Evaluating the changes in attitudes towards mental illness and physical disabilities after an anti-stigma course for occupational therapy students

Abstract

Objective

This study assessed changes in attitudes towards mental illness and physical disabilities in occupational therapy (OT) students after an anti-stigma course (AS group) and compared the changes in attitudes with a control (CT group) attending a sociology course.

Methods

A quasi-experimental design was used in this study with 65 OT students across two academic years (AS group: n = 33; CT group: n = 32). Stigmatizing attitudes and social distance towards mental illness and physical disabilities were measured before and after course completion.

Results

Compared with the CT group, the AS group showed a significantly greater reduction in social distance towards mental illness (t = 1.974, p = .027) and decreases in stigmatizing attitudes (t = 2.087, p = .021) and social distance (t = 2.512, p = .008) towards physical disabilities. In addition, both groups reported greater social distance towards mental illness than towards physical disabilities in both the pretest and posttest.

Conclusions

A multimodal anti-stigma course may decrease social distance towards mental illness as well as stigmatizing attitudes and social distance concerning physical disabilities among OT students. However, further refinement of the anti-stigma course, with a particular emphasis on mental health stigma, is warranted.

Keywords

anti-stigma attitudes bias occupational therapy education

Introduction

Stigma is broadly defined as a set of negative beliefs, attitudes, and behaviors directed towards individuals who are perceived as different or deviant due to certain attributes or conditions (Corrigan, 2004, 2014). It often involves the convergence of stereotypes (cognitive), prejudice (affective), and discrimination (behavioral), leading to social exclusion, reduced opportunities, and health disparities—particularly for people with mental illness or disabilities.

Occupational therapy (OT) has increasingly focused on the study of stigma in relation to mental illness and physical disabilities. Studies have shown that stigma is linked to fears of employment and a barrier to occupational engagement among adults with mental illness (Hielscher & Waghorn, 2017; Woolley et al., 2020). For people with physical disabilities, stigma has been identified as a significant factor contributing to satisfaction with social roles and a key determinant of quality of life in individuals with neurologic conditions (Ma et al., 2016; Warner et al., 2018). Therefore, addressing stigma-related issues is crucial for OT practitioners aiming to enhance clients’ occupational engagement and quality of life.

Healthcare providers may also internalize public stigma ingrained in society, leading to negative attitudes towards individuals with disabilities (Lyons, 1991). Research has identified the healthcare system, including mental health professionals, as a major source of stigmatization experienced by individuals with schizophrenia (Mestdagh & Hansen, 2014; Valery & Prouteau, 2020). The attitude of healthcare providers can affect the quality of care, patient’s receptiveness to treatment, and treatment outcomes (Dovidio & Fiske, 2012). For example, research on cumulative stigma experienced by injured immigrant workers has highlighted that negative anticipatory judgments from practitioners can harm therapeutic relationships and erode mutual trust that is essential during the rehabilitation process (Côté et al., 2020). These findings align with the recognition of the American Occupational Therapy Association that discrimination, stigma, and implicit bias can adversely impact the provision of OT services (AOTA, 2020). Therefore, addressing stigma-related issues during OT education is imperative.

Anti-stigma programs for healthcare students mainly address mental illness stigma and are often provided to medical, pharmacy, and nursing students (Lien et al., 2021). In addition, although some courses covering disabilities have been offered to improve healthcare students’ disability-related knowledge and attitudes (Clarke et al., 2024), the prevalence of ableism, defined as discrimination and social prejudice against people with disabilities, calls for critical reflection of attitudes for OT students (Friedman & VanPuymbrouck, 2021a, 2021b).

Although different clinical populations may be associated with unique stigmas, there are also shared stigma among different types of clinical populations. In a pilot study (Ma & Hsieh, 2020a), an anti-stigma course began with the provision of fundamental information about stigma and incorporated experiential activities (e.g., social contact and role-playing) and critical reflection to expand the focus to not only mental illness but also various disorders/disabilities. With a single-group pretest-posttest design including 16 OT students, the study reported significantly reduced stigmatizing attitudes and social distance towards mental illness after the course (Ma & Hsieh, 2020a). To validate these findings, a larger sample size and a control group are necessary.

