Chinese Culture-Specific Intervention to Decrease the Stigma of Nursing Students Towards Schizophrenia--A Pilot Randomized Controlled Trial
Phase: NA
Conditions: Stigma, Social
Sponsor: The Hong Kong Polytechnic University

 
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Chinese Culture-Specific Intervention to Decrease the Stigma of 
Nursing Students towards Schizophrenia——A Pilot Randomized 
Controlled Trial  
 
 
 
 
 
 
 
 
 
June 7， 2022 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

 
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Chinese Culture-Specific Intervention to Decrease the Stigma of Nursing Students 
towards Schizophrenia——A Pilot Randomized Controlled Trial  
 
Introduction 
Mental illness stigma does enormous damage to those with mental illness as well as 
their families, and the health care system (Brouwers, 2020). Schizophrenia is the most 
stigmatized disease among mental illnesses (Valery & Prouteau, 2020). In China, nearly 
7.8 million people are diagnosed with schizophrenia, and 100,000 new diagnoses are 
recorded each year (Hu, 2018; Yao et al., 2013). The stigma of schizophrenia is mainly 
characterized by the stereotypes of danger, unpredictability, and a poor prognosis (Crisp, 
Gelder, Rix, Meltzer, & Rowlands, 2000). People with schizophrenia are widely 
considered as more dangerous and unpredictable than people with other mental illnesses 
(Reavley & Jorm, 2014). 
 
In different cultures, people have different understandings of stigma meanings, treat it 
in different ways and yield different results (Yang, 2007). In China, some people believe 
that schizophrenia is caused by black magic or possessed or disturbed by spirits (gods 
or devils) (Tseng et al., 2013). Studies showed that socio-cultural and religious factors 
strongly affect stigmatizing attitudes (Waqas et al., 2020).  
 
However, in China, few studies have been conducted with a focus on Chinese culture 
when it comes to decreasing mental illness stigma. China is a developing country with 
a culture of face-saving and Confucianism, totally different from western countries 
(Yang et al., 2014). Nurses play an essential role in all health care systems. When 
nursing students begin their nursing career, their attitude and behavior toward 
schizophrenia will affect the treatment and nursing of people with schizophrenia. A 
study showed that compared with medical students, nursing students hold even a more 
negative attitude towards people with schizophrenia (Taşkın et al., 2003).  
 
In mainland China, fourth-year nursing students have finished their theoretical 
knowledge and then undertake clinical practice in the hospital prior to their graduation. 
Given the high prevalence of mental illness, such as schizophrenia, it is likely for the 
nursing students to meet some mental health consumers who require physical treatment 
and nursing care. Their stigma on consumers with schizophrenia will affect their 
delivery of quality healthcare and consumers’ achievement of optimal health outcomes 
and prevent them from entering the mental health workforce after graduation. It is 
fundamental to address nursing students’ stigma with appropriate intervention strategies.      
 
There are three ways of decreasing mental illness stigma: protest, education, and 
contact with people who have a mental illness (Corrigan, Edwards, et al., 2001). The 
“contact” has superior efficacy and effectiveness in decreasing stigma as it may evoke 
an empathic emotional reaction (Tippin et al., 2019).  Empathy is recognized as how 
an individual know other people’s thinking and feeling and figure out what makes 
someone give a response to other people’s suffering with sensitivity and care (Batson, 

 
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2009). It is found that improvement of empathy for the stigmatized group will be 
extended to a larger group of people with other mental illness (Batson et al., 2002;).  
 
Besides, transformative learning can help individuals to transform their beliefs, 
assumptions, and experiences from new perspectives (Dincer & Inangil, 2021). It may 
develop nursing students’ empathy and positive attitude towards people with 
schizophrenia. There are four transformative learning methods in education: 
investigative, collaborative, higher-order thinking, and interactive learning activities 
(Tsimane & Downing, 2020). To decrease nursing students’ stigma towards 
schizophrenia, intervention methods should incorporate the transformative learning.  
 
Knowledge-attitude-behavior practice (KABP) paradigm was used to guide researchers 
to develop intervention to decrease mental illness stigma (Foster, 2017;) as the lack of 
mental health knowledge and misconception of the fact will lead to stigma (Thornicroft, 
2006). Thus, a good intervention framework should combine transformative learning 
and KABP paradigm. 
 
