Twenty PHW were recruited by availability sampling through a county psychiatric hospital liaison office in southwestern China. The stigma reduction program was designed and delivered by a China-U.S. team of bilingual mental health researchers and practitioners. The study protocol was approved, respectively, by the human research ethics committees of the two collaborating universities. All participates signed informed consent.
As Chinese rural households are embedded in close-knit webs of kinship and village networks, providing in-person testimony of patients and family members about individuals’ lived experiences of stigma and discrimination while maintaining social discretion was deemed unfeasible. As such, the research team conducted 32 photo-elicitation interviews of 16 patient-caregiver dyads in the study site prior to launching the training program to generate narratives and storylines (9). Interview transcripts of two dyads with the highest scores in recovery and hope as rated by the research team were developed into two audio-taped vignettes presented by voice actors.
In addition, four focus groups were conducted with 36 healthcare providers to explore their attitudes toward mental illness and patient care. Providers identified professional knowledge (e.g. diagnosis and medication) and communication skills with patients, families, and other stakeholders as their top training priorities (6). An educational lecture on community-based case management and prevalence, diagnosis, and treatment of schizophrenia, as well as communication training through role-playing were therefore included in the program. The lecture and vignettes focused on schizophrenia, the most common psychiatric diagnosis in the county mental health system.
Figure 1 illustrates a workflow of the training protocol. The program began with a didactic lecture, followed by a case study (see the bottom panel of Fig. 1 for the life-history calendar of the vignette) with participants completing workbook exercises and participating in an interactive brainstorming session. The program continued with skills training centering on three scenarios: 1) providing emotional support to the caregiver at illness onset; 2) reaching out to the patient who did not consider himself to have mental illness; and 3) continuing support for the family when the patient recovered. The program concluded with a second vignette reinforcing the message of recovery and hope. English version of the two vignettes are included as supplementary materials.
Participants’ mental health knowledge, attitudes and behaviors toward people with mental illness, and empathy for psychiatric patients were assessed before and after the program. Mental health knowledge was assessed with the Mental Health Knowledge Schedule (MAKS). Participants’ attitudes toward mental illness and psychiatry was measured with the Mental Illness: Clinicians’ Attitudes Scale (MICA). Participants’ intended mental health-related behavioral discrimination was measured by the Reported and Intended Behaviors Scale (RIBS). The Social Distance Scale (SDS), a vignette-based measure, assessed the social distance participants intended to put between themselves and a hypothetical individual experiencing psychotic symptoms. The Jefferson Scale of Physician Empathy-Health Professional version (JSE-HP) assessed participants’ empathetic reactions to patient care. All five measures have shown high reliability and validity, and have been translated and used in Chinese populations (5, 10, 11, 12). In addition, an 11-item evaluation form assessed participants’ perceptions on the accomplishment of training objectives, quality of training experience, and relevance of training to participants’ work.
Paired-sample t-tests were conducted to examine the changes in the outcome measures before and after the training program. Mean scores were computed to assess the acceptability of the intervention using the training evaluation form.