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. Author manuscript; available in PMC: 2022 May 1.
Published in final edited form as: Int J Soc Psychiatry. 2021 Feb 7;68(3):610–618. doi: 10.1177/0020764021992807

Mental health-related stigma and attitudes toward patient care among providers of mental health services in a rural Chinese county

Yuer Deng 1, An-Li Wang 2, Rosemary Frasso 3, Mao-Sheng Ran 4, Tian-Ming Zhang 5, Dexia Kong 6, Yin-Ling Irene Wong 7
PMCID: PMC8668239  NIHMSID: NIHMS1748531  PMID: 33554704

Abstract

Background and aims:

The increasing prevalence of mental illness and low treatment rate presents a pressing public health issue in China. Pervasive stigma is a significant barrier to mental health recovery and community inclusion. In particular, stigmatizing or supportive attitudes held by healthcare providers could either perpetuate or mitigate self-stigma of people with mental illness. Moreover, mental health resources are unevenly distributed in China, with most of them concentrated in urban centers and provincial capitals. This study explores healthcare providers’ attitudes toward mental illness and the challenges they faced at work in a rural Chinese county.

Method:

Four focus groups were conducted with 36 healthcare providers from a three-tier mental healthcare system in a rural county in southwestern China. Focus group discussions were recorded and transcribed verbatim. The team employed a conventional content analysis approach for data analysis. All transcripts were double-coded by three bilingual team members who are native Chinese speakers. Coding discrepancies were resolved by consensus.

Results:

Healthcare providers recruited from the county, township, and village levels varied in educational background, professional qualification, and experience of working with people with mental illness. Five thematic categories identified across four groups include (1) barriers to mental healthcare delivery, (2) keys to mental health recovery, (3) providers’ attitudes toward providing care, (4) providers’ perception toward patients and family members, and (5) providers’ perception of training needs.

Conclusions:

This is a unique study that included healthcare providers from a three-tier healthcare system. Findings signal the importance of understanding healthcare practitioners’ experiences and views to inform the design of training initiatives in rural or low-resource communities.

Keywords: Mental healthcare delivery, healthcare providers’ attitudes, rural China, mental health-related stigma

Introduction

Mental health-related stigma is considered a public health issue that hampers the proclivity of people living with mental health challenges toward seeking help and treatment (Clement et al., 2014; Corrigan, 2004; Schomerus & Angermeyer, 2008; Thornicroft et al., 2008; Wrigley et al., 2005). Numerous studies found that stigma had an adverse effect on severity of symptoms, engagement in mental health treatment, self-esteem, sense of empowerment, and recovery among people with mental illness (Dabby et al., 2015; Li et al, 2014; Link et al., 2001; Wang et al., 2018; Zhang et al., 2019). The structural disadvantages associated with stigma and discrimination are prevailing in the spheres of education, employment, social relationships, community inclusion, and access to and quality of health care (Corrigan et al., 2004; Hatzenbuehler et al., 2013; Link & Phellan, 2006; Tsang et al., 2007).

Since China adopted its economic reform and open-door policy in the late 1970s, unparalleled economic growth and rapid marketization have prompted shifting demands on Chinese citizens, leading to elevated levels of psychological distress and anxiety, increasing prevalence of mental disorders, and alarmingly high rates of suicide (Chang & Kleinman, 2002). An estimated 16.6% of China’s 1.3 billion people have a diagnosis of at least one psychiatric disorder in their lifetime and more than 90% of those with a serious disorder never received treatment (Huang et al., 2019; Phillips et al., 2009). Care seeking is impacted by stigma of mental illness, which is deep-rooted in a collectivist and family-centered culture like China. Devaluating attitudes and discriminatory actions are extended to the family, further undermining the likelihood of utilization of mental health services (Lam et al., 2010; Ramsay, 2010; Wong et al., 2018).

While people with mental illness and their family members who established positive relationships with knowledgeable, approachable and empathetic healthcare providers reported feeling less labelled or stigmatized (Knox et al., 2014), some providers still hold stigmatizing attitudes towards people with mental illness. This has shown to adversely affect the quality of health care people with mental illness received and the willingness of family members to engage with healthcare providers as partners in care (Henderson et al., 2014; Mestdagh & Hansen, 2014; Pearson, 1993). Although medical doctors who specialize in psychiatry have advanced training about mental illness, the extent to which mental health knowledge and experience mitigate against stigma is inconclusive. For example, two studies found no group differences in explicit, that is, conscious and controllable, forms of negative bias between medical residents and psychiatrists, and between medical students and mental health professionals (Dabby et al., 2015; Kopera et al., 2015). Despite the evidence that psychiatrists and psychiatric staff hold more positive views toward people with mental illness than non-psychiatric medical staff, mental health professionals have consistently hold a desire to distance themselves from patients, particularly from those with schizophrenia (Hori et al., 2011; Reavley et al., 2014; Van Dorn et al. 2005).