Furthermore, Huskin et al. (2018) compared undergraduate students’ attitudes towards individuals with various disabilities, including mental illness and physical impairment. The study used the social distance scale to measure the willingness of students to engage in social interactions across 10 disability types. The study found that mental illness evoked lower acceptance compared with physical impairment in all items of the social distance scale. Given that OT practitioners work with individuals with mental illness and also those with physical disabilities, determining whether such attitudes also exist among OT students is essential.

The purpose of this study was to examine the change in attitudes towards mental illness and physical disabilities of OT students who had completed an anti-stigma course and to compare with the change in attitudes of OT students who had completed the sociology course (historical control). In addition, we would like to compare OT students’ attitudes towards mental illness to their attitudes towards physical disabilities.

We hypothesized that first, students who completed the anti-stigma course (AS group) would report a greater decrease in stigmatizing attitudes and social distance towards mental illness and physical disabilities than students who completed the control course (CT group), and second, that students would report greater social distance towards mental illness compared with physical disabilities.

Method

Design and Participants

This study employed a quasi-experimental design, involving a nonrandomized control group with pretest and posttest. Participants were divided into two groups: the AS group, consisting of students who voluntarily enrolled in the anti-stigma course, and the CT group, comprising students required to take the sociology course as part of their curriculum. Both courses were two-credit offerings. Students were invited to participate based on course enrollment, and only OT majors were included in the analysis. The AS group included first- or second-year OT students who took the anti-stigma course in the fall semesters of 2020 and 2021, while the CT group consisted of first-year OT students who took the sociology course in the spring semesters of 2020 and 2021. A total of 61 students enrolled in the anti-stigma course and 131 in the sociology course across four semesters. After excluding non-OT students, those who declined participation, and those with incomplete data, 65 OT students were included in the final analysis (33 in the AS group and 32 in the CT group). As this study used a historical control group, random allocation was not applied. Figure 1 presents the study flowchart.

Figure 1.

Flow Chart of Research Process. AS Group: Anti-Stigma Group

This study was conducted according to the Declaration of Helsinki, and ethical approval to conduct the study was obtained from the National Cheng Kung University Human Research Ethics Committee (NCKU HREC-E-105-300-2; NCKU HREC-E-108-230-2). Informed written consent was obtained from all participants.

Measures

The participants were assessed using two questionnaires to gauge their stigmatizing attitudes towards mental illness and physical disabilities. The “Questionnaire on Stigmatizing Attitudes Towards Mental Illness” consists of 16 items grouped into four subscales: deviant behavior, social isolation, negative stereotypes, and self-stigma (Ma & Hsieh, 2020b). Similarly, the “Questionnaire on Stigmatizing Attitudes Towards Disabilities” comprises six items distributed across two subscales: negative stereotypes and pessimistic expectations (Ma & Hsieh, 2020b). For both questionnaires, a six-point Likert scale was used, with higher scores indicating stronger negative stigmatizing attitudes. Psychometric evaluation confirmed the satisfactory internal consistency of the questionnaires, with Cronbach’s α coefficients of 0.89 for mental illness and 0.71 for physical disabilities.

To further understand the participants’ willingness to engage in social interactions with individuals having mental illness or physical disabilities, a social distance scale was used (Huskin et al., 2018). The scale consists of seven scenarios describing different levels of closeness with such individuals: (1) as a neighbor, (2) as a coworker, (3) as a friend, (4) renting my house, (5) recommending for a job, (6) as an in-law, and (7) taking care of my child. Participants used a 6-point Likert scale to indicate their preferences for social distance, with higher scores indicating greater reluctance to engage in close social contact and thus more negative attitudes. The applicability of the scale in the local context in Taiwan has been supported by a large-scale survey conducted by Lien and Kao (2019), which reported good internal consistency (Cronbach’s α = 0.80 for schizophrenia and 0.78 for depression). In this study, the average scores for the items on each questionnaire were computed, yielding a possible range of 1–6.

Procedures

To establish the baseline, students completed stigmatizing attitudes questionnaires and social distance scales on the first day of both the anti-stigma and sociology courses as the pretest. Students also completed the same surveys on the last day of the anti-stigma course as the posttest. However, the sociology course underwent a transition to online teaching in the spring semesters - May 2020 and May 2021, because of the COVID-19 pandemic. Consequently, the posttest was postponed until September (in 2020) or administered online (in 2021).

