Skip to main content

Mental health stigma and mental health knowledge in Chinese population: a cross-sectional study

Abstract

Background

Little is known about the public stigma on mental illness and mental health knowledge (MHK) in China, public stigma and low MHK can negatively affect patients’ health and increase the burden of mental disorders on society. This study aimed at investigating the rates of stigma and MHK, the correlates of stigma and MHK, and the association between MHK and stigma among a Chinese population.

Methods

The data is from the Tianjin Mental Health Survey (TJMHS), which involved a large and a representative sample of adult community residents in the Chinese municipality of Tianjin (n = 11,748). In a 12% random subsample (n = 1775) the Perceived Discrimination and Devaluation scale (PDD) and a Mental Health Knowledge Questionnaire (MHKQ) were administered. First, percentages of the responses to the individual items of the PDD and MHKQ were investigated. Second, sociodemographic correlates of PDD and MHK, and the association between stigma and MHK were investigated.

Results

We found that a sizable proportion of participants responded that others would hold a negative attitude towards (former) mental patients, especially with regard to engaging in closer personal relationships. Most people were not familiar about the causes, treatments and prevention of mental illness. Resident area, age, education level, Per capita family income and employment status were related to devaluation score and MHKQ score. MHK was negatively associated with public stigma.

Conclusions

There is room for improvement with regard to levels of public stigma and MHK in China. Providing psychoeducation to improve public MHK could also contribute to reduction of public stigma.

Peer Review reports

Background

The public stigma on mental illnesses manifests itself in the way the population reacts to mental [1, 2]. Public stigma have negative effects on the lives of people with mental illness, by preventing them from pursuing vocational, housing, and healthcare goals, and holding them back from seeking treatment [3, 4] and affecting the quality of delivered healthcare [5]. The Global Context–Mental Health Study has shown public hold high prejudice attitude to patients with mental illness in 16 countries [6]. Therefore, researchers and policy-makers have sought to develop strategies to destigmatize mental illness. One suggested strategy has been to increase mental health knowledge (MHK) with education programs. Indeed, a range of studies have shown that brief courses about mental illness may reduce prejudices and stigmatizing attitudes among a wide variety of participants [7, 8]. In China, it has been proposed that mental health stigma in China might be addressed by increasing MHK, using national education programs [9]. However, the number of investigations of mental-health stigma and MHK, and their interrelatedness, has been limited, making it hard to judge if and how educational programs should be targeted. Previous work about stigma on mental illness in china has indicated that public stigma is indeed perceived by patients and their families [10, 11]. In addition, several surveys have shown high public stigma [12,13,14] and low MHK about depression [15, 16] and schizophrenia [17, 18]. Finally, recent research has raised concerns that mental health professionals hold discriminatory attitudes towards psychiatric patients in China [19]. However, an important research question concerns the actual relationship between MHK and public stigma. In addition, different aspects and/or types of stigma (devaluation vs. discrimination) and their relationships to MHK need to be further investigated. Finally, the role of sociodemographic characteristics (e.g. gender, age, education) and mental health status need to be considered when investigating stigma and its relationship to MHK.

To this end, stigma and MHK were both measured in a large and representative sub-sample (n = 1775), drawn from the Tianjin Mental Health Survey (TJMHS) [20]. Tianjin is a municipality that has seen rapid socioeconomic development (e.g., migration, urbanization) and, as such, is a typical example of the rapid changes that occur in many regions of China. Therefore, results from the current study could also give an indication of the prevalence and interrelatedness of stigma and MHK in other regions in China, for which up-to-date data on mental illness stigma and MHK are currently scarce. This study aimed to investigate: (1) the rates of stigma and MHK, (2) the associations of stigma and MHK with sociodemographic characteristics, and (3) the association between MHK and stigma.

Methods

Sample and procedures

Tianjin, one of the four municipalities directly under the central government, is also the largest port city and industrial and commercial city in northern China. It is located in the northeast of the North China Plain, north of Beijing in and lies at the coast of the Bohai Sea. By the end of 2018, Tianjin had a permanent population of 15.60 million with a per capita gross domestic product (GDP) of Ұ120,711 [21]. Data came from the TJMHS (n = 11,748), which was conducted between July 2011 and March 2012. A detailed description of the survey design, methods and objectives can be found elsewhere [20]. In short, the TJMHS used a two-phase design to include a large, representative community sample of respondents aged 18 and older in the Tianjin region. Participants were selected with a multistage cluster random sampling method, and were selected using probability proportionate to size of the population of each primary sampling unit. Initially, a total of 11,748 subjects were screened for psychopathology risk.