Providers’ characteristics such as length of practice in the mental health field, causal attribution beliefs, contact quality with psychiatric patients, personal and family experience of mental illness, satisfaction with income, and professional burnout, have been shown to be correlates of stigma in mental healthcare settings (Corrigan et al., 2003; Henderson et al., 2014; Wang et al., 2017). A systematic review on stigma among healthcare professionals toward patients with substance use disorders further identified contextual factors including supportive organizational policy, role support by colleagues, availability and accessibility of support structures, and clinical supervision, and education and training to be associated with improved attitudes among healthcare professionals (Van Boekel et al., 2013).

Effective stigma reduction interventions are essential for inculcating positive attitudes held by healthcare providers toward people with mental illness and their families. However, stigma reduction programs targeting healthcare providers are scant in China, and most of those that were identified, were conducted in urban areas (Li et al., 2014; Li et al., 2015). To date, there are only a few published studies that explored attitudes toward mental illness held by healthcare providers in rural China (Ma et al., 2015; Ma et al., 2018). Rural areas lack professional mental health services, which are otherwise available in city-level and provincial-level hospitals in the Chinese healthcare system (Ma et al., 2015).

The data reported in this study were collected as a needs assessment of rural healthcare providers about their perspectives on and experiences of providing mental healthcare and training needs. In contrast to most prior studies that examined attitudes held by mental health professionals with formal medical training such as psychiatrists and psychiatric nurses, this study focused on mental health professionals with medical training, primary healthcare providers, as well as lay community health workers who had non-healthcare backgrounds. These healthcare providers were part of a local three-tier mental healthcare system in rural China. This exploratory, qualitative study documented healthcare providers’ attitudes toward mental illness and mental health services delivery.

Methodology

This study was an international collaboration and it was approved by the Human Research Ethics Committee at The University of Hong Kong in China and the Institutional Review Board at the University of Pennsylvania in the United States. All study participants provided written informed consent.

Study site

The study was conducted in a rural county in Chengdu, located in the southwestern region of China. A three-tier mental healthcare system delivers mental health services, treatment, and prevention in the study site through a county-level psychiatric hospital, 13 township hospitals and 73 village clinics. Physicians with 4-year or 2-year college-level medical training provide outpatient and inpatient care in a 300-bed county psychiatric hospital. The hospital medical staff also coordinate community-based care management, and conduct mental health education and psychological counseling. Healthcare providers at the township level and community health workers at the village level work under county-level physicians as members of the community care management team, performing prevention services including regular wellness visits with mental health patients who are in the county registry, ensuring treatment and medication adherence of patients, facilitating yearly physical examination by nurses, and maintaining paperwork for the patient registry. In addition to working in the community care management team, township and village providers deliver clinical services and public health education to the general population.

Study sample

Four focus groups were conducted at the study site. Participants were recruited through the liaison office in the county psychiatric hospital. Participants were 18 years old or above who were providing services and support to people with mental illness at the time of the study. Invitation letters were sent to potential participants in the mental healthcare system.

As the study county has 13 townships and each township hospital has a mental healthcare provider, all township-level providers were invited and they all agreed to participate. For the village-level providers, the hospital liaison office invited 13 village health workers, one from each of the 13 townships. These 13 village-level participants were drawn from a population of 73 village health workers using convenience sampling. All 13 invited village health workers agreed to participate. There were 13 physicians working in the county psychiatric hospital and 10 were invited based on their availability to join the group. All 10 physicians accepted the invitation and they were assigned to either the “senior” or “junior” group based on their position and rank in the hospital, and work experience with the population.

A total of 36 healthcare providers participated in the study (Table 1). The distribution of educational level was similar between the two county physician groups but varied between township and village groups. Some township healthcare providers had college-level education in nursing, public health, or other allied health disciplines, whereas most village community health workers did not have formal health-related training.

Table 1:

Characteristics of the study sample.

