Effectiveness of an anti-stigma training on improving attitudes and decreasing discrimination towards people with mental disorders among care assistant workers in Guangzhou, China

After decades of sustained global efforts, mental health is considered a global priority in the Sustainable Development Goals in 2015, which means mental health is now firmly included in the global development agenda [1, 2]. Mental disorders are closely correlated with high disability and premature mortality [3]. It is reported that mental illness accounts for 32.4% of years lived with disability and 13.0% of disability-adjusted life-years [4]. The treatment gaps mean that over 95% of people with common mental disorders in low- and middle-income countries (LMICs) do not receive effective treatment [5]. Human resource scarcity and ubiquitous stigma associated with mental disorders contribute to such disadvantage [6].

Mental disorders are different from some other diseases to some extent. For example, its assessment is mainly focused on professionals, not relying on advanced technology or medical equipment [7]. The shortage of mental health related specialist workers increases the difficulty in delivering mental health care in LMICs. Evidence-based practices recommend task sharing as an effective approach to overcome the treatment gap and to scale up mental health care [8‐10]. The core of task sharing is to reallocate tasks from specialists to non-specialist workers. Kakuma et al. have given a report about human resources of mental health care, which describes three groups of mental health workforce, such as specialist workers (psychiatrists, psychologists, neurologists, et al.), non-specialist health workers (doctors, lay health workers, caregivers, et al.) and other professionals (teachers, community workers). Trained and skilled non-specialist health workers and other professionals could deliver effective mental health care and relieve human resource crises [11‐13].

According to the current situation of China, more and more mental health service users receive mental health care in community, which motivate a new pattern of mental health care provider called the care assistant workers. Care assistant workers in China usually include primary health workers, community policemen, community cadres, volunteer and others. Primary health workers are usually general practitioners, public health doctors and nurses who provide general primary health care services. Community cadres are a group of relatively fixed people providing comprehensive services for the residents living in the community. These workers are established to assist mental health professionals to provide follow-up care, supervise medication compliance, support rehabilitation services, and to help patients and caregivers during crisis. Additionally, these workers are also supervised and monitored by the mental health professionals. The advantages of the care assistant workers are obvious. For example, the collaborations with different sectors could increase the detection of mental disorders and improve the mental health care delivery. What is more, sharing similar community culture with mentally ill persons, care assistant workers can handle certain health challenges and act as additional supporters for caregivers [14, 15].

Similar to other countries, severe mental disorders (SMD) in China are associated with long duration and high disability, which can increase family economical burden and the emotional costs of caregivers [16, 17]. Care assistant workers in China priority provide mental health care for people with SMD, which can provide a strong support for caregivers, a new gatekeeper for social harmony and a reasonable cost. This is also the product of the new social governance model based on collaboration, participation and common interests in current China. Patients with SMD, such as schizophrenia, schizoaffective disorder and bipolar disorder, who are assessed with a higher risk level, are equipped with a caregiver (always family members) and two care assistant workers, which is also called “1 + 2” model in China.

However, there is strong evidence suggesting that the ignorance of mental illness knowledge and prejudice and discrimination against people with mental illness among the care assistant workers are significant barriers in mental health care implementation [18‐20]. These negative attitudes and discriminatory behaviors could lead to adverse consequences, such as unwillingness to provide mental health care, feeling impatient, spending less time on them, and paying unequal attention and substandard care for their physical health complaints and sometimes even ignore their human rights [21‐24]. What’s worse, training programs for care assistant workers that integrate health education and stigma and discrimination reduction techniques are rarely implemented in China. Interventions are urgently needed to address the negative attitudes and discrimination among care assistant workers. Guangzhou, one of the megacities in China, has its own mental health service model, which named “PTSA” (Policy, Training, Service, and Assessment) [25]. Mental health training and assessment are important ingredients of this model. This study aims to evaluate an anti-stigma training program among these care assistant workers. We hypothesized that the anti-stigma intervention would reduce care assistant workers’ stigmatizing attitudes and increase their mental health knowledge after the training.

From more evidence-based policies to more evidence-based practices, provision of care for mental health problems has achieved significant development in recent years. The balanced care model increases service accessibility and task sharing relieves the human resource shortage in LMICs [2, 35]. However, care assistant workers are important members during task sharing, their service qualities could be influenced by the stigma and discrimination against people with mental illness [36]. To our best knowledge, this is the first study to conduct anti-stigma training among care assistant workers and explore its effectiveness on decreasing perceived discrimination, increasing mental health knowledge and improving attitudes towards mental illness in China.

From the perspective of Chinese collectivism culture, policies on mental disorders have significantly changed from the “public prevention and public treatment” in twentieth century to a social governance model—collaboration, participation and common interests—in twenty-first century. It points to the importance of protecting the human rights of people with mental disorders [37]. This is consistent with the goals of the Comprehensive Mental Health Action Plan 2013–2020 [38]. Care assistant workers could be a double-edged sword in delivering mental health care. The service quality could be influenced by their knowledge, attitudes and behaviours. Thus, interventions on care assistant workers are crucial. During this study, we found some encouraging improvements on the PDD and MICA scores after 3 h training, which showed that participants in the intervention group had significantly lower scores of PDD and MICA when compared with the control group after the training.