Review of previous intervention studies in decreasing mental illness stigma show 
certain limitations. Studies showed that socio-cultural and religious factors strongly 
affect stigmatizing attitudes, but seldom taken in consideration in most previous studies 
(Waqas et al., 2020). They were mostly not guided by theoretical frameworks, and only 
two studies guided by theoretical frameworks (Papish et al., 2013).  Previous studies 
mainly focused on decreasing common or severe mental disorders stigma without in-
depth study targeting for schizophrenia (Amsalem et al., 2020). Most studies were also 
lack of follow-up time, and the efficacy of the interventions in the long-term was unsure 
(Amsalem et al., 2020). Furthermore, interventions were traditionally conducted face 
to face Amsalem et al., 2020), and this is not feasible during the Covid-19 pandemic 
period. But with the development of internet technology, time and social distance is no 
longer a problem. Thus, developing an online intervention programme to decrease the 
stigma towards schizophrenia will be more convenient and flexible without the 
restriction. Such intervention programme will be the first of its kind in mainland China.  
 
Aim 
This study aims to develop a Chinese culture specific intervention to decrease 
schizophrenia stigma among fourth-year nursing students in mainland China. The 
intervention will also be assessed for its feasibility, acceptability and the preliminarily 
efficacy in a pilot RCT study. 
Method 
Study Design 
This study consists of quantitative and qualitative research design. There are three 
phases of the whole study.  
1) In the first phase, a literature review and descriptive qualitative focus group interview 
will be used to inform the intervention development of a pilot RCT.  
2) The second phase will be a pilot RCT. The pilot RCT consists of three stages, 

 
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including the investigative learning activity (6 hours), the collaborative learning 
activity (4 hours), and the higher-order thinking activity (4 hours). The control group 
has one stage—reading a book about schizophrenia knowledge. 
3) The third phase is a process evaluation to explore the barriers or facilitators of the 
intervention in implementation, figure out additional problems which may affect the 
intervention in implementation, and refine the study design for a future full power RCT.  
 
Study Setting, Participants, Sampling and Sample size 
This study will be implemented in Xiang Ya Hospital, Changsha, Hu Nan province in 
mainland China. The participant will be fourth-year nursing students in mainland China. 
The first phase and third phase of focus group interviews will initially involve four 
participants in each focus group and the number of participants will increase until 
reaching data saturation. Based on the previous literature review on sample size 
calculations for feasibility studies, the sample size of the second phase of study was 
suggested between 24 and 50 (Julious, 2005; Sim & Lewis, 2012). Considering a drop-
out rate of 20% reported in many psychosocial intervention studies (Van Daele, 
Hermans, Van Audenhove, & Van den Bergh, 2011), the total number of participants 
will be set at 60 (both intervention and control group will have 30 participants). 
Convenience sampling method will be used to recruit the participants. 
 
Inclusion criteria of participants are those: 
• 
Participants should be 18 years old or above. 
• 
Participants should complete all the school courses to ensure that they have 
similar theoretical knowledge in psychiatric nursing. 
• 
Participants can communicate in Mandarin. 
• 
Participants are voluntarily participating in this study. 
• 
Participants have not participated in any other similar intervention before. 
• 
Participants are doing a clinical practicum in Xiangya Hospital, Changsha, 
Hunan Province. 
 
Exclusion criteria are those: 
• 
Participants are receiving treatment of schizophrenia or other mental illness. 
• 
Participants are lack of essential equipment to take an online interview. 
• 
Regular personal contact with someone with schizophrenia or other mental     
illness (more than three times a month). Because people's prejudice may 
decrease when they meet and interact with people with mental illness. 
       
 
Procedures 
 
Phase 1: Pre-intervention qualitative study 

 
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The first phase study aims to explore the knowledge, attitude, empathy, and intention 
behavior towards people with schizophrenia among nursing students through online 
focus group interview which is essential for developing an intervention programme. 
 
Phase 2: Pilot intervention study 
It involves the implementation of this study intervention based on the literature review, 
findings of phase one focus group interview and transformative learning theory (Dincer 
& Inangil, 2021; Tsimane & Downing, 2020). A feasibility study using a pilot 
randomized controlled trial design will assess the preliminary effect of the intervention 
on knowledge, attitude, empathy, and intention behavior of the fourth-year nursing 
students towards people with schizophrenia. The research outcome will be measured at 
three time points: Baseline (T0), after the intervention (T1), three months post-
intervention (T2).  
 
R software will be used to generate a randomization table in this study. To decrease the 
potential selection bias, allocation concealment will be applied to ensure there is no 
prior knowledge for group assignment (Suresh, 2011). A postgraduate student will be 
invited to help us generate the randomization table by R software. The participants’ 
group belonging will be determined after the participants have signed the consent form. 
 
The intervention programme will include investigative, collaborative, higher-order 
thinking, and interactive learning activities. For investigative learning activities, 
nursing students will be encouraged to access information through evidence-based 
research to discover the information by themselves and which will last about 6 hours.  
 