Of the total sample, a random 12% was selected and was administered additional questionnaires about stigma and MHK. We calculated the number of subjects that needed to complete the MHKQ to achieve sufficient statistical power based on the formula n = μα2 p (1 - p)/δ2 , where μα = the one-sided magnitude of the confidence level (at α = 0.05, μα = 1.96), p = expected proportion of the outcome of interest (we assume that 50% individuals have the correct answers of MHKQ), and δ = margin of error (δ = 50% × 0.05 = 0.025). The calculated necessary minimum sample size was 1537. The number of subjects to be approached was set 20% higher, at 1844, which comprises about 12% of the total TJMHS sample of n = 15,482. As part of the survey design, participants were included from randomly selected households located in primary sampling units (villages or neighborhoods). All households within each PSU were assigned a unique ID number (1000, 1001, 1002, 1003 etc.) and only participants with ID numbers ending with the numbers 00 to 11 were selected into the subsample, which contained roughly 12% of all subjects. Of the initially selected subsample (n = 1775), 130 persons refused to participate and 30 persons only partially completed the assessment. Of the selected participants, 1609 completed the stigma questionnaire, 1615 completed the MHK questionnaire (MHKQ) and 1591 respondents completed both. The latter sample was used for the current analyses. The study protocol was approved by the medical ethics committee of the Tianjin Mental Health Center and all respondents signed informed consent prior to participation.

Measures

Although the instruments were originally self-report questionnaires, they were interviewer-administered in the TJMHS because a considerable part of respondents were expected to be semi- or illiterate. In these versions, the interviewer read the items aloud and recorded the participant’s responses. These versions were used in all participants, including literate respondents, to ensure standardized measurements.

The perceived discrimination and devaluation scale (PDD)

The PDD [2, 22] is a 12-item questionnaire to assess expectations of devaluation and discrimination toward current or former psychiatric patients. The items assess how “most people” or “most employers” think or act toward persons with a current or a prior psychiatric disorder. The items are rated on a five-point scale. Two subdomains are assessed in the PDD [23, 24]. Perceived devaluation refers to expectations about how others see (former) mentally ill persons (e.g., as being dangerous, untrustworthy). Perceived discrimination refers to expectations about how others will act toward (former) mentally ill persons (e.g., keeping them at a distance, denying them opportunities). The current study used the Chinese version of the PDD, which has the same items as the original but uses a slightly modified response scale, adding the option ‘not sure’. This version was previously shown to have acceptable psychometric properties [25]. Individual PDD items were also inspected. For this, each item response was categorized into three categories, coding ‘completely agree’ and ‘basically agree’ as ‘agree’, and ‘basically disagree and ‘completely disagree’ as ‘disagree’.

Mental health knowledge questionnaire (MHKQ)

A 16-item questionnaire, developed by the Ministry of Health of China was used to assess MHK (see Table 3). The scale consists of sixteen items rated on a dichotomous response scale (yes/no). One point is given for each ‘yes’ response on items 1, 3, 5, 7, 8, 11, 12, 15, 16 and 1 point is given for each ‘no’ response on items 2, 4, 6, 9, 10, 13 and 14. The item scores are added up to a total score (range: 0–16), with higher scores indicating higher MHK.

General health questionnaire (GHQ-12)

The Chinese version of the GHQ-12 [26] assesses general psychological distress with 12 items, rated on 4-point scale. Each item was scored as follows: 0 = ‘better than usual’, 0 = ‘as usual’, 1 = ‘less than usual’ and 1 = ‘much less than usual’, resulting in a sum score with a range of 0–12. Respondents with a GHQ-12 score above 3 were considered to have some mental problems. Previous work showed the Chinese GHQ-12 to have adequate internal consistency (alpha = 0.75) and test-retest reliability (0.72) [27].

Statistical analyses

Results of participants who completed the assessments (n = 1591) were weighted up to project the total number of individuals in the different research sites and the data were further weighted to make sure that the sociodemographic distribution (i.e. gender, age, urban vs. rural) of the sample corresponded to population census data. Several analyses were done. First, cross-tabs were used to gain insight into the distributions of the responses to the individual items of the PDD and MHKQ. Second, PDD and MHK scores were compared between sociodemographic groups, using independent samples t-tests or one-way ANOVA. Third, to investigate the association between stigma (subdomains) and MHK, univariate linear regression analyses were run with stigma score as dependent variable and MHK score as independent variable. Finally, these analyses were run with covariates (sociodemographic factors and experienced general psychological distress). The analyses were run with SPSS (v19.0) with alpha set at 0.05 (two tailed).