Intervention: Anti-Stigma Course

The anti-stigma course aimed to heighten students’ awareness, encourage self-reflection, and foster critical thinking regarding stigma related to healthcare. The development of the course followed a preliminary framework based on the Process Model for Successful Anti-Stigma Programming for Students in Healthcare (Knaak & Patten, 2015) and was subsequently adapted and refined through a focus group interview (Ma & Hsieh, 2020a). In addition to lectures, this course incorporated experiential activities such as social contact, role-playing, and critical reflection. Two major group assignments were undertaken: (1) accompanying an individual living with disabilities in the community to jointly perform activities chose by the individual, and (2) role-playing a person living with disabilities and their companions in the community. The purpose of the role-playing assignment was clarified as focusing not on the disabilities themselves, but on experiencing physical and social environmental barriers that may have previously gone unnoticed (Barney, 2012). Students wrote reflection essays based on their group activities and were encouraged to propose practical ideas for promoting friendly interactions with individuals living with disabilities. An overview of the course objectives, thematic structure, and core activities is presented in Table 1.

Table 1.

Objectives, Themes, and Activities of the Anti-Stigma Course

Anti-stigma course	Components
Objectives	• To enhance knowledge related to improving the quality of professional healthcare relationships
	• To increase sensitivity to stigma, including prejudice, stereotypes, and discrimination towards illness in the environment
	• To strengthen understanding and awareness of friendly and respectful interactions in healthcare settings
	• To cultivate a reflective attitude and foster the capacity to take inclusive actions
Main themes	• Understand healthcare relationship
	○ Empathic skills
	○ Reciprocity of care dynamics
	• The concept of stigma
	○ Labeling, stereotype, prejudice, discrimination, microaggression, implicit bias
	○ Stigma associated with disorders and disabilities, influence of stigma especially in healthcare settings
	• Disability awareness
	○ Convention on the Rights of Persons with Disabilities (CRPD)
	○ Social contact and the human library®
	○ Medical model versus social model of health
	• Everyday advocacy
In-class discussions	• “My caregiving network”
	• “Naming, Blaming, and Framing: How Labels Shape Us”
	• “Looking back: Sharing our experiences with classmates with special needs”
Assignments	• Collaborative community engagement with individuals with disabilities
	○ To engage in shared community-based activities with individuals with disabilities to foster mutual understanding, empathetic reflection, and critical awareness of stigma through direct interaction
	• Simulated disability experience in community context
	○ To simulate the everyday experiences of individuals with disabilities in public spaces through role-play, and critically reflect on social stigma, accessibility barriers, and inclusive practices from a first-person perspective
Key references	• The logic of care: Health and the problems of patient choice (Mol, 2008)
	• The stigma complex (Pescosolido & Martin, 2015)
	• The stigma experience of patients with Schizophrenia receiving mental health services (Wang et al., 2017)

Control: Sociology Course

The sociology course served as an introductory course for healthcare students, focusing on essential concepts and theories. Primarily delivered through lectures, the course also incorporated documentaries, classroom activities, and discussions to enhance understanding. The curriculum covered various themes, including sociological imagination, culture, social classes, gender, deviance, and stigma. Students completed two writing assignments: one related to films about infectious diseases (particularly relevant given the recent COVID-19 pandemic) and another focused on popular sociology books. Students also engaged in a group project involving critical analysis of social issues. The control group received only a 2-hour reading and lecture about stigma, without any assignments specifically addressing anti-stigma practices.

Statistical Analysis

Statistical analyses were conducted using IBM SPSS 17.0 software (SPSS Inc., Chicago, IL, USA). Baseline characteristics of the AS and CT groups were compared using χ² tests for categorical variables and independent t tests for continuous variables. In addition, one-tailed paired t tests were used to examine the differences between pretest and posttest scores for the AS and CT groups separately. To test Hypothesis 1, one-tailed independent t tests were conducted to compare change scores (posttest minus pretest) between the AS and CT groups. For Hypothesis 2, one-tailed paired t tests were used to compare the social distance between mental illness and physical disabilities in all students.

Results

The study included 65 OT students, with 33 in the AS group and 32 in the CT group. Participant characteristics are summarized in Table 2, and no significant differences were found between the two groups.

Table 2.

