Abstract
Help-seeking for depression and anxiety disorders from primary care physicians in Western countries is at three times the rate of China. Western help-seeking models for common mental disorders have limitations in the Chinese settings. This article argues that an adapted model based on Andersen's Behavioral Model of Health Services Use could be an appropriate tool to better understand patients’ help-seeking behaviors and improve outcomes. We applied a narrative review approach to integrate research findings from China into Andersen's model to generate a model that fits the Chinese context. We found 39 relevant articles in PubMed, MEDLINE, and Chinese journal databases from 1999 to 2022. Findings were mapped onto predisposing, enabling, and need factors of the model. This model emphasizes that predisposing factors including demographics, social norms, and health beliefs influence help-seeking preferences. Mental health service users in China tend to be older and female. Chinese generally have high concern about psychotropic medications, and social norms that consider psychological distress a personal weakness may discourage help-seeking. However, help-seeking can be enhanced by enabling factors in the health system, including training of primary care physicians, longer consultation time, and continuity of care. Need factors for treatment increase with the severity of distress symptoms, and doctor's skills and attitudes in recognizing psychosomatic symptoms. While predisposing factors are relatively hard to change, enabling factors in the health system and need factors for treatment can be targeted by enhancing the role of family doctors and training in mental health.
Introduction
The World Health Organization (WHO) promotes the integration of mental health into primary care (World Health Organization and World Organization of Family Doctors, 2008). However, Western help-seeking models, which are predominant in the literature, have limitations in Chinese primary care settings. In Western countries, people seek help for depression and anxiety disorders from primary care physicians (15–25%) at three times the rate of Chinese people (5–10%) (Sun, Lam, & Wu, 2018). This article argues that a better understanding of barriers to and enablers of help-seeking behaviors could improve outcomes for people in China. An adapted model based on Andersen's Behavioral Model of Health Services Use could be an appropriate tool in integrating the factors in a solid framework for policy planning and implementation (Andersen, 1995). This article discusses research findings related to the factors in the model, and suggests specific ideas on how to improve the integration of mental health into primary care in the Chinese context.
We first describe the background context of mental health care in Mainland China and Hong Kong, and then provide an overview of Western help-seeking models. (In this article, China refers to the whole of China, including Hong Kong, whereas the term Mainland China is used to specify the major area excluding Hong Kong.) Further, we focus on Andersen's model and review Chinese research findings to generate a model that better fits Chinese culture. We argue that interventions and health policies targeting multiple key factors in a structured model will be more effective in enhancing help-seeking and treatment than currently used approaches. This would be beneficial to China and other Asian countries in the development of more effective community mental health services.
Background
The Mental Health Action Plan 2013–2020 published by WHO considered implementing comprehensive, integrated, and responsive mental health and social care services in community-based settings as a key objective (Saxena & Setoya, 2014). This objective echoed WHO's previous report on integrating mental health into primary care, which highlighted potential benefits including enhanced access to mental health care, greater affordability and cost-effectiveness, and good health outcomes with improved access to services in the community (World Health Organization and World Organization of Family Doctors, 2008).
In Mainland China, the Framework of the Healthy China 2030 Vision was developed to establish a comprehensive health infrastructure, in which community care was one of the priorities (Tan et al., 2017). Community-based management programs of mental health have been piloted, such as establishing community mental health facilities and training of community health care professionals. The mental health service has been incorporated as part of the public health program which is focused on managing people with psychotic disorders (Liu et al., 2011), including follow-up of cases with a mild to moderate degree of psychotic disorders in the community by primary care physicians following a diagnosis by psychiatrists (Sun et al., 2023; Xu et al., 2022). Apart from managing psychotic disorders, there is a strong need for expanding community mental health care services to include depression and anxiety disorders, which are highly prevalent among the general public and have increasingly become a public health concern since the beginning of the COVID-19 pandemic (Shi, Lu, et al., 2020; Shi, Shen, et al., 2020; Zhang et al., 2021).
