Abstract
Background:
Primary care physicians (PCPs) in rural township health centers are the most easily accessible doctors to the residents in rural China, which covers 35% of the population. High prevalence of depression was reported among rural left-behind elderly and children as many workers had migrated to urban cities.
Aim:
This study explored mental health care provision by PCPs in rural China and the association with their training background.
Methods:
Rural township health centers in both developed and less developed counties of Zhejiang Province, China were chosen as the study sites. A total of 697 PCPs completed questionnaires between December 2019 and January 2020, and the number of valid questionnaires was 673, with a valid response rate of 79.3%.
Results:
The rural PCPs reported a median range of seeing 1 to 5 mental health patients per week. Over two-thirds (68.2%) of the respondents had never received any training on treating common mental health disorders (depression and anxiety) while 20.3% received at most 2 days of training; 6.4% received 3 to 20 days of training; and 5.1% received over 20 days of training. PCPs with mental health training were significantly associated with better mental health care in terms of confidence and practice characteristics (e.g. having patients who brought up mental health issues, providing follow-up), while years of practice made a difference in practice but not confidence.
Conclusions:
Training is the key determinant of the practice of mental health care by the PCPs in rural China. Our findings have implications for national policy to target two-thirds of rural PCPs who received no mental health training.
Introduction
The Chinese government has promulgated its health care reform initiative – Health China 2030 (Tan et al., 2017) to promote management for common mental disorders including depression and anxiety. A nationwide epidemiological survey conducted across 31 provinces found that the weighted lifetime prevalence of mood disorders and anxiety disorders identified from standard screening tools were 7.4% and 7.6% respectively (Huang et al., 2019). Another study analyzing data from a national health and wellness survey found that only 8.0% of patients with depression were properly diagnosed in clinical settings, and half of these diagnosed individuals were treated with anti-depressants (Gupta et al., 2016). A study in four provinces of China found that while the help-seeking rate for common mental disorders was low, a higher percentage of patients had sought help from primary care physicians (PCPs) than psychiatrists (Phillips et al., 2009). More detailed information about the PCPs’ involvement in diagnosing, managing and referring mental health patients is needed. Such information is especially lacking in the rural areas, which cover over 35% of the population in China (National Bureau of Statistics of China, 2021).
The prevalence of depressive symptoms in Liaoning Province (a less developed province) among middle-aged people was 5.9% (Zhou et al., 2014). Mental health of children and elderly in rural areas is a bigger concern (Cheng & Sun, 2015; He et al., 2016). With the rapid economic development in the past few decades, the traditional family structure in rural China has experienced dramatic changes. A report revealed that 159 million rural residents have migrated to major cities in 2011, and only 33 million brought their families with them since many were unable to afford the high living costs in urban areas (National Bureau of Statistics of the People’s Republic of China, 2012). Their children and parents are thus left in the rural hometowns. Being left behind with less family contact and support may increase their vulnerability to mental health problems (Cheng & Sun, 2015; He et al., 2012). A systematic review revealed that the prevalence of depression of left-behind children in China ranged from 12.1% to 51.4% and the prevalence of anxiety ranged from 13.2% to 57.6% (Cheng & Sun, 2015). The prevalence of depressive symptoms in rural left-behind elderly was found to be 36.9% (He et al., 2016), which was much higher than that of the 23.6% among the general Chinese population (Li et al., 2014).
Despite the high prevalence of depression, utilization of mental health services is relatively low among patients living in rural areas (Wei et al., 2011). Mental health services are available in the psychiatric departments of the hospitals in urban areas, however, they are usually not accessible by the rural population due to financial hardships, stigma, and distance (Zhang, 2008). Instead, PCPs working in rural township health centers are the most easily accessible and affordable doctors to the patients in rural areas, especially for the elderly and those with lower socioeconomic status. Therefore, PCPs should play a crucial role in managing rural residents’ mental health issues. However, challenges in delivering mental health care were reported by rural PCPs that some lacked professional knowledge in psychiatry and some others claimed that the insufficient subsidies made mental health care service delivery difficult (Ma et al., 2015). Additionally, some were reluctant to provide mental health care as they held negative perceptions toward mental disorders, such as feared of being attacked by patients with schizophrenia; some were also worried about discrimination against those who served the mental health patients (Ma et al., 2015). Hence, rural residents often fail to receive timely and good quality mental health care services. Furthermore, formal diagnosis of mental health problems including depression and anxiety disorders often need to be made by psychiatrists. It is uncertain about PCPs’ involvement in managing and referring patients with mental health problems (Sun et al., 2018).