Results

Sample characteristics

Socio-demographic characteristics are shown in Table 1.

Table 1 Socio-demographic characteristics of the participants (n = 1591)

Stigma

The PDD item responses are shown in Table 2. To statements about devaluation, a considerable number of participants (9.2–14.5%) responded that they were ‘not sure’. Of those providing a response, the majority agreed that others see persons with mental illness as just as intelligent (item 2; 47.7%) and trustworthy (item 3; 47.0%) as others, and disagreed that others see entering a mental hospital as a personal failure (item 5; 69.2%) or think less of persons that enter a mental hospital (item 7; 62.4%). However, a majority of participants agreed with the statement that most people will take a person’s opinion less serious once they know a person has been in a mental hospital (item 12; 55.3%).

Table 2 The public’s perception of the stigma attached to former mental patients in Tianjina

To statements about discrimination, a sizable percentage (11.7–17.0%) responded that there were ‘not sure’. Of the other participants, the majority disagreed with the statement that a former mental patient would be hired as a teacher (item 4; 55.1%) and agreed with the statements that most people would not hire a (former) mental patient to take care of their kids (item 6; 68.2%), that most employers would pass over the application of a former mental patient (item 9; 54.9%), and that most women would be reluctant to date a man with a history of mental illness (item 11; 70.6%). However, roughly equal percentages of participants agreed and disagreed with the statement that most employers will hire former mental patient if he/she is qualified for the job (item 8; 43.7% agree vs. 39.3% disagree) and the statement that most people would willingly accept a former mental patient as a close friend (item 1; 43.3% agree vs. 44.9% disagree). The majority agreed with the statement that most people in their community would treat a former mental patient just as they would treat anyone (item 10; 65.7%).

Mean devaluation scores were higher in rural compared to urban areas, older age groups, those with 0–6 years of education, those with below-median income and farmers (See Table 3). Discrimination scores showed no differences across sociodemographic groups.

Table 3 Socio-demographic characteristics and differences in scores of PDD scale and MHKQ by socio-demographic variables

Mental health knowledge

The responses on the MHK items are shown in Table 4. High percentages of participants showed signs of basic knowledge about mental health, as shown by their affirmative responses (all > 80%) to statements about mental health as an integral part of health (item 1), everyday aspects that are helpful to keep good mental health (item 11), the unnoticed existence of mental health problems (item 3), the existence of multiple components of mental health (item 5), the possibility of mental-health problems at any age (item 8), the role of stress and/or major life events in mental health problems (item 16), the need to see a mental health professional in case of mental problems (item 7), and the heritability of mental health problems (item 12). Also, 75.2% acknowledged the fact that mental problems can influence adolescents’ functioning (item 13). There were also signs of lacking knowledge in the population: 48.7% of respondents thought middle-aged or older adults were less likely to have mental problems (item 14), 43.2% believed that mental health problems cannot be cured (item 6), 59.4% agreed that mental illness cannot be prevented (item 9), and 46.0% agreed that diagnosed patients should only take medication for a short period of time (item 10). Of the respondents, 86.7% agreed with the statement that persons with an unstable temperament were more likely to have mental illness (item 15), 75.0% endorsed the statement that mental illness results from something wrong in thought (item 2) and 69.7% endorsed the statement that all mental illness is caused by stress (item 4).

Table 4 The public’s knowledge related to mental health in Tianjin

MHK levels were lower in rural areas, older age-groups, the low (0–6 years) education group, farmers, and in those who were never married (Table 3).

The association between MHK and stigma

In univariable analyses (Table 5), devaluation, discrimination and PDD total score all showed significant negative associations with MHK score (R2 = 0.01–0.07), with the strongest association between MHK and devaluation (R2 = 0.07). When adjusted, the associations remained largely the same (R2 = 0.04–0.10).

Table 5 unadjusted and adjusted associations between MHK and public stigma

Discussion

This study showed that the Tianjin public holds some negative attitudes to mental health patients, especially with regard to engaging in closer personal relationships with (former) mental patients. Most people did have general knowledge about how to obtain and maintain mental health, but had less knowledge about the causes, treatment and prevention of mental illness. MHK level was negatively associated with devaluation and discrimination of persons with mental health problems. When asked about others’ perceptions of (former) mental patients, many participants thought that the public holds a negative attitude with regard to engaging in closer personal relationships with (former) mental patients. These findings are in line with previous studies in China [10, 13, 28, 29]. Interestingly, negative attitudes were more often endorsed on discrimination items than on devaluation items, indicating that public stigma may be especially manifested in discrimination in the closer personal realm.