In Hong Kong, a special administrative region of China since 1997 (after the British colonial governance), concerns about improving community mental health care became evident earlier than in Mainland China. Postgraduate mental health training for primary care physicians (PCPs) started in 2002. PCPs with relevant training have started playing an important role in the management of patients with common mental disorders (Food and Health Bureau, 2017). Both Hong Kong and Mainland China are in a development stage in the implementation of the concepts of family doctor and community mental health care (Hanzhi et al., 2019; Sun et al., 2015; Wu & Lam, 2017; Wun et al., 2011), and Hong Kong may be ahead in terms of research and professional training in these areas (Lam et al., 2018, 2011; Sun, Lam, Lam, Lo, Chao, Lam, & Chan, 2019; Sun, Lam, Lam, Lo, Chao, Lam, & Wu, 2019).
Western help-seeking models for mental health
A commonly used model to explore factors affecting help-seeking behaviors is the Health Belief Model developed in the United States (Rosenstock, 1974). This model included variables such as perceived susceptibility, severity, benefits, barriers, and self-efficacy, all of which may influence the effectiveness of health programs (Rosenstock et al., 1988). The model has been applied in a wide range of medical contexts, including for example mental health help-seeking behaviors of young people (O’Connor et al., 2014). An extended version of the model regarded socio-demographic factors as being fundamental and associated with a person's health beliefs. These include the perceived threat of the condition (perceived susceptibility and severity of symptoms) and expectations of treatment (perceived benefits, barriers, and self-efficacy) (Henshaw & Freedman-Doan, 2009). These factors, along with cues to action (trigger for help-seeking) such as media and family, contributed to the mental health care utilization behaviors.
Other help-seeking behavior models emphasize mental health literacy. The Information-Motivation-Behavioral Skills Model highlights that the positive association between mental health literacy and intention to seek help is mediated by social stigma (DeBate et al., 2018). Further, a conceptual framework developed in Australia (Rickwood & Thomas, 2012) recognized help-seeking behavior as an adaptive coping process attempting to obtain external assistance, and its major components included the help-seeking process, the respective time frame, the source and type of assistance, and the type of mental health concern.
Overall, there is no universal consensus on a standard model for health-seeking behaviors in relation to mental health. Most models have a strong emphasis on health beliefs and perceived treatment needs but pay less attention to barriers and enablers in health care settings, which can potentially have an important impact on help-seeking behavior.
Andersen's Behavioral Model of Health Services Use
The Behavioral Model of Health Services Use developed by R. M. Andersen (1995) is a multi-stage model integrating some of the concepts of other models, such as health beliefs, with sociodemographic and health service factors (see Figure 1).
A conceptual framework adapted from Andersen's (1995) Behavioral Model of Health Services Use.
Determinant factors of the model are grouped into three categories: predisposing, enabling, and need factors (Afilalo et al., 2004; Babitsch et al., 2012). Predisposing factors include demographic characteristics, social structures (e.g., social network, values, culture), and health beliefs. The second category describes enabling factors which are more modifiable. These include health services and health policies, which may facilitate or impede health service use. The third category involves the perceived and evaluated needs for treatment by service users and health professionals respectively (Andersen et al., 2013; Babitsch et al., 2012). These three categories of factors influence the consumer's use of formal health care services and personal health practices (e.g., self-care).
It is common for health services studies to address some or most of the factors described in Andersen's model (Babitsch et al., 2012). The groupings, linkage, and order of the factors have been reorganized several times over the decades (Andersen, 1995; Andersen et al., 2013). The model has made a significant contribution to research by incorporating individual and contextual determinants of health services use into a single framework (Babitsch et al., 2012). It has been applied in primary care and mental health studies in Western countries (Babitsch et al., 2012; Biddle et al., 2007; Goodwin & Andersen, 2002). Despite the wide coverage of health service use factors in Andersen's model, it has certain limitations in the Chinese context. First, being a generic model, it has only stated social structure and demographics as important predisposing factors, without discussion of what they are like in Chinese and other Asian cultures. Second, it has not captured a specific context for mental health services in the primary care settings of China. Thus, adaptation of the model based on Chinese research findings is needed.