Despite the influencing factors summarized, there was limited information about PCPs’ contribution to mental health care in rural China. This study aims to quantify mental health care provision by PCPs in rural China and explore the association with their training background.
Methods
Sampling and data collection
This study was part of a larger research project investigating primary care services in rural China. Details of the study design and findings on the factors for enhancing patients’ trust were published elsewhere (Cai et al., 2021). Ethical approvals were obtained from the Institutional Review Board of the University of Hong Kong/Hospital Authority Hong Kong West Cluster (UW19-346) and Zhejiang University (ZGL201904-2). We conducted a cross-sectional survey in rural areas of Zhejiang Province, China, from December 2019 to January 2020. There were around 21,100 PCPs in community-based health facilities in Zhejiang. PCPs were recruited using a stratified cluster sampling method. We randomly selected two counties (Ning Hai and Wu Yi) in the developed areas, and two counties (Pan An and Jiang Shan) in the less developed areas. All township health centers and affiliated units located within the four selected counties were included in this study. The target population of this study was PCPs who were working in a township-based health center or unit and holding a qualification for clinical practices certified by health authorities.
We collaborated with local health bureaus and a list of local township health facility directors and contact details were provided. We emphasized voluntary participation to directors and refusal to participate would not affect interests of their facilities. After obtaining approval from facility directors, we invited eligible PCPs working on survey days. We explained the research purpose and survey content, and ensured potential participants’ anonymity for the study. The PCPs were invited with informed consent to answer a questionnaire using an online questionnaire tool ‘Sojump’.
Questionnaire
The questionnaire was developed based on formative qualitative data, our previous primary care study conducted in Zhejiang province (Wu, 2017) and our mental health study on PCPs in Hong Kong (Lam et al., 2018). The survey questionnaire collected information about (1) socio-demographic information of the rural PCPs including age, sex, education, annual income, general practitioner qualification, years of practice; (2) mental health training background and self-reported confidence in diagnosing and managing mental health problems; (3) patients’ consultation pattern for mental health related issues; (4) the PCPs’ clinical practice in mental health care, including asking questions relating to mental wellbeing, managing patients’ mental health problems, and making referrals to psychiatrists; and (5) whether the PCPs made formal diagnoses of anxiety and depression in their working institutions.
Data analysis
The survey data were analyzed using SPSS Version 25 (IBM Corporation, NY, USA). Descriptive analysis was conducted to summarize the demographic characteristics of rural PCPs, and their clinical practice in managing mental health problems. Pearson Chi-squared test was used to test for the association of PCPs’ clinical practice with their background including gender, education level, and mental health training, whereas two-sample t-test and one-way ANOVA were conducted for the continuous variable years of practice. A p-value <.05 was considered statistically significant.
Results
Demographic and clinical backgrounds of respondents
Among 849 invited, 697 PCPs participated in this study. Excluding duplicated responses, the number of valid questionnaires was 673, resulting in a valid response rate of 79.3%. There were slightly more PCPs working in developed rural areas (57.9%), and slightly more female physicians responded (54.8%). Nearly two-fifths of the respondents reported less than 10 years of experience. The majority of PCPs had obtained formal general practitioner qualification (70.6%), and university level of education or above (71.2%). Details of their demographic characteristics were reported elsewhere (Cai et al., 2021).
Training background and confidence in mental health care
Over two-thirds of the respondents (68.2%) had never received any training on treating common mental health disorders while 20.3% received at most 2 days of training; 6.4% received 3 to 20 days of training; and 5.1% received more than 20 days of training (Table 1). Respondents had varied responses to their confidence in diagnosing patients with mental health problems. Less than 10% of respondents felt ‘very confident’ in diagnosing patients, 45.2% were ‘rather confident’ in diagnosing patients and 42.3% were ‘not very confident’. Only 2.7% felt they were ‘not confident at all’. A similar pattern was observed when it comes to respondents’ confidence in managing these patients. Around 10% were ‘very confident’ in managing patients, 42.9% were ‘rather confident’, 43.5% were ‘not very confident’, and 3.0% felt that they were ‘not confident at all’.