County
(senior)		 County
(junior)		 Township Village
Sample size 5 5 13 13
Education N (%)
 High school or below 0 (0%) 0 (0%) 1 (8%) 6 (46%)
 Associate degree 3 (60%) 3 (60%) 12 (92%) 7 (54%)
 Bachelor degree 2 (40%) 2 (40%) 0 (0%) 0 (0%)
Age (year) MEAN (SD) 45.6 (10.7) 29.6 (5.9) 35.3 (7.5) 41.9 (6.4)
Gender N (%)
 Females 0 (0%) 4 (80%) 10 (77%) 9 (69%)
 Males 5 (100%) 1 (20%) 3 (23%) 4 (31%)
Work experience (year) N (%)
 <5 0 (0%) 3 (60%) 8 (62%) 9 (69%)
 5-10 2 (40%) 0 (0%) 5 (38%) 4 (31%)
 >10 3 (60%) 2 (40%) 0 (0%) 0 (0%)
Monthly income (renminbi/Chinese Yuan) N (%)
2,000-3,999 0 (0%) 2 (40%) 11 (85%) 10 (77%)
4,000-5,999 0 (0%) 3 (60%) 2 (15%) 2 (15%)
6,000-8,000 4 (80%) 0 (0%) 0 (0%) 1 (8%)
>8,000 1 (20%) 0 (0%) 0 (0%) 0 (0%)
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Mean age of participants varied from 29.6 (±5.9) in junior physician group to 45.6 (±10.7) in senior physician group. The mean age of township healthcare providers was 35.3 (±7.5) and that of village health workers was 41.9 (±6.4). Apart from the group of senior county physicians that was 0% female, the other three groups each had more female than male participants. In terms of experience in mental healthcare, 50% of the county physicians (i.e. senior and junior) had more than 10 years of work experience, while 62% of township healthcare providers and 69% of village health workers had less than five years of experience. As for monthly income, senior county physicians earned 6000 renminbi (RMB) or more, while most of the participants from the township and village groups earned less than 4000 RMB.

Study procedure

The focus groups were conducted in March 2018 by a team of trained facilitators at the county psychiatric hospital and lasted between 1.5 and 2 hours. All team members had advanced degrees in neuroscience or social work and training/experience in qualitative research. The facilitators worked in pairs, including a moderator and a note taker. The moderators explained the purpose of the study and the format of focus group discussions, and reviewed the consent form with each individual to assure they understood that participation was voluntary and they had an opportunity to decline the invitation to participate.

All focus groups were conducted in Mandarin Chinese using a focus group discussion script with seven questions. The questions included: perceptions about and experience of working with patients and family members (question 1 and question 2); barriers and challenges in providing mental healthcare (question 3); strategies to manage challenges and overcome barriers (question 4); types of training and knowledge considered to be helpful to participants (question 5 and question 6); and other services that benefit patients and family members. Participants received a small honorarium for participating at the conclusion of the focus groups.

Data analysis

Focus group discussions were audio-recorded, transcribed verbatim, and analyzed using a conventional content analysis approach by the interdisciplinary research team. According to Hsieh and Shannon (2005), this approach is used when existing theory or related literature is limited, and it allows the categories to develop directly from the data instead of using preconceived categories.

All transcripts were double-coded independently by three bilingual team members who were native Chinese speakers to ensure trustworthiness (Y.D., A.W., Y.W.). First, two coders (Y.D., A.W.) reviewed the transcripts line by line and coded words and phrases (in vivo coding/open coding) that captured the key ideas conveyed in the discussions. Second, the first author (Y.D.) reviewed all the codes and derived a preliminary code book with thematic categories and sub-themes based on in vivo codes. Third, A.W. and Y.W. reread and recoded all the transcripts following the preliminary code book. In the process, they identified additional categories and sub-themes that were not included in the preliminary code book. Each focus group transcript was then re-coded by two coders based on the revised code book. The overall Cohen’s kappa for the four focus groups was 0.85, with individual kappa for each of the four groups ranging from 0.78 to 0.89. Coding discrepancies were then resolved by consensus among the three coders. The entire coding process was conducted in Chinese to preserve the cultural and linguistic nuances of the discussions.

Two coders, Y.D. and Y.W., reviewed the data iteratively and identified illustrative quotes for all sub-themes. Illustrative quotes for the top three sub-themes per each thematic category, based on the number of times the sub-theme was found in focus group discussion, were translated into English using backward translation method and included in the results section.

Results

Five thematic categories were identified across 4 focus groups. Within each category, between 4 and 8 subthemes were identified. As table 2 shows, the 5 thematic categories are: 1) barriers to mental healthcare delivery, 2) keys to mental health recovery, 3) providers’ attitudes toward providing care, 4) providers’ perception toward patients and family members, and 5) providers’ perception of training needs. Table 2 also shows the number of times each group mentioned the 31 subthemes. As the data show, county physicians (particularly junior level) were less interested in training initiatives but mentioned more about their attitudes toward providing care. Township healthcare providers spoke mostly about the barriers to mental healthcare delivery. Keys to mental health recovery were the most frequently discussed theme among village health workers.