A Chinese help-seeking model for psychological distress in primary care
Literature review and integration of findings
This article applied a narrative review approach to integrate relevant research findings into Andersen's model. The search was performed using the PubMed and MEDLINE databases, for articles with the publication date of period 1999–2019, using different combinations of the following keywords: “China,” “Chinese,” “primary care,” “community,” “general practice,” “family medicine,” “mental health,” “depression,” “anxiety,” “psychological distress,” “help-seeking,” “management,” “treatment,” “stigma,” and “demographics.” Some local journals published in the Chinese language were also reviewed. Forward and backward searches of reference lists were performed to further identify relevant articles. An updated search was conducted in June 2022 to include recently published articles. We included only findings which are relevant to the conceptual framework of Andersen's model. Studies on Chinese people living outside of China were excluded. Regarding mental health services and help-seeking characteristics, we selected literature published since 2010 because of its relevance to the current context. We included 39 relevant articles to support the discussion of the construct of the model. Of these 39 articles, 33 were from international journals and six were from local journals in the Chinese language. Using a framework analysis approach, findings were mapped to factors and components of the model. The classification reached consensus among the authors.
Overview of the model
We use Andersen's model as a conceptual framework to cover factors involved in the help-seeking process of Chinese people for psychological distress in primary care. The factors are classified into predisposing, enabling, and need factors, which influence help-seeking behaviors. Components based on a specific Chinese context for mental health care reported from research findings are added under these factors (see Figure 2).
A Chinese help-seeking model for psychological distress in primary care (adapted from Andersen's (1995) Behavioral Model of Health Services Use).
In this model, predisposing demographic factors including age, sex, and socioeconomic status are associated with the likelihood of help-seeking behaviors and with particular preferences for sources of help (Lam, Lam, et al., 2015; Lam, Wong, et al., 2015; Sun et al., 2017; Zhou et al., 2012). Mental health service users in China tend to be older and female (Lam, Lam, et al., 2015; Lam, Wong, et al., 2015; Zhou et al., 2012). Younger adults are more likely to use alternative help such as online resources (Chen & Zhu, 2016; Sun et al., 2017). Health beliefs affect trust in different treatment approaches. Chinese individuals tend to have high levels of concern regarding the side effects of psychotropic medications and prefer counselling to medication (Sun et al., 2016), although individuals who are older and have lower educational attainment show greater acceptance of psychotropic medications (Sun, Lam, Lam, Lo, Chao, Lam, & Chan, 2019; Sun, Lam, Lam, Lo, Chao, Lam, & Wu, 2019). Chinese social norms do not favor help-seeking for psychological problems. Distress is often seen as a sign of personal weakness (Kung, 2004; Sun, Lam, Lam, Lo, Chao, Lam, & Chan, 2019; Sun, Lam, Lam, Lo, Chao, Lam, & Wu, 2019), and self-reliance is emphasized (Shi, Shen, et al., 2020). Despite this, support from family and friends is recognized as an important factor for people who have sought help (Sun, Lam, Lam, et al., 2018).
At the systemic level, enabling factors, including health service resources and policies, influence the availability and quality of mental health care. The community mental health workforce is a main concern in China. The community mental health workers are affected by training of PCPs, consultation time, and how well they understand service users’ psychosocial background through a long-term doctor–patient relationship (Lam, Lam, et al., 2015; Sun, Lam, Lam, Lo, Chao, Lam, & Chan, 2019; Sun, Lam, Lam, Lo, Chao, Lam, & Wu, 2019; Sun et al., 2015). On the other hand, service users’ perceived needs for treatment increase with severity of distress (Chen et al., 2020), and this is particularly true for sufferers of somatic symptoms, because their symptoms interfere with daily life (Sun, Lam, Lam, et al., 2018; Xu et al., 2022). Recognition of psychological distress, often through somatic symptom complaints, is determined by the competence and attitude of PCPs in mental health care (Sun et al., 2015, 2023), and their relationship with service users (Sun, Lam, Lam, Lo, Chao, Lam, & Chan, 2019; Sun, Lam, Lam, Lo, Chao, Lam, & Wu, 2019). The combined effects of the specific components under predisposing, enabling, and need factors influence the help-seeking behaviors, determining the use of professional or informal help sources, or not seeking help (Jiang et al., 2018; Shi, Lu, et al., 2020; Shi, Shen, et al., 2020; Sun et al., 2017).