Limitations of this study

The present study has several limitations. First, the MHK questionnaire was developed by the Chinese MOH for use in China specifically, limiting generalizability of the findings to other regions of the world. However, several well-known aspects of MHK [30] were included in the MHK questionnaire and several items were quite similar to those used in other developed scales [31,32,33] and used in other studies [34, 35]. Second, the generalizability of the findings to all of China may be limited due to large regional differences. However, the Tianjin area is quite a typical example of the highly urbanized areas, of which many are found in China and that make up a large part of its population. Third, the cross-sectional nature of the study forbids any causal inference.

Public stigma on mental illness

The PDD has been used to investigate mental health stigma in many other countries, such as Germany [36], Vietnam [37], Russia and Slovakia [38]. On some items, the Tianjin public seemed to endorse more negative attitudes than other investigated populations. For example, 47.7% of the Tianjin sample stated that most others thought a person who has been in a mental hospital is just as intelligent as the average person, compared to percentages that ranged from 49.3% (Vietnam) to 67.8% (Russia). However, 69.2% of the Tianjin sample reported that they did not think that most people see entering a mental hospital as a sign of personal failure, compared to percentages in other samples that ranged from of 32.0% (Germany) to 51.9% (Russia). Also, 62.4% of the Tianjin sample stated that they did not think that most others thought less of a person who has been in a mental hospital compared to percentages of 21.8% (Germany) to 44.8% (Vietnam). With regard to the PDD discrimination items, The Tianjin sample showed a more positive attitude toward the job opportunities of former mental patients even being a teacher in a public school: 43.7% agreed that most employers will hire a former mental patient, compared to percentages in other samples that ranged from 23.3% (Slovakia) to 40.6% (Vietnam); 31.9% of the Tianjin sample agreed with the statement that most people would accept a fully recovered former mental patient as a teacher of young children in a public school, which was higher than in Slovakia and Germany (15.5 and 27.6%, respectively). Also, a majority of the Tianjin sample stated that they thought that most persons treat a former mental patient like they would treat anyone, compared to percentages in other countries from 28.3% (Slovakia) to 46.8% (Vietnam). However, when circumstances were related to close relationships (being a close friend with a former mental patient, letting a former mental patient take care of their children or dating a former mental patient), the Tianjin sample showed a higher endorsement of statements about rejection of (former) mental health patients. For example, 44.9% of Tianjin sample disagreed with the statement that people would accept a former mental patient as a close friend, compared to lower percentages in in Russia (24.7%), Slovakia (29.6%), Germany (23.9%) and Vietnam (25.9%). This results were consistent with the results in the Global Context–Mental Health Study, which showed that the highest levels of stigmatizing responses were concentrated on aspects relating to providing child care, marriage into the family and teaching of children [6]. The survey in Beijing [13] and a survey using a web-based approach [12] also have shown that while most respondents perceived the public has positive attitude about the status of individuals with mental illness, they perceived more negative attitudes when considering personal interactions. More previous studies have shown that discrimination prominently occurred in work, marriage, and interpersonal relationships which are closely related to basic social life [10, 39].

The observed attitudes toward mental illness and differences from other countries could be related to cultural factors [29, 38, 40]. Yang et al. [41, 42] showed that the particular manifestations of stigma in Chinese people are shaped by cultural meanings embedded in Confucianism, pejorative etiological beliefs about mental illnesses and the centrality of ‘face’ (i.e. one’s moral standing within society. One of the central principles of Confucianism is that every member of society must follow the moral demands of society to achieve personal and social harmony. People with mental illnesses may be unable to fully meet these demands, leading others to question their moral status. In addition, Chinese traditional beliefs attribute mental illness to possession by demons, wrongful child bearing behavior, or wrong-doing by one’s ancestors [40]. As a result, people with psychiatric illnesses are regarded as ‘morally bankrupt’ and relegated to a lower moral level. Losing one’s moral standing or ‘face’ in a community may lead others to avoid contact out of fear for moral contamination, leading to social exclusion (‘social death’) [42]. Patients may be excluded from participating in social networks to prevent embarrassment to the family and lowering of their moral status. These specific Chinese cultural factors could explain why manifestations of public stigma toward mental illness are observed especially in closer personal relationships. However, the results also showed relatively positive public attitudes with regard to mental illness patients in general, which could partly be due to previous efforts to reduce public stigma, although this cannot be determined based on the current study.

