Severe mental disorders (SMD), such as schizophrenia and bipolar disorder, are a leading cause of disability and premature mortality in the world [1]. It is shown that mental disorders could lead to 32.4% of years lived with disability and 13.0% of disability-adjusted life-years [2, 3]. Moreover, there is also increasing evidence suggesting that mental disorders account for more than approximately 13% of the global burden of disease [1, 4, 5]. It is predicted that mental disorders will take up one third of the economic burden of all non-communicable diseases by 2030 [6]. Give that SMD have an influence on well-being of individuals, happiness of families and harmony of society, including the related stigma, which sets barriers to patients’ psycho-social recovery and returning to school, work settings and community. Effective measures should be taken to deliver better services to those living with SMD [7, 8]. With the development of economy and society in middle- and high-income countries, it is important to strike a balanced model between hospitals and communities for improving mental health services in the middle- and high- income countries [9].
When compared to high-income countries, however, there are more challenges to improve mental health services in low- and middle-income countries (LMICs), given that such as a huge treatment gap (TG) exists, and the shortage of human resources which are available [10]. The treatment gap refers that more than 95% of people with common mental disorders in LMICs receive no effective treatment [11]. WHO also have reported that 97% of high-income countries deliver community-based care, but the proportion in low-income countries is only about 52% [12]. Due to the fact that mental health care mainly relies on professionals, rather than advanced technology or medical equipment, WHO has proposed strategies called task shifting (TS) for increasing human resources in mental health care, which means to shift part of services or roles from mental health staff to non-specialist health workers in the community [13].
China, one of the middle-income countries in the world, has large numbers of people diagnosed with mental disorders. In 2012, it is reported that 173 million Chinese people are estimated to have been diagnosed as psychiatric disorders, of whom 158 million receive no treatment [14]. However, policies on mental health in China have been developed accord to different characteristics in the different historical periods. There are three major changes in the period of delivering mental health care in China: The policy of ‘public prevention and public treatment’ adopted in the 1950s for people with SMD, the prevention and treatment management mode dominated by specialized psychiatric hospitals from the 1960s to the 1990s, and a rehabilitation management mode featuring community combined hospitals since the 1990s. To be specific, the Chinese government has taken effective measures to face challenges and to satisfy part of mental health needs in recent years, including efforts in 2005 to cover psychotropic drugs in basic health insurance, an initiative in 2010 to build more psychiatric hospitals and psycho-psychiatric units in general hospitals, and the ‘686 Programme’ in 2004 which aims to integrate resources of hospital and community services together and train mental health staff in case management and use individual service plans [14, 15].
China is experiencing a shift from a model of care focusing on single psychiatric institution to a new combination of multiple specialized hospitals, general hospitals and community services which results in the emergence of a new pattern of mental health care providers in communities, named care assistant workers (CAWs). CAWs arise from the specific socio-political ecological culture in China, especially for community policemen. CAWs mainly consist of community cadres, community mental health staff and community policemen. Among them, community mental health staff is primarily responsible for the diagnosis and treatment of patients with mental disorders in community settings. Community cadres are mainly in charge of providing comprehensive services for people living in the community and help with follow-up care, supervise medication compliance, and the crisis management of patients and caregivers. Local policemen in the community usually have close contact with SMD patients with unstable psychiatric symptoms or even violent behaviour, and they can assist patients with mental disorders to go to hospital if needed. For community policemen, there is trend that they are in transition from seeing psychiatric patients as ‘bad’ to ‘mad’ in their work. Community policemen used to be in charge of most criminals and a small part of criminals suffering from mental disorders. Gradually, the scope of their work has expanded, from managing people who have severe violent behaviour to those who have manifest less disturbed behaviour. In this context, community cadres and community policemen are also regarded as lay mental health workers (LHWs) [16]. It refers to those workers who lack a formal medical professional certificate or degree, but who are part of the workforce in the field of mental health.
The knowledge and attitudes of CAWs towards people with SMD can influence their behavior and quality of services provided for patients. Negative attitudes and discriminatory behaviors could cause adverse consequences, such as unwillingness to deliver care, or spending less time with such patients, or disregarding ignoring human rights [17]. However, it is still unclear what the current levels of knowledge and attitudes are among CAWs, especially for community policemen who are groups arising from Chinese socio-ecological system and their data are usually difficult to acquire. Therefore, assessing these baseline levels of CAWs is crucial to improve mental health care, especially in Guangzhou which is one of the largest metropolitan cities in China. Guangzhou has its own mental health service model named ‘PTSA’ (Policy, Training, Service, and Assessment) and implementing assessment need to figure out baseline levels [18].
This is the first study aiming at assessing the current level of knowledge and attitudes among CAWs in Guangzhou, China. We hypothesized that different types of CAWs with different age groups, care willingness and attitudes towards additional items would have different level of knowledge and attitudes related to mental health.