Examining Workshops in Reducing Mental Illness Self and Social Stigma Among Asian Men in Vancouver, Canada: A Randomized Control Trial

Examining Workshops in Reducing Mental Illness Self and Social Stigma Among Asian Men in Vancouver, Canada: A Randomized Control Trial | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Article Examining Workshops in Reducing Mental Illness Self and Social Stigma Among Asian Men in Vancouver, Canada: A Randomized Control Trial Natasha Patel, Silvia Koso, Marina Morrow, Stephanie Bryson, Cindy Jiang, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3844198/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Asian men may be more susceptible to stigmatizing attitudes towards mental illness and treatment due to the gendered and cultural expectations created by society, compared to Asian women. This may result in an internalization of devaluing beliefs and discriminatory attitudes towards others affected by mental illness and can delay or prevent this population from seeking professional help. In this randomized control trial (RCT), data from 428 Asian men from Vancouver, Canada were used to examine Acceptance and Commitment Training (ACT), Contact-based Empowerment and Education (CEE), and ACT + CEE. Data were collected at pre-intervention, immediately post-intervention, 3 months post-intervention, and 6 months post-intervention using the ISMI and the CAMI scales to assess self and social stigma. Repeated measures ANOVA were performed to determine if there was a significant interaction between the intervention and multiple time points on ISMI and CAMI scores. Linear mixed effects models were performed on ISMI and CAMI composite scores to control for confounding. No significant differences in ISMI scores were seen across all time points for all interventions. Significant reduction in CAMI scores were seen for the CEE intervention up to 3 months, suggesting that effects of the intervention were short-lived. Biological sciences/Psychology Health sciences/Health care/Public health INTRODUCTION Mental illness is heavily associated with stigma and has been reported as one of the greatest barriers for those seeking help from healthcare professionals (1,2). Mental health stigma is defined as negative attitudes, such as shame or disapproval, towards those affected by mental illness or those seeking help (3). The internalization of stigma responses and prejudicial attitudes towards one’s self is known as self stigma and can result in negative behaviours and emotions (4,5). Studies have shown that factors such as ideologies, values, and beliefs shared by society can affect internalized stigma (6). The awareness of stigma’s presence in a society impacts an individual even without direct perpetrators as the fear of being labelled due to having a mental illness and due to seeking help causes internalization of stigma (7). Furthermore, these factors may invoke an emotional response from the affected individual such as anger, humiliation, or isolation (7). Social stigma, on the other hand, is defined as an identity that discredits an individual in society and involves discrimination, stereotyping, and status loss of the individual (8). Stigma may arise from stereotypes and prejudices, which are often negative and inaccurate generalizations towards individuals or groups (9). For example, individuals affected by depression may “lack motivation” or be viewed as “lazy” and “weak” (9). As stigma is ingrained in society, stereotypes and prejudices may not always occur consciously, resulting in unintentional shaping of behaviour towards stigmatized individuals (9). This often leads to discrimination, whereby certain individuals or groups are treated differently due to their status (10). The Asian population is at risk of developing stigma-associated mental illness due to factors such as the desire to avoid being judged by their community members, the fear of being discriminated by their family and community members, and the common belief that it may bring shame to themselves and their family (11)(12). Mental health stigma among the Asian population has led to an underutilization of mental health services due several factors. Studies in East Asia examining schizophrenia have shown that over 60% of family members hid relationships with those affected (13) and recognize the illness as a weakness rather than a brain condition (14). Similar trends are reported among other Asian groups. Studies conducted in Southeast Asia revealed that adults view individuals affected by mental illness as weak, high risk, and unpredictable (15), while 25% of youth believed mental illness to be nonexistent (16). In South Asian and Arabian countries, the belief that mental illness is caused by paranormal beings (17,18) and karma (19,20) affects people’s attitudes. Social stigma is a major concern in countries such as India as families worry that mental illness will result in a decreased likelihood of prospects such as employment and marriage (21). Moreover, studies from these countries have shown that individuals tend to somatize their symptoms to reduce potential negative attitudes from the public (22,23). Asian communities are affected by the gender roles created by society (24), whereby men are expected to be independent, successful, and in control of their emotions (25). Thus, Asian men perceive mental illness as an inability to meet masculinity standards and to provide for others (26), resulting in more stigmatizing attitudes towards mental illness than Asian women (27). The expectation to adhere to the masculine role of remaining strong and stoic makes it difficult for men to seek help, putting them at a higher risk of denying mental health concerns (28). There is limited evidence in the Canadian context on gender differences in mental health related stigma. One Canadian study found no gender differences in help-seeking attitudes among older Chinese participants (29). Another Canadian study found that racialized men, including Asians, in this had less positive attitudes and more stigmatizing attitudes than racialized women towards mental health services (30). As the Asian population represents many groups, each with its own language, religion, culture, and immigration history, it is vital for mental health professionals to be aware of the issues that arise with caring for this population. Recent Canadian reviews have highlighted that a majority of research focuses on women from racialized populations and that there is a gap regarding men’s experiences in seeking healthcare services (31,32). Due to the lack of data on gender differences and the ubiquitous nature of stigma, further research is needed to develop mental health services for these racialized populations and to foster Canada’s diversity (33). METHODS The Strengths in Unity (STiU) project is a community-based action research study that took place in three cities in Canada: Toronto, Metro Vancouver, and Calgary. The current study focused on data collected from Vancouver. Asian men were recruited using purposeful convenience and snowball sampling. Eligibility criteria included: a) self-identification as a male, b) 17 years or older at recruitment time, c) South, Southeast, or East Asian living in Metro Vancouver, d) able to speak and understand English (or Cantonese or Mandarin for Chinese cohorts), and e) living with mental illness OR living with a family member affected by mental illness OR a community member unaffected by mental illness but interested in reducing mental health stigma. Participants were randomized to one of the four interventions: ACT, CEE, ACT + CEE, or psychoeducation. Data related to self and social stigma were collected in the form of self-reported questionnaires before and immediately after interventions, as well as, 3 and 6 months post-intervention. All methods and procedures in this research were performed in accordance with the relevant guidelines and regulations. As declared in the Ethics Declaration section of this paper, all protocols were approved by the appropriate ethics committees. Additionally, written informed consent was obtained from all individual participants included in the study. Assent and parental consent were obtained for 17 year old participants. Interventions . Details of the interventions described below are further explained in the study protocol published by Guruge et al. (2018). ACT : The intervention was divided into three sessions for a total of 14 hours. The sessions focused on the six core processes of psychological flexibility: acceptance, cognitive defusion, present moment, self-as-context, values, and committed action. CEE The intervention was divided into four sessions for a total of 14 hours. The sessions focused on critical learning, health promotion, and collective empowerment. ACT + CEE A combination of ACT and CEE was used in this study due to potential synergistic effects. Participants attended seven sessions over the span of four weeks. Psychoeducation Participants in this control group received one 3-hour traditional lecture on mental health and illness, the stigma associated with mental health, and the principles of equity and justice. Outcome Measures. The outcomes, self and social stigma, were determined using the Internalized Stigma of Mental Illness (ISMI) and Community Attitude Towards Mental Illness (CAMI) scales, respectively. The ISMI scale was administered to participants who self-identified as having experience with mental illness. It was designed to determine the subjective measure of self stigma and contains 29 questions divided into five four-point Likert scales: alienation (“spoiled identity”), stereotype endorsement (identify with stereotypes), discrimination experience (perspective and treatment by others), social withdrawal (withdraw from engaging with others), and stigma resistance (resisting stigma) (34). The stigma resistance subscale is reverse-coded to serve as a validity check (34). A composite score was also created by calculating the average for all subscales, with a higher score indicating greater self stigma. As per previous research, this score excluded the stigma resistance subscale due to its weak psychometric properties (34–36). The Cronbach’s alpha for the ISMI composite score was ɑ = 0.95. The CAMI scale was designed to determine public stigmatizing attitudes towards individuals affected by mental illness. It contains 40 questions divided equally into four five-point Likert scales: authoritarianism (perspective that individuals with mental illness are less capable), social restrictiveness (perspective that individuals with mental illness are dangerous), benevolence (sympathetic perspectives towards individuals with mental illness), and community mental health ideology (importance of including individuals with mental illness in community) (37). Each CAMI subscale is composed of five positive statements and five negative statements (37). The positive statements were reverse-scored so that a higher score on this scale indicated greater stigma. The total score for each subscale was calculated by adding the score for each individual item for that subscale. An average was then calculated to determine the average participant score for each subscale. The composite score was calculated by adding the total scores from each subscale. Then, an average was calculated to determine the average overall participant score. The Cronbach’s alpha for the CAMI summative score was ɑ = 0.91. Statistical Analysis. We performed descriptive statistics on all sociodemographic characteristics collected in this study. For the purpose of this study, the Southeast Asian and Other subcategories under Asian ethnicity were combined due to the small number of participants in the Other (n = 10) subcategory, which would have resulted in an unstable test on its own. Repeated measures ANOVA was conducted to determine significant interaction between the intervention groups and time. Multiple pairwise t-tests were performed to determine differences between groups. Lastly, linear mixed effects models were performed on ISMI and CAMI composite scores to control for confounding. Objectives. In the study, we seeked to determine whether participation in ACT, CEE, or ACT + CEE effectively reduced self and social stigma, compared to participation in the psychoeducation group. We hypothesized that all interventions will be effective in reducing self and social stigma, as measured by ISMI and CAMI scores. Furthermore, ACT participation will be effective in reducing self stigma and CEE participation will be effective in reducing social stigma. Lastly, ACT + CEE participation will be effective in reducing self and social stigma. RESULTS A total of 428 participants enrolled in the study at baseline. Among these participants, 348 attended immediate post-intervention, 140 attended 3 months post-intervention, and 228 attended 6 months post-intervention. A majority of participants self-identified as East Asian, were between 25–55 years old, had immigrated to Canada, had undergraduate-level education, were single, and reported no direct experience with mental illness. Sociodemographic characteristics of study participants can be found in Table I, with more detailed information on characteristics found in a previous study (Table 1 ) (38). A total of 122 (28.5%) participants were randomized to the ACT intervention, 125 (29.2%) participants were randomized to the CEE intervention, 127 (29.7%) participants were randomized to the ACT + CEE intervention, and 54 (12.6%) participants were randomized to receive psychoeducation (control group). Table 1 Sociodemographic characteristics of study participants at baseline (Total = 428). Variables n (%) Age 17–24 years 132 (31.2) 25–55 years 211 (49.9) 56 + years 80 (18.9) Asian ethnicity East 211 (49.9) South 144 (34.0) Southeast/Other 68 (16.1) Country of birth Canada 93 (21.9) Other 332 (78.1) Time since immigration to Canada 5 or less years 99 (30.7) 6–10 years 51 (15.8) 11–20 years 74 (23.0) 20 + years 98 (30.4) Education High school or less 128 (30.0) Undergraduate 177 (41.5) Graduate 121 (28.4) Relationship status Partnered 175 (41.2) Single 250 (58.8) Employment status Employed 224 (52.3) Not employed 204 (47.7) Student status Student 154 (36.0) Not student 274 (64.0) Direct experience with mental illness Has a mental illness 94 (22.0) Has family member with mental illness 80 (18.7) None indicated 254 (59.3) Self stigma. A total of 231 participants completed the ISMI questionnaire as it was administered to only those that self-identified as having experience with mental illness. We analyzed the data to determine if there were any changes in self stigma immediately