Mental health knowledge

The MHK results showed that, on the one hand, most people did have basic knowledge about how to obtain and maintain mental health: above 90% of individuals had correct general knowledge mental health. On the other hand, more specific knowledge, for instance about the manifestations of mental illness in different age periods and the influences of mental illness on adolescents, was less widespread. A similar ambiguity could be observed in the reported knowledge about the causes of mental illness: most people thought the family history and ‘unstable temperament’ were risk factors to develop mental disorders, but only about 70% believed that mental illness could result from something wrong in thought or stress. Above 90% of the respondents knew that seeking professional help was necessary in case of mental illness but many (43%) also thought mental illness could not be cured or prevented. The same MHK questionnaire has previously been administered in Zhengzhou and Guangzhou, where similar response patterns were found [43, 44]. About 50% people think that it is less likely to have mental problems or disorders in middle or old age. An explanation might be that general public might not see dementia as a psychiatric illness. Another explanation might be that people at middle or old age might be perceived to be at a low risk to develop a mental disorder because of having a ‘stable temperament’. There have also been studies comparing MHK between China and other countries. A study comparing Chinese and British beliefs about schizophrenia showed that Chinese respondents held more religious and superstitious beliefs and British respondents put more emphasis on beliefs about causes and treatment [34]. Two other studies [16, 17] on MHK in Chinese subjects in Shanghai, Chinese-speaking Australians in Melbourne and Chinese subjects in Hong Kong showed lower MHK in Shanghai Chinese than Hong Kong and Australian Chinese. Another nationally-representative survey in China to understand the public’s profile of mental health literacy showed a low recognition of mental health problems and that this recognition was better for depression than schizophrenia [14]. Together, these results suggest that specific knowledge about mental illness in the Chinese population is relatively limited. This specific knowledge could be a particular focus of attention in future educational campaigns. The current results suggest that such campaigns could be specifically targeted at socioeconomic groups with comparatively lower MHK, including rural residents, older persons (> 39 years), those with no/low education and farmers.

The relationship between stigma and MHK

The results showed that MHK was negatively associated with devaluation and discrimination, in line with previous findings [45] and supporting the idea that improving MHK could help reduce public stigma. However, there have also been studies that found no or an inverse relationship between knowledge-levels and attitudes towards people with mental illness [15]. For instance, a longitudinal study in Germany showed that an increase of public knowledge did not change or even increased the desire of subjects for social distance from people with mental illness [36]. A review of studies about mass media intervention, a common way to increase MHK and to reduce prejudice and discrimination, concluded that mass media interventions may reduce prejudice, but that there was insufficient evidence to determine the effects on discrimination [46] . Reviews of the literature on interventions to reduce mental-health stigma in the medium and long term, found some evidence for the effectiveness of such interventions [47, 48]. Future research is required to evaluate the use of smartphone applications to increase MHK [49] and support caregivers [50]. Taken together, the current and previous results indicate that increased MHK may be related to less prejudice, devaluation and discrimination of mental-health patients. However, the extent to which MHK can actually be modified by interventions and whether such changes in MHK are causally related to decreases in public stigma remains a topic for further study.

Conclusions

In conclusion, there is room for improvement with regard to levels of public stigma and MHK in Tianjin. The observed negative association between stigma and MHK indicates that, in addition to targeted programs to reduce mental health stigma, improvement of public MHK could contribute to reduction of public stigma.

Availability of data and materials

All the data supporting our findings have been presented in the manuscript; the datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Abbreviations

GHQ-12:

12-item General Health Questionnaire

MHK:

Mental Health Knowledge

MHKQ:

Mental Health Knowledge Questionnaire

NOS:

Not Otherwise Specified

PDD:

The Perceived Discrimination and Devaluation scale

SCID:

The Structured Clinical Interview for DSM-IV axis I disorders

TJMHS:

The Tianjin Mental Health Survey

References

  1. 1.

    Corrigan P, Watson A. Understanding the impact of stigma on people with mental illness. World Psychiatry. 2002;1:16–20.

    PubMed  PubMed Central  Google Scholar 

  2. 2.

    Link BG, Struening EL, Neese-Todd S, Asmussen S, Phelan JC. Stigma as a barrier to recovery: the consequences of stigma for the self-esteem of people with mental illnesses. Psychiatr Serv. 2001;52:1621–6.

    CAS  PubMed  Google Scholar 

  3. 3.

    Henderson C, Evans-Lacko S, Thornicroft G. Mental illness stigma, help seeking, and public health programs. Am J Public Health. 2013;103:777–80.

    PubMed  PubMed Central  Google Scholar 

  4. 4.

    Linz SJ, Sturm BA. The phenomenon of social isolation in the severely mentally ill. Perspect Psychiatr Care. 2013;49:243–54.

    PubMed  Google Scholar 

  5. 5.