The collaborative learning activities will include people recovered from schizophrenia 
to share their experiences throughout the treatment and recovery period with nursing 
students who will be encouraged to raise their questions. Nursing student will create 
scenario‐based simulation and take roles in it. The contact activity will be held through 
online interviews. These collaborative learning activities will last about 4 hours. 
 
The higher-order thinking activities will include nursing students’ self-criticism after 
scenario-based simulation, nursing students will be asked to write their opinions about 
schizophrenia and people with schizophrenia. Nursing students will prepare concept 
maps for the problems a person with schizophrenia in daily life encounter and the 
corresponding solutions. The higher-order thinking activities are also held online and 
will last about 4 hours. Nursing students will interactively take part in the above-
mentioned activities, which belong to interactive learning activities. 
 
Blinding 
This research is an open-label study due to the practical impossibility of blinding 
participants and the self-completed measures. Some strategies for minimizing 
allocation and assessor bias will be implemented. To minimize allocation bias, the 
assistant who performed randomization will be blinded. To minimize the assessor bias, 

 
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the research assistants who collected and entered the data for analysis in this study will 
be blinded. They were concealed of group allocation and not notified what the group 
labels (group 1 and groups 2) mean. 
 
Feasibility of Intervention 
The outcome of this study will be mainly measured by the feasibility and acceptability 
of the intervention. Summary of the outcome measures feasibility of the intervention is 
shown in table 1. 
Table 1 Primary Outcome of the Intervention 
Primary 
outcome 
feasibility 
outcomes 
① Subject recruitment time 
② Achievable recruitment rate 
③ Eligibility rate of participants 
④ The response rate of scales 
acceptability 
outcomes 
① Drop-out rate of participants                                     
 
Preliminary Efficacy of the Intervention 
We will assess the intervention efficacy at baseline, post intervention, and at three-
month follow-up, including the participants’ change in knowledge, attitude, intention 
behavior, and empathy. The self-assessment questionnaires will include as following: 
1) Basic socio-demographic data will be gathered, and which will include 
information like age, gender, marital status, ethnic groups, university, province, religion, 
average family income per year, friends or family members with mental illness 
problems, mental illness history, whether they had contact with people with 
schizophrenia in the past, and whether they participated in any similar research before.  
2) Knowledge about Schizophrenia Test (KAST)-Chinese version will be used to 
measure the stigma-related schizophrenia knowledge of participants. KAST, including 
18 items, demonstrate an acceptable reliability coefficient of 0.68. The content validity 
index of items (I-CVI) ranged from 0.83 to 1.00, while the S-CVI/UA and S-CVI/Ave 
were 0.83 and 0.97, respectively, and known-group validity was satisfactory (Zhou et 
al., 2020).  
3) Mental Illness Clinicians’ Attitudes Scale (MICA)- Chinese version (Kassam, 
Glozier, Leese, Henderson, & Thornicroft, 2010; Li et al., 2014) will be used to 
measure stigma-related mental illness attitude of participants. MICA is a six-point 
scale that includes 16 items, and response options are from 1=totally agree to 
6=totally disagree. The total score range is taken from 16-96. A lower score indicates 
participants having a positive attitude towards mental illness. The internal consistency 
is 0.72-0.75, and test-retest reliability is 0.76-0.87 of MICA in the Chinese version (Li 
et al., 2014; Pan Shengmao et al., 2013).  
4) Reported and Intended Behavior Scale (RIBS)-Chinese version (Li et al., 
2014) will be used to measure the stigma-related mental illness behavior of 
participants. RIBS is a five-point scale that includes eight items, and response options 
are designed as 1=totally disagree, 2=disagree, 3=do not know, 4=agree, 5=totally 
agree. The total score range is taken from 4-20 of items 5-8. The higher score 

 
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indicates the participants are more willing to contact people who have a mental 
illness. The internal consistency is 0.82, and test-retest reliability is 0.68 of RIBS in 
the Chinese version.  
5) Jefferson Scale of Empathy-Health Profession Students (JSE-HPS)-Chinese 
version (Hsiao et al., 2012) will be used to measure the nursing students’ empathy 
towards people with schizophrenia. S-JSE-HPS is a seven-point scale that includes 
twenty items, and response options are designed as 1=totally disagree to 7= totally 
agree. The total score range is taken from 20-140. The higher score indicates the 
participants have greater empathic attitudes. The internal consistency is 0.93, and test-
retest reliability is 0.92 of JSE-HPS in the Chinese version.  
 
