction with participation in the study.

All students in the two groups had to pass a 34-hour deductive course as well as a 4-week clerkship or internship. The current clinical rotation consisted of a 4-week training in outpatient clinics and psychiatric wards in Roozbeh Hospital, a teaching mental hospital in the center of Tehran. All students had the clinical encounter including two days per week in an acute locked psychiatric ward and one day per week in an outpatient clinic. During this study, due to the widespread spread of COVID-19, the possibility of increasing face-to-face contact was restricted. Therefore, all the theoretical interventions were prepared as a virtual package and presented to the students online.

Intervention design

Evidence from anti-stigma interventions among medical students and health professionals indicated several key components for effective interventions [21, 22]. In the present study, we chose three important components including “increasing knowledge and awareness concerning stigma and consequences”, “exposing to individuals who had a lived experience of mental illness”, and “showing recovery, competence and successful living of a famous person with lived experience of mental illness”. Additionally, we used “writing a reflection” as an effective learning tool in medical education after conducting an interview with a patient by the medical students [23]. Therefore, an anti-stigma educational package was provided for the students in the intervention group. This package consisted of three components, including a one-hour virtual training session titled “Stigma, its importance, and coping strategies”, watching three short documentary films on the experiences of successfully treated patients with mental illness, and writing a reflection after a face-to-face interview with a hospitalized patient. The content of the one-hour session included defining the stigma, its negative effects, and methods of coping with it. To increase students’ awareness of patients with psychiatric disorders, three short documentary films were shown to depict the experiences of successfully treated patients, and then, an opportunity was provided for discussion in a virtual session. Due to ethical considerations in this area, films available on the TED.com website with the titles “There’s No Shame in Taking Care of Your Mental Health,” “A Tale of Mental Illness from the Inside,” and “Confessions of a Depressed Comic” were utilized. Additionally, a handwritten note by Professor Bahauddin Khoramshahi, a successful contemporary Iranian poet and writer who has written about his experiences with bipolar disorder, was presented to the students. Then, the students were asked to interview one of the patients in the hospital who had recently shown improvement in their experience with their illness. In the final week of the course, the students in the intervention group were asked to write a reflection on their experience, which included the following sections: (1) Description: Briefly describe the subject, situation, or experience. (2) Emotions and Thoughts: Identify and express your emotions and thoughts regarding this experience. (3) Evaluation: express the positive and negative aspects of the situation or experience. (4) Analysis: Analyze the details of the experience to the extent possible. (5) Conclusion: What else could you have done? (6) Future Plan: How would you act differently in a similar situation in the future?

Assessment

To assess students’ attitudes toward patients with psychiatric disorders, the Attitudes Toward Mental Illness (ATMI) questionnaire was utilized. This instrument has been previously used in numerous studies and has demonstrated its validity [20, 24, 25]. To evaluate content validity, the items were adapted based on the opinions of five mental health professionals and adjusted in terms of social and cultural conditions. In order to examine the reliability, the scale was distributed to 70 students and handed out again after two weeks. The Cronbach’s alpha ranged from 0.603 to 0.857 across dimensions. This 22-item questionnaire consisted of five dimensions: (1) attitudes toward social relations in people with mental illness (six questions), (2) willingness to self-disclose mental illness (three questions), (3) attitudes toward the treatment of mental illness (six questions), (4) attitudes toward the etiology of mental illness (three questions), and (5) stereotypic attitudes toward people with mental illness (four questions). The scores were on a five-point Likert scale from 1 (strongly disagree) to 5 (strongly agree), with a higher score indicating a more favorable attitude. The scoring of some of the items was reversed to avoid response bias.

Furthermore, at the beginning of the course and before implementing the abovementioned package, the students were asked to complete the ATMI questionnaire to measure their level of stigma. The same questionnaire was administered again at the end of the course, following the completion of the intervention.

The study was conducted in accordance with the principles of the Declaration of Helsinki (1996, revised in 2008). All participants were provided with information on the study gave oral consent. The study was approved by the Ethics Committee of Tehran University of Medical Sciences in Tehran, Iran (code: IR.TUMS.MEDICINE.REC.1399.1174).