Participant Characteristics (N = 65)

	Anti-stigma group (n = 33)	Control group (n = 32)
Gender (n, %)
Women	25 (75.0%)	24 (75.8%)
Men	8 (25.0%)	8 (24.2%)
Age, years, M (SD)	18.52 (0.83)	19.50 (0.92)
SES, M (SD)	3.12 (0.70)	3.19 (0.78)
Have suffered from physical or mental illness? (n, %)
Yes	3 (9.1%)	3 (9.4%)
No	30 (90.9%)	29 (90.6%)
Have family members or friends with disabilities? (n, %)
Yes	3 (9.1%)	10 (31.3%)
No	30 (90.3%)	22 (68.8%)

Note. SES = socioeconomic status, ranging from 1 (low) to 5 (high).

Table 3 presents the pretest and posttest data of the two groups. For the within group differences, the AS group had significant decreases in social distance towards mental illness (total score: t₍₃₂₎ = 2.24, one-tailed p = .016; item 4: t₍₃₂₎ = 2.60, p = .007). The AS group also had significant decreases in stigmatizing attitudes (t₍₃₂₎ = 1.98, p = .028) and social distance towards physical disabilities (total score: t₍₃₂₎ = 2.14, p = .020; item 1: t₍₃₂₎ = 2.26, p = .016; item 4: t₍₃₂₎ = 2.44, p = .011; item 5: t₍₃₂₎ = 1.76, p = .044; item 7: t₍₃₂₎ = 2.52, p = .009). In contrast, the CT group had significant increases in social distance towards physical disabilities (item 3: t₍₃₁₎ = −1.76, p = .044; item 4: t₍₃₁₎ = −2.35, p = .013; item 6: t₍₃₁₎ = −2.37, p = .012).

Table 3.

Results of t Tests on the Pretest and Posttest Scores of the Stigmatizing Attitudes Questionnaires and Social Distance Scales in the Anti-Stigma Group and Control Group

	Anti-stigma group (n = 33)			Control group (n = 32)			Independent t test
	Pretest	Posttest	Change	Pretest	Posttest	Change	t ₍₆₃₎	p
	M (SD)	M (SD)	M (SD)	M (SD)	M (SD)	M (SD)	t ₍₆₃₎	p
Stigmatizing attitudes towards …
Mental illness	2.32 (0.64)	2.35 (0.59)	0.03 (0.63)	2.39 (0.61)	2.55 (0.77)	0.16 (0.70)	0.767	.223
Physical disabilities	2.96 (0.59)	2.68 (0.74)	−0.27 (0.79)^*	2.79 (0.62)	2.92 (0.60)	0.13 (0.74)	2.087^*	.021
Social distance scale towards mental illness
Item 1-as a neighbor	2.82 (0.95)	2.64 (1.11)	−0.18 (0.92)	2.78 (1.04)	2.84 (0.92)	0.06 (0.95)	1.056	.148
Item 2-as a co-worker	2.64 (0.86)	2.48 (0.87)	−0.15 (0.83)	2.56 (0.88)	2.50 (0.72)	−0.06 (0.76)	0.450	.328
Item 3-as a friend	2.39 (0.90)	2.18 (0.77)	−0.21 (0.82)	2.19 (0.78)	2.41 (0.71)	0.22 (0.83)	2.103^*	.020
Item 4-rent my house	3.03 (1.02)	2.61 (1.00)	−0.42 (0.94)^*	2.66 (1.04)	2.94 (0.95)	0.28 (1.30)	2.515^*	.007
Item 5-recommend for a job	2.34 (0.75)	2.15 (0.83)	−0.19 (0.78)	2.09 (0.86)	2.28 (0.77)	0.19 (0.90)	1.786^*	.040
Item 6-as an in-law	3.61 (1.20)	3.42 (1.03)	−0.18 (1.01)	3.09 (1.28)	3.34 (0.83)	0.25 (0.98)	1.742^*	.043
Item 7-take care of my child	4.03 (1.21)	3.79 (0.99)	−0.24 (1.00)	3.97 (1.28)	3.78 (1.01)	−0.19 (1.20)	0.200	.421
Total score	2.98 (0.73)	2.75 (0.73)	−0.23 (0.59)^*	2.76 (0.84)	2.87 (0.62)	0.11 (0.77)	1.974^*	.027
Social distance scale towards physical disabilities
Item 1-as a neighbor	2.18 (0.77)	1.88 (0.70)	−0.30 (0.77)^*	2.03 (0.86)	2.25 (0.76)	0.22 (0.87)	2.562^*	.007
Item 2-as a co-worker	2.24 (0.87)	2.03 (0.85)	−0.21 (0.89)	2.13 (0.83)	2.22 (0.66)	0.09 (0.82)	1.439	.078
Item 3-as a friend	2.00 (0.79)	1.85 (0.67)	−0.15 (0.76)	1.81 (0.69)	2.06 (0.67)	0.25 (0.80)^*	2.077^*	.021
Item 4-rent my house	2.42 (0.90)	2.00 (0.75)	−0.42 (1.00)^*	2.00 (0.80)	2.34 (0.83)	0.34 (0.83)^*	3.366^*	.001
Item 5-recommend for a job	2.00 (0.71)	1.76 (0.66)	−0.24 (0.79)^*	1.97 (0.74)	2.12 (0.75)	0.16 (0.85)	1.962^*	.027
Item 6-as an in-law	3.13 (1.29)	3.06 (1.00)	−0.09 (0.89)	2.72 (1.20)	3.16 (0.77)	0.44 (1.05)^*	2.186^*	.017
Item 7-take care of my child	3.00 (1.12)	2.61 (1.03)	−0.39 (0.90)^*	3.44 (1.22)	3.19 (1.15)	−0.25 (1.27)	0.529	.301
Total score	2.42 (0.77)	2.17 (0.66)	−0.25 (0.68)^*	2.30 (0.75)	2.48 (0.59)	0.18 (0.71)	2.512^*	.008
	Paired t₍₃₂₎	Paired t₍₃₂₎		Paired t₍₃₁₎	Paired t₍₃₁₎
Social distance scale-total scoreMental illness versus physical disabilities	5.557 (p < .001)	5.906 (p < .001)		4.078 (p < .001)	3.727 (p = .001)