Training background and confidence in mental health care.
Practice in managing patients with mental health problems
A significant number of respondents reported that their patients would mention to them about their mental health problems (Table 2). Nearly one-fourth (23.9%) of respondents reported that their patients ‘always’ mentioned their mental health issues and 49.6% ‘sometimes’ did so. Less than 20% of respondents reported their patients ‘rarely’ raised the issue and only 7.1% ‘never’ mentioned it. It was not uncommon for respondents to encounter patients with a mental-health-related chief complaint/symptom. Forty-five percent of respondents had 1 to 5 patients who came to them for mental-health-related issues on average each week; 11.9% encountered 6 to 10 patients; 7.6% had 11 to 20 patients; and 5% had over 20 patients per week. The remaining 30.3% reported no such patients seen.
Practice in managing patients with mental health problems.
Although many respondents reported that they ‘always’ (42.2%) or ‘sometimes’ (42.2%) provided follow-up for patients with mental health problems, a large majority had not referred these patients to psychiatrists. Almost 40% had never referred patients and 49.8% referred 1% to 20% of their patients. Only 6.4% referred 21% to 60% of patients with mental health issues and 4.8% referred 60% to 100% of these patients to psychiatrists. Most participants reported that according to their workplace instructions, they were not allowed to make a diagnosis of common mental health disorders during patients’ first visit. Only 8.5% and 7.0% reported that they could make a diagnosis of anxiety and depression respectively.
Association between PCPs’ background characteristics and their management of mental health problems
We explored the association of PCP’s personal and training background with their management of mental health problems (Table 3). Respondents who had received some sort of training on treating common mental health disorders were more likely to have a higher level of confidence in diagnosing (p < .001) and managing patients (p < .001).
Association between PCPs’ background characteristics and their management of mental health problems.
#Pearson χ2 test to test for the association of PCPs’ clinical practice with gender, education level, and mental health training; two-sample t-test and one-way ANOVA for years of practice.
p < 0.05. **p < 0.001.
In terms of identifying patients with potential mental health problems, respondents who had received training (p < .001) and with longer years of practice (p < .001) were also more likely to have patients who brought up their mental health issues. Respondents received training (p < .001), being male (p < .001), with longer years of practice (p < .001), and having higher level of education (p = .003) tended to perceive seeing a higher number of patients who came with a mental-health related chief complaint/symptom.
In terms of management of mental health disorders, respondents who received mental health training were more likely to provide follow-up for patients (p = .002) who brought up mental health issues during consultation, as well as referring potential cases to psychiatrists (p < .001). Male respondents (p < .001) and those with longer years of practice (p < .001) were also more likely to make referrals to psychiatrists.
Association between training length in mental health and management of mental health problems
We further analyzed the association of PCP’s training length in mental health and their management of mental health problems (Table 4). Significant differences in response patterns were shown for all indicators (ranging from p = .028 to p < .001). Specific trends can be observed for some items. Compared with no training, higher proportion of respondents who had received a half day of training or less were confident of diagnosing (49.7% vs. 62.1%) and managing patients with mental health problems (48.4% vs. 59.1%). The proportions reached 76.7% and 69.8% for diagnosis and management, respectively for respondents with 3 to 20 days of training, and no/minimal rise for those with over 20 days of training. Similarly, perceived number of patients who came with a mental-health related chief complaint/symptom was highest among those respondents with 3 to 20 days or over 20 days of training. Respondents with 3 to 20 days training had the highest percentage of patients with mental health problems referred to psychiatrists, and the percentage dropped for the group with over 20 days of training.
Association between hours of mental health training hours and PCPs’ management of mental health problems.
p < 0.05. **p < 0.001.
Discussion
Despite there were large scale studies on the prevalence of common mental health problems in China (Huang et al., 2019; Zhou et al., 2014), findings about PCPs’ involvement in mental health care were limited and tended to suggest negative outcomes (Gupta et al., 2016). Our study addressed a knowledge gap to quantify the clinical practice of the rural PCPs and explored the association with their personal and training background. Overall, the rural PCPs reported a median range of seeing 1 to 5 mental health patients per week. Estimated from the median range, the numbers of mental health-related consultations encountered by each rural PCP were approximately 150 per year, which means over 30 million such consultations by the 21,100 PCPs in Zhejiang province of China. There is a substantial scope for improvement in practice considering the large number of PCPs and patients.