after the delivery of interventions, as well as, 3 months and 6 months after the interventions. Overall, the means across time points for each intervention were comparatively similar, suggesting that none of the interventions were effective in reducing self stigma (Table 2 ). Bivariate analyses consisting of repeated measures ANOVA did not reveal any significant differences in ISMI scores for the ACT and ACT + CEE interventions and the control group. Interestingly, participants randomized to the CEE intervention experienced a significant increase for the discrimination experience subscale at 3 months (M = 2.99, SD = 0.52) than at baseline (M = 2.26, SD = 0.63). The linear mixed effects model revealed no statistically significant association between the interventions and ISMI composite score. However, non significant results were seen among key independent variables. Compared to the control group, an overall decrease in self stigma was seen for the ACT + CEE intervention (β = -0.11, 95% CI = -0.37, 0.14) and the ACT intervention (β = -0.13, 95% CI = -0.39, 0.12), but not for the CEE intervention (β = 0.019, 95% CI = -0.24, 0.28). Overall, the model suggests that no interventions were effective in reducing self stigma over time. Table 2 ISMI means across interventions at each time point. ACT CEE ACT + CEE CTRL ISMI B (122) I (100) 3M (41) 6M (67) F B (125) I (101) 3M (37) 6M (68) F B (127) I (105) 3M (41) 6M (66) F B (54) I (42) 3M (21) 6M (27) F Mean (SD) Alienation 2.29 (0.67) 2.21 (0.76) 2.19 (0.71) 2.32 (0.88) 0.211 2.47 (0.68) 2.38 (0.57) 2.26 (0.76) 2.35 (0.73) 0.314 2.27 (0.62) 2.20 (0.50) 2.17 (0.55) 2.05 (0.69) 0.843 2.51 (0.52) 2.30 (0.56) 2.15 (0.53) 2.22 (0.50) 1.387 Stereotype Endorsement 1.91 (0.61) 1.90 (0.75) 2.02 (0.82) 1.91 (0.74) 0.16 2.04 (0.61) 1.96 (0.57) 2.01 (0.70) 1.87 (0.62) 0.441 1.84 (0.53) 1.87 (0.53) 1.98 (0.60) 1.84 (0.67) 0.319 1.81 (0.59) 1.75 (0.59) 1.60 (0.50) 1.84 (0.67) 0.359 Discrimination Experience 2.16 (0.66) 2.14 (0.73) 2.31 (0.69) 2.18 (0.69) 0.275 2.26 (0.63) 2.31 (0.70) 2.99 (0.52) 2.16 (0.69) 2.951 ✝ 2.17 (0.66) 2.20 (0.53) 2.20 (0.59) 2.04 (0.67) 0.433 2.07 (0.62) 2.21 (0.67) 2.11 (0.66) 2.23 (0.60) 0.212 Social Withdrawal 2.15 (0.67) 2.17 (0.78) 2.25 (0.79) 2.24 (0.84) 0.153 2.27 (0.73) 2.30 (0.66) 2.25 (0.73) 2.12 (0.69) 0.329 2.23 (0.65) 2.18 (0.51) 2.08 (0.57) 1.98 (0.72) 1.124 2.41 (0.56) 2.26 (0.60) 2.33 (0.66) 2.43 (0.44) 0.251 Total ISMI 2.11 (0.55) 2.10 (0.71) 2.24 (0.76) 2.16 (0.74) 0.223 2.25 (0.58) 2.22 (0.57) 2.38 (0.61) 2.16 (0.63) 0.295 2.12 (0.52) 2.11 (0.46) 2.10 (0.52) 1.97 (0.61) 0.569 2.20 (0.44) 2.12 (0.53) 2.03 (0.49) 2.18 (0.40) 0.306 ✝ p < 0.05 Higher score indicates greater stigma Social stigma. We analyzed the data to determine if there were any changes in social stigma immediately after the delivery of interventions, as well as, 3 months and 6 months after the interventions. Overall, the means across time points for the ACT + CEE and ACT interventions and the control group are comparatively similar, suggesting that these interventions were not effective in reducing social stigma (Table 3 ). However, a notable difference was seen for the CEE intervention between baseline and other time points. Bivariate analyses consisting of repeated measures ANOVA revealed that the CEE intervention was effective in reducing social stigma for all CAMI subscales at immediate and 3 months. However, only the social restrictiveness subscale was found to be significant at the 6 months follow up for the CEE intervention. The ACT and ACT + CEE interventions and the control group were not found to be effective in reducing social stigma. As the “direct experience with mental illness” category was found to be a confounder (Χ 2 = 14.156, p = 0.028), linear mixed effects models were used to control for this category. The linear mixed effects model revealed no statistically significant association between the ACT + CEE and ACT interventions and CAMI composite score. However, non-significant results revealed an overall decrease in social stigma scores for the ACT + CEE intervention (β = -2.99, 95% CI = -8.54, 2.58) and the ACT intervention (β = -1.13, 95% CI = -6.71, 4.54). The model also showed that participants scored lower, indicating less social stigma, over time after receiving the CEE intervention compared to the control group. On average, participants reported greater reductions in social stigma immediately after the CEE intervention (β = -6.55, 95% CI = -13.85, 0.73) than at the 3 months (β = -5.13, 95% CI = -14.61, 4.33) and 6 months (β = -0.04, 95% CI = -8.09, 7.98). Overall, the model did not yield any significant results; however, there was a suggestion that the CEE intervention in particular, may be associated with reduced social stigma. Table 3 CAMI means across interventions at each time point. ACT CEE ACT + CEE CTRL CAMI B (122) I (100) 3M (41) 6M (67) F B (125) I (101) 3M (37) 6M (68) F B (127) I (105) 3M (41) 6M (66) F B (54) I (42) 3M (21) 6M (27) F Mean (SD) Authoritarianism 24.02 (5.35) 23.00 (5.38) 22.56 (5.91) 22.40 (5.86) 1.589 23.82 (5.39) 21.11 (6.95) 21.24 (7.74) 22.40 (5.23) 4.111* 22.37 (5.53) 21.37 (4.90) 20.88 (5.63) 21.56 (6.03) 1.087 23.17 (4.87) 21.81 (5.08) 21.52 (4.95) 21.78 (4.75) 0.97 Benevolence 21.20 (5.16) 21.27 (5.27) 20.98 (5.09) 20.46 (5.11) 0.383 21.58 (5.05) 19.13 (6.70) 18.68 (7.20) 20.71 (4.96) 4.429* 20.20 (5.22) 20.50 (5.06) 20.10 (4.97) 20.61 (5.45) 0.154 21.19 (4.06) 20.60 (4.79) 19.48 (4.03) 20.00 (3.91) 0.997 Social Restrictiveness 22.02 (4.94) 22.08 (5.61) 22.15 (5.16) 21.10 (4.78) 0.626 22.99 (5.41) 19.91 (6.59) 19.22 (7.00) 21.18 (5.24) 6.728** 21.97 (5.42) 21.13 (5.02) 21.54 (5.31) 21.33 (5.33) 0.523 21.93 (4.24) 20.81 (5.34) 20.52 (4.91) 21.41 (5.27) 0.621 Community Mental Health Ideology 22.89 (5.39) 22.30 (5.68) 22.39 (6.20) 21.84 (5.73) 0.538 23.65 (6.05) 20.12 (6.95) 19.38 (7.92) 22.26 (5.41) 7.757** 22.58 (5.82) 21.45 (5.74) 21.59 (4.89) 22.12 (6.10) 0.474 23.22 (4.85) 22.14 (4.69) 22.05 (4.41) 22.67 (5.92) 0.488 Total CAMI 90.14 (17.65) 88.65 (18.82) 88.07 (19.58) 85.81 (18.88) 0.801 92.04 (19.14) 80.27 (24.79) 78.51 (28.10) 86.54 (18.17) 6.897** 87.12 (18.97) 84.46 (18.51) 84.10 (18.87) 85.62 (20.52) 0.475 89.50 (13.59) 85.36 (17.24) 83.57 (14.02) 85.85 (16.29) 1.03 * p < 0.05 ** p < 0.001 Higher scores indicate greater stigma DISCUSSION Self stigma. Results revealed that interventions were not effective in reducing internalized stigma. It is possible that the interventions did not yield significant results because the internalized stigma surrounding mental illness was so deeply rooted that it was not easily affected by the interventions and may require repeated contact. One potential reason may be due to religion and culture based on ancient belief systems that play a major role in stigma.(39). For example, Confucianism encourages individuals not to disclose their mental illness in order to maintain the family’s reputation (40). A study on Chinese immigrants suggested that individuals with stronger ties to cultural values and beliefs may exhibit less positive attitudes than individuals with weaker ties (29). Additionally, while the interventions do focus on participants’ experiences, patriarchal views towards mental illness may form internalized ideals of masculinity for Asian men (26), resulting in psychological inflexibility and a lack of understanding towards mental illness that is not easily improved by the interventions. Another potential explanation may be related to Metro Vancouver’s large minority population. As of 2016, 46.5% of Metro Vancouver’s population was of Asian origin (41). With a large percentage of the population identifying as Asian, it is possible that the communities the participants reside in resemble those of their home countries. Research has shown that Asians exposed to Western societies have lower levels of stigma and may be more willing to seek professional help (42); however, that exposure may be limited to participants residing in Vancouver. It may be possible that being surrounded by Asian communities constantly reinforces stereotypical attitudes and gendered expectations towards mental illness,deterring Asian men from seeking help. It is also possible that lack of Western influence led to unfamiliarity and hesitancy towards Western-based approaches (43), negatively affecting the effectiveness of the interventions in reducing mental health stigma. An especially surprising finding was that participants randomized to the ACT intervention did not report a reduction in self stigma scores; this was inconsistent with our hypothesis based on previous research (44). However, it is important to note that previous research mostly focused on students, while our current study includes individuals above 17 years of age. It is possible that ACT makes a greater impact on youth as they may be more receptive to such approaches, and encouraging help-seeking behaviours at a younger age may result in more positive attitudes extending into adulthood (45,46). As the current study does not examine age groups separately, further investigation would be needed to determine if ACT makes a greater impact on the younger population. Furthermore, a majority of studies examining ACT have not focused on the Asian population and more specifically, Asian men. ACT emphasizes acceptance and mindfulness strategies to engage the individual more with the present moment (47) and to be aware of themselves without judgment (48). This is in line with Buddhist practices (48) and thus, was interesting that the current study did not yield significant results as previous research has suggested ACT to be an effective intervention for the Asian population. The data published from the Toronto site included exploratory analyses of ethnicity and found that ACT had a greater impact on East Asians compared to other groups (49). The authors suggested that Buddhism is largely practiced in East Asian countries and therefore, East Asians may be more impressionable (49). While the current study did not find Asian ethnicity to be a confounder, further research may be needed to determine the impact of ACT on various Asian subgroups. It is important to note that we were unable to compare sites to determine if effects were present at the 3 month and 6 month follow up as data from the Toronto site only included immediate follow up. Further research is needed to determine whether a longer, sustainable intervention may be effective. Social stigma. Results revealed that the ACT, ACT + CEE, and psychoeducation interventions did not yield significant reductions in social stigma scores. However, in large part, our hypotheses were confirmed. Results revealed that Asian men randomized to the CEE intervention reported a significant decrease in social stigma, suggesting that the CEE intervention may have been the most effective intervention in reducing negative attitudes towards those with mental illness. This is consistent with findings from previous research (50). Data published from the Toronto site also revealed reduction in social stigma scores for a majority of CAMI subscales (49). It is important to note that the method used to calculate social stigma scores in Fung’s study differs from that used in the current study. Thus, a comparison of social stigma scores between sites may not be appropriate. Our findings revealed that while the CEE intervention was found to be the most effective intervention in reducing social stigma, its effects were not found to be significant at the 6 month follow up. This is also consistent with previous research (51,52) and suggests that repeated contact may be necessary to counter the effects of social stigma. The contact-based component in this intervention provided participants with the opportunity to gain a deeper understanding towards those affected by mental illness (53), while the empowerment component allowed for high group identification (54), leading to improved well-being and stigma. The CEE intervention in this study invited guest speakers of similar backgrounds to share their experience regarding stigma and its impact and how they addressed it. Participants in this study may have been encouraged to adjust their perspectives and behaviour towards those affected by mental illness. Moreover, hearing similar experiences may have helped participants acknowledge the societal demands placed on Asian men and its effect on seeking help. This may have resulted in reduced social stigma due to an established sense of empowerment and new ways to take action in the participants’ respective communities. STUDY LIMITATIONS AND STRENGTHS A limitation in this study may be the potential for selection bias. Asian men who chose to participate in this study may be different from Asian men who chose not to participate. It may be possible that men who chose to participate were more interested in the topic area (reducing stigma) compared to the rest of the population. Additionally, recruiting strategies involved purposeful convenience sampling and snowball sampling. As these were non-random sampling strategies, there may be a possibility that the sample was not entirely representative of the population, thus affecting the generalizability from the sample to the target population. Social desirability bias was also possible in this study. As both the ISMI and CAMI scales were self-reported questionnaires, participants may have answered questions in a manner that was viewed as favourable to others and what society considers as “good” behaviour. In an attempt to mitigate this bias, each participant had a unique identification label and were given privacy during survey completion, eliminating the need for any identifying information. Lastly, it is important to consider that the gender of the facilitator may have affected the results of the study. A female facilitator for a men’s study may have led to questions and uncertainty regarding her ability to understand men’s mental health experiences and deliver workshops. Men may have treated female facilitators differently than male facilitators and engaged in flirtatious behaviour or asked personal questions. Men also may have exhibited stereotypical behaviours such as remaining stoic and providing unemotional responses. However, it could have also been the case that men were more willing and comfortable to discuss mental health experiences with a female facilitator than a male facilitator. Despite these limitations, this study has demonstrated the effectiveness of three evidence-based anti-stigma interventions in reducing self and social stigma mental illness by using measures that have been accepted in previous research on people of various ethnic backgrounds. As the STiU project is the first study to target the effects of mental health stigma in Asian men living in Canada (55), its findings are crucial to contributing to the limited evidence in the Canadian context. Additionally, the large sample size will provide a smaller margin of error, representative results, and a derivation of accurate insights from the study. CONCLUSION In conclusion, our findings highlight the need of implementing interventions to reduce the mental health stigma among Asian men. Previous studies in Canada have found that a majority of research has focused on the experiences of immigrant women and limited studies have focused on immigrant men. The findings from this study may be important in addressing this gap and in facilitating efforts to advocate for change. This study provides evidence that the CEE intervention may be effective in reducing social stigma in Asian men. However, further research is needed to determine the effectiveness of the ACT intervention in reducing self stigma. It would also be worthwhile to determine whether residing in an area with a large percentage of the population identifying as Asian impacts the effectiveness of a Western approach to recovery. Nevertheless, this study may be crucial in the promotion of mental health and may encourage stigma reduction activities within this community. Declarations AUTHORS CONTRIBUTION STATEMENT N.P. analyzed and interpreted the data, and wrote the initial draft of the manuscript. S.K. supervised the project and contributed to manuscript submission. M.M. and S.B. designed and conducted the study, and contributed to manuscript revision. C.J. and R.L. revised the manuscript critically for important intellectual content. N.B.P.