    Henderson C, Noblett J, Parke H, Clement S, Caffrey A, Gale-Grant O, et al. Mental health-related stigma in health care and mental health-care settings. Lancet Psychiatry. 2014;1:467–82.

    PubMed  Google Scholar 

  6. 6.

    Pescosolido BA, Medina TR, Martin JK, Long JS. The “backbone” of stigma: identifying the global core of public prejudice associated with mental illness. Am J Public Health. 2013;103:853–60.

    PubMed  PubMed Central  Google Scholar 

  7. 7.

    Crisp A, Gelder M, Goddard E, Meltzer H. Stigmatization of people with mental illnesses: a follow-up study within the changing minds campaign of the Royal College of psychiatrists. World Psychiatry. 2005;4:106–13.

    PubMed  PubMed Central  Google Scholar 

  8. 8.

    Corrigan PW, Scott Morris PB, Michaels PJ, Jennifer Rafacz MD, Rüsch N. Challenging the public stigma of mental illness: a meta-analysis of outcome studies. Psychiatr Serv. 2012;63:963–73.

    PubMed  Google Scholar 

  9. 9.

    Xiong W, Phillips MR. Translated and annotated version of the 2015-2020 National Mental Health Work Plan of the people ’ s republic of China. Shanghai Arch Psychiatry. 2016;28:4–17.

    PubMed  PubMed Central  Google Scholar 

  10. 10.

    Phillips MR, Pearson V, Li F, Xu M, Yang L. Stigma and expressed emotion : a study of people with schizophrenia and their family members in China. Br J Psychiatry. 2002;181:488–93.

    PubMed  Google Scholar 

  11. 11.

    Yang LH, Lo G, WonPat-Borja AJ, Singla DR, Link BG, Phillips MR. Effects of labeling and interpersonal contact upon attitudes towards schizophrenia: implications for reducing mental illness stigma in urban China. Soc Psychiatry Psychiatr Epidemiol. 2012;47:1459–73.

    PubMed  Google Scholar 

  12. 12.

    Li J, Zhang MM, Zhao L, Li WQ, Mu JL, Zhang ZH. Evaluation of attitudes and knowledge toward mental disorders in a sample of the Chinese population using a web-based approach. BMC Psychiatry. 2018;18:367.

    PubMed  PubMed Central  Google Scholar 

  13. 13.

    Liu J, Yan F, Ma X, Guo HL, Tang YL, Rakofsky JJ, et al. Perceptions of public attitudes towards persons with mental illness in Beijing, China: results from a representative survey. Soc Psychiatry Psychiatr Epidemiol. 2016;51:443–53.

    CAS  PubMed  Google Scholar 

  14. 14.

    Huang D, Yang LH, Pescosolido BA. Understanding the public’s profile of mental health literacy in China: a nationwide study. BMC Psychiatry. 2019;19:1–12.

    Google Scholar 

  15. 15.

    Wang J, Lai D. The relationship between mental health literacy, personal contacts and personal stigma against depression. J Affect Disord. 2008;110:191–6.

    PubMed  Google Scholar 

  16. 16.

    Wong DFK, Xuesong H, Poon A, Lam AYK. Depression literacy among Chinese in Shanghai, China: a comparison with Chinese-speaking Australians in Melbourne and Chinese in Hong Kong. Soc Psychiatry Psychiatr Epidemiol. 2012;47:1235–42.

    PubMed  Google Scholar 

  17. 17.

    Wong DFK, He X. Schizophrenia literacy among Chinese in Shanghai, China: a comparison with Chinese-speaking Australians in Melbourne and Chinese in Hong Kong. Aust N Z J Psychiatry. 2011;45:524–31.

    PubMed  Google Scholar 

  18. 18.

    Phillips MR, Li Y, Scott ST, Xin L. Causes of schizophrenia reported by patients’ family members in China. Br J Psychiatry. 2000;177:20–5.

    CAS  PubMed  Google Scholar 

  19. 19.

    Zhang Z, Sun K, Jatchavala C, Koh J, Chia Y, Bose J, et al. Overview of stigma against psychiatric illnesses and advancements of anti-stigma activities in six asian societies. Int J Environ Res Public Health. 2020;17:280.

    Google Scholar 

  20. 20.

    Yin H, Phillips MR, Wardenaar KJ, Xu G, Ormel J, Tian H, et al. The Tianjin mental health survey (TJMHS): study rationale, design and methods. Int J Methods Psychiatr Res. 2017;26:e1535.

    Google Scholar 

  21. 21.