The following sections describe in detail empirical findings for each component of this model. We note that over one-third of the research findings came from Hong Kong, which has a stronger track record in conducting mental health research for primary care. The Hong Kong Chinese have been influenced by both Chinese and Western cultures. Similar situations may happen in other Chinese urban cities with international exchanges such as Shanghai and Hangzhou. While the social values of the citizens in Hong Kong might be different, they share many similar health beliefs and barriers to help-seeking with the Mainland Chinese, including concerns about taking psychotropic medications, social stigma, somatic presentation of psychological distress, and short consultation time. These factors can be discussed across regions. However, we highlight specific differences, such as differences in the training and qualification of PCPs diagnosing common mental disorders between Hong Kong and Mainland China.
Predisposing factors
Demographic factors
In general, the reviewed literature from China showed that mental health service users were more likely to be older and female (Lam, Lam, et al., 2015; Lam, Wong, et al., 2015; Zhou et al., 2012). However, there was considerable diversity in socioeconomic status. While service users with lower socioeconomic status in Beijing were less likely to be mental health service users (Chen, 2012), the opposite was reported in Hong Kong (Lam, Lam, et al., 2015; Lam, Wong, et al., 2015), where public mental health services are relatively accessible to low-income mental health service users despite long waiting times (several months to a year) for non-urgent cases to obtain an appointment with a psychiatrist (Sun et al., 2016). When differentiating the help sources, people who had sought help from professionals in Hong Kong tended to be less educated and to have a lower income. In contrast, those using informal and self-help sources exclusively were younger, better educated, and had a higher income (Sun et al., 2017). A study conducted in Beijing also reported that youth and high socio-economic status were significant predictors of internet access to mental health information (Chen & Zhu, 2016).
Social structures
There is a common view that social stigma with regard to mental illness inhibits help-seeking behavior, because the illness may be considered as something to be ashamed of for the individual and the family (Kung, 2004; Yang et al., 2013). However, similar to findings reported in Western publications, stigma was found to be more prevalent with regards to psychotic disorders than common mental disorders (Lam et al., 2013; Lam & Sun, 2014). Qualitative studies revealed that while Chinese individuals regard psychological distress as a common problem in modern life (Lam & Sun, 2014), distressed people may be seen as weak and troublesome (Sun, Lam, Lam, Lo, Chao, Lam, & Chan, 2019; Sun, Lam, Lam, Lo, Chao, Lam, & Wu, 2019). Health professionals might also hold stigmatizing opinions (Lam et al., 2013). A survey on PCPs in Hangzhou found that most respondents felt uncomfortable managing mental health patients (Chen et al., 2010). One-third of the surveyed PCPs in Hong Kong also felt uncomfortable dealing with the mental health problems of their patients (Lam et al., 2013). On the other hand, trust in doctors and encouragement by family and friends were rated among the top enablers to seeking help by people experiencing distress in Hong Kong (Sun, Lam, Lam, et al., 2018). While increased mental health literacy helps to reduce stigma (Li et al., 2022), empathy for conditions of psychological distress seems to be lower in China compared to the West (Sun, Lam, Lam, Lo, Chao, Lam, & Chan, 2019; Sun, Lam, Lam, Lo, Chao, Lam, & Wu, 2019).
Health beliefs
Research conducted in China studies found that survey respondents were unlikely to think that depression is similar to physical health problems (Jiang et al., 2018; Sun, Lam, Lam, Lo, Chao, Lam, & Chan, 2019; Sun, Lam, Lam, Lo, Chao, Lam, & Chan, 2019). Over two-thirds of the survey respondents in Hangzhou believed that depression was a disease, but less than half would seek any formal or informal help. Nearly one-third saw depression as the fault of the depressed individual (Jiang et al., 2018). A preference for self-reliance was a common barrier (Shi, Lu, et al., 2020; Shi, Shen, et al., 2020). About 60% and 78% of survey respondents in Hangzhou and Hong Kong respectively had a belief in self-resilience to get over depression (Jiang et al., 2018; Sun, Lam, Lam, Lo, Chao, Lam, & Chan, 2019; Sun, Lam, Lam, Lo, Chao, Lam, & Wu, 2019), although one-third of the Hong Kong respondents agreed that psychological distress could get better without seeking professional help (Sun, Lam, Lam, Lo, Chao, Lam, & Chan, 2019; Sun, Lam, Lam, Lo, Chao, Lam, & Wu, 2019). While health literacy was shown to be associated with recognition of the need for treatment (Wong et al., 2012), patients might be hindered by their concerns about the treatment (Shi, Lu, et al., 2020; Shi, Shen, et al., 2020). In line with Western findings, Chinese patients were more receptive to psychological counselling than to medication (Chen et al., 2020; Sun, Lam, Lam, Lo, Chao, Lam, & Chan, 2019; Sun, Lam, Lam, Lo, Chao, Lam, & Wu, 2019). However, concerns about side effects of drugs and drug dependency played a stronger role among Chinese patients and were reported as the top barriers to help-seeking (Sun et al., 2016).