Note. ^*p < .05.

For the between-group differences, results of independent t tests indicated that compared with the CT group, the AS group had significantly greater decreases in social distance towards mental illness (total score and items 3, 4, 5, and 6), as well as decreases in stigmatizing attitudes and social distance towards physical disabilities (total score and items 1, 3, 4, 5, and 6).

Finally, we compared the total score of the social distance scale between mental illness and physical disabilities. Results of paired t tests indicated the AS and CT groups both had significantly greater social distance towards mental illness than physical disabilities in the pretest and posttest (Table 3).

Discussion

Stigma has been identified as a crucial issue in delivering OT services (AOTA, 2020). Offering an anti-stigma program for OT students becomes imperative in addressing stigma-related challenges. This study examined the changes in stigmatizing attitudes and social distance after an anti-stigma course and compared OT students’ social distance towards mental illness and physical disabilities. The overall results support our hypotheses. For Hypothesis 1, we found that, compared with the CT group, the AS group reported a greater reduction in social distance towards mental illness and decreases in both stigmatizing attitudes and social distance towards physical disabilities. These significant differences were primarily driven by a reduction in negative attitudes within the AS group, while the CT group reported an increase in such attitudes. Regarding Hypothesis 2, the AS and CT groups both reported greater social distance towards mental illness than physical disabilities in the pretest and posttest.

The findings of the AS group in this study are partially consistent with those of the pilot study (Ma & Hsieh, 2020a) that reported a decrease of social distance towards mental illness. This study additionally reported decreases in stigmatizing attitude and social distance towards physical disabilities that were not observed in the pilot study. With a sample size larger than the pilot study, the present study provides stronger evidence supporting the benefits of the anti-stigma course.

We believe that the combination of social contact, role-playing, and critical reflection strategies in the anti-stigma course contributed to the attitude changes observed in students. For Assignment 1, interacting with individuals living with disabilities in the community gave students opportunities to understand them as full human beings in their everyday life rather than merely viewing them as sick roles in the clinical context. Notably, those individuals tended to select activities that they enjoyed or were skilled at to do with our students, showing their strength and competence and thus counteracting disability stereotypes the students might previously have had.

In Assignment 2, students reported that role-playing as individuals with disabilities and their companions in the community enabled them to delve into the inner world of these roles and experience the implicit and explicit stigma prevalent in society. Barney (2012) emphasized the value of disability simulation from the perspective of the social model of disability. By being guided to observe social interactions, students had the opportunity to confront and reassess their own attitudes as they experienced such biases being directed towards them during the role-play.