These results indicated that participants who received the anti-stigma training presented lower perceptions of devaluation-discrimination against people with mental illness and lower levels of negative stigma-related mental health attitudes. In our study, care assistant workers have good social contact with patients experiencing SMD by providing mental health care to them in their daily work. The education about anti-stigma may contribute to the positive outcomes to some degree. During the training, we explained the mechanism of stigma and discrimination and its negative consequences to the care assistant workers in order to renew their understanding of stigma and discrimination. The contents were formulated according to the effective interventions around the world and combined with the local mental health situations. Care assistant workers could understand and absorb the anti-stigma knowledge and skills easily. This might explain the positive changes after a short training. Our findings are consistent with those which have shown that attitudes can be improved following education aimed at reducing stigma [39, 40]. A systematic review of reducing mental health stigma among primary health care settings in LMICs demonstrated that education could have important impacts on stigma such as reducing stigmatizing attitudes [41]. Additional evidence indicates that education can positively change attitude, while there is less evidence for improving knowledge [42].

It is worth noting that care assistant workers in the study prioritized providing mental health care to individuals with SMD, such as schizophrenia, schizoaffective disorder, paranoid mental disorders, bipolar disorder, and epilepsy and mental retardation associated with mental disorders, which is consistent with the content of the “686 Program” [26]. And schizophrenia (nearly 70%) was the most common mental disorder in their management. Studies have shown that people with schizophrenia generally experience a higher level of stigma than other disorders [43, 44]. Public negative attitudes towards people with mental disorder are a potential source of self-stigma, which is produced in patients themselves [45]. Self-stigma and public stigma could produce a negative impact on the mental health help-seeking [46‐48]. Care assistant workers share similar community culture and their positive attitudes could help patients increase their accessibility to mental health care. So, it is significant and meaningful to improve care assistant workers’ attitudes towards mental disorders in order to reduce the stigma among schizophrenia patients.

The pattern of the care assistant workers is a representative performance of multi-sectoral collaboration, which is necessary in promoting mental health care [49]. People with SMD are thought as dangerous, violent and unpredictable, which contribute to the close relationship between people with mental illness and the police [50]. Under the influence of deinstitutionalization and the development of the balanced mental health care model, more and more people are released from the hospital and enter community and this relationship seems to be strengthened [51]. In our study, care assistant workers are responsible for this group of patients who have potential violence to themselves, family or even society. From the perspective of public security, patients with SMD live in a mostly controlled environment. From the legal perspective, patients with SMD have the rights to get mental health care in a “least restricted environment” [52]. This is a very real social contradiction in China. Without keeping the balance between freedom and treatment, mental health care can have negative consequences. In our study, anti-stigma and discrimination training could help care assistant workers understand the principle of treating patients as the centre and treating patients with compassion and respect. Because of the small sample of the community policemen in this study, we did not analyze the specific effectiveness of the training on them. Further studies should explore the effectiveness among large number of the community policemen.

It is well known that lack of knowledge and negative stereotypes about mental illness could increase stigmatizing attitudes towards people with mental illness. In our study, we did not find any significant differences on MAKS total scores between the two groups. Both groups had a high score of MAKS at baseline, which means that they have a better understanding of the stigma-related mental health knowledge. This may be explained from the long-term health education in Guangzhou. Mental health education has been held in Guangzhou for more than 10 years, people could achieve the knowledge from print media and other multi-media. Abundant communication channels contribute to the widespread dissemination of mental health-related knowledge. There is a promise that stigma and discrimination towards people with mental illness could also be decreased through communication channels that spread anti-stigma knowledge and skills.

Additionally, the outcomes also showed that care assistant workers had better identification on schizophrenia, bipolar disorder and depression. And there was an increasing correct rate on recognizing drug addiction as a mental illness. However, nearly half of care assistant workers recognized stress and grief as mental illnesses in this study. These results indicate that some mental illness could be better understood after education, while there are still some complicated symptoms or emotional reactions which are difficult to understand and can easily be mistaken for mental illnesses. Without correct identification, individuals suffering from non-pathological mental health problems might be misdiagnosed as a mental illness, which may lead to stigmatization and discrimination [53]. There is a need to continue to improve mental health literacy among care assistant workers and help them distinguish mental health problems and mental illness.

Training care assistant workers to deliver mental health care could bridge the shortage of human resources, which may result in positive treatment outcomes for people with mental disorders [11, 54]. Training care assistant workers with knowledge and skills to combat stigma could reduce their perceived discrimination and improve the attitudes towards people with mental disorders. Stigma and discrimination is the product of historical-cultural context [55]. Long term and multidimensional education on reduction stigma and discrimination is necessary in the future.