Enabling factors
Health service resources
Resources are expected to affect health service provision and quality, including that for mental health. In Mainland China, the average consultation time in general practice ranges from 3 to 8 min (Jin et al., 2015; Peng et al., 2012). Patients treated by PCPs for their psychological distress had a longer average consultation time. In Hong Kong, the median consultation time was found to be 10 min for consultations involving discussion of mental health problems, which was double the usual consultation time (Lam et al., 2019). Another important factor is whether service users have continuity of care by PCPs, which is still a developing concept in China. Hong Kong data showed that people with a regular PCP were twice as likely to be treated for their distress by the PCP (Sun, Lam, Lam, Lo, Chao, Lam, & Chan, 2019; Sun, Lam, Lam, Lo, Chao, Lam, & Wu, 2019).
Health policy
While PCPs in Hong Kong are qualified to diagnose mental disorders, the PCPs in Mainland China are required to refer people with suspected mental health problems to psychiatrists for a formal diagnosis before management (Li et al., 2015; Phillips et al., 2013; Sun, Lam, & Wu, 2018). The low rate of PCPs in China with mental health training weakens their overall ability to identify mental health problems (Chen et al., 2010; Lyu et al., 2015; Wu et al., 2007). However, the training rate may be increasing. A recent study in rural areas of Zhejiang revealed that nearly one-third of PCPs had some mental health training, most having had around 4–16 sessions. They had more patients who brought up mental health issues (Sun et al., 2023). Findings from Hong Kong also showed that PCPs with mental health training treated three times the number of people with common mental disorders compared to other PCPs (Lam et al., 2018).
Need factors
Perceived treatment needs
While fewer than half of the patients were willing to seek any formal or informal help if they had depression (Jiang et al., 2018), it was common for them to seek help when the condition affected their daily life (Chen et al., 2020). Although the individuals experiencing distress due to mental illness might not seek help for subtle symptoms (Fung et al., 2021), they would be triggered to seek help when the symptoms become severe, especially for dizziness, palpitations, and insomnia, regardless of their awareness of the psychological cause (Sun, Lam, Lam, et al., 2018; Xu et al., 2022). A somatization rate of as high as 87% was reported in China, compared with an international average of 69% (Simon et al., 1999). While service users might be reluctant to accept a diagnosis of depression (Sun et al., 2015; Wu et al., 2007), they may instead be willing to consult for somatic symptoms (Shi, Lu, et al., 2020; Shi, Shen, et al., 2020; Sun, Lam, Lam, et al., 2018). A recent study in Mainland China found that the most common somatic symptoms of people with depression were insomnia (65%), pre-verbal physical complaints (47%), weight loss (39%), and low appetite (38%). Nearly one-third had circulatory system complaints, headache, hyposexuality, gastrointestinal symptom complaints, and respiratory system complaints (Zhao et al., 2018). Another recent study in Shanghai found that frequent primary care attenders had a higher rate of depression (Li & Shou, 2021).