    Tianjin Municipal Statistics Bureau and NBS Survey Office in Tianjin. Tianjin statistical yearbook 2019. 2019.

    Google Scholar 

  22. 22.

    Link BG, Cullen FT, Struening E, Shrout PE, Bruce P, Link BG, et al. a Modified Labeling Theory Approach To Mental Disorders : an Empirical Assessment. Am Sociol Rev. 1989;54:400–23.

    Google Scholar 

  23. 23.

    Smith SM, Dawson DA, Goldstein RB, Grant BF. Examining perceived alcoholism stigma effect on racial-ethnic disparities in treatment and quality of life among alcoholics. J Stud Alcohol Drugs. 2010;71:231–6.

    PubMed  PubMed Central  Google Scholar 

  24. 24.

    Glass JE, Kristjansson SD, Bucholz KK. Perceived alcohol stigma: factor structure and construct validation. Alcohol Clin Exp Res. 2013;37(Suppl.1):237–46.

    Google Scholar 

  25. 25.

    Yin H, Xu G, Yang G, Tian H. Reliability and validity of the Chinese-version of the perceived devaluation-discrimination scale in community population. Chinese Ment Heal J. 2014;28:63–9.

    Google Scholar 

  26. 26.

    Goldberg DP, Williams PDP. A user’s guide to the General Health Questionnaire. Windsor, Berks: NFER-Nelson; 1988.

    Google Scholar 

  27. 27.

    Yang T, Huang L, Wu Z. Study on the appropriateness of the Chinese version of the general health questionnaire as a screening instrument for psychological disorders in mainland China. Chinese J Epidemiol. 2003;24:769–73.

    CAS  Google Scholar 

  28. 28.

    Feng S, Gao H, Wang L, Wang B, Fang Y, Wang G, et al. Perceptions of stigma and its correlates among patients with major depressive disorder: A multicenter survey from China. Asia Pac Psychiatry. 2017;9:10.1111/appy.12260.

  29. 29.

    Haraguchi K, Maeda M, Mei YX, Uchimura N. Stigma associated with schizophrenia: cultural comparison of social distance in Japan and China. Psychiatry Clin Neurosci. 2009;63:153–60.

    PubMed  Google Scholar 

  30. 30.

    Jorm AF. Mental health literacy: public knowledge and beliefs about mental disorders. Br J Psychiatry. 2000;177:396–401.

    CAS  PubMed  Google Scholar 

  31. 31.

    Chen H, Wang Z, Phillips MR. Assessing knowledge and attitudes about mental illness in Ningxia, China. Transcult Psychiatry. 2018;55:94–119.

    PubMed  Google Scholar 

  32. 32.

    Evans-Lacko S, Little K, Meltzer H, Rose D, Rhydderch D, Henderson C, et al. Development and psychometric properties of the mental health knowledge schedule. Can J Psychiatr. 2010;55:440–8.

    Google Scholar 

  33. 33.

    O’Connor M, Casey L. The mental health literacy scale (MHLS): a new scale-based measure of mental health literacy. Psychiatry Res. 2015;229:511–6.

    PubMed  Google Scholar 

  34. 34.

    Furnham A, Wong L. A cross-cultural comparison of British and Chinese beliefs about the causes, behaviour manifestations and treatment of schizophrenia. Psychiatry Res. 2007;151:123–38.

    PubMed  Google Scholar 

  35. 35.

    Yeap R, Low WY. Mental health knowledge , attitude and help- seeking tendency : A Malaysian context. Singap Med J. 2009;50:1169–76.

    CAS  Google Scholar 

  36. 36.

    Angermeyer MC, Holzinger A, Matschinger H. Mental health literacy and attitude towards people with mental illness: a trend analysis based on population surveys in the eastern part of Germany. Eur Psychiatry. 2009;24:225–32.

    CAS  PubMed  Google Scholar 

  37. 37.

    Ta TMT, Zieger A, Schomerus G, Cao TD, Dettling M, Do XT, et al. Influence of urbanity on perception of mental illness stigma: a population based study in urban and rural Hanoi, Vietnam. Int J Soc Psychiatry. 2016;62:685–95.

    PubMed  Google Scholar 

  38. 38.

    Schomerus G, Matschinger H, Kenzin D, Breier P, Angermeyer MC. Public attitudes towards mental patients: a comparison between Novosibirsk, Bratislava and German cities. Eur Psychiatry. 2006;21:436–41.

    PubMed  Google Scholar 

  39. 39.

    Gao S, Phillips M, Wang X, Xu D, Jia Z, Gao W, et al. Experience of stigma among patients with schizophrenia and their family members and attitudes of different groups about this stigma. Chinese Ment Heal J. 2005;19:82–5.