Intervention Fidelity 
A fidelity checklist will be used to assess the intervention fidelity (Borrelli et al., 2005). 
All sessions will be videotaped and rated independently by a research assistant. The 
assessor of the checklist will be an independent research assistant, who will be trained 
to use the checklist to assess the intervention fidelity. 
 
Phase 3: Process evaluation 
This phase aims to collect feedbacks from online focus group interview to explore the 
barriers and facilitating factors in implementing the intervention, figure out additional 
problems which may affect the intervention, and refine the study design for a future full 
power RCT. 
 
Ethical issues and data safety 
Ethical approval has been obtained from the Research Ethics Committee of The Hong 
Kong Polytechnic University (HSEARS20220127002) and the Research Ethics 
Committee of Xiang Ya Hospital of Central South University (KE202203129) to 
conduct this study. All participants will be reminded of the voluntary nature of the 
research and will be provided a participant information sheet. All information of 
participants will be kept confidential, and the information will be destroyed three years 
after the whole research. Participants can withdraw during any period in this research 
without any penalty or influence in their clinical rotation. There will be a clear written 
and verbal explanation of this study to all participants. The protocol will be 
prospectively registered at ClinicalTrials.gov. All participants will be asked to sign a 
written consent before this study starts. 
 
Data Collection 
The interview guide for focus group interview will include a series of open-ended 
questions. The interview guide will be used to interview one participant before an 
official interview (phase 1 and 3). All focus groups’ discussions will be recorded with 
videotaping online and transcribed verbatim. A detailed field note will be used to record 
the participants’ non-verbal expressions, and emotional status of the informant and 
reflective notes will be used to record the researcher’s speculation, feelings, and 
impressions towards the participants in the interview. Wen Juan Xing, an online 

 
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platform will be used to administer the self-assessment questionnaires. Only the 
researcher (the Ph.D. student) who has the password can login into this platform and 
access the data. The data will be kept in a U Disk Encryption that could only be accessed 
by the Ph.D. student with the password or others who is authorized. Tencent Video 
Conference will be used to conduct online intervention. All participants will receive a 
password and one-time access link to login the Tencent Video Conference. All 
participants’ voices and facial expressions can be wholly captured. Each interview 
which lasts about 60 minutes will be recorded by videotape.  
 
Data Management 
Information on the scales will be collected, coded, and enter SPSS 26.0 software to 
establish a database. A research assistant will help data entry. The PhD student and the 
research assistant will double-check the dataset of the raw data to make sure the data is 
accurate. Data will be kept strictly confidential. All participants will be anonymous in 
this study with only a code to represent his or her identity. Personal particulars will be 
removed in the analysis, all electronic files will be kept in a U Disk Encryption that 
could only be accessed by the PhD student with the password or others who is 
authorized. 
 
Data Analysis 
Quantitative data analysis 
The demographic characteristics of participants will be presented by using descriptive 
statistics; means, standard deviation (SD), or percentage, if appropriate. The 
demographical variables and outcome variables were compared between groups at 
baseline. Numerical variables will be analyzed by an independent t-test, and nominal 
variables will be analyzed by χ2. Supposing the data cannot satisfy the requirement of 
parametric analyses, the Mann-Whitney U tests will be performed to compare the scores 
obtained from the four Scale among intervention and control groups created according 
to demographic characteristics. Generalized estimated equations (GEE) will be used to 
analyze the effectiveness of the intervention at three-time points as compared with 
control group. The significance level will be set at P < 0.05, for a two-tailed test. SPSS 
26.0 of IBM will be used to analyze collected data (SPSS Inc., Chicago, IL, USA). 
Multiple imputations would be used to replace missing data if data missing is inevitable. 
 
Qualitative Content Analysis 
Manifest and latent content analysis will be adopted in this analysis. We will stop 
interview participants until data saturation is reached. NVivo 12 will be used to manage 
and organize qualitative data. There are five steps of the qualitative content analysis, 
which includes data preparing and organizing, reading and memoing, codes developing, 
generating categories, and representing the description and themes (Creswell, 2013). 
Issues of Trustworthiness of Data 
Qualitative validity requires the researcher use some procedures to examine the 
accuracy of the findings; while qualitative reliability requires the approach be consistent 
between different researchers and projects (Gibbs, 2018). Credibility, Dependability, 

 
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Transferability, and Confirmability are the four criteria in the trustworthiness of rigor 
qualitative studies (Lincoln & Guba, 1986). The quantitative data will be examined by 
two independent research assistants who will double-check the data collected to avoid 
data missing or inconsistency and ask the participants to reassure the data they provide 
if possible. 
 