Table 2:

Thematic categories and sub-themes

Number of times the sub-theme was raised
Thematic categories Sub-themes County
(senior)		 County
(junior)		 Township Village Total
1. Barriers to mental healthcare delivery Healthcare system barriers such as cost and lack of government leadership 8 12 31 3 54
Weak family support such as lack of resources, negligence, rejection 11 9 19 12 51
Prejudice, discrimination and devaluation from the public 6 4 8 4 22
Internalized stigma experienced by patients or family members 1 6 7 5 19
Societal factors such as elevated level of stress and poverty 6 1 3 5 15
Complex nature of mental illness such as comorbidity and chronicity 1 5 0 2 8
Lack of knowledge about mental health policy and services 0 1 1 5 7
Cultural barriers such as lay beliefs, folk religion 3 0 0 2 5
2. Keys to mental health recovery Importance of government leadership in policy and support 4 3 7 21 35
Restored functioning in work and integration of patients as normal people 2 6 3 14 25
Society-wide publicity campaign and family psychoeducation 1 5 6 13 25
Psychological support through empathy, mutual care, self-affirmation 0 1 4 12 17
Social acceptance from the general public 2 1 9 2 14
Strengthening support network including family and healthcare provider 0 1 3 9 13
Adherence to medication regimens 0 3 1 2 6
3. Providers’ attitude toward providing care Stress including occupational hazard, personal safety, public accountability 18 13 25 4 60
Choice/willingness in taking up mental healthcare work 7 6 8 2 23
Associative stigma experienced by provider because of working with patients 4 11 0 1 16
Providing mental healthcare is just another job 3 1 3 3 10
Lack of adequate knowledge to do the job well 5 1 2 2 10
Accepting patients as who they are and start where they are 0 1 0 6 7
4. Providers’ perception toward patients and family members Ambivalent feelings toward patients 13 7 11 10 41
Negative perception toward patients 5 4 10 12 31
Negative perception toward family members 5 6 6 6 23
Ambivalent feelings toward family members 2 2 0 10 14
Positive perception toward patients 2 0 1 4 7
Positive perception toward family members 1 1 0 5 7
5. Providers’ perception of training needs Professional knowledge such as diagnosis and medication 6 0 11 13 30
Communication skills with patients, families, other stakeholders 2 0 6 11 19
Practical knowledge to operate in real-world situations 3 1 6 5 15
Counseling and psychotherapy with patients 0 4 1 4 9
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Illustrative quotes identified for the three most frequently mentioned sub-themes for all groups (last column of table 2) under each of the five thematic categories are presented in the following.

Barriers to mental healthcare delivery

The top three barriers mentioned by participants included healthcare system barriers, weak family support, and discrimination and devaluation from the public.

Mental health services cannot be provided solely by village ‘doctors’ or hospitals…I do this mental health work, but the government did not take an interest in our work…What is important is the government…they should pay attention to our village doctors and help us get the job done easier. (Village Health Worker)

The attitude of the family is that they don’t take care of the patients. Sometimes they just abandon patients in the hospital and let us take care of them. Only few family members pay attention. After all, after patients have been sick for a long time, they (family) just give up. (County Physician, Junior)

Actually, except for those who work in this field or those who are related to this field like us, most people in the society now treat people with mental illness with a lot of discrimination. (County Physician, Junior)

Keys to mental health recovery

In consonance with the view that an inadequate health care system was a major barrier to effective service delivery, healthcare providers at all levels emphasized that the government should take up the leadership role in supporting patients to integrate into society. Relatedly, there is consensus among participants regarding restoring patients’ social functioning through paid work and other productive activities as the chief avenue for normalization. Healthcare providers also pointed to the importance of launching publicity campaign to increase mental health literacy, and providing psychoeducation for families affected by mental illness.

Patients with mental illness need well-rounded services. People became poor because of illness or returned to poverty due to illness, which is a serious phenomenon right now…I feel like patients can be provided with help from policy, medical and even monthly financial assistance…not only medical help is needed, their daily life also needs help. (County Physician, Senior)

Employment: it seems like simple jobs are suitable for patients with mild mental illness…Well, if their needs are guaranteed, their illness can be better controlled. If financial problems emerge, patients are prone to get sick again. (Village Health Worker)

I think we should increase publicity…Everyone should think that mental illness is not a big deal. It is just like other chronic diseases such as hypertension and diabetes, these are all the same…Only relying on us, mental health providers, is not enough. We definitely need the whole society working together…so that everyone, the whole society accepts this group of people. (Township Healthcare Provider)

Providers’ attitudes toward providing care

Occupational hazards and personal safety related to their job as healthcare providers was the most common sub-theme, followed by the extent of choice or willingness in taking up mental healthcare work, and associative stigma experienced because of working with mental health patients.