We found that the PCPs’ practice in mental health care was mainly determined by whether they had received mental health training, followed by years of practice. Nearly one third of the PCPs had some sort of training and this group significantly performed better in mental health care in terms of confidence and practice characteristics, while years of practice made a difference in practice but not confidence. Interestingly, PCPs with training for 3 days or above perceived highest number of patients coming with a mental-health related chief complaint/symptom. They might be more likely to be able to ‘identify’ patients with mental health problems. For example, a patient with anxiety disorder who presents with dizziness (which can also be a symptom of biological complaint) would be more likely to have his/her mental health problem identified by a PCP with more training. A PCP with less training may treat it as a ‘dizziness’ due to a biological complaint for example problem of the ear’s vestibular system. To enhance recognition of common mental health problems which often present as somatic complaints, mental health training should be promoted widely to most PCPs in China. Considering feasibility, training can focus on recognition and initial management of mental health problems. Our study suggests the training length to be 3 to 20 days (over 16 sessions) as minimal additional effect was reported for those with over 20 days of training. Similar short training with significant outcomes were reported in Hong Kong (Lam et al., 2016).
Only 8.5% and 7.0% of the PCPs reported that they were allowed to make a diagnosis of anxiety and depression respectively in their working institutions. Previous studies reported that apart from having insufficient knowledge on mental health care (Ma et al., 2015), PCPs also faced challenges in prescribing medication for patients with mental disorders (Searle et al., 2019). Due to resources and safety concerns, Chinese essential drug list for primary care did not cover psychiatric drugs. The PCPs were not generally qualified to prescribe antidepressants (Searle et al., 2019). Patterns of psychotropic drug use can be affected by local regulations, facility types (Terada et al., 2019), and traditions of psychiatric practice (Xiang et al., 2007). Our study found that PCPs who had mental health training were more likely to follow-up patients with mental health issues and refer them to psychiatrists. This indicates that despite the limited legitimacy of PCPs to make formal diagnosis for mental health patients, they can still have significant contribution in recognizing these patients and make proper referrals. This is indeed the holistic approach emphasized by the concept of ‘family doctor’. However, it needs further exploration to investigate whether the PCPs would continue to follow-up their patients’ mental health problems after making referrals.
There is also a need to extend national basic public health services package to cover PCPs’ mental health services for depression and anxiety disorders. Currently, the package includes management of psychiatric patients by PCPs but limited to those with a severe mental disorder. PCPs are asked to follow-up these patients (e.g. update health information and conduct medical examinations) after diagnosis by psychiatrists. We suggest extending the coverage to patients with common mental health problems. Furthermore, policy makers may consider increasing the unit payment of the public health services package by the government to rural township health centers as an incentive for enhancing mental health service coverage.
This study had several limitations. First, only rural PCPs in an economically better off eastern province were included in this study. The results may not be generalizable to other geographical areas of rural China. Second, we adopted self-reported measures in this study, and when it comes to clinical practice characteristics, PCPs may prefer to report more positive feedback which would cause reports bias. To triangulate the findings, future studies can evaluate rural patients’ views and experiences in mental health care by PCPs. Third, our study was conducted before the COVID-19 pandemic. There may be increase in mental health care demand during and after the pandemic (Xu et al., 2021).
Conclusions
Our findings indicate that there is a high demand for mental health care services by PCPs in rural China. Training in mental health is the key determinant of their practice. Some training, even for a half-day, could significantly improve their mental health care capacity. Balancing the time cost and effect of training, we suggest the training length to be 3 to 20 days, which can inform national policy to target the two-thirds of the PCPs who received no training in mental health. Along with training, there is a need to overcome structural barriers including legitimacy of PCPs to make a diagnosis of depression/anxiety and extending the national basic public health services package to cover common mental health problems.
Footnotes
Conflict of interest
None declared.
Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Seed Fund for Basic Research, University Research Committee, the University of Hong Kong, and the Academy of Medical Sciences and the Newton Fund (grant number NIF\R1\181020).
Ethical approvals
Ethical approvals were obtained from the Institutional Review Board of the University of Hong Kong/Hospital Authority Hong Kong West Cluster (UW19-346) and Zhejiang University (ZGL201904-2).