Implications for the future research 
This research is an open-label, small sample size pilot study. Guided by the theories of 
transformative learning and KAB theory. Intervention in decreasing schizophrenia 
stigma among nursing students through the online intervention will be more flexible for 
participants under the COVID-19 pandemic or other inconvenient face-to-face 
situations. Our result will also inform other population groups in mainland China about 
the education and contact intervention to decrease stigma of different kinds of mental 
disorders. Thus, we anticipate this study can guide future full power RCTs in decreasing 
different kinds of mental disorders stigma. 
 
Research Schedule 
Time 
Research implement process 
July,2022-August,2022 
First phase focus group interview 
August 2022-October,2022 
Second phase Pilot RCT intervention 
October 2022-December,2022 
Second phase process evaluation 
January 2023-February,2022 
Data analysis 
March,2022-August,2023 
Thesis writing 
 
 
 

 
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Appendix 1 Activities of schizophrenia education and contact intervention 
Time 
Intervention group activities 
Control group activities 
Week 1 
-Week 
4 
investigative learning: nursing 
students to access information through 
evidence-based research to discover the 
information themselves. 
A guide outline will be used to help 
nursing students to search information, 
and this outline may add some more 
guidance when stage one is done. 
Nursing students will be asked relevant 
information during week one, and every 
two points will require one hour. 
Students will be asked to spend two 
hours every two days to search relevant 
information of schizophrenia. 
Collaborative learning activities 
Higher-order thinking activities 
interactive learning activities (Week 
1-Week 4) 
 
Week one: 1) Traditional Chinese culture and religion toward mental illness 
or schizophrenia.2) Reasons of schizophrenia stigma formation. 3)  
Diagnosis and treatment of schizophrenia. 4)  Violent, aggressiveness, and 
independence about schizophrenia. 5) How to communicate with people who 
have schizophrenia. 6) Daily stigma toward schizophrenia from media, like 
newspapers, TV series, movies, news, advertisement.  7) The early warning 
signs of schizophrenia and how to provide initial help to someone in a 
schizophrenia crisis and the symptoms, causes, and evidence-based 
treatments for schizophrenia. 
Summary: Knowledge and information sharing among students 
Week two: Nursing students interview people who recover from 
schizophrenia share their experiences throughout the treatment and recovery 
period and discuss problems with them (a female and a male). 
Summary: Knowledge and information sharing among students 
Week three:  
Scenario‐based simulation, in the simulation application, students took the 
roles of the persons with schizophrenia or the nurses, and evaluate their 
performance, and view the events from a different perspective. 
Summary: Knowledge and information sharing among students 
Week four: Nursing students’ self-criticism after scenario-based simulation, 
nursing students will be asked to write their opinion about schizophrenia and 
People with Schizophrenia. After that, nursing students were read their 
opinions and discussed their assumptions. Self‐reflection, critical reflection, 
and imaginative activities enabled them to examine themselves critically 
(Theme: What would I feel if I have schizophrenia). Nursing students 
prepared concept maps for the problems and solutions of a person with 
schizophrenia in the daily life.  
Giving a book about 
schizophrenia to 
nursing students in the 
control group and 
asking them to finish 
reading it in a month. 

 
14 
 
 
Appendix 2 Questioning route in the focus groups before pilot study 
1 
What do you know about Schizophrenia (SZ)? (Probe: causal factors, manifestation, prognosis; where you 
obtained such information? 
2 
What do you think the life of people with SZ? (Probe: social support> intimate relationship > education> working) 
3 
What’s your experiences of interacting with people with SZ and/or their family members, (if no personal 
encounter, any story you heard?) [When> what happened> who> what did you say> How do you feel>]. 
4 
What do you think of traditional Chinese culture and religion on schizophrenia? [How do Confucianism, 
Taoism, and Buddhism view and deal with schizophrenia> What do these religions think the reason of 
schizophrenia and how to deal with it] 
5 
What do you think of the pressure experienced by people with SZ compared with other mental illnesses? 
6 
How do you think the stigma often encountered by people with SZ? 
7 
What do you think of caring people with SZ in the future? 
 
 
 
 

 
15 
 
 
Appendix 3 Basic socio-demographic Information 
 
Age 
 
Gender 
Male                                                 Female 
Ethnic groups (Please fill in your 
nationality, such as Han, Miao, etc.) 
 