Evaluated treatment need by PCPs
The treatment need depends on the PCPs’ ability to recognize psychological problems in the people they treat, often through somatic expressions (Sun, Lam, Lam, et al., 2018). Influenced by the term neurasthenia used in North America in the early 20th century to describe syndrome of fatigue, poor concentration, headache, and insomnia, a Chinese term shen jing shuai ruo (weakness of the nerves) was commonly used in Mainland China until the diagnostic classification reform in 1995 (Lee & Kleinman, 2007). Although modern diagnostic terms of depression, anxiety disorders, and somatoform disorders are available, some PCPs may still treat the symptoms as exclusively physical in nature and neglect or ignore potential psychological causes. A study in Shanghai found that PCPs tended to treat physical problems ahead of depression (Wu et al., 2007). Studies in Hong Kong and Zhejiang showed that PCPs’ ability and intention in mental health care could be enhanced by physician training (Lam et al., 2018; Sun et al., 2023) and long-term doctor–patient relationships (Sun, Lam, Lam, Lo, Chao, Lam, & Chan, 2019; Sun, Lam, Lam, Lo, Chao, Lam, & Wu, 2019).
Health behaviors
Influenced by the factors described above, distressed individuals may 1) use professional sources of help such as PCPs, psychiatrists, and other health professionals, 2) use informal sources such as family, friends, self-help websites, or books, or 3) not seek help (Jiang et al., 2018; Shi, Lu, et al., 2020; Shi, Shen, et al., 2020; Sun et al., 2017). Demographics, health beliefs, and social structure affect help-seeking preferences. However, feasibility of treatment is determined by health resources and policies, especially by the role and competence of PCPs in mental health care. The effect of health literacy is unclear, as formal mental health service users tend to be older, and younger adults tend to use informal sources (Lam, Wong, et al., 2015; Lam, Lam, et al., 2015; Sun et al., 2017; Zhou et al., 2012).
Implications for policy and practice
While most of the predisposing factors, and especially demographic characteristics, are rarely controllable, the attitudes of the public toward help-seeking for psychological distress may be influenced by public education. The enabling factors in the health system are modifiable by policy changes and interventions. Components that are feasibly influenced are marked with a “#” symbol in Figure 2. We argue that interventions and health policies targeting specific influencing factors would be effective in enhancing help-seeking and treatment in China. We recommend five key strategies.
Reduce service users’ concerns about treatment with psychotropic medication
Service users’ concerns about treatment with psychotropic medication are the most important barrier reported by Chinese people. To reduce these concerns, service users should be well informed about the usual length of treatment and the likelihood of common and uncommon side effects. Counselling could be the first-line treatment for mild-to-moderate distress (Sun et al., 2016). However, some people might have better treatment outcomes if medications are used. Public education may use metaphors in a Chinese context to reduce service users’ negative views of medication. For instance, Chinese health beliefs related to balance and harmony within the body could be applied to describe depression as a state of imbalance related to stress which can be adjusted through medications. Furthermore, the balance between treatment with psychotropic medication and alternative medicine such as traditional Chinese medicine should be explored.
Reduce social stigma
Improving mental health literacy by public education campaigns may reduce social stigma toward mental illnesses (Saporito et al., 2011; Thornicroft et al., 2007), which was a key concept in the Information-Motivation-Behavioral Skills Model by DeBate et al. (2018). Mental health education for the general public could be added into part of China's mental health care reform to target social stigma (Tan et al., 2017). Online platforms are a useful means of public education, especially for younger people (Chen & Zhu, 2016). Previous anti-stigma interventions in China only yielded a small effect on stereotype reduction and improvement of mental health literacy (Xu et al., 2017). New strategies should be explored to reduce the stigma with regards to depression and anxiety in order not to focus on somatic symptoms exclusively. The potential psychological causes of distress, such as depression and anxiety, should become part of the diagnostic toolbox, which would help their acceptance. Borrowing concepts from the “stress bucket model” (Brabban & Turkington, 2002), the public should be educated that depression and anxiety disorders are not signs of personal weaknesses or faults but could happen to anyone encountering substantial stress from family, work, or health issues which exceed their usual capacity to cope. Similar metaphors in a Chinese context may be applied.