* designed and conducted the study, supervised the project, and contributed to manuscript revision. All authors read and approved the final manuscript. COMPETING INTERESTS The authors declare that they have no competing interests. ETHICS DECLARATION The original and current study was approved by the Research Ethics Board (REB) of Ryerson University, Simon Fraser University, University of British Columbia, and Vancouver Coastal Health. Written informed consent was obtained from all individual participants included in the study. FUNDING The original study received funding from Movember Canada under its Mental Health and Suicide Prevention Program. DATA AVAILABILITY The datasets analyzed in this study are kept safe and protected among the authors. Requests for access to the data can be directed to the corresponding author, subject to reasonable conditions. References Corrigan PW, Edwards AB, Green A, Diwan SL, Penn DL. Prejudice, social distance, and familiarity with mental illness. Schizophr Bull. 2001;27(2):219–25. Corrigan P. How stigma interferes with mental health care. Am Psychol. 2004 Oct;59(7):614–25. Stigma and Discrimination [Internet]. [cited 2022 Feb 20]. Available from: https://www.psychiatry.org/patients-families/stigma-and-discrimination Meta-analysis of stigma and mental health. Soc Sci Med. 2007 Jul 1;65(2):245–61. Corrigan PW, Watson AC. The Paradox of Self-Stigma and Mental Illness [Internet]. Vol. 9, Clinical Psychology: Science and Practice. 2006. p. 35–53. Available from: http://dx.doi.org/10.1093/clipsy.9.1.35 Corrigan PW, Markowitz FE, Watson AC. Structural levels of mental illness stigma and discrimination. Schizophr Bull. 2004;30(3):481–91. Corrigan PW. How clinical diagnosis might exacerbate the stigma of mental illness. Soc Work. 2007 Jan;52(1):31–9. Link BG, Phelan JC. Conceptualizing Stigma [Internet]. Vol. 27, Annual Review of Sociology. 2001. p. 363–85. Available from: http://dx.doi.org/10.1146/annurev.soc.27.1.363 Sickel, A.E., Seacat, J.D., & Nabors, N.A. Mental health stigma update: A review of consequences. Advances in Mental Health. 2014 Nov 2;12(3):202–15. Major B, O’Brien LT. The social psychology of stigma. Annu Rev Psychol [Internet]. 2005 [cited 2021 Jan 12];56. Available from: https://pubmed.ncbi.nlm.nih.gov/15709941/ Wood J, Bruce Newbold K. Provider Perspectives on Barriers and Strategies for Achieving Culturally Sensitive Mental Health Services for Immigrants: A Hamilton, Ontario Case Study [Internet]. Journal of International Migration and Integration. 2011. Available from: http://dx.doi.org/10.1007/s12134-011-0215-3 Guzder J, Yohannes S, Zelkowitz P. Helpseeking of immigrant and native born parents: a qualitative study from a montreal child day hospital. J Can Acad Child Adolesc Psychiatry. 2013 Nov;22(4):275–81. Stigmatizing experience and structural discrimination associated with the treatment of schizophrenia in Hong Kong. Soc Sci Med. 2006 Apr 1;62(7):1685–96. Tateyama M, Asai M, Hashimoto M, Bartels M, Kasper S. Transcultural Study of Schizophrenic Delusions. PSP. 1998;31(2):59–68. Subramaniam M, Abdin E, Picco L, Pang S, Shafie S, Vaingankar JA, et al. Stigma towards people with mental disorders and its components - a perspective from multi-ethnic Singapore. Epidemiol Psychiatr Sci. 2017 Aug;26(4):371–82. Pang S, Liu J, Mahesh M, Chua BY, Shahwan S, Lee SP, et al. Stigma among Singaporean youth: a cross-sectional study on adolescent attitudes towards serious mental illness and social tolerance in a multiethnic population. BMJ Open. 2017 Oct 1;7(10):e016432. Charles H, Manoranjitham SD, Jacob KS. Stigma and explanatory models among people with schizophrenia and their relatives in Vellore, south India. Int J Soc Psychiatry. 2007 Jul;53(4):325–32. Dardas LA, Simmons LA. The stigma of mental illness in Arab families: a concept analysis. J Psychiatr Ment Health Nurs. 2015 Nov;22(9):668–79. M FEI. Arab culture and mental health care. Transcult Psychiatry [Internet]. 2008 Dec [cited 2021 Jan 16];45(4). Available from: https://pubmed.ncbi.nlm.nih.gov/19091731/ Kohrt BA, Hruschka DJ. Nepali concepts of psychological trauma: the role of idioms of distress, ethnopsychology and ethnophysiology in alleviating suffering and preventing stigma. Cult Med Psychiatry [Internet]. 2010 Jun [cited 2021 Jan 16];34(2). Available from: https://pubmed.ncbi.nlm.nih.gov/20309724/ Salve H, Goswami K, Sagar R, Nongkynrih B, Sreenivas V. Perception and Attitude towards Mental Illness in an Urban Community in South Delhi - A Community Based Study. Indian J Psychol Med [Internet]. 2013 Apr [cited 2021 Jan 16];35(2). Available from: https://pubmed.ncbi.nlm.nih.gov/24049226/ Raguram R, Raghu TM, Vounatsou P, Weiss MG. Schizophrenia and the cultural epidemiology of stigma in Bangalore, India. J Nerv Ment Dis [Internet]. 2004 Nov [cited 2021 Jan 16];192(11). Available from: https://pubmed.ncbi.nlm.nih.gov/15505517/ Al-Krenawi A. Mental health practice in Arab countries. Curr Opin Psychiatry. 2005 Sep;18(5):560. Vogel DL, Heimerdinger-Edwards SR, Hammer JH, Hubbard A. “Boys don’t cry”: Examination of the links between endorsement of masculine norms, self-stigma, and help-seeking attitudes for men from diverse backgrounds [Internet]. Vol. 58, Journal of Counseling Psychology. 2011. p. 368–82. Available from: http://dx.doi.org/10.1037/a0023688 Mansfield, A.K., Addis, M.E., & Mahalik, J.R. “Why Won’t He Go to the Doctor?”: The Psychology of Men’s Help Seeking. International Journal of Men’s Health. 2003;2(2):93–109. Weiss MG, Jadhav S, Raguram R, Vounatsou P, Littlewood R. Psychiatric stigma across cultures: Local validation in Bangalore and London [Internet]. Vol. 8, Anthropology & Medicine. 2001. p. 71–87. Available from: http://dx.doi.org/10.1080/13648470120063906 Lauber C, Rössler W. Stigma towards people with mental illness in developing countries in Asia. Int Rev Psychiatry. 2007 Apr;19(2):157–78. Yim JY. “Being an Asian American Male is Really Hard Actually”: Cultural Psychology of Asian American Masculinities and Psychological Well-Being [Internet]. 2009 [cited 2021 Jan 14]. Available from: https://www.semanticscholar.org/paper/%22Being-an-Asian-American-Male-is-Really-Hard-of-and-Yim/7fdfa8f76a4a4e8985e7077316767e4e0d329956 Tieu Y, Konnert CA. Mental health help-seeking attitudes, utilization, and intentions among older Chinese immigrants in Canada. Aging Ment Health. 2014 Mar;18(2):140–7. Lal RJ. How Do the Attitudes and Beliefs Towards Mental Health- Seeking Behaviour Differ Between Racialized and Non-Racialized Students in a University Environment? [Internet]. 2020 [cited 2021 Apr 26]. Available from: https://yorkspace.library.yorku.ca/xmlui/handle/10315/37414 Kalich A, Heinemann L, Ghahari S. A Scoping Review of Immigrant Experience of Health Care Access Barriers in Canada. J Immigr Minor Health. 2016 Jun;18(3):697–709. Ahmed S, Shommu NS, Rumana N, Barron GRS, Wicklum S, Turin TC. Barriers to Access of Primary Healthcare by Immigrant Populations in Canada: A Literature Review [Internet]. Vol. 18, Journal of Immigrant and Minority Health. 2016. p. 1522–40. Available from: http://dx.doi.org/10.1007/s10903-015-0276-z McKenzie K, Agic B, Tuck A, Antwi, M. The Case for Diversity: Building the Case to Improve Mental Health Services for Immigrant, Refugee, Ethno-cultural and Racialized Populations [Internet]. 2016 [cited 2020 Aug 14]. Available from: https://www.mentalhealthcommission.ca/sites/default/files/2016-10/case_for_diversity_oct_2016_eng.pdf Ritsher JB, Otilingam PG, Grajales M. Internalized stigma of mental illness: psychometric properties of a new measure. Psychiatry Res. 2003 Nov 1;121(1):31–49. Chang CC, Wu TH, Chen CY, Wang JD, Lin CY. Psychometric Evaluation of the Internalized Stigma of Mental Illness Scale for Patients with Mental Illnesses: Measurement Invariance across Time. PLoS One [Internet]. 2014 [cited 2021 Nov 14];9(6). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4041772/ Tanabe Y, Hayashi K, Ideno Y. The Internalized Stigma of Mental Illness (ISMI) scale: validation of the Japanese version. BMC Psychiatry [Internet]. 2016 [cited 2021 Nov 14];16. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4850681/ Taylor SM, Dear MJ. Scaling community attitudes toward the mentally ill. Schizophr Bull. 1981;7(2):225–40. Livingston J, Patel N, Bryson S, Hoong P, Lal R, Morrow M, et al. Stigma associated with mental illness among Asian men in Vancouver, Canada. Int J Soc Psychiatry. 2018 Nov;64(7):679–89. Lam C, Tsang H, Corrigan P, Lee YT, Angell B, Shi K, et al. Chinese Lay Theory and Mental Illness Stigma: Implications for Research and Practices. 2010 [cited 2022 Jan 24]; Available from: https://www.semanticscholar.org/paper/Chinese-Lay-Theory-and-Mental-Illness-Stigma%3A-for-Lam-Tsang/b30375ac47f63eebb21f3e6172e91726f1fa6911 Lv Y, Wolf A, Wang X. Experienced stigma and self-stigma in Chinese patients with schizophrenia. Gen Hosp Psychiatry. 2013 Jan;35(1):83–8. Statistics Canada. Census Profile, 2016 Census - Vancouver [Census metropolitan area], British Columbia and British Columbia [Province] [Internet]. 2017 [cited 2021 Mar 8]. Available from: https://www12.statcan.gc.ca/census-recensement/2016/dp-pd/prof/details/page.cfm?Lang=E&Geo1=CMACA&Code1=933&Geo2=PR& ;Code2=59&SearchText=vancouver&SearchType=Begins& SearchPR=01&B1=Ethnic%20origin&TABID=1&type=1 Chen SX, Mak WWS. Seeking professional help: Etiology beliefs about mental illness across cultures. J Couns Psychol. 2008 Oct;55(4):442–50. Yang LH, Phelan JC, Link BG. Stigma and beliefs of efficacy towards traditional Chinese medicine and Western psychiatric treatment among Chinese-Americans. Cultur Divers Ethnic Minor Psychol. 2008 Jan;14(1):10–8. Masuda A, Hayes SC, Lillis J, Bunting K, Herbst SA, Fletcher LB. The Relation between Psychological Flexibility and Mental Health Stigma in Acceptance and Commitment Therapy: A Preliminary Process Investigation [Internet]. Vol. 18, Behavior and Social Issues. 2009. p. 25–40. Available from: http://dx.doi.org/10.5210/bsi.v18i1.2525 Chen SP, Koller M, Krupa T, Stuart H. Contact in the Classroom: Developing a Program Model for Youth Mental Health Contact-Based Anti-stigma Education. Community Ment Health J. 2016 Apr;52(3):281–93. Kenny A, Bizumic B. Learn and ACT: Changing prejudice towards people with mental illness using stigma reduction interventions [Internet]. Vol. 5, Journal of Contextual Behavioral Science. 2016. p. 178–85. Available from: http://dx.doi.org/10.1016/j.jcbs.2016.06.004 Hayes SC, Luoma JB, Bond FW, Masuda A, Lillis J. Acceptance and Commitment Therapy: Model, processes and outcomes [Internet]. Vol. 44, Behaviour Research and Therapy. 2006. p. 1–25. Available from: http://dx.doi.org/10.1016/j.brat.2005.06.006 Fung K. Acceptance and Commitment Therapy: Western adoption of Buddhist tenets? Transcult Psychiatry. 2015 Aug;52(4):561–76. Fung K, Liu JJW, Sin R, Shakya Y, Guruge S, Bender A, et al. Examining Different Strategies for Stigma Reduction and Mental Health Promotion in Asian Men in Toronto. Community Ment Health J [Internet]. 2020 Oct 19; Available from: http://dx.doi.org/10.1007/s10597-020-00723-3 Wong EC, Collins RL, Cerully JL, Yu JW, Seelam R. Effects of contact-based mental illness stigma reduction programs: age, gender, and Asian, Latino, and White American differences. Soc Psychiatry Psychiatr Epidemiol. 2018 Mar;53(3):299–308. Corrigan P, Michaels PJ, Morris S. Do the effects of antistigma programs persist over time? Findings from a meta-analysis. Psychiatr Serv. 2015 May 1;66(5):543–6. Yamaguchi S, Wu SI, Biswas M, Yate M, Aoki Y, Barley EA, et al. Effects of short-term interventions to reduce mental health-related stigma in university or college students: a systematic review. J Nerv Ment Dis [Internet]. 2013 Jun [cited 2022 Jan 30];201(6). Available from: https://pubmed.ncbi.nlm.nih.gov/23719324/ Chan JYN, Mak WWS, Law LSC. Combining education and video-based contact to reduce stigma of mental illness: “The Same or Not the Same” anti-stigma program for secondary schools in Hong Kong. Soc Sci Med. 2009 Apr;68(8):1521–6. Rüsch N, Angermeyer MC, Corrigan PW. Mental illness stigma: concepts, consequences, and initiatives to reduce stigma. Eur Psychiatry. 2005 Dec;20(8):529–39. Guruge S, Fung KPL, Sidani S, Este D, Morrow M, McKenzie K, et al. Study protocol: Mobilizing Asian men in Canada to reduce stigma of mental illness. Contemp Clin Trials. 2018 Aug;71:133–9. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3844198","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Article","associatedPublications":[],"authors":[{"id":269948227,"identity":"bb6904ef-8292-4971-867e-da54d45d675c","order_by":0,"name":"Natasha Patel","email":"","orcid":"","institution":"University of Lethbridge","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Natasha","middleName":"","lastName":"Patel","suffix":""},{"id":269948228,"identity":"4755cead-b678-4af6-8e62-2a1bb53dffae","order_by":1,"name":"Silvia Koso","email":"","orcid":"","institution":"University of Lethbridge","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Silvia","middleName":"","lastName":"Koso","suffix":""},{"id":269948229,"identity":"ca45d68e-95ef-4350-8a5d-e1829948f76e","order_by":2,"name":"Marina Morrow","email":"","orcid":"","institution":"York University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Marina","middleName":"","lastName":"Morrow","suffix":""},{"id":269948230,"identity":"fa27f871-5fbe-448a-b003-006ad32055e3","order_by":3,"name":"Stephanie Bryson","email":"","orcid":"","institution":"Portland State University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Stephanie","middleName":"","lastName":"Bryson","suffix":""},{"id":269948231,"identity":"cfa60efa-51d8-4f7a-bcf9-dc9c517e077a","order_by":4,"name":"Cindy Jiang","email":"","orcid":"","institution":"York University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Cindy","middleName":"","lastName":"Jiang","suffix":""},{"id":269948232,"identity":"a12c7bd7-a75a-475e-b944-16456f6c4fa8","order_by":5,"name":"Rodrick Lal","email":"","orcid":"","institution":"York University","correspondingAuthor":false,"submittingAuthor":false,"prefix":"","firstName":"Rodrick","middleName":"","lastName":"Lal","suffix":""},{"id":269948233,"identity":"7ead5774-d5aa-40a3-81f3-390b0cea9b66","order_by":6,"name":"Nimesh B. Patel","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA80lEQVRIiWNgGAWjYDACZiBmbAAzGQ98YLBgYJAgWgsbA8PBGUD1PAS1MCBpOcxDjBZzdu7Ehz93MOTxz28+cNi2TULOXrqB8cMPPFosm3k3G/OeYSiWOMaWcDi3TcKYR+YAs2QPHi0Gh3m3STO2MSQ2HOMxAGlJ7JFIYGPgwa9l+8+fQC3zj/F/OGzZJlEP0sL4h4AtDLxALRuO8TAcZmyTSOABamEmYMtmad42iWLDY2kGB3vOSRj23EhslpbBp+X82Y0ff7bZ5MkdPvzwwY8yG3n2GckHP77BowUKJBKQONDEQAgkEFQxCkbBKBgFIxcAAJ2BSlZJKAxdAAAAAElFTkSuQmCC","orcid":"","institution":"University of Lethbridge","correspondingAuthor":true,"submittingAuthor":false,"prefix":"","firstName":"Nimesh","middleName":"B.","lastName":"Patel","suffix":""}],"badges":[],"createdAt":"2024-01-08 01:44:11","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3844198/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3844198/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":73821575,"identity":"94374577-f855-4750-85d8-f5a03a05c367","added_by":"auto","created_at":"2025-01-15 04:31:34","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":602726,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3844198/v1/00e5c832-d092-43d5-8cc6-0f86dbc565fa.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eExamining Workshops in Reducing Mental Illness Self and Social Stigma Among Asian Men in Vancouver, Canada: A Randomized Control Trial\u003c/p\u003e","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eMental illness is heavily associated with stigma and has been reported as one of the greatest barriers for those seeking help from healthcare professionals (1,2). Mental health stigma is defined as negative attitudes, such as shame or disapproval, towards those affected by mental illness or those seeking help (3). The internalization of stigma responses and prejudicial attitudes towards one\u0026rsquo;s self is known as self stigma and can result in negative behaviours and emotions (4,5). Studies have shown that factors such as ideologies, values, and beliefs shared by society can affect internalized stigma (6). The awareness of stigma\u0026rsquo;s presence in a society impacts an individual even without direct perpetrators as the fear of being labelled due to having a mental illness and due to seeking help causes internalization of stigma (7). Furthermore, these factors may invoke an emotional response from the affected individual such as anger, humiliation, or isolation (7). Social stigma, on the other hand, is defined as an identity that discredits an individual in society and involves discrimination, stereotyping, and status loss of the individual (8). Stigma may arise from stereotypes and prejudices, which are often negative and inaccurate generalizations towards individuals or groups (9). For example, individuals affected by depression may \u0026ldquo;lack motivation\u0026rdquo; or be viewed as \u0026ldquo;lazy\u0026rdquo; and \u0026ldquo;weak\u0026rdquo; (9). As stigma is ingrained in society, stereotypes and prejudices may not always occur consciously, resulting in unintentional shaping of behaviour towards stigmatized individuals (9). This often leads to discrimination, whereby certain individuals or groups are treated differently due to their status (10).\u003c/p\u003e \u003cp\u003eThe Asian population is at risk of developing stigma-associated mental illness due to factors such as the desire to avoid being judged by their community members, the fear of being discriminated by their family and community members, and the common belief that it may bring shame to themselves and their family (11)(12). Mental health stigma among the Asian population has led to an underutilization of mental health services due several factors. Studies in East Asia examining schizophrenia have shown that over 60% of family members hid relationships with those affected (13) and recognize the illness as a weakness rather than a brain condition (14). Similar trends are reported among other Asian groups. Studies conducted in Southeast Asia revealed that adults view individuals affected by mental illness as weak, high risk, and unpredictable (15), while 25% of youth believed mental illness to be nonexistent (16). In South Asian and Arabian countries, the belief that mental illness is caused by paranormal beings (17,18) and karma (19,20) affects people\u0026rsquo;s attitudes. Social stigma is a major concern in countries such as India as families worry that mental illness will result in a decreased likelihood of prospects such as employment and marriage (21). Moreover, studies from these countries have shown that individuals tend to somatize their symptoms to reduce potential negative attitudes from the public (22,23).\u003c/p\u003e \u003cp\u003eAsian communities are affected by the gender roles created by society (24), whereby men are expected to be independent, successful, and in control of their emotions (25). Thus, Asian men perceive mental illness as an inability to meet masculinity standards and to provide for others (26), resulting in more stigmatizing attitudes towards mental illness than Asian women (27). The expectation to adhere to the masculine role of remaining strong and stoic makes it difficult for men to seek help, putting them at a higher risk of denying mental health concerns (28). There is limited evidence in the Canadian context on gender differences in mental health related stigma. One Canadian study found no gender differences in help-seeking attitudes among older Chinese participants (29). Another Canadian study found that racialized men, including Asians, in this had less positive attitudes and more stigmatizing attitudes than racialized women towards mental health services (30). As the Asian population represents many groups, each with its own language, religion, culture, and immigration history, it is vital for mental health professionals to be aware of the issues that arise with caring for this population. Recent Canadian reviews have highlighted that a majority of research focuses on women from racialized populations and that there is a gap regarding men\u0026rsquo;s experiences in seeking healthcare services (31,32). Due to the lack of data on gender differences and the ubiquitous nature of stigma, further research is needed to develop mental health services for these racialized populations and to foster Canada\u0026rsquo;s diversity (33).\u003c/p\u003e"},{"header":"METHODS","content":"\u003cp\u003eThe Strengths in Unity (STiU) project is a community-based action research study that took place in three cities in Canada: Toronto, Metro Vancouver, and Calgary. The current study focused on data collected from Vancouver. Asian men were recruited using purposeful convenience and snowball sampling. Eligibility criteria included: a) self-identification as a male, b) 17 years or older at recruitment time, c) South, Southeast, or East Asian living in Metro Vancouver, d) able to speak and understand English (or Cantonese or Mandarin for Chinese cohorts), and e) living with mental illness OR living with a family member affected by mental illness OR a community member unaffected by mental illness but interested in reducing mental health stigma. Participants were randomized to one of the four interventions: ACT, CEE, ACT\u0026thinsp;+\u0026thinsp;CEE, or psychoeducation. Data related to self and social stigma were collected in the form of self-reported questionnaires before and immediately after interventions, as well as, 3 and 6 months post-intervention. All methods and procedures in this research were performed in accordance with the relevant guidelines and regulations. As declared in the Ethics Declaration section of this paper, all protocols were approved by the appropriate ethics committees. Additionally, written informed consent was obtained from all individual participants included in the study. Assent and parental consent were obtained for 17 year old participants.\u003c/p\u003e \u003cp\u003e \u003cb\u003eInterventions\u003c/b\u003e.\u003c/p\u003e \u003cp\u003eDetails of the interventions described below are further explained in the study protocol published by Guruge et al. (2018).\u003c/p\u003e \u003cp\u003e \u003cem\u003eACT\u003c/em\u003e: The intervention was divided into three sessions for a total of 14 hours. The sessions focused on the six core processes of psychological flexibility: acceptance, cognitive defusion, present moment, self-as-context, values, and committed action.\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eCEE\u003c/strong\u003e \u003cp\u003eThe intervention was divided into four sessions for a total of 14 hours. The sessions focused on critical learning, health promotion, and collective empowerment.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eACT\u0026thinsp;+\u0026thinsp;CEE\u003c/strong\u003e \u003cp\u003eA combination of \u003cem\u003eACT\u003c/em\u003e and \u003cem\u003eCEE\u003c/em\u003e was used in this study due to potential synergistic effects. Participants attended seven sessions over the span of four weeks.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003ePsychoeducation\u003c/strong\u003e \u003cp\u003eParticipants in this control group received one 3-hour traditional lecture on mental health and illness, the stigma associated with mental health, and the principles of equity and justice.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eOutcome Measures.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eThe outcomes, self and social stigma, were determined using the Internalized Stigma of Mental Illness (ISMI) and Community Attitude Towards Mental Illness (CAMI) scales, respectively. The ISMI scale was administered to participants who self-identified as having experience with mental illness. It was designed to determine the subjective measure of self stigma and contains 29 questions divided into five four-point Likert scales: alienation (\u0026ldquo;spoiled identity\u0026rdquo;), stereotype endorsement (identify with stereotypes), discrimination experience (perspective and treatment by others), social withdrawal (withdraw from engaging with others), and stigma resistance (resisting stigma) (34). The stigma resistance subscale is reverse-coded to serve as a validity check (34). A composite score was also created by calculating the average for all subscales, with a higher score indicating greater self stigma. As per previous research, this score excluded the stigma resistance subscale due to its weak psychometric properties (34\u0026ndash;36). The Cronbach\u0026rsquo;s alpha for the ISMI composite score was ɑ = 0.95.\u003c/p\u003e \u003cp\u003eThe CAMI scale was designed to determine public stigmatizing attitudes towards individuals affected by mental illness. It contains 40 questions divided equally into four five-point Likert scales: authoritarianism (perspective that individuals with mental illness are less capable), social restrictiveness (perspective that individuals with mental illness are dangerous), benevolence (sympathetic perspectives towards individuals with mental illness), and community mental health ideology (importance of including individuals with mental illness in community) (37). Each CAMI subscale is composed of five positive statements and five negative statements (37). The positive statements were reverse-scored so that a higher score on this scale indicated greater stigma. The total score for each subscale was calculated by adding the score for each individual item for that subscale. An average was then calculated to determine the average participant score for each subscale. The composite score was calculated by adding the total scores from each subscale. Then, an average was calculated to determine the average overall participant score. The Cronbach\u0026rsquo;s alpha for the CAMI summative score was ɑ = 0.91.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis.\u003c/h2\u003e \u003cp\u003eWe performed descriptive statistics on all sociodemographic characteristics collected in this study. For the purpose of this study, the Southeast Asian and Other subcategories under Asian ethnicity were combined due to the small number of participants in the Other (n\u0026thinsp;=\u0026thinsp;10) subcategory, which would have resulted in an unstable test on its own. Repeated measures ANOVA was conducted to determine significant interaction between the intervention groups and time. Multiple pairwise t-tests were performed to determine differences between groups. Lastly, linear mixed effects models were performed on ISMI and CAMI composite scores to control for confounding.\u003c/p\u003e \u003cp\u003e \u003cb\u003eObjectives.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eIn the study, we seeked to determine whether participation in ACT, CEE, or ACT\u0026thinsp;+\u0026thinsp;CEE effectively reduced self and social stigma, compared to participation in the psychoeducation group. We hypothesized that all interventions will be effective in reducing self and social stigma, as measured by ISMI and CAMI scores. Furthermore, ACT participation will be effective in reducing self stigma and CEE participation will be effective in reducing social stigma. Lastly, ACT\u0026thinsp;+\u0026thinsp;CEE participation will be effective in reducing self and social stigma.