We are providers in primary health centers, all working part-time in this job. I feel that we don’t have sufficient energy…you have to engage in both clinical work and mental health prevention work. The level of stress is really high, not to mention that there are many inspections every other day or so…I really want to do this job well…but I am really unable to do what I hope to…I have to call those seriously ill patients frequently. (Township Healthcare Provider)

Because government policy designates that village “doctors” have to provide a certain amount of public health work, so I did not choose to do this job in the beginning. After I started doing this, I just went with the flow doing my job. (Village Health Worker)

I am embarrassed to say that I’m working in a psychiatric unit when we have college alumni gatherings…I feel a little bit despised…mental health doctors are not being respected in society. (County Physician, Junior)

Providers’ perception toward patients and family members

The overwhelming response from participants when asked about their perception toward patients and family members was either ambivalent or negative. Healthcare providers simultaneously expressed having compassion and strong dislike toward patients. They found some of their patients to be grateful for their support and services, whereas others lacked illness insights and were treatment non-adherent. Township and village providers decried the potential danger they faced because of the tendency of patients to act violently and unpredictably.

Patients with mental illness are pitiful but sometimes very hateful. What are they doing? It is a social problem, and not just a health problem. When people with mental illness are in relapse, first they harm themselves, then they attack their families. They are also a danger to society. So sometimes you feel both pitiful and hateful for them. But as a group, if people who work in psychiatric hospitals don’t care about this group, then no one cares about them. After all, the society should care about them. (County Physician, Senior)

A person with mental illness is definitely hard to communicate with…I feel annoyed by patients who tend to be violent. When you do your job, you are in danger when you conduct follow-up visits. (Village Health Worker)

Many family members do not do well providing care and guardianship for people with mental illness. They are indifferent to their sick relatives. (Township Healthcare Provider)

Providers’ perception of training needs

Participants identified several areas of training for enhancing their capacity as mental healthcare providers including professional and practical knowledge, as well as communication and counseling skills to work with patients, families, and other stakeholders in the system of care.

Regarding the follow-up visit, we are not familiar with issues related to serious mental illness. For example, what kind of illness and what are the symptoms, such as people with anxiety disorder, depression, bipolar, etc. We don’t know about the symptoms of these patients. Basic knowledge may be more important. (Village Health Worker)

I think we have areas that require us to fill in the gaps and pay more attention to, such as doctor-patient communication and medical ethics. (County Physician, Senior)

I think we should be more like clinical doctors. We should learn more and see how they actually do things. Then we pick up what we learn and use them according to our actual practice. (Township Healthcare Provider)

Discussion

Consistent with findings from two recent studies (Ma et al., 2015; Ma et al., 2018), we found healthcare providers delivering mental health support and services in rural China to be holding negative or ambivalent views about people with mental illness and their families. County physicians who received formal medical training were full-time practitioners in mental healthcare and had more years of experience working with patients with mental illness than township healthcare providers and village health workers. However, regardless of educational background or duration of practice, healthcare providers at all levels expressed the intention of social distancing from people with mental illness, and the lack of trust in family members as partners of care to support the rehabilitation of patients.

As prior research suggests, provider stigmatizing attitudes ought to be understood in the context of the healthcare delivery system (Henderson et al., 2014). Building on the National Continuing Management and Intervention Program for Psychoses (686 Program) initiated in 2004, China has moved toward integrating hospital-based treatment with community mental health services, resulting in massive expansion of local community mental health service networks (Liu et al., 2011; Ma, 2012; Patel et al. 2016). Despite government policy in community care, healthcare providers in the local care network at our study site raised a number of supply-side barriers, which they considered to be hampering their capacity to provide quality care for their mentally ill patients. Foremost of all is the perceived lack of government leadership of and interest in implementing community-based services, which, according to study participants, resulted in inadequate resources available for them to perform their job well. In the context of limited government support, healthcare providers in our study enumerated myriad occupational stress that had diminished their job satisfaction and quality of life. For township and village providers, the lack of job satisfaction was compounded by having no choice in taking up mental healthcare as part of their job assignment or the hardship incurred for taking it up as overtime work. Although county physicians had choice in selecting their specialty in medical school, they expressed feelings of being victims of stigma themselves because of their association with patients who are discriminated and devaluated by the general public, and low status of psychiatry among medical specialties, which consequently decreased they job satisfaction.

Our findings highlighted the multiple challenges that healthcare providers experienced in working with family members to facilitate recovery of patients living with mental illness. However, while healthcare providers painted an overly pessimistic picture of family members, including family members’ indifference and negligence as guardians and caregivers, they also acknowledged various hardships that rural families faced, including persistent poverty, long working hours, cost of psychiatric care, trauma of family violence, and emotional exhaustion. Overcoming these hardships requires policy change that orientates the mental healthcare system to support and strengthen families rather than focusing exclusively on meeting the needs of the patients with mental illness (Kilmer et al., 2010). On-the-job training in knowledge and skills regarding working with families is, therefore, essential to instill more positive attitudes toward family and to provide communication skills for engaging families as partners of care (Kim & Salyers, 2008).