Data analysis

For the quantitative data analysis, after utilizing the Statistics 27 SPSS IBM software, the Wilcoxon test was employed to compare the attitude scores before and after the course. Additionally, for comparing other quantitative variables, either the unpaired t-test or the Mann‒Whitney U test was used. For qualitative background variables, the chi-square test was utilized. A significance level of 0.05 was considered. Furthermore, to assess the effect size of the difference between the two groups, Cohen’s d was utilized.

De-identified electronic copies of the reflection essays were analyzed to extract themes using MAXQDA 2020 software, employing a content analysis approach. The primary coder (MZ) initially reviewed the essays to gain an overall understanding and defined the primary codes for each section. Related categories were then grouped and identified as secondary codes. A second investigator (MT) reviewed the coding process, and several meetings were held to discuss and refine the codes and themes; however, only one researcher performed the coding. Data were primarily reported using a quantitatively informed mode of representation [26].

Results

All 371 medical students who started clinical psychiatry posts during the study period were invited to participate. The participants included 151 interns (final-year medical students) and 220 externs (4^th− or 5th -year medical students). Each group was randomly assigned to the intervention or control group. In the intervention group, 142 individuals (66%), and in the control group, 92 individuals (59%) cooperated to complete the questionnaires and remained in the study.

Demographic information

Table 1 shows the baseline demographic characteristics of the study participants in the two groups. Despite the group randomization, both groups significantly differed in terms of sex and educational level.

Table 1.

Basic characteristics of the control group (n = 92) and the intervention group (n = 142)

Variable	Intervention group	Control group	P value	Df
Age, year Mean (± SD)	24.24 (± 2.06)	24.51 (± 1.80)	0.304	232
Gender, n (%)	88 women (62%)	37 women (40.2%)	< 0.001	1
Educational level, n(%)	108 (76.1%) externs	46 (50%) externs	< 0.001	1
	34 (23/9%) interns	46 (50%) interns
Past psychiatry history, n(%)	52 (36/6%) positive	36 (39/1%) positive	0.699	1
The existence of a psychiatrist in close relatives, n (%)	21 (14/8%) positive	12 (13%) positive	0.708	1
History of studying psychology books, n (%)	113 (79/6%) positive	81 (88%) positive	0.093	1

Table 2 shows the ATMI dimensions and total scores for the two groups. There were no statistically significant within- or between-group differences in dimension 1 (social relations) or dimension 2 (willingness to self-disclose). For dimension 3 (treatment), both groups’ attitude scores significantly improved within each group; however, the difference between the two groups was not statistically significant. For dimension 4 (etiology), both groups’ attitude scores significantly decreased within each group; however, the difference between the two groups was not statistically significant. The score for dimension 5 (stereotypic attitude) in the intervention group did not significantly improve within the intervention group, while the score within the control group did not significantly decrease. However, the difference between the two groups in dimension 5 was statistically significant. For the ATMI total score, the intervention group showed no significant improvement within the group, while the control group demonstrated a nonsignificant decrease within the thin group. However, the difference in the ATMI total score between the two groups was nearly statistically significant. Additionally, the effect size was small to medium (Cohen’s d = 0.285, 95% CI = 0.021–0.945).

Table 2.

Results of the ATMI questionnaire in the intervention (n = 142) and control group (n = 92)

Dimensions	Target group	Negative ranks	Positive ranks	Ties	Wilcoxon test		Mann‒Whitney U test		Cohen’s d (95% CI)
					Z score	P value	Z score	P value
(1) Social Relationships with People Affected by Mental Illness	intervention	58	48	36	-1.37	0.168	-0.188	0.851	0.150 (-0.247, 0.278)
	control	35	26	31	-1.21	0.224
(2) Willingness to Self-Disclosure Regarding Mental Illness	intervention	47	50	45	-1.25	0.206	-0.596	-0.551	0.125 (-0.138, 0.387)
	control	33	35	24	-0.27	0.785
(3) Treatment of Mental Illness	intervention	39	79	24	-3.90	0.001	-0.525	0.600	0.120 (-0.143, 0.382)
	control	32	51	9	-1.97	0.048
(4) The etiology of Mental Illness	intervention	61	38	43	-2.78	0.005	-0.495	0.621	0.025 (-0.237, 0.288)
	control	44	19	29	-2.81	0.005
(5) Stereotypic Attitude Toward People With Mental Illness	intervention	41	66	35	-1.81	0.069	-2.767	0.006	0.333 (0.069, 0.597)
	control	45	29	18	-1.92	0.055
Total	intervention	54	72	16	-1.57	0.115	-1.763	0.078	0.285 (0.021, 0.549)
	control	47	38	7	-1.00	0.314