    Google Scholar 

  40. 40.

    Wong DFK, Tsui HKP, Pearson V, Chen EYH, Chiu SN. Family burdens, Chinese health beliefs, and the mental health of Chinese caregivers in Hong Kong. Transcult Psychiatry. 2004;41:497–513.

    PubMed  Google Scholar 

  41. 41.

    Yang LH, Pei CF, Sia KJ, Lam J, Lam K, Ngo H, et al. “What matters most:” a cultural mechanism moderating structural vulnerability and moral experience of mental illness stigma. Soc Sci Med. 2014;103:84–93.

    PubMed  Google Scholar 

  42. 42.

    Yang LH, Kleinman A. “Face” and the embodiment of stigma in China: the cases of schizophrenia and AIDS. Soc Sci Med. 2008;67:398–408.

    PubMed  PubMed Central  Google Scholar 

  43. 43.

    Hu H, Yan Y, Chen L, Pu W, Liao W, Li J. Knowledge about mental health and attitude to mental disorder in urban and rural residents in Guangzhou. Chinese Ment Heal J. 2012;26:30–5.

    Google Scholar 

  44. 44.

    Yao M, Yan X, Chang Z, Liu J, Yan L, Gao Q, et al. Awareness rate of mental health knowledge in residents in Zhengzhou City. Chinese Ment Heal J. 2013;27:682–5.

    Google Scholar 

  45. 45.

    Kitchener BA, Jorm AF. Mental health first aid training: review of evaluation studies. Aust N Z J Psychiatry. 2006;40:6–8.

    PubMed  Google Scholar 

  46. 46.

    Clement S, Lassman F, Barley E, Evans-Lacko S, Williams P, Yamaguchi S, et al. Mass media interventions for reducing mental health-related stigma. Cochrane Database Syst Rev. 2013;7:CD009453.

    Google Scholar 

  47. 47.

    Mehta N, Clement S, Marcus E, Stona AC, Bezborodovs N, EvansLacko S, et al. Evidence for effective interventions to reduce mental Healthrelated stigma and discrimination in the medium and long term: systematic review. Br J Psychiatry. 2015;207:377–84.

    CAS  PubMed  PubMed Central  Google Scholar 

  48. 48.

    Thornicroft G, Mehta N, Clement S, Evans-Lacko S, Doherty M, Rose D, et al. Evidence for effective interventions to reduce mental-health-related stigma and discrimination. Lancet. 2016;387:1123–32.

    PubMed  Google Scholar 

  49. 49.

    Zhang MW, Tsang T, Cheow E, Ho CS, Ho RC. Enabling psychiatrists to be Mobile phone app developers: insights into app development methodologies. JMIR mHealth uHealth. 2014;2:e53.

    PubMed  PubMed Central  Google Scholar 

  50. 50.

    Zhang MWB, Chan S, Wynne O, Jeong S, Hunter S, Wilson AJ, et al. Conceptualization of an evidence-based smartphone innovation for caregivers and persons living with dementia. Technol Heal Care. 2016;24:769–73.

    CAS  Google Scholar 

Download references

Acknowledgments

The authors thank all the clinicians and fieldworkers, who participated in the data collection. The authors also thank Prof. Michael Phillips from Shanghai Mental Health Center for involving in the design and training for Tianjin Mental Health Survey.

Funding

This study was supported by funds form the Tianjin Finance Bureau and Tianjin Municipal Health Bureau (Tianjin Key Programs for Science and Technology Development in Health Industry, No. 13KG119). The funding organization had no role in the design of the study and collection, analysis and interpretation of data and in writing the manuscript.

Author information

Affiliations

Authors

Contributions

GX designed the study. HY analyzed the data and wrote the initial draft of the paper. GX, HY, HT, RAS, and KJW contributed to the interpretation of the data and writing of the manuscript. All authors critically reviewed the draft and helped revise the manuscript. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Guangming Xu.

Ethics declarations

Ethics approval and consent to participate

The study was conducted in accordance with the regulations and ethics followed at Tianjin Mental Health Center and in compliance with the Declaration of Helsinki. The study protocol was approved by the medical ethics committee of the Tianjin Mental Health Center and all respondents signed informed consent before participation.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Yin, H., Wardenaar, K.J., Xu, G. et al. Mental health stigma and mental health knowledge in Chinese population: a cross-sectional study. BMC Psychiatry 20, 323 (2020). https://doi.org/10.1186/s12888-020-02705-x

Download citation

Keywords

  • China, stigma
  • Mental health knowledge
  • Survey