It is noteworthy that recovery emerges as one of the core themes in the focus group discussions. To healthcare providers in our study, recovery embodied restored functioning of people living with mental health challenges, as well as social acceptance by neighbors and community residents to facilitate community inclusion. Unsurprisingly and consistent with the primacy of work in Chinese culture, having a paid job, even when it meant simple work like casual labor, was considered to be key to the restoration of patients’ dignity and their place in society (Yang et al., 2014). Indeed, healthcare providers in all focus groups pointed to the benefits of paid work in generating income security, which in turn would lead to more effective management of psychiatric symptoms and eventually, recovery.

Study participants considered government policy and administrative support to be critical for the recovery of people with mental illness. Regardless of level of practice, healthcare providers concurred that the government should take up a more proactive role in addressing “basic” needs by providing free mental healthcare, including free psychiatric medication, particularly for those who are chronically ill, and income maintenance for families affected financially by mental illness. Healthcare providers also saw the importance of prioritizing government investment in community mental health services over institutionalized care, and the need for ongoing training in knowledge and skills to strengthen the community-based workforce.

In summary, our study suggests that focus groups constitute a viable method to explore and document healthcare providers’ perceptions and thoughts about mental illness and mental healthcare delivery in rural China. Our study is unique in that it included a diverse range of healthcare providers in terms of educational backgrounds, roles and responsibilities in the local care delivery system, and duration of practice. The inclusion of county-level, township-level and village-level practitioners in the study is unique in that perspectives and experiences that the sample represented were derived from different vantage points within the three-tier local system. Results from this study signal the importance of understanding contextual factors related to mental healthcare delivery to inform the design of training initiatives, including stigma reduction efforts, for providers of mental health services in rural communities.

Several caveats must be kept in mind when drawing inferences from our findings. First, the study is conducted in one rural county in the southwestern region of China, thereby limiting the transferability of its findings to other contexts. Secondly, the sample size is relatively small, and because of the use of convenience sampling for county physicians and village health workers, their views might not be representative of all county-level and village-level providers. Thirdly, the recruitment of participants through the liaison office in the county psychiatric hospital could have inhibited the expression of views that were considered to be unfavorable to the administrative leadership of the county mental health system.

Contributor Information

Yuer Deng, School of Social Policy & Practice, University of Pennsylvania.

An-Li Wang, Department of Psychiatry, Icahn School of Medicine at Mount Sinai.

Rosemary Frasso, College of Population Health, Thomas Jefferson University.

Mao-Sheng Ran, Department of Social Work and Social Administration, The University of Hong Kong.

Tian-Ming Zhang, Department of Social Work, Shanghai University.

Dexia Kong, Rutgers Institute for Health, Health Care Policy and Aging Research, Rutgers.

Yin-Ling Irene Wong, School of Social Policy & Practice, University of Pennsylvania.