Given that the intervention and control groups differed in terms of gender and educational level in the baseline assessment, the differences in the five dimensions of attitude were examined separately for these two variables, which were not statistically significant. Moreover, we performed subgroup analyses for gender and educational level in terms of ATMI total score differences. Female students’ ATMI total scores significantly improved in the intervention group compared to male students’ ATMI total scores (t = 2.30, df = 123, p-value = 0.023; Cohen’s d = 0.45). Also, interns’ ATMI total scores significantly improved in the intervention group compared to externs’ ATMI total scores (t = 2.68, df = 78, p-value = 0.009; Cohen’s d = 0.61).

Main findings of the reflection writing

The primary and secondary codes obtained from the content analysis of 142 reflections from intervention group students are presented in Table 3. The analysis revealed three main themes: increased awareness and attention to the issue of stigma, deeper empathy and understanding of people with mental illness, and the need for more exposure and increased training.

Table 3.

Primary and secondary codes of reflection in intervention group (n = 142)

Section	Primary codes	%	Secondary codes	%
Description	Family stigma	40.4	Family stigma	40.4
	Self-stigma	22.6	Self-stigma	22.6
	Social stigma	22	Social stigma	22
	Stigma from healthcare providers	17	Stigma from healthcare providers	17
Emotion and thought	Sadness	39.8	Sadness	39.8
	Compassion	5.6	Sympathy and empathy	12.7
	Sympathy and empathy	8.4
	Others (shame, fear, surprise, etc.)	17	Other (shame, fear, surprise, etc.)	11.9
Evaluation, analysis, and conclusion	More stigma awareness	31	More stigma awareness	31
	More empathy towards patients	13.4	Deeper understanding of the patient	25.3
	Better understanding of the patient’s condition	11.9
	More awareness of the importance of family support	24	More awareness of the importance of family support	24
	Patients with mental illness are not incapable	9	Patients with mental illness are not incapable	9
	Improved skills	7	Improved skills	7
Plan	More sensitivity to stigma	24.6	Empathetic approach and sensitivity to stigma	64.4
	More humane approach	28.1
	More empathy	40.1
	Raising awareness	51.1	Raising awareness	51.1
	More education about stigma for others	59.1	More education about stigma for others	59.1
Doctor’s Educational needs	Need for exposure to relevant articles and references	21.8	Need for knowledge and information about mental health problems	69.4
	Awareness and knowledge of mental illness	47.8
	Active listening skill	9.1	Need for interview and communication skills	77.3
	Patient interview skill	25.3
	Communication skills	61.2
	Empathy skills	44.3
	More activity during rotation	20.4	More educational opportunities	32.3
	More direct interaction with patients	16.9

Section 1 (description)

Students noted various types of stigma that patients faced during their illness. The most frequently mentioned was family stigma (40.4%), as illustrated by participant 131 (P131): “His family mistreated him due to his psychiatric disorders and frequently labeled him as ‘crazy’ and ‘worthless’.” Other frequently mentioned codes included self-stigma (22.6%), social stigma (22%), and stigma from healthcare providers (17%). It is important to note that these percentages do not indicate the prevalence of different types of stigma but rather the frequency with which they were mentioned in students’ reflections.

Section 2 (emotion and thought)

Regarding stigma towards mental health problems, students reported a range of negative emotions, including anger, fear, surprise, and shame. The most reported emotions were sadness and sorrow (39.8%), followed by compassion, sympathy, and empathy toward patients (12.7%). One student (P16) reflected, “In interviews with patients, I felt profound sadness as I considered the immense psychological burden these individuals endure, not only battling their illness but also facing stigma from those around them.”