Marital status 
Married                                              unmarried 
Name of university (University 
name) 
 
 
Name of province 
 
Grade 
Year 4                                                    Year 5 

 
16 
 
Religion (Religion of belief such as 
Buddhism, Taoism, if not, fill in 
none) 
 
Average families income per year 
(Ten thousand yuan) 
 
Friends or family members with 
mental illness problem 
Yes                   No 
Have you been in contact with a 
People with Schizophrenia in the 
past 
Yes                   No 
Did you suffer from mental illness? 
Yes                   No 

 
17 
 
Have you participated in similar 
research before 
Yes                   No 
 
 
 
Appendix 4 Knowledge about Schizophrenia Test (KAST) 
1. Schizophrenia is most likely caused by: 
A. Brain problem 
B. Drug use 
C. Evil spirits 
D. Pollution 
E. Stress 
 

 
18 
 
2. A common symptom of schizophrenia is: 
A. Being overly happy and having extra energy 
B. Overeating and weight gain 
C. Sudden anxiety attacks 
D. Thinking that others are watching or following 
E. Violence, theft, or physical attacks toward others 
 
3. The best person to decide if someone has schizophrenia is a(n): 
A. Emergency room doctor 
B. Family member 
C. Preacher or Minister 
D. Psychiatrist 
E. School teacher 

 
19 
 
 
4. With treatment, the most common long-term outcome 
for schizophrenia is: 
A. Complete cure 
B. Dementia 
C. Mild to moderate mental retardation 
D. Relief of symptoms, with possibility of relapse 
E. Severe mental deterioration 
 
5. Medicines that are used for hearing voices are called: 
A. Antibiotics 
B. Anti-depressants 
C. Anti-psychotic 

 
20 
 
D. Sedatives 
E. Tranquilizers 
 
6. The best place to get information about schizophrenia is from: 
A. Books or websites 
B. Friends 
C. Neighbors 
D. Newspapers 
E. Preachers or ministers 
7. To help deal with stress, most patients with schizophrenia benefit from: 
A. Alcohol use 
B. Counseling or psychotherapy 
C. Cutting back on social activities 

 
21 
 
D. Pain-relief medications 
E. Physical therapy 
 
8. The cause of schizophrenia is most likely related to: 
A. Biology 
B. Environment 
C. Family 
D. Personality 
E. Society 
 
9. A person strongly believes that the FBI has put a computer chip in his/her body. This symptom is called a: 
A. Daydream 
B. Delusion 

 
22 
 
C. Hallucination 
D. Phobia 
E. Worry 
10. A doctor usually makes a diagnosis of schizophrenia by a(n): 
A. Blood test 
B. CAT scan 
C. Interview 
D. Reading test 
E. Urine test 
 
11. Most people who have schizophrenia need to be in some sort of treatment for: 
A. Days 
B. Weeks 

 
23 
 
C. Months 
D. Years 
E. Not at all 
 
12. The best treatment for the symptoms of schizophrenia is: 
A. Medicine 
B. Operation 
C. Relaxation 
D. Strict diet 
E. Vitamins 
 
13. People with Schizophrenia benefit most from: 
A. Being put into a hospital for years 

 
24 
 
B. Having fun or exercising 
C. Strict schedules with full-time employment 
D. Support from family/friends and low stress 
E. Vitamins, minerals, or herbs 
 
14. A 19-year-old begins to hear voices and act paranoid several months after graduating from high school. The most 
likely causes of his symptoms is: 
A. Drinking alcohol 
B. Genetic tendency toward developing an illness 
C. Graduating high school 
D. Personality weakness 
E. Puberty and adolescence 
 

 
25 
 
15. The symptoms of schizophrenia usually begin in which stage of life? 
A. As a baby 
B. Elementary school years 
C. Late teen-age years or young adulthood 
D. 40–50 years old 
E. 60–70 years old 
 
16. Which of the following is one of the new “atypical” medicines for schizophrenia? 
A. Chlorpromazine (Thorazine) 
B. Haloperidol (Haldol) 
C. Fluphenazine (Prolixin) 
D. Trifluoperazine (Stelazine) 
E. Quetiapine (Seroquel) 

 
26 
 
 
17. Which group is the best source of information and support for family members of People with Schizophrenia? 
A. American Medical Association (AMA) 
B. Association of Psychologists and Psychiatrists (APAP) 
C. Centers for Disease Control and Prevention (CDC) 
D. National Alliance for the Mentally Ill (NAMI) 
E. Schizophrenia Family Association (SFA) 
 
18. After hospitalization, a patient with schizophrenia would benefit most from: 
A. Constant observation by family 
B. Eating more meats and breads 
C. Follow-up with a preacher or minister 
D. Follow-up with an outpatient psychiatrist 

 
27 
 
E. Getting a full-time job and staying busy 
 
 
 
 
 
Appendix 5 Clinicians, attitudes to people with mental illness (healthcare students and professionals) 
Instruction: For each question of 1-16, please tick √ in the appropriate box. The mental illness (illness) referred to here 
refers to an illness that requires a visit to a psychiatrist. 
 
strongly 
agree 
agree 
somewhat 
agree 
somewhat 
disagree 
disagree 
strongly 
disagree 
1. I just learn about mental health when I have to and would not bother 
reading additional material on it.                     
 