References

  1. Chang DF, & Kleinman A (2002). Growing pains: Mental health care in a developing China. Yale-China Health Studies Journal, 1(1), 85–98. [Google Scholar]
  2. Clement S, Schauman O, Graham T, Maggioni F, Evans-Lacko S, Bezborodovs N, … & Thornicroft G (2015). What is the impact of mental health-related stigma on help-seeking? A systematic review of quantitative and qualitative studies. Psychological Medicine, 45(1), 11–27. [DOI] [PubMed] [Google Scholar]
  3. Corrigan P (2004). How stigma interferes with mental health care. American Psychologist, 59(7), 614–625. [DOI] [PubMed] [Google Scholar]
  4. Corrigan PW, Markowitz FE, & Watson AC (2004). Structural levels of mental illness stigma and discrimination. Schizophrenia Bulletin, 30(3), 481–491. [DOI] [PubMed] [Google Scholar]
  5. Corrigan P, Markowitz FE, Watson A, Rowan D, & Kubiak MA (2003). An attribution model of public discrimination towards persons with mental illness. Journal of Health and Social Behavior, 44(2), 162–179. [PubMed] [Google Scholar]
  6. Dabby L, Tranulis C, & Kirmayer LJ (2015). Explicit and implicit attitudes of Canadian psychiatrists toward people with mental illness. The Canadian Journal of Psychiatry, 60(10), 451–459. [DOI] [PMC free article] [PubMed] [Google Scholar]
  7. Hatzenbuehler ML, Phelan JC, & Link BG (2013). Stigma as a fundamental cause of population health inequalities. American Journal of Public Health, 103(5), 813–821. [DOI] [PMC free article] [PubMed] [Google Scholar]
  8. Henderson C, Noblett J, Parke H, Clement S, Caffrey A, Gale-Grant O, … & Thornicroft G (2014). Mental health-related stigma in health care and mental health-care settings. The Lancet Psychiatry, 1(6), 467–482. [DOI] [PubMed] [Google Scholar]
  9. Hori H, Richards M, Kawamoto Y, & Kunugi H (2011). Attitudes toward schizophrenia in the general population, psychiatric staff, physicians, and psychiatrists: a web-based survey in Japan. Psychiatry Research, 186(2-3), 183–189. [DOI] [PubMed] [Google Scholar]
  10. Hsieh HF, & Shannon SE (2005). Three approaches to qualitative content analysis. Qualitative Health Research, 15(9), 1277–1288. [DOI] [PubMed] [Google Scholar]
  11. Huang Y, Wang Y, Wang H, Liu Z, Yu X, Yan J, … & Wang Z (2019). Prevalence of mental disorders in China: a cross-sectional epidemiological study. The Lancet Psychiatry, 6(3), 211–224. [DOI] [PubMed] [Google Scholar]
  12. Kilmer RP, Cook JR, & Munsell EP (2010). Moving from principles to practice: Recommended policy changes to promote family-centered care. American Journal of Community Psychology, 46(3-4), 332–341. [DOI] [PMC free article] [PubMed] [Google Scholar]
  13. Kim HW, & Salyers MP (2008). Attitudes and perceived barriers to working with families of persons with severe mental illness: mental health professionals’ perspectives. Community Mental Health Journal, 44(5), 337–345. [DOI] [PubMed] [Google Scholar]
  14. Knox K, Fejzic J, Mey A, Fowler JL, Kelly F, McConnell D, … & Wheeler AJ (2014). Mental health consumer and caregiver perceptions of stigma in Australian community pharmacies. International Journal of Social Psychiatry, 60(6), 533–543. [DOI] [PubMed] [Google Scholar]
  15. Kopera M, Suszek H, Bonar E, Myszka M, Gmaj B, Ilgen M, & Wojnar M (2015). Evaluating explicit and implicit stigma of mental illness in mental health professionals and medical students. Community Mental Health Journal, 51(5), 628–634. [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Lam CS, Tsang HW, Corrigan PW, Lee YT, Angell B, Shi K, … & Larson JE (2010). Chinese lay theory and mental illness stigma: Implications for research and practices. Journal of Rehabilitation, 76(1), 35–40. [Google Scholar]
  17. Li J, Li J, Huang Y, & Thornicroft G (2014). Mental health training program for community mental health staff in Guangzhou, China: effects on knowledge of mental illness and stigma. International Journal of Mental Health Systems, 8(1), 49. [DOI] [PMC free article] [PubMed] [Google Scholar]
  18. Li J, Li J, Thornicroft G, Yang H, Chen W, & Huang Y (2015). Training community mental health staff in Guangzhou, China: evaluation of the effect of a new training model. BMC Psychiatry, 15(1), 263. [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Link BG, & Phelan JC (2001). Conceptualizing stigma. Annual Review of Sociology, 27(1), 363–385. [Google Scholar]
  20. Link BG, & Phelan JC (2006). Stigma and its public health implications. The Lancet, 367(9509), 528–529. [DOI] [PubMed] [Google Scholar]
  21. Liu J, Ma H, He YL, Xie B, Xu YF, Tang HY, … & Li X (2011). Mental health system in China: history, recent service reform and future challenges. World psychiatry, 10(3), 210–216. [DOI] [PMC free article] [PubMed] [Google Scholar]
