Examining the Meaning of the Rural Advantage in Employment for Social Integration

Dr. Gnanavel’s letter has raised several interesting methodological issues related to our paper (1) comparing employment status of individuals with psychotic disorders in rural versus urban areas of China.

Employment is only one measure of social integration and social inclusion. We certainly agree that other measures of social integration beyond employment are needed (2). But fundamental differences in urban and rural environments make it extremely difficult to develop instruments that can validly assess social integration in both settings. Employment status is one of a very small set of variables about social functioning that can be readily measured and meaningfully compared (with the caveats noted below) between urban and rural settings. More detailed evaluation of community networking and social support may require the development of rural-specific and urban-specific measures; information from surveys that use these scales could then be used to devise and assess targeted interventions.

The need to consider work hours and work satisfaction when assessing the occupational functioning of persons with schizophrenia. We agree with the general point that more indepth quantitative and qualitative data would enhance the interpretation of rural vs urban differences in employment, and encourage researchers to collect such data in future studies. Separate consideration of part-time versus full-time work would provide a more detailed understanding of the work status of persons with schizophrenia. As we indicate in the discussion, we believe that the greater flexibility of work in rural areas (i.e., allowing for part-time and full-time work depending on the individual’s condition) may be an important factor in the higher rates of employment in rural areas. Comparisons of work satisfaction could also be useful, but such comparisons would require careful development of measures of work satisfaction that can be meaningfully compared for people with schizophrenia across these settings; to our knowledge, such measures are not yet available.

Collapsing all psychotic illnesses under the ‘schizophrenia’ rubric when assessing work status. In this study 90% (86/96) of urban residents with a psychotic illness and 81% (240/297) of rural residents with a psychotic illness had schizophrenia so we used ‘schizophrenia’ as the overarching label for these individuals. We agree with Dr. Gnanavel that there may be differences in the employment status of individuals with schizophrenia compared to those with other psychotic disorders, but inclusion of this variable (i.e., schizophrenia vs. other psychotic disorders) as a separate variable in our multivariate analysis did not appreciably affect our final results.

The need to adjust comparison of urban versus rural employment rates in persons with schizophrenia for differences in rural versus urban rates of employment in the general population. Official unemployment rates –the proportion of individuals 15 to 59 years of age in the workforce--in China are notoriously unreliable. Moreover, comparison of urban versus rural employment rates are confounded by the much larger number of young adults in school in urban versus rural areas (an issue we have adjusted for in our analysis) and by the huge number of individuals who migrate from rural to urban areas for work. Thus it was not feasible to adjust for this factor in our analysis. We think it is unlikely that any differences in general employment levels between urban and rural residents would explain the more than three-fold difference in employment (94% v. 27%) we identified in rural versus urban residents with psychotic disorders. Nonetheless, if reliable data on rural versus urban differences in the general population were available, they might enhance interpretation of our results.

These issues raised by Dr. Gnanavel, in addition to considering premorbid employment as we indicate in the discussion, certainly merit consideration and suggest directions for future research. We do not, however, believe that they seriously undermine the key finding of our paper. This large, community-based study in China (3) (4) found that opportunities for employment for individuals with psychotic illnesses is much greater in rural than urban areas. The employment available in rural areas is largely restricted to that of agricultural worker and may only be part-time, but it is, nevertheless, an important indicator of social integration. Further studies are needed to unravel the full implications of this rural versus urban employment difference for social integration, and to determine the extent to which the increased employment opportunities of rural residents with schizophrenia are related to stigma (5) and to other measures of social integration.