 
 
 
 
 
2. People with severe mental illness can never recover enough to have 
a good quality of life. 
 
 
 
 
 
 
3. Working in the mental health field is just as respectable as other 
fields of health and social care                     
 
 
 
 
 
 
4. If I had a mental illness, I would never admit this to any of my friends 
because I would fear being treated differently 
 
 
 
 
 
 
5. People with mental illness are dangerous more often than not              
 
 
 
 
 
6. Health/social care staff know more about the lives of people treated 
for a mental illness than do family members and friends 
 
 
 
 
 
 
7.  If I had a mental illness, I would never admit this to any of my  
colleagues because I would fear being treated differently 
 
 
 
 
 
 

 
28 
 
Appendix 6 Reported and Intended Behaviour Scale（RIBS） 
Instructions: The following questions ask about your experiences and views in relation to people who have mental health problems (for example, 
people seen by healthcare staff), For each of questions1-4, please respond by taking one box only. 
 
Yes 
No 
Don’t 
know 
1. Are you currently living with, or have you ever lived with, someone with a mental health problem?                                
 
 
 
2. Are you currently working with, or have you ever worked with, someone with a mental health problem?                            
 
 
 
3. Do you currently have, or have you ever had, a neighbor with a mental health problem?                      
 
 
 
4.  Do you currently have, or have you ever had, a close friend with a mental health problem?       
 
 
 
Instructions: For each of the questions 5-8, please respond by ticking one box only. 
 
Agree 
strongly 
Agree 
slightly 
Neither agree 
nor disagree 
Disagree 
slightly 
Disagree 
strongly 
Don’t 
know 
5. In the future, I would be willing to live with someone with a mental 
health problem 
 
 
 
 
 
 
6. In the future, I would be willing to work with someone with a mental 
health problem 
 
 
 
 
 
 
7. In the future, I would be willing to live nearby to someone with a 
mental health problem 
 
 
 
 
 
 
8. . In the future, I would be willing to continue a relationship with a 
friend who developed a mental health problem 
 
 
 
 
 
 
Thank you very much for your help 
 

 
29 
 
Appendix 7 Jefferson Scale of Empathy-Health Profession Students 
Answer instructions: Please circle the answer that best suits your opinion according to the following questions. 
The evaluation method of each question adopts a 7-point method, 1 point means very disagree, 7 points means very agree 
1______ 2 ______ 3 ______ 4 ______ 5 ______ 6 ______ 7______ 
Strongly disagree                           strongly agree 
Items 
Item content 
1 
2 
3 
4 
5 
6 
7 
1 
My understanding of how my patients and their families feel does not influence medical or surgical treatment 
 
 
 
 
 
 
 
2 
My patients feel better when I understand their feelings. 
 
 
 
 
 
 
 
3 
It is difficult for me to view things from my patients’ perspectives. 
 
 
 
 
 
 
 
4 
consider understanding my patients’ body language as important as verbal communication in caregiver-patient relationships.  
 
 
 
 
 
 
5 
I have a good sense of humor that I think contributes to a better clinical outcome. 
 
 
 
 
 
 
 
6 
Because people are different, it is difficult for me to see things from my patients’ perspectives. 
 
 
 
 
 
 
 
7 
I try not to pay attention to my patients’ emotions in history taking or in asking about their physical health. 
 
 
 
 
 
 
 
8 
Attentiveness to my patients’ personal experiences does not influence treatment outcomes. 
 
 
 
 
 
 
 
9 
I try to imagine myself in my patients’ shoes when providing care to them. 
 
 
 
 
 
 
 
10 
My patients value my understanding of their feelings which is therapeutic in its own right. 
 
 
 
 
 
 
 
11 
Patients’ illnesses can be cured only by medical or surgical treatment; therefore, emotional ties to my patients do not have a 
significant influence on medical or surgical outcomes. 
 
 
 
 
 
 
 
12 
Asking patients about what is happening in their personal lives is not helpful in understanding their physical complaints. 
 
 
 
 
 
 
 
13 
I try to understand what is going on in my patients’ minds by paying attention to their non-verbal cues and body language. 
 
 
 
 
 
 
 

 
30 
 
14 
I believe that emotion has no place in the treatment of medical illness. 
 
 
 
 
 
 
 
15 
Empathy is a therapeutic skill without which success in treatment is limited. 
 
 
 
 
 
 
 
16 
An important component of the relationship with my patients is my understanding of their emotional status, as well as that of 
their families. 
 