  22. Ma H (2012). Integration of hospital and community services—the ‘686 Project’—is a crucial component in the reform of China's mental health services. Shanghai Archives of Psychiatry, 24(3), 172–174. [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Ma Z, Huang H, Chen Q, Chen F, Abdullah AS, Nie G, … & Wei B (2015). Mental health services in rural China: A qualitative study of primary health care providers. BioMed Research International, 2015. [DOI] [PMC free article] [PubMed] [Google Scholar]
  24. Ma Z, Huang H, Nie G, Silenzio V, & Wei B (2018). Attitude towards mental Illness among primary healthcare providers: A community-based study in Rural China. BioMed Research International, 2018. [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. Mestdagh A, & Hansen B (2014). Stigma in patients with schizophrenia receiving community mental health care: a review of qualitative studies. Social Psychiatry and Psychiatric Epidemiology, 49(1), 79–87. [DOI] [PubMed] [Google Scholar]
  26. Patel V, Xiao S, Chen H, Hanna F, Jotheeswaran AT, Luo D, … & Druss BG (2016). The magnitude of and health system responses to the mental health treatment gap in adults in India and China. The Lancet, 388(10063), 3074–3084. [DOI] [PubMed] [Google Scholar]
  27. Pearson V (1993). Families in China: An undervalued resource for mental health?. Journal of Family Therapy, 15(2), 163–185. [Google Scholar]
  28. Phillips MR, Zhang J, Shi Q, Song Z, Ding Z, Pang S, … & Wang Z (2009). Prevalence, treatment, and associated disability of mental disorders in four provinces in China during 2001–05: an epidemiological survey. The Lancet, 373(9680), 2041–2053. [DOI] [PubMed] [Google Scholar]
  29. Ramsay G (2010). Mainland Chinese family caregiver narratives in mental illness: disruption and continuity. Asian Studies Review, 34(1), 83–103. [Google Scholar]
  30. Reavley NJ, Mackinnon AJ, Morgan AJ, & Jorm AF (2014). Stigmatising attitudes towards people with mental disorders: a comparison of Australian health professionals with the general community. Australian & New Zealand Journal of Psychiatry, 48(5), 433–441. [DOI] [PubMed] [Google Scholar]
  31. Schomerus G, & Angermeyer MC (2008). Stigma and its impact on help-seeking for mental disorders: what do we know?. Epidemiology and Psychiatric Sciences, 17(1), 31–37. [DOI] [PubMed] [Google Scholar]
  32. Thornicroft G (2008). Stigma and discrimination limit access to mental health care. Epidemiology and Psychiatric Sciences, 17(1), 14–19. [DOI] [PubMed] [Google Scholar]
  33. Tsang HW, Angell B, Corrigan PW, Lee YT, Shi K, Lam CS, … & Fung KM (2007). A cross-cultural study of employers’ concerns about hiring people with psychotic disorder: implications for recovery. Social Psychiatry and Psychiatric Epidemiology, 42(9), 723–733. [DOI] [PubMed] [Google Scholar]
  34. Van Boekel LC, Brouwers EP, Van Weeghel J, & Garretsen HF (2013). Stigma among health professionals towards patients with substance use disorders and its consequences for healthcare delivery: systematic review. Drug and Alcohol Dependence, 131(1-2), 23–35. [DOI] [PubMed] [Google Scholar]
  35. Van Dorn RA, Swanson JW, Elbogen EB, & Swartz MS (2005). A comparison of stigmatizing attitudes toward persons with schizophrenia in four stakeholder groups: perceived likelihood of violence and desire for social distance. Psychiatry: Interpersonal and Biological Processes, 68(2), 152–163. [DOI] [PubMed] [Google Scholar]
  36. Wang K, Link BG, Corrigan PW, Davidson L, & Flanagan E (2018). Perceived provider stigma as a predictor of mental health service users’ internalized stigma and disempowerment. Psychiatry Research, 259, 526–531. [DOI] [PMC free article] [PubMed] [Google Scholar]
  37. Wang Y, Wang X, Zhang W, Liang X, Tian D, & Qu Z (2017). Risk factors of the stigma towards psychiatric patients among primary healthcare workers in China: a county study. BMC psychiatry, 17(1), 62. [DOI] [PMC free article] [PubMed] [Google Scholar]
  38. Wong YLI, Kong D, Tu L, & Frasso R (2018). “My bitterness is deeper than the ocean”: understanding internalized stigma from the perspectives of persons with schizophrenia and their family caregivers. International Journal of Mental Health Systems, 12(1), 14. [DOI] [PMC free article] [PubMed] [Google Scholar]
  39. Wrigley S, Jackson H, Judd F, & Komiti A (2005). Role of stigma and attitudes toward help-seeking from a general practitioner for mental health problems in a rural town. Australian and New Zealand Journal of Psychiatry, 39(6), 514–521. [DOI] [PubMed] [Google Scholar]
  40. Yang LH, Chen FP, Sia KJ, Lam J, Lam K, Ngo H, … & Good B (2014). “What matters most:” A cultural mechanism moderating structural vulnerability and moral experience of mental illness stigma. Social Science & Medicine, 103, 84–93. [DOI] [PubMed] [Google Scholar]
  41. Zhang TM, Wong IYL, Yu YH, Ni SG, He XS, Bacon-Shone J, … & Ran MS (2019). An integrative model of internalized stigma and recovery-related outcomes among people diagnosed with schizophrenia in rural China. Social Psychiatry and Psychiatric Epidemiology, 54(8), 911–918. [DOI] [PubMed] [Google Scholar]

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