\u003c/p\u003e \u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eA total of 428 participants enrolled in the study at baseline. Among these participants, 348 attended immediate post-intervention, 140 attended 3 months post-intervention, and 228 attended 6 months post-intervention. A majority of participants self-identified as East Asian, were between 25\u0026ndash;55 years old, had immigrated to Canada, had undergraduate-level education, were single, and reported no direct experience with mental illness. Sociodemographic characteristics of study participants can be found in Table I, with more detailed information on characteristics found in a previous study (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) (38). A total of 122 (28.5%) participants were randomized to the ACT intervention, 125 (29.2%) participants were randomized to the CEE intervention, 127 (29.7%) participants were randomized to the ACT\u0026thinsp;+\u0026thinsp;CEE intervention, and 54 (12.6%) participants were randomized to receive psychoeducation (control group).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSociodemographic characteristics of study participants at baseline (Total\u0026thinsp;=\u0026thinsp;428).\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eVariables n (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eAge\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e17\u0026ndash;24 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e132 (31.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e25\u0026ndash;55 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e211 (49.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e56\u0026thinsp;+\u0026thinsp;years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e80 (18.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eAsian ethnicity\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEast\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e211 (49.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSouth\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e144 (34.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSoutheast/Other\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e68 (16.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eCountry of birth\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCanada\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e93 (21.9)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e332 (78.1)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eTime since immigration to Canada\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5 or less years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e99 (30.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u0026ndash;10 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51 (15.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u0026ndash;20 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e74 (23.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e20\u0026thinsp;+\u0026thinsp;years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e98 (30.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eEducation\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHigh school or less\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e128 (30.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eUndergraduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e177 (41.5)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGraduate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e121 (28.4)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eRelationship status\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePartnered\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e175 (41.2)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSingle\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e250 (58.8)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eEmployment status\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eEmployed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e224 (52.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot employed\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e204 (47.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eStudent status\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStudent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e154 (36.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNot student\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e274 (64.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003e\u003cem\u003eDirect experience with mental illness\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHas a mental illness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e94 (22.0)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHas family member with mental illness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e80 (18.7)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNone indicated\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e254 (59.3)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eSelf stigma.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eA total of 231 participants completed the ISMI questionnaire as it was administered to only those that self-identified as having experience with mental illness. We analyzed the data to determine if there were any changes in self stigma immediately after the delivery of interventions, as well as, 3 months and 6 months after the interventions. Overall, the means across time points for each intervention were comparatively similar, suggesting that none of the interventions were effective in reducing self stigma (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Bivariate analyses consisting of repeated measures ANOVA did not reveal any significant differences in ISMI scores for the ACT and ACT\u0026thinsp;+\u0026thinsp;CEE interventions and the control group. Interestingly, participants randomized to the CEE intervention experienced a significant increase for the discrimination experience subscale at 3 months (M\u0026thinsp;=\u0026thinsp;2.99, SD\u0026thinsp;=\u0026thinsp;0.52) than at baseline (M\u0026thinsp;=\u0026thinsp;2.26, SD\u0026thinsp;=\u0026thinsp;0.63). The linear mixed effects model revealed no statistically significant association between the interventions and ISMI composite score. However, non significant results were seen among key independent variables. Compared to the control group, an overall decrease in self stigma was seen for the ACT\u0026thinsp;+\u0026thinsp;CEE intervention (β = -0.11, 95% CI = -0.37, 0.14) and the ACT intervention (β = -0.13, 95% CI = -0.39, 0.12), but not for the CEE intervention (β\u0026thinsp;=\u0026thinsp;0.019, 95% CI = -0.24, 0.28). Overall, the model suggests that no interventions were effective in reducing self stigma over time.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eISMI means across interventions at each time point.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"21\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c14\" colnum=\"14\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c15\" colnum=\"15\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c16\" colnum=\"16\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c17\" colnum=\"17\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c18\" colnum=\"18\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c19\" colnum=\"19\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c20\" colnum=\"20\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c21\" colnum=\"21\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c6\" namest=\"c2\"\u003e \u003cp\u003eACT\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c11\" namest=\"c7\"\u003e \u003cp\u003eCEE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c16\" namest=\"c12\"\u003e \u003cp\u003eACT\u0026thinsp;+\u0026thinsp;CEE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c21\" namest=\"c17\"\u003e \u003cp\u003eCTRL\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eISMI\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eB\u003c/p\u003e \u003cp\u003e(122)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eI\u003c/p\u003e \u003cp\u003e(100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3M (41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6M (67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eB\u003c/p\u003e \u003cp\u003e(125)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eI\u003c/p\u003e \u003cp\u003e(101)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e3M (37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e6M (68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eB\u003c/p\u003e \u003cp\u003e(127)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eI\u003c/p\u003e \u003cp\u003e(105)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e3M (41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e6M (66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003eB\u003c/p\u003e \u003cp\u003e(54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003eI\u003c/p\u003e \u003cp\u003e(42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c19\"\u003e \u003cp\u003e3M\u003c/p\u003e \u003cp\u003e(21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c20\"\u003e \u003cp\u003e6M\u003c/p\u003e \u003cp\u003e(27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c21\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"19\" nameend=\"c20\" namest=\"c2\"\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c21\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAlienation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.29 (0.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.21 (0.76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.19 (0.71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.32 (0.88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.211\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2.47 (0.68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2.38 (0.57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e2.26 (0.76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e2.35 (0.73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.314\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e2.27 (0.62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e2.20 (0.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e2.17 (0.55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e2.05 (0.69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e0.843\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003e2.51 (0.52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003e2.30 (0.56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c19\"\u003e \u003cp\u003e2.15 (0.53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c20\"\u003e \u003cp\u003e2.22 (0.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c21\"\u003e \u003cp\u003e1.387\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eStereotype Endorsement\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.91 (0.61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.90 (0.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.02 (0.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e1.91 (0.74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2.04 (0.61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e1.96 (0.57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e2.01 (0.70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e1.87 (0.62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.441\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e1.84 (0.53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e1.87 (0.53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e1.98 (0.60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e1.84 (0.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e0.319\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003e1.81 (0.59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003e1.75 (0.59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c19\"\u003e \u003cp\u003e1.60 (0.50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c20\"\u003e \u003cp\u003e1.84 (0.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c21\"\u003e \u003cp\u003e0.359\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDiscrimination Experience\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.16 (0.66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.14 (0.73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.31 (0.69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.18 (0.69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.275\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2.26 (0.63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2.31 (0.70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e2.99 (0.52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e2.16 (0.69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u003cb\u003e2.951\u003c/b\u003e\u003csup\u003e\u003cb\u003e✝\u003c/b\u003e\u003c/sup\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e2.17 (0.66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e2.20 (0.53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e2.20 (0.59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e2.04 (0.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e0.433\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003e2.07 (0.62)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003e2.21 (0.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c19\"\u003e \u003cp\u003e2.11 (0.66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c20\"\u003e \u003cp\u003e2.23 (0.60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c21\"\u003e \u003cp\u003e0.212\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocial Withdrawal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.15 (0.67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.17 (0.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.25 (0.79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.24 (0.84)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.153\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2.27 (0.73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2.30 (0.66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e2.25 (0.73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e2.12 (0.69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.329\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e2.23 (0.65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e2.18 (0.51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e2.08 (0.57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e1.98 (0.72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e1.124\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003e2.41 (0.56)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003e2.26 (0.60)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c19\"\u003e \u003cp\u003e2.33 (0.66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c20\"\u003e \u003cp\u003e2.43 (0.