Sections 3, 4, and 5 (evaluation, analysis, and conclusion)

Approximately 31% of intervention group students identified familiarizing themselves with the issue of stigma and gaining more information about it as a positive aspect of the experience. Participant 115 noted, “I learned that psychiatric disorders can be treated and that people with these conditions can do really well in school and life with the right treatment and support.” Additionally, 25.3% of students reported developing a deeper understanding of patients’ situations and feeling more empathetic toward them by the end of the course. As mentioned by P125, “A great thing was changing my preconceived ideas about patients, which helped me understand their emotions better and feel more empathy for them”.

Section 6 (plan)

About 64.4% of intervention group members stated they would be more sensitive to the stigma associated with mental health problems and adopt a more empathetic and humane approach toward people with these illnesses. Additionally, 51.5% of students expressed a sense of responsibility to raise awareness and educate others about stigma. Participant 18 shared, “In my everyday life, I’m going to make sure I treat people with psychiatric conditions without any stigma or judgment. If I see someone being treated unfairly because of their mental health, whether at work or anywhere else, I’ll speak up about it.” Participant 43 shared, “As a doctor, I feel it’s my responsibility to help change this mindset in society. I think every medical professional should do the same.”

Educational needs

Regarding the educational needs of medical students, 77.3% expressed the need for more training in communication and interview skills with patients. Additionally, 69.4% highlighted the need for educational content on mental health problems, the significance of stigma, and how to address it.

Discussion

This study revealed a mixed impact of a multicomponent educational intervention on reducing stigma toward psychiatric patients among medical students. Although the intervention improved students’ stereotypic attitudes, it did not enhance their perspectives on the treatability of mental illness. Critically, student reflections revealed three key themes: increased awareness of stigma, greater empathy for patients, and the need for more comprehensive education. These findings align with the conclusions of Potts et al. (2022) [27], who suggested that targeted interventions can shift mindsets, but current approaches have limitations. In particular, simply adding this type of educational package to standard clinical training may only partially address the multifaceted nature of stigma in medicine. More sustained, multifaceted efforts may be required to meaningfully transform attitudes and behaviors.

Notably, both the intervention and control groups demonstrated significant improvements in attitudes toward the treatment of mental illness. This suggests that standard clinical training and exposure to psychiatric patients may be sufficient to enhance students’ perspectives on the treatability of mental illness.

Current literature indicates mixed results regarding differences in terms of attitudes toward patients with mental disorders between female and male medical students. In accordance with our study, some studies suggest that female students may have more positive attitudes compared to male students. However, other studies found no significant differences in attitudes based on gender [28, 29]. In line with our findings, some studies demonstrated senior medical students may exhibit more positive attitudes toward patients with mental disorders [28, 29]. Interns often have more opportunities to contact with patients, receive training in mental health care, and develop deeper understanding of mental illness. The additional multicomponent intervention may provide further benefits in some domains of attitudes toward mental illness. As one student reflected, “I became familiar with the treatability of mental disorders and realized that even someone with a mental disorder can achieve high levels of academic and social success through treatment and social support.” (115, Pos. 1) These findings align with those of previous studies by Kohrt et al. (2020) [8] and Amini et al. (2013) [25], underscoring how conventional medical education can positively shape attitudes toward the management of psychiatric conditions.

Regarding attitudes toward the etiology of mental illness, both the intervention and control groups demonstrated a significant increase in negative attitudes. This suggests that intervention and standard clinical training may not effectively overcome deep-seated sociocultural beliefs about the causes of psychiatric disorders. For instance, students’ views worsened on items such as “The close relatives of patients with mental illness are prone to this kind of illness” and “Accompanying a patient with mental illness may make me mentally ill.” This indicates that medical education may struggle to challenge ingrained misconceptions, even as it improves other dimensions of stigma. Importantly, the uncertain etiologies of many mental illnesses likely contribute to these entrenched attitudes. This finding contrasts with previous studies [18] [22] but aligns with Mino et al. (2001) [23]. Overall, these results underscore the difficulty in transforming beliefs about the origins of psychiatric conditions within medical training.