 
 
 
 
 
 
17 
I try to think like my patients in order to render better care. 
 
 
 
 
 
 
 
18 
I do not allow myself to be influenced by strong personal bonds between my patients and their family members. 
 
 
 
 
 
 
 
19 
I do not enjoy reading non-medical literature or the arts. 
 
 
 
 
 
 
 
20 
I believe that empathy is an important therapeutic factor in medical or surgical treatment. 
 
 
 
 
 
 
 
Jefferson Scale of Physician Empathy 
Scoring Algorithm 
A respondent must answer at least 16 (80%) of the 20 items; otherwise, the form should be regarded as incomplete and excluded from the data 
analysis. 
In the case of a respondent with 4 or fewer unanswered items, missing values should be replaced with the mean score calculated from items 
completed by the respondent. 
To score the scale, items 1, 3, 6, 7, 8, 11, 12, 14, 18, and 19 are reverse scored items (i.e., Strongly Agree=1,…Strongly Disagree=7), while the 
other items are directly scored on their Likert weights (i.e., Strongly Agree=7,…Strongly Disagree=1). 
The total score is the sum of all item scores. 
The higher the score, the more empathic the behavioral orientation. 
 

 
31 
 
Appendix 8 Fidelity checklist 
Treatment fidelity strategies 
present 
absent but 
should be 
present 
not 
applicable 
Treatment design 
1.Provided information about treatment dose in the intervention condition 
 
Length of contact session(s) 
 
 
 
Number of contacts 
 
 
 
Content of treatment 
 
 
 
Duration of contact over time 
 
 
 
2.Provided information about treatment dose in the comparison condition 
 
Length of contact session(s) 
 
 
 
Number of contacts 
 
 
 
Content of treatment 
 
 
 
Duration of contact over time 
 
 
 
3. Mention of provider credentials 
 
 
 
4. Mention of a theoretical model or clinical guidelines on which the intervention is 
based 
 
 
 
Training providers 
 
1.Description of how providers were trained 
 
 
 
2.Standardized provider training 
 
 
 
3.Measured provider skill acquisition post-training 
 
 
 
4.Described how provider skills maintained over time 
 
 
 
Delivery of treatment 
 
1.Included method to ensure that the content of the intervention was being delivered 
 
 
 

 
32 
 
as specified (e.g., treatment manual, checklist, computer program) 
2．Included method to ensure that the dose of the intervention was being delivered 
as specified (e.g., records number of contact minutes. 
 
 
 
3. Included mechanism to assess if the provider actually adhered to the intervention 
plan (applies to human providers only?) (e.g., audiotape, observation, self-report of 
provider, exit interview with participant) 
 
 
 
4. Assessed nonspecific treatment effects 
 
 
 
5. Used treatment manual 
 
 
 
Receipt of treatment 
 
1.Assessed subject comprehension of the intervention during the intervention period 
 
 
 
2. Included a strategy to improve subject comprehension of the intervention above 
and beyond what is included in the intervention 
 
 
 
3. Assessed subject’s ability to perform the intervention skills during the intervention 
period 
 
 
 
4. Included a strategy to improve subject performance of intervention skills during 
the intervention period 
 
 
 
Enactment of treatment skills 
 
 
 
1. Assessed subject performance of the intervention skills assessed in settings in 
which the intervention might be applied 
 
 
 
2. Assessed strategy to improve subject performance of the intervention skills in 
settings in which the intervention might be applied 
 
 
 
 
 

 
33 
 
Appendix 9 Questioning route used in the focus groups 
1 
How do you evaluate the program？(The investigative learning，high-order thinking, and collaborative learning 
activities) [Which part do you like the most or which part you dislike the most, and why? ] 
2 
How do you comment on the ease of finish of the intervention? (The cost of time). Why do you think it is easy or 
difficult to adherence? >What do you think of the frequency of intervention and the duration of each 
intervention? >How often do you think is the best frequency and how long do you think is the best duration of 
intervention? ] 
3 
What do you think of online intervention? [What do you think of the effects of online intervention of these three 
interventions (investigative learning, higher-order thinking, and collaborative learning activities), and why?] 
3 
How would you evaluate the questionnaires that you completed in the study? [Are these questionnaires suitable for 
measuring schizophrenia knowledge, attitudes, behavior, empathy, and stigmatization intention behavior? Why? ] 
4 
Please describe how this intervention affects the ways you think of SZ. 
5 
What are your suggestions to improve the study design? 
6 
Is there anything else related to the study that has not been discussed?