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c21\"\u003e \u003cp\u003e0.251\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal ISMI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.11 (0.55)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.10 (0.71)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e2.24 (0.76)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e2.16 (0.74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.223\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2.25 (0.58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2.22 (0.57)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e2.38 (0.61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e2.16 (0.63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e0.295\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e2.12 (0.52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e2.11 (0.46)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e2.10 (0.52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e1.97 (0.61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e0.569\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003e2.20 (0.44)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003e2.12 (0.53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c19\"\u003e \u003cp\u003e2.03 (0.49)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c20\"\u003e \u003cp\u003e2.18 (0.40)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c21\"\u003e \u003cp\u003e0.306\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"21\"\u003e\u003csup\u003e✝\u003c/sup\u003e p\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"21\"\u003eHigher score indicates greater stigma\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003e \u003cb\u003eSocial stigma.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eWe analyzed the data to determine if there were any changes in social stigma immediately after the delivery of interventions, as well as, 3 months and 6 months after the interventions. Overall, the means across time points for the ACT\u0026thinsp;+\u0026thinsp;CEE and ACT interventions and the control group are comparatively similar, suggesting that these interventions were not effective in reducing social stigma (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). However, a notable difference was seen for the CEE intervention between baseline and other time points. Bivariate analyses consisting of repeated measures ANOVA revealed that the CEE intervention was effective in reducing social stigma for all CAMI subscales at immediate and 3 months. However, only the social restrictiveness subscale was found to be significant at the 6 months follow up for the CEE intervention. The ACT and ACT\u0026thinsp;+\u0026thinsp;CEE interventions and the control group were not found to be effective in reducing social stigma. As the \u0026ldquo;direct experience with mental illness\u0026rdquo; category was found to be a confounder (Χ\u003csup\u003e2\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;14.156, p\u0026thinsp;=\u0026thinsp;0.028), linear mixed effects models were used to control for this category. The linear mixed effects model revealed no statistically significant association between the ACT\u0026thinsp;+\u0026thinsp;CEE and ACT interventions and CAMI composite score. However, non-significant results revealed an overall decrease in social stigma scores for the ACT\u0026thinsp;+\u0026thinsp;CEE intervention (β = -2.99, 95% CI = -8.54, 2.58) and the ACT intervention (β = -1.13, 95% CI = -6.71, 4.54). The model also showed that participants scored lower, indicating less social stigma, over time after receiving the CEE intervention compared to the control group. On average, participants reported greater reductions in social stigma immediately after the CEE intervention (β = -6.55, 95% CI = -13.85, 0.73) than at the 3 months (β = -5.13, 95% CI = -14.61, 4.33) and 6 months (β = -0.04, 95% CI = -8.09, 7.98). Overall, the model did not yield any significant results; however, there was a suggestion that the CEE intervention in particular, may be associated with reduced social stigma.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eCAMI means across interventions at each time point.\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"21\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c12\" colnum=\"12\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c13\" colnum=\"13\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c14\" colnum=\"14\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c15\" colnum=\"15\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c16\" colnum=\"16\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c17\" colnum=\"17\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c18\" colnum=\"18\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c19\" colnum=\"19\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c20\" colnum=\"20\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c21\" colnum=\"21\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c6\" namest=\"c2\"\u003e \u003cp\u003eACT\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c10\" namest=\"c7\"\u003e \u003cp\u003eCEE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"4\" nameend=\"c15\" namest=\"c12\"\u003e \u003cp\u003eACT\u0026thinsp;+\u0026thinsp;CEE\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c16\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c21\" namest=\"c17\"\u003e \u003cp\u003eCTRL\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cem\u003eCAMI\u003c/em\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eB\u003c/p\u003e \u003cp\u003e(122)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eI\u003c/p\u003e \u003cp\u003e(100)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3M (41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6M (67)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eB\u003c/p\u003e \u003cp\u003e(125)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eI\u003c/p\u003e \u003cp\u003e(101)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e3M (37)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e6M (68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003eB\u003c/p\u003e \u003cp\u003e(127)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003eI\u003c/p\u003e \u003cp\u003e(105)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e3M (41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e6M (66)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003eB\u003c/p\u003e \u003cp\u003e(54)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003eI\u003c/p\u003e \u003cp\u003e(42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c19\"\u003e \u003cp\u003e3M\u003c/p\u003e \u003cp\u003e(21)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c20\"\u003e \u003cp\u003e6M\u003c/p\u003e \u003cp\u003e(27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c21\"\u003e \u003cp\u003eF\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"19\" nameend=\"c20\" namest=\"c2\"\u003e \u003cp\u003eMean (SD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c21\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAuthoritarianism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e24.02 (5.35)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23.00 (5.38)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22.56 (5.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e22.40 (5.86)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1.589\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e23.82 (5.39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e21.11 (6.95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e21.24 (7.74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e22.40 (5.23)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u003cb\u003e4.111*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e22.37 (5.53)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e21.37 (4.90)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e20.88 (5.63)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e21.56 (6.03)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e1.087\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003e23.17 (4.87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003e21.81 (5.08)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c19\"\u003e \u003cp\u003e21.52 (4.95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c20\"\u003e \u003cp\u003e21.78 (4.75)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c21\"\u003e \u003cp\u003e0.97\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBenevolence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e21.20 (5.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21.27 (5.27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20.98 (5.09)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e20.46 (5.11)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.383\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e21.58 (5.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e19.13 (6.70)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e18.68 (7.20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e20.71 (4.96)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u003cb\u003e4.429*\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e20.20 (5.22)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e20.50 (5.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e20.10 (4.97)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e20.61 (5.45)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e0.154\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003e21.19 (4.06)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003e20.60 (4.79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c19\"\u003e \u003cp\u003e19.48 (4.03)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c20\"\u003e \u003cp\u003e20.00 (3.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c21\"\u003e \u003cp\u003e0.997\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSocial Restrictiveness\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22.02 (4.94)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.08 (5.61)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22.15 (5.16)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e21.10 (4.78)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.626\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e22.99 (5.41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e19.91 (6.59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e19.22 (7.00)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e21.18 (5.24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u003cb\u003e6.728**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e21.97 (5.42)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e21.13 (5.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e21.54 (5.31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e21.33 (5.33)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e0.523\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003e21.93 (4.24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003e20.81 (5.34)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c19\"\u003e \u003cp\u003e20.52 (4.91)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c20\"\u003e \u003cp\u003e21.41 (5.27)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c21\"\u003e \u003cp\u003e0.621\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eCommunity Mental Health Ideology\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e22.89 (5.39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e22.30 (5.68)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e22.39 (6.20)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e21.84 (5.73)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.538\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e23.65 (6.05)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e20.12 (6.95)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e19.38 (7.92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e22.26 (5.41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u003cb\u003e7.757**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e22.58 (5.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e21.45 (5.74)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e21.59 (4.89)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e22.12 (6.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e0.474\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003e23.22 (4.85)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003e22.14 (4.69)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c19\"\u003e \u003cp\u003e22.05 (4.41)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c20\"\u003e \u003cp\u003e22.67 (5.92)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c21\"\u003e \u003cp\u003e0.488\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal CAMI\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e90.14 (17.65)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e88.65 (18.82)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e88.07 (19.58)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e85.81 (18.88)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e0.801\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e92.04 (19.14)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e80.27 (24.79)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e78.51 (28.10)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e86.54 (18.17)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003e\u003cb\u003e6.897**\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c12\"\u003e \u003cp\u003e87.12 (18.97)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c13\"\u003e \u003cp\u003e84.46 (18.51)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c14\"\u003e \u003cp\u003e84.10 (18.87)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c15\"\u003e \u003cp\u003e85.62 (20.52)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c16\"\u003e \u003cp\u003e0.475\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c17\"\u003e \u003cp\u003e89.50 (13.59)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c18\"\u003e \u003cp\u003e85.36 (17.24)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c19\"\u003e \u003cp\u003e83.57 (14.02)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c20\"\u003e \u003cp\u003e85.85 (16.29)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c21\"\u003e \u003cp\u003e1.03\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"21\"\u003e* p\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"21\"\u003e** p\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"21\"\u003eHigher scores indicate greater stigma\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003e \u003cb\u003eSelf stigma.