Training of PCPs
Strengthening PCPs’ competency in mental health care is one of the most direct ways to improve their performance (Lam et al., 2018). The proportion of PCPs with mental health training is small in Mainland China. Less than one-third of the surveyed rural PCPs had training in managing depression and anxiety (Sun et al., 2023). Short courses delivered by psychiatrists and focused on recognizing common mental health problems, psychosomatic symptoms, and their initial management can be applied to a larger number of PCPs (Clarke et al., 2006; Lam et al., 2016; Naismith et al., 2001; Walters et al., 2007). A biopsychosocial approach should be emphasized in the training of medical students and trainees so that both physical and mental health management become routine practice for future PCPs (England et al., 2017). After training, the image and legitimacy of PCPs in mental health care should be raised in Mainland China, echoing the Healthy China 2030 plan on reforming the primary care system (Li et al., 2017; Tan et al., 2017). The Hong Kong experience has shown an example of the impact of training on PCPs’ involvement in mental health care: the trained PCPs saw and treated more patients with mental health problems than the other PCPs (Lam et al., 2018).
Family doctor, continuity of care, and longer consultation time
A long-term doctor–patient relationship can enhance PCPs’ understanding of patients’ medical history and facilitate their ability to describe psychological issues. People who regularly use the services of their PCPs are more likely to be treated for their distress (Sun, Lam, Lam, Lo, Chao, Lam, & Chan, 2019; Sun, Lam, Lam, Lo, Chao, Lam, & Wu, 2019). Alongside the Healthy China 2030 Vision on enhancing primary health management, continuity of care amongst PCPs in China could be promoted (Tan et al., 2017; Wong et al., 2017). Furthermore, there is a need to increase the average consultation time so that psychosocial problems can be dealt with. This is not only related to manpower but is also an understanding of the benefits of holistic care, which is indeed the fundamental reason for integrating mental health into primary care (World Health Organization and World Organization of Family Doctors, 2008).
Include mental health nurses in community health centers and expand community mental health services to cover common mental disorders
Community health centers are major sources of primary care services in Mainland China (Wu et al., 2017). It is impossible to overcome the deficiency of community mental health care by increasing the training of PCPs alone. It would be helpful to explore the collaboration opportunities with other health professionals. Currently, mental health nurses in China mostly work in psychiatric hospitals, although some are located in the community (Li et al., 2015). Facing social stigma, it is unlikely that people with depression or anxiety will visit psychiatric hospitals directly. We suggest that a significant proportion of the mental health nurses could be allocated to community health centers as members of the primary care team. This happens in Western countries like Australia and the UK. Mental health nurses may provide information about mental health conditions, review mental health states, and monitor medication or other treatment recommended by psychiatrists or PCPs (Beyond Blue, 2022). They may also provide motivational interviewing and supportive counselling (Browne et al., 2012). They share core values similar to those of family doctors, such as building a strong therapeutic relationship. Collaboration with mental health nurses in care provision may overcome the barriers of short consultation times and limited mental health training of PCPs in China. However, research trials are needed to explore the feasibility and applicability of this proposal. A similar strategy has been implemented by the “686 Program” (named for its first financial allotment of 6.86 million Renminbi) since 2004 to scale up urban and rural community mental health services with multifunctional teams for managing patients with serious mental illnesses (Good & Good, 2012; Ma, 2012). We suggest expanding the 686 program to cover depression and anxiety disorders.
Limitations
We did not conduct a systematic review approach (which usually aims to answer a specific research question) but explored a broad range of factors relevant to a conceptual model. We suggest conducting further systematic review to target specific factors. The proposed model is based mainly on findings from urban cities in China. Further modifications may be needed to address other contexts, including rural or poor regions.
Conclusions
Building on Andersen's model (Andersen, 1995; Andersen et al., 2013), this article provides a new conceptual framework for implementing WHO perspectives “Integration of Mental Health into Primary Care” in a Chinese context (World Health Organization and World Organization of Family Doctors, 2008). Researchers and policy makers in mental health services can take it as a reference framework for public education and policy development. In addition to China, this model could be applied to recently industrialized countries, or countries with a history of utilizing other conceptual models of health and medicine, such as Ayurvedic medicine in India, which may have a similar impact on health beliefs as Traditional Chinese Medicine does in China. The model also applies to cultures in which somatization is a common expression of psychological distress. Testing the model in health care settings would be a valuable next step in confirming its validity. Further adaptation of the model to fit in the context of other countries is expected, especially in Asia.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