In contrast, the CT group reported significant increases in some items of the social distance scale towards physical disabilities (e.g., friend, renting, and in-law) after completing the sociology course that included only a brief 2-h lecture on stigma. Unlike the anti-stigma course, the sociology course did not include structured engagement with individuals with disabilities or opportunities for guided reflection. Moreover, this course was delivered partially online during the COVID-19 pandemic, with posttests either delayed or conducted remotely. We speculate that the lack of face-to-face interaction and experiential learning may have limited students’ opportunities to challenge biases or develop empathetic understanding.

In addition, we speculate that the broader social context of the pandemic may have contributed to increased social distance scores. During the height of COVID-19, heightened fear of contagion, widespread health-related anxiety, and persistent media narratives emphasizing vulnerability and risk may have unconsciously reinforced avoidance-based thinking and risk-averse attitudes (Pfefferbaum & North, 2020). These social and emotional conditions may have generalized into a more cautious or distanced attitude not only towards illness but also towards people perceived as more “vulnerable,” such as those with physical disabilities (Sotgiu & Dobler, 2020).

Taken together, these contextual observations highlight the need for intensive, multimodal anti-stigma education—particularly in the post-pandemic era—when residual social anxiety and public perceptions of vulnerability may continue to shape students’ implicit attitudes. Well-designed educational interventions that incorporate experiential learning, social contact, and critical reflection are essential to address these lingering effects and foster more inclusive attitudes among future healthcare professionals.

In addition, using the concept and methodology of the social distance scale, we conducted a comparative analysis of the willingness of OT students to engage in relationships of varying levels of intimacy with individuals with mental illness versus physical disabilities. The AS and CT groups both reported significantly greater social distance towards mental illness compared with physical disabilities, in both the pretest and posttest. These findings align with previous research that reported greater social distance towards mental illness as opposed to physical impairment (Huskin et al., 2018). Although these results may reflect the prevalent public stigma in society, they also highlight the urgent need to address mental health stigma among OTs (Pan & Muñoz, 2019).

This study has some limitations. First, because we were unable to randomly assign students to the anti-stigma or sociology course, there is a potential threat of selection bias to the establishment of causal relationships between the anti-stigma program and attitude changes. Second, explicit measures of stigmatizing attitudes, such as those used in this study, might not fully reflect students’ true attitudes due to social desirability bias. Future research could incorporate measures of implicit bias, such as the implicit association test (Friedman & VanPuymbrouck, 2021a, 2021b), to obtain a more comprehensive understanding of students’ attitudes towards individuals with disabilities.

Third, the COVID-19 pandemic necessitated a shift to online teaching for the sociology course during the semester, resulting in postponed or online administration of the posttest. In addition to introducing procedural heterogeneity, the broader social context of the pandemic may have influenced participants’ attitudes, which could pose a historical threat to the internal validity of our study. Finally, the anti-stigma course was designed based on a literature review and focused group interview with experts. Co-designing the course with individuals with lived experience of mental illness or physical disabilities may provide valuable insights and enhance its effectiveness.

Conclusions

Individuals with mental illness and physical disabilities are major recipients of OT services. Our study demonstrated that OT students who participated in the anti-stigma course reported greater decreases of negative attitudes towards mental illness and physical disabilities compared with the control group. The results suggest that a multimodal teaching approach involving social contact, role-playing, and critical reflection may diminish negative attitudes in OT students. Moreover, given the positive outcomes observed among OT students, this course model also holds potential for broader application. With appropriate adaptation of content and learning objectives, the anti-stigma course could be implemented as a general education offering to promote critical awareness of stigma, diversity, and inclusion among students across various disciplines. However, it is important to acknowledge that all students, regardless of the course they took, reported greater social distance towards mental illness compared with physical disabilities in both the pretest and posttest. Therefore, ongoing refinement of anti-stigma courses, with a specific focus on addressing mental health stigma, is crucial to enhancing awareness of bias towards OT service recipients.

Footnotes

ORCID iD

Hui-Ing Ma

Ethical Consideration

Informed Consent

Informed written consent was obtained from all participants.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was funded by the Ministry of Science and Technology in Taiwan (MOST 105-2511-S-006-007-MY3, MOST 108-2511-H-006-010-MY3).

Declaration of Conflicting Interest

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

Data Availability Statement

The data of this study are available on the reasonable request to the corresponding author.*

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