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eResults revealed that interventions were not effective in reducing internalized stigma. It is possible that the interventions did not yield significant results because the internalized stigma surrounding mental illness was so deeply rooted that it was not easily affected by the interventions and may require repeated contact. One potential reason may be due to religion and culture based on ancient belief systems that play a major role in stigma.(39). For example, Confucianism encourages individuals not to disclose their mental illness in order to maintain the family\u0026rsquo;s reputation (40). A study on Chinese immigrants suggested that individuals with stronger ties to cultural values and beliefs may exhibit less positive attitudes than individuals with weaker ties (29). Additionally, while the interventions do focus on participants\u0026rsquo; experiences, patriarchal views towards mental illness may form internalized ideals of masculinity for Asian men (26), resulting in psychological inflexibility and a lack of understanding towards mental illness that is not easily improved by the interventions.\u003c/p\u003e \u003cp\u003eAnother potential explanation may be related to Metro Vancouver\u0026rsquo;s large minority population. As of 2016, 46.5% of Metro Vancouver\u0026rsquo;s population was of Asian origin (41). With a large percentage of the population identifying as Asian, it is possible that the communities the participants reside in resemble those of their home countries. Research has shown that Asians exposed to Western societies have lower levels of stigma and may be more willing to seek professional help (42); however, that exposure may be limited to participants residing in Vancouver. It may be possible that being surrounded by Asian communities constantly reinforces stereotypical attitudes and gendered expectations towards mental illness,deterring Asian men from seeking help. It is also possible that lack of Western influence led to unfamiliarity and hesitancy towards Western-based approaches (43), negatively affecting the effectiveness of the interventions in reducing mental health stigma.\u003c/p\u003e \u003cp\u003eAn especially surprising finding was that participants randomized to the ACT intervention did not report a reduction in self stigma scores; this was inconsistent with our hypothesis based on previous research (44). However, it is important to note that previous research mostly focused on students, while our current study includes individuals above 17 years of age. It is possible that ACT makes a greater impact on youth as they may be more receptive to such approaches, and encouraging help-seeking behaviours at a younger age may result in more positive attitudes extending into adulthood (45,46). As the current study does not examine age groups separately, further investigation would be needed to determine if ACT makes a greater impact on the younger population. Furthermore, a majority of studies examining ACT have not focused on the Asian population and more specifically, Asian men. ACT emphasizes acceptance and mindfulness strategies to engage the individual more with the present moment (47) and to be aware of themselves without judgment (48). This is in line with Buddhist practices (48) and thus, was interesting that the current study did not yield significant results as previous research has suggested ACT to be an effective intervention for the Asian population. The data published from the Toronto site included exploratory analyses of ethnicity and found that ACT had a greater impact on East Asians compared to other groups (49). The authors suggested that Buddhism is largely practiced in East Asian countries and therefore, East Asians may be more impressionable (49). While the current study did not find Asian ethnicity to be a confounder, further research may be needed to determine the impact of ACT on various Asian subgroups. It is important to note that we were unable to compare sites to determine if effects were present at the 3 month and 6 month follow up as data from the Toronto site only included immediate follow up. Further research is needed to determine whether a longer, sustainable intervention may be effective.\u003c/p\u003e \u003cp\u003e \u003cb\u003eSocial stigma.\u003c/b\u003e \u003c/p\u003e \u003cp\u003eResults revealed that the ACT, ACT\u0026thinsp;+\u0026thinsp;CEE, and psychoeducation interventions did not yield significant reductions in social stigma scores. However, in large part, our hypotheses were confirmed. Results revealed that Asian men randomized to the CEE intervention reported a significant decrease in social stigma, suggesting that the CEE intervention may have been the most effective intervention in reducing negative attitudes towards those with mental illness. This is consistent with findings from previous research (50). Data published from the Toronto site also revealed reduction in social stigma scores for a majority of CAMI subscales (49). It is important to note that the method used to calculate social stigma scores in Fung\u0026rsquo;s study differs from that used in the current study. Thus, a comparison of social stigma scores between sites may not be appropriate. Our findings revealed that while the CEE intervention was found to be the most effective intervention in reducing social stigma, its effects were not found to be significant at the 6 month follow up. This is also consistent with previous research (51,52) and suggests that repeated contact may be necessary to counter the effects of social stigma.\u003c/p\u003e \u003cp\u003eThe contact-based component in this intervention provided participants with the opportunity to gain a deeper understanding towards those affected by mental illness (53), while the empowerment component allowed for high group identification (54), leading to improved well-being and stigma. The CEE intervention in this study invited guest speakers of similar backgrounds to share their experience regarding stigma and its impact and how they addressed it. Participants in this study may have been encouraged to adjust their perspectives and behaviour towards those affected by mental illness. Moreover, hearing similar experiences may have helped participants acknowledge the societal demands placed on Asian men and its effect on seeking help. This may have resulted in reduced social stigma due to an established sense of empowerment and new ways to take action in the participants\u0026rsquo; respective communities.\u003c/p\u003e\n\u003ch3\u003eSTUDY LIMITATIONS AND STRENGTHS\u003c/h3\u003e\n\u003cp\u003eA limitation in this study may be the potential for selection bias. Asian men who chose to participate in this study may be different from Asian men who chose not to participate. It may be possible that men who chose to participate were more interested in the topic area (reducing stigma) compared to the rest of the population. Additionally, recruiting strategies involved purposeful convenience sampling and snowball sampling. As these were non-random sampling strategies, there may be a possibility that the sample was not entirely representative of the population, thus affecting the generalizability from the sample to the target population. Social desirability bias was also possible in this study. As both the ISMI and CAMI scales were self-reported questionnaires, participants may have answered questions in a manner that was viewed as favourable to others and what society considers as \u0026ldquo;good\u0026rdquo; behaviour. In an attempt to mitigate this bias, each participant had a unique identification label and were given privacy during survey completion, eliminating the need for any identifying information. Lastly, it is important to consider that the gender of the facilitator may have affected the results of the study. A female facilitator for a men\u0026rsquo;s study may have led to questions and uncertainty regarding her ability to understand men\u0026rsquo;s mental health experiences and deliver workshops. Men may have treated female facilitators differently than male facilitators and engaged in flirtatious behaviour or asked personal questions. Men also may have exhibited stereotypical behaviours such as remaining stoic and providing unemotional responses. However, it could have also been the case that men were more willing and comfortable to discuss mental health experiences with a female facilitator than a male facilitator.\u003c/p\u003e \u003cp\u003eDespite these limitations, this study has demonstrated the effectiveness of three evidence-based anti-stigma interventions in reducing self and social stigma mental illness by using measures that have been accepted in previous research on people of various ethnic backgrounds. As the STiU project is the first study to target the effects of mental health stigma in Asian men living in Canada (55), its findings are crucial to contributing to the limited evidence in the Canadian context. Additionally, the large sample size will provide a smaller margin of error, representative results, and a derivation of accurate insights from the study.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eIn conclusion, our findings highlight the need of implementing interventions to reduce the mental health stigma among Asian men. Previous studies in Canada have found that a majority of research has focused on the experiences of immigrant women and limited studies have focused on immigrant men. The findings from this study may be important in addressing this gap and in facilitating efforts to advocate for change. This study provides evidence that the CEE intervention may be effective in reducing social stigma in Asian men. However, further research is needed to determine the effectiveness of the ACT intervention in reducing self stigma. It would also be worthwhile to determine whether residing in an area with a large percentage of the population identifying as Asian impacts the effectiveness of a Western approach to recovery. Nevertheless, this study may be crucial in the promotion of mental health and may encourage stigma reduction activities within this community.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAUTHORS CONTRIBUTION STATEMENT\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eN.P. analyzed and interpreted the data, and wrote the initial draft of the manuscript. S.K. supervised the project and contributed to manuscript submission. M.M. and S.B. designed and conducted the study, and contributed to manuscript revision. C.J. and R.L. revised the manuscript critically for important intellectual content. N.B.P.* designed and conducted the study, supervised the project, and contributed to manuscript revision. All authors read and approved the final manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCOMPETING INTERESTS\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eETHICS DECLARATION\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe original and current study was approved by the Research Ethics Board (REB) of Ryerson University, Simon Fraser University, University of British Columbia, and Vancouver Coastal Health. Written informed consent was obtained from all individual participants included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFUNDING\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe original study received funding from Movember Canada under its Mental Health and Suicide Prevention Program.\u0026nbsp;\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eDATA AVAILABILITY\u003c/h2\u003e \u003cp\u003eThe datasets analyzed in this study are kept safe and protected among the authors. Requests for access to the data can be directed to the corresponding author, subject to reasonable conditions.\u003c/p\u003e \u003c/div\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003e\u003cspan\u003eCorrigan PW, Edwards AB, Green A, Diwan SL, Penn DL. Prejudice, social distance, and familiarity with mental illness. Schizophr Bull. 2001;27(2):219\u0026ndash;25.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eCorrigan P. How stigma interferes with mental health care. Am Psychol. 2004 Oct;59(7):614\u0026ndash;25.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eStigma and Discrimination [Internet]. [cited 2022 Feb 20]. Available from: https://www.psychiatry.org/patients-families/stigma-and-discrimination\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eMeta-analysis of stigma and mental health. Soc Sci Med. 2007 Jul 1;65(2):245\u0026ndash;61.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eCorrigan PW, Watson AC. The Paradox of Self-Stigma and Mental Illness [Internet]. Vol. 9, Clinical Psychology: Science and Practice. 2006. p. 35\u0026ndash;53. Available from: http://dx.doi.org/10.1093/clipsy.9.1.35\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eCorrigan PW, Markowitz FE, Watson AC. Structural levels of mental illness stigma and discrimination. Schizophr Bull. 2004;30(3):481\u0026ndash;91.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eCorrigan PW. How clinical diagnosis might exacerbate the stigma of mental illness. Soc Work. 2007 Jan;52(1):31\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eLink BG, Phelan JC. Conceptualizing Stigma [Internet]. Vol. 27, Annual Review of Sociology. 2001. p. 363\u0026ndash;85. Available from: http://dx.doi.org/10.1146/annurev.soc.27.1.363\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eSickel, A.E., Seacat, J.D., \u0026amp; Nabors, N.A. Mental health stigma update: A review of consequences. Advances in Mental Health. 2014 Nov 2;12(3):202\u0026ndash;15.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eMajor B, O\u0026rsquo;Brien LT. The social psychology of stigma. Annu Rev Psychol [Internet]. 2005 [cited 2021 Jan 12];56. Available from: https://pubmed.ncbi.nlm.nih.gov/15709941/\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eWood J, Bruce Newbold K. Provider Perspectives on Barriers and Strategies for Achieving Culturally Sensitive Mental Health Services for Immigrants: A Hamilton, Ontario Case Study [Internet]. Journal of International Migration and Integration. 2011. Available from: http://dx.doi.org/10.1007/s12134-011-0215-3\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eGuzder J, Yohannes S, Zelkowitz P. Helpseeking of immigrant and native born parents: a qualitative study from a montreal child day hospital. J Can Acad Child Adolesc Psychiatry. 2013 Nov;22(4):275\u0026ndash;81.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eStigmatizing experience and structural discrimination associated with the treatment of schizophrenia in Hong Kong. Soc Sci Med. 2006 Apr 1;62(7):1685\u0026ndash;96.