Regarding stereotypic attitudes toward people with mental illness, the intervention group demonstrated significantly more positive outcomes than the control group. This suggests that educational classes and patient interactions were effective in challenging students’ preconceptions. As one student reflected, “The positive aspect of the stigma class and patient interview was to correct the perception I had of these individuals in my mind and to create a better understanding of the emotions and feelings that such patients experience.” (125, Pos. 1) Another noted, “The predominant feeling in the initial visits was negative, and fear was dominant, but with establishing connections and familiarity with illnesses, this feeling was less at the end of the course.” (120, Pos. 1) These findings align with previous research [8, 29–31]], underscoring how targeted educational interventions combined with direct patient interactions can effectively challenge medical students’ stereotypic attitudes.

Based on the reflection form, patients’ primary concerns often involved stigma from their families. It appears that cultural factors present in Iran as a collective society contribute to a greater level of family stigma than other types of factors. Jacobsson et al. (2013) reported that the level of self-stigma among patients in Sweden is lower than that among patients in Iran, attributing this difference to cultural and religious differences between the two societies [32].

Additionally, students mentioned their initial exposure to the stigma topic and acquiring more information about it as a positive aspect. In the study by Heim et al. (2019), it was mentioned that following the interventions, individuals’ awareness initially increased and their attitudes changed, but discriminatory behaviors against patients were observed to change in subsequent stages [15]. Therefore, it can be inferred that the interventions in the present study were able to take initial steps toward reducing stigma.

Most students expressed that they would have increased sensitivity to the stigma of psychiatric illnesses and would exhibit greater empathy toward and more humane interaction with individuals affected by these illnesses. Kohrt et al. (2020) reported that interventions led to a greater sense of responsibility among healthcare providers for changing patients’ conditions and educating other members of society, which is consistent with the findings of the present study [8].

In the educational needs section, the need for more learning communication skills and interviews with patients, as well as the need for educational content to increase knowledge in the field of mental health issues, were identified as their primary educational needs. The majority of individuals acknowledged that they lacked these skills. In the study by Sarikoc et al. (2017), it was also mentioned that the use of the “role-playing” method before encountering patients significantly reduced the stress and fear of students, followed by a reduction in their stigma [33]. Additionally, in the study by Pescosolido et al. (2013), it was stated that having a sufficient level of communication skills before facing patients is necessary to improve interviewing and conversational abilities; otherwise, it may lead to the development of negative attitudes in individuals [34].

The present study had several limitations and should be taken into account in the interpretation of the study results. High dropouts may affect the study findings. The follow-up period was short, the sample was limited to a single psychiatric referral center focused on severe disorders, and the data were collected during the COVID-19 pandemic. Crucially, the study did not assess behavioral changes in the learners. Additionally, the randomization process resulted in intervention and control groups that differed in gender and education level, which is a significant methodological limitation. The other limitation was using only one scale to measure the outcome and it would be better if the other appropriate scale was simultaneously used.

Recommendations for future research include recruiting participants from multiple university centers, delivering interventions in person, using additional quantitative assessment tools, evaluating long-term intervention effects, and explicitly measuring changes in learner behaviors resulting from attitudinal shifts.

Conclusion

The multi-component educational intervention had a limited additional impact on improving students’ attitudes. Further investigation is needed to understand the nuanced effects of the training. Many students reported newfound familiarity with the issue of stigma, increased sensitivity, greater empathy, and more humane interactions with those experiencing psychiatric illnesses. They also expressed an intention to raise awareness on this topic. However, the various aspects and long-term effects of the intervention on medical students’ attitudes and behaviors require more in-depth assessment.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Abbreviations

ATMI

The Attitudes Toward Mental Illness questionnaire

Author contributions

HA, and MT contributed sufficiently in the conception and design of the study. MZ participated in acquisition of data. HA undertook the statistical analysis. HA, MT, and MZ participated in interpretation of data. MZ prepared the draft. HA, MT, and MZ read the draft and contributed sufficiently to revise the draft. All authors read and revised the manuscript critically for important intellectual content. All authors approved the final manuscript.

Funding

This study was supported by a grant (IR.TUMS.MEDICINE.REC.1399.1174) from Tehran University of Medical Sciences.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

Declarations

Ethics approval and consent to participate

The study was conducted in accordance with the principles of the Declaration of Helsinki (1996, revised in 2008). All participants were provided with information on the study gave oral consent. The study was approved by the Ethics Committee of Tehran University of Medical Sciences in Tehran, Iran (code: IR.TUMS.MEDICINE.REC.1399.1174).

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.