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eTateyama M, Asai M, Hashimoto M, Bartels M, Kasper S. Transcultural Study of Schizophrenic Delusions. PSP. 1998;31(2):59\u0026ndash;68.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eSubramaniam M, Abdin E, Picco L, Pang S, Shafie S, Vaingankar JA, et al. Stigma towards people with mental disorders and its components - a perspective from multi-ethnic Singapore. Epidemiol Psychiatr Sci. 2017 Aug;26(4):371\u0026ndash;82.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003ePang S, Liu J, Mahesh M, Chua BY, Shahwan S, Lee SP, et al. Stigma among Singaporean youth: a cross-sectional study on adolescent attitudes towards serious mental illness and social tolerance in a multiethnic population. BMJ Open. 2017 Oct 1;7(10):e016432.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eCharles H, Manoranjitham SD, Jacob KS. Stigma and explanatory models among people with schizophrenia and their relatives in Vellore, south India. Int J Soc Psychiatry. 2007 Jul;53(4):325\u0026ndash;32.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eDardas LA, Simmons LA. The stigma of mental illness in Arab families: a concept analysis. J Psychiatr Ment Health Nurs. 2015 Nov;22(9):668\u0026ndash;79.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eM FEI. Arab culture and mental health care. Transcult Psychiatry [Internet]. 2008 Dec [cited 2021 Jan 16];45(4). Available from: https://pubmed.ncbi.nlm.nih.gov/19091731/\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eKohrt BA, Hruschka DJ. Nepali concepts of psychological trauma: the role of idioms of distress, ethnopsychology and ethnophysiology in alleviating suffering and preventing stigma. Cult Med Psychiatry [Internet]. 2010 Jun [cited 2021 Jan 16];34(2). Available from: https://pubmed.ncbi.nlm.nih.gov/20309724/\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eSalve H, Goswami K, Sagar R, Nongkynrih B, Sreenivas V. Perception and Attitude towards Mental Illness in an Urban Community in South Delhi - A Community Based Study. Indian J Psychol Med [Internet]. 2013 Apr [cited 2021 Jan 16];35(2). Available from: https://pubmed.ncbi.nlm.nih.gov/24049226/\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eRaguram R, Raghu TM, Vounatsou P, Weiss MG. Schizophrenia and the cultural epidemiology of stigma in Bangalore, India. J Nerv Ment Dis [Internet]. 2004 Nov [cited 2021 Jan 16];192(11). Available from: https://pubmed.ncbi.nlm.nih.gov/15505517/\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eAl-Krenawi A. Mental health practice in Arab countries. Curr Opin Psychiatry. 2005 Sep;18(5):560.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eVogel DL, Heimerdinger-Edwards SR, Hammer JH, Hubbard A. \u0026ldquo;Boys don\u0026rsquo;t cry\u0026rdquo;: Examination of the links between endorsement of masculine norms, self-stigma, and help-seeking attitudes for men from diverse backgrounds [Internet]. Vol. 58, Journal of Counseling Psychology. 2011. p. 368\u0026ndash;82. Available from: http://dx.doi.org/10.1037/a0023688\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eMansfield, A.K., Addis, M.E., \u0026amp; Mahalik, J.R. \u0026ldquo;Why Won\u0026rsquo;t He Go to the Doctor?\u0026rdquo;: The Psychology of Men\u0026rsquo;s Help Seeking. International Journal of Men\u0026rsquo;s Health. 2003;2(2):93\u0026ndash;109.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eWeiss MG, Jadhav S, Raguram R, Vounatsou P, Littlewood R. Psychiatric stigma across cultures: Local validation in Bangalore and London [Internet]. Vol. 8, Anthropology \u0026amp; Medicine. 2001. p. 71\u0026ndash;87. Available from: http://dx.doi.org/10.1080/13648470120063906\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eLauber C, R\u0026ouml;ssler W. Stigma towards people with mental illness in developing countries in Asia. Int Rev Psychiatry. 2007 Apr;19(2):157\u0026ndash;78.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eYim JY. \u0026ldquo;Being an Asian American Male is Really Hard Actually\u0026rdquo;: Cultural Psychology of Asian American Masculinities and Psychological Well-Being [Internet]. 2009 [cited 2021 Jan 14]. Available from: https://www.semanticscholar.org/paper/%22Being-an-Asian-American-Male-is-Really-Hard-of-and-Yim/7fdfa8f76a4a4e8985e7077316767e4e0d329956\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eTieu Y, Konnert CA. Mental health help-seeking attitudes, utilization, and intentions among older Chinese immigrants in Canada. Aging Ment Health. 2014 Mar;18(2):140\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eLal RJ. How Do the Attitudes and Beliefs Towards Mental Health- Seeking Behaviour Differ Between Racialized and Non-Racialized Students in a University Environment? [Internet]. 2020 [cited 2021 Apr 26]. Available from: https://yorkspace.library.yorku.ca/xmlui/handle/10315/37414\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eKalich A, Heinemann L, Ghahari S. A Scoping Review of Immigrant Experience of Health Care Access Barriers in Canada. J Immigr Minor Health. 2016 Jun;18(3):697\u0026ndash;709.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eAhmed S, Shommu NS, Rumana N, Barron GRS, Wicklum S, Turin TC. Barriers to Access of Primary Healthcare by Immigrant Populations in Canada: A Literature Review [Internet]. Vol. 18, Journal of Immigrant and Minority Health. 2016. p. 1522\u0026ndash;40. Available from: http://dx.doi.org/10.1007/s10903-015-0276-z\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eMcKenzie K, Agic B, Tuck A, Antwi, M. The Case for Diversity: Building the Case to Improve Mental Health Services for Immigrant, Refugee, Ethno-cultural and Racialized Populations [Internet]. 2016 [cited 2020 Aug 14]. Available from: https://www.mentalhealthcommission.ca/sites/default/files/2016-10/case_for_diversity_oct_2016_eng.pdf\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eRitsher JB, Otilingam PG, Grajales M. Internalized stigma of mental illness: psychometric properties of a new measure. Psychiatry Res. 2003 Nov 1;121(1):31\u0026ndash;49.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eChang CC, Wu TH, Chen CY, Wang JD, Lin CY. Psychometric Evaluation of the Internalized Stigma of Mental Illness Scale for Patients with Mental Illnesses: Measurement Invariance across Time. PLoS One [Internet]. 2014 [cited 2021 Nov 14];9(6). Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4041772/\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eTanabe Y, Hayashi K, Ideno Y. The Internalized Stigma of Mental Illness (ISMI) scale: validation of the Japanese version. BMC Psychiatry [Internet]. 2016 [cited 2021 Nov 14];16. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4850681/\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eTaylor SM, Dear MJ. Scaling community attitudes toward the mentally ill. Schizophr Bull. 1981;7(2):225\u0026ndash;40.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eLivingston J, Patel N, Bryson S, Hoong P, Lal R, Morrow M, et al. Stigma associated with mental illness among Asian men in Vancouver, Canada. Int J Soc Psychiatry. 2018 Nov;64(7):679\u0026ndash;89.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eLam C, Tsang H, Corrigan P, Lee YT, Angell B, Shi K, et al. Chinese Lay Theory and Mental Illness Stigma: Implications for Research and Practices. 2010 [cited 2022 Jan 24]; Available from: https://www.semanticscholar.org/paper/Chinese-Lay-Theory-and-Mental-Illness-Stigma%3A-for-Lam-Tsang/b30375ac47f63eebb21f3e6172e91726f1fa6911\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eLv Y, Wolf A, Wang X. Experienced stigma and self-stigma in Chinese patients with schizophrenia. Gen Hosp Psychiatry. 2013 Jan;35(1):83\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eStatistics Canada. Census Profile, 2016 Census - Vancouver [Census metropolitan area], British Columbia and British Columbia [Province] [Internet]. 2017 [cited 2021 Mar 8]. Available from: https://www12.statcan.gc.ca/census-recensement/2016/dp-pd/prof/details/page.cfm?Lang=E\u0026amp;Geo1=CMACA\u0026amp;Code1=933\u0026amp;Geo2=PR\u0026amp\n;Code2=59\u0026amp;SearchText=vancouver\u0026amp;SearchType=Begins\u0026amp; SearchPR=01\u0026amp;B1=Ethnic%20origin\u0026amp;TABID=1\u0026amp;type=1\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eChen SX, Mak WWS. Seeking professional help: Etiology beliefs about mental illness across cultures. J Couns Psychol. 2008 Oct;55(4):442\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eYang LH, Phelan JC, Link BG. Stigma and beliefs of efficacy towards traditional Chinese medicine and Western psychiatric treatment among Chinese-Americans. Cultur Divers Ethnic Minor Psychol. 2008 Jan;14(1):10\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eMasuda A, Hayes SC, Lillis J, Bunting K, Herbst SA, Fletcher LB. The Relation between Psychological Flexibility and Mental Health Stigma in Acceptance and Commitment Therapy: A Preliminary Process Investigation [Internet]. Vol. 18, Behavior and Social Issues. 2009. p. 25\u0026ndash;40. Available from: http://dx.doi.org/10.5210/bsi.v18i1.2525\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eChen SP, Koller M, Krupa T, Stuart H. Contact in the Classroom: Developing a Program Model for Youth Mental Health Contact-Based Anti-stigma Education. Community Ment Health J. 2016 Apr;52(3):281\u0026ndash;93.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eKenny A, Bizumic B. Learn and ACT: Changing prejudice towards people with mental illness using stigma reduction interventions [Internet]. Vol. 5, Journal of Contextual Behavioral Science. 2016. p. 178\u0026ndash;85. Available from: http://dx.doi.org/10.1016/j.jcbs.2016.06.004\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eHayes SC, Luoma JB, Bond FW, Masuda A, Lillis J. Acceptance and Commitment Therapy: Model, processes and outcomes [Internet]. Vol. 44, Behaviour Research and Therapy. 2006. p. 1\u0026ndash;25. Available from: http://dx.doi.org/10.1016/j.brat.2005.06.006\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eFung K. Acceptance and Commitment Therapy: Western adoption of Buddhist tenets? Transcult Psychiatry. 2015 Aug;52(4):561\u0026ndash;76.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eFung K, Liu JJW, Sin R, Shakya Y, Guruge S, Bender A, et al. Examining Different Strategies for Stigma Reduction and Mental Health Promotion in Asian Men in Toronto. Community Ment Health J [Internet]. 2020 Oct 19; Available from: http://dx.doi.org/10.1007/s10597-020-00723-3\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eWong EC, Collins RL, Cerully JL, Yu JW, Seelam R. Effects of contact-based mental illness stigma reduction programs: age, gender, and Asian, Latino, and White American differences. Soc Psychiatry Psychiatr Epidemiol. 2018 Mar;53(3):299\u0026ndash;308.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eCorrigan P, Michaels PJ, Morris S. Do the effects of antistigma programs persist over time? Findings from a meta-analysis. Psychiatr Serv. 2015 May 1;66(5):543\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eYamaguchi S, Wu SI, Biswas M, Yate M, Aoki Y, Barley EA, et al. Effects of short-term interventions to reduce mental health-related stigma in university or college students: a systematic review. J Nerv Ment Dis [Internet]. 2013 Jun [cited 2022 Jan 30];201(6). Available from: https://pubmed.ncbi.nlm.nih.gov/23719324/\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eChan JYN, Mak WWS, Law LSC. Combining education and video-based contact to reduce stigma of mental illness: \u0026ldquo;The Same or Not the Same\u0026rdquo; anti-stigma program for secondary schools in Hong Kong. Soc Sci Med. 2009 Apr;68(8):1521\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eR\u0026uuml;sch N, Angermeyer MC, Corrigan PW. Mental illness stigma: concepts, consequences, and initiatives to reduce stigma. Eur Psychiatry. 2005 Dec;20(8):529\u0026ndash;39.\u003c/span\u003e\u003c/li\u003e\n \u003cli\u003e\u003cspan\u003eGuruge S, Fung KPL, Sidani S, Este D, Morrow M, McKenzie K, et al. Study protocol: Mobilizing Asian men in Canada to reduce stigma of mental illness. Contemp Clin Trials. 2018 Aug;71:133\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-3844198/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3844198/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eAsian men may be more susceptible to stigmatizing attitudes towards mental illness and treatment due to the gendered and cultural expectations created by society, compared to Asian women. This may result in an internalization of devaluing beliefs and discriminatory attitudes towards others affected by mental illness and can delay or prevent this population from seeking professional help. In this randomized control trial (RCT), data from 428 Asian men from Vancouver, Canada were used to examine Acceptance and Commitment Training (ACT), Contact-based Empowerment and Education (CEE), and ACT\u0026thinsp;+\u0026thinsp;CEE. Data were collected at pre-intervention, immediately post-intervention, 3 months post-intervention, and 6 months post-intervention using the ISMI and the CAMI scales to assess self and social stigma. Repeated measures ANOVA were performed to determine if there was a significant interaction between the intervention and multiple time points on ISMI and CAMI scores. Linear mixed effects models were performed on ISMI and CAMI composite scores to control for confounding. No significant differences in ISMI scores were seen across all time points for all interventions. Significant reduction in CAMI scores were seen for the CEE intervention up to 3 months, suggesting that effects of the intervention were short-lived.\u003c/p\u003e","manuscriptTitle":"Examining Workshops in Reducing Mental Illness Self and Social Stigma Among Asian Men in Vancouver, Canada: A Randomized Control Trial","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-31 05:02:24","doi":"10.21203/rs.3.rs-3844198/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"dc5a00df-1ce4-4065-92ad-b79dd930a267","owner":[],"postedDate":"January 31st, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":28473129,"name":"Biological sciences/Psychology"},{"id":28473130,"name":"Health sciences/Health care/Public health"}],"tags":[],"updatedAt":"2025-01-15T04:23:19+00:00","versionOfRecord":[],"versionCreatedAt":"2024-01-31 05:02:24","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3844198","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3844198","identity":"rs-3844198","version":["v1"]},"buildId":"rHA-KDH7Qsr4HCuvH75dn","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}