Gerontology & Geriatrics Education
ISSN: 0270-1960 (Print) 1545-3847 (Online) Journal homepage: http://www.tandfonline.com/loi/wgge20
Knowledge, Attitudes, and Clinical Practices for Patients With Dementia Among Mental Health Providers in China: City and Town Differences Hsin-Yi Hsiao, Zhaorui Liu, Ling Xu, Yueqin Huang & Iris Chi To cite this article: Hsin-Yi Hsiao, Zhaorui Liu, Ling Xu, Yueqin Huang & Iris Chi (2015): Knowledge, Attitudes, and Clinical Practices for Patients With Dementia Among Mental Health Providers in China: City and Town Differences, Gerontology & Geriatrics Education, DOI: 10.1080/02701960.2014.990152 To link to this article: http://dx.doi.org/10.1080/02701960.2014.990152
Accepted author version posted online: 27 Jan 2015. Published online: 27 Jan 2015. Submit your article to this journal
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Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=wgge20 Download by: [Deakin University Library]
Date: 09 November 2015, At: 05:22
Gerontology & Geriatrics Education, 00:1–17, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 0270-1960 print/1545-3847 online DOI: 10.1080/02701960.2014.990152
Knowledge, Attitudes, and Clinical Practices for Patients With Dementia Among Mental Health Providers in China: City and Town Differences
Downloaded by [Deakin University Library] at 05:22 09 November 2015
HSIN-YI HSIAO School of Social Work, University of Southern California, Los Angeles, California, USA
ZHAORUI LIU Institute of Mental Health, Peking University, Beijing, China
LING XU School of Social Work, University of Texas at Arlington, Arlington, Texas, USA
YUEQIN HUANG Institute of Mental Health, Peking University, Beijing, China
IRIS CHI School of Social Work, University of Southern California, Los Angeles, California, USA
Mental health providers are the major resource families rely on when experiencing the effects of dementia. However, mental health resources and manpower are inadequate and unevenly distributed between cities and towns in China. This study was conducted to examine similarities and differences in knowledge, attitudes, and clinical practices concerning dementia and working with family caregivers from mental health providers’ perspectives in city versus town settings. Data were collected during focus group discussions with 40 mental health providers in the Xicheng (city) and Daxing (town) districts in Beijing, China in 2011. Regional disparities between providers’ knowledge of early diagnosis of dementia and related counseling skills were identified. Regional similarities included training needs, dementia-related stigma, and low awareness of dementia among family caregivers. Culturally sensitive education specific to dementia for mental health providers and a specialized dementia care model for people with dementia Address correspondence to Hsin-Yi Hsiao, School of Social Work, University of Southern California, 1150 S. Olive Street, Suite 1400-1434F, Los Angeles, CA 90015. E-mail: [email protected] 1
2
H.-Y. Hsiao et al.
and their family caregivers are urgently needed. Implications for geriatric practitioners and educators are discussed. KEYWORDS dementia, city/town, dementia-related stigma, China
mental
health
provider,
Downloaded by [Deakin University Library] at 05:22 09 November 2015
INTRODUCTION Two thirds of people age 65 years and older with dementia live in developing countries (Albanese et al., 2009). Dementia has become a major public health crisis, especially in China, where more than 70% of older adults live in rural towns and villages (National Bureau of Statistics of China, 2010). The prevalence of dementia is approximately 5.6% for rural towns in China (Stokes & Pan, 2010). Providers tasked with delivering mental health services in hospitals or community clinics, including physicians and nurses, are the major resource that families rely on when experiencing the effects of dementia, particularly in areas in which specialist care for dementia is not available, which is a common occurrence in Western societies (Be´dard, Gibbons, Lambert-Belanger, & Riendeau, 2014; Robinson et al., 2011). As a matter of fact, mental health resources and capacity for dementia care are unevenly distributed between cities and towns in China. Far more financial resources have been put into hospital care in cities than toward developing comprehensive community-based mental health clinics in rural towns (Liu et al., 2011). Accordingly, most physicians cluster in cities, and relatively few professionals work in towns, which indicates that better trained mental health professionals who tend to stay in cities have more exposure to new ideas and advanced knowledge acquired from on-the-job training (Wang, 2012). In China, families residing in towns visit physicians in communitybased clinics more often than hospitals because most residents are excluded from accessing mental health services due to a lack of medical insurance (Jian, Chan, Lu, Reidpath, & Xu, 2010). This is especially true for individuals with dementia. Moreover, physicians in China do not receive formal training or education specific to dementia care as part of their regular curricula in medical school (Wang, 2012). Therefore, knowledge of and attitudes about dementia among mental health providers may affect the quality of dementia care in China. However, based on the literature, little is known about mental health providers’ knowledge, attitudes, and practices regarding dementia in China. Most of the relevant studies on the topic have been conducted in developed regions, such as Europe and North America (Iracleous et al., 2009; Koch, Iliffe, & EVIDEM-ED Project, 2010). Dementia-related stigma, difficulty differentiating between normal aging and dementia, a paucity of specialist diagnostic services, and a lack of confidence and training have been identified by Western scholars as major obstacles preventing providers (e.g.,
Downloaded by [Deakin University Library] at 05:22 09 November 2015
Knowledge, Attitudes, and Clinical Practices
3
physicians) from recognizing and responding to patients with dementia (Bradford, Kunik, Schulz, Williams, & Singh, 2009; Iracleous et al., 2009; Koch et al., 2010). Most studies examining the factors involved with dementia care have been from the perspective of caregivers, patients (Nápoles, Chadiha, Eversley, & Moreno-John, 2010; Reamy, Kim, Zarit, & Whitlatch, 2011; Woo, Mak, Cheng, & Choy, 2011), or primary care physicians and nurses (Fortinsky, Zlateva, Delaney, & Kleppinger, 2010; Harris, Chodosh, Vassar, Vickrey, & Shapiro, 2009). Hence, given the dearth of relevant research and fragmented nature of the mental health system in China, there is a need to examine knowledge, attitudes, and practices of providers whose job responsibilities include mental health service delivery at different levels to improve understanding of dementia care in China. Moreover, because of insufficient and uneven distribution of medical resources in China, regional differences in providers’ knowledge and skills specific to dementia care deserve further investigation. To fill this critical research void, this study used focus group discussions to gain an in-depth perspective of Chinese mental health providers’ attitudes, knowledge, and practices regarding dementia. The objectives of this study were to examine similarities and differences among mental health providers in city versus town settings regarding the following: (1) sociodemographic characteristics and work experiences, (2) knowledge of dementia as a disease, (3) attitudes toward dementia, (4) clinical practices for patients with dementia, and (5) experiences working with family caregivers. Findings and their implications will not only assist mental health practitioners in China in identifying barriers to effective diagnosis and treatment of dementia, as well as training needed to increase quality of care, but will also help geriatric educators improve mental health programs and policies.
METHOD Study Design To reflect the differences in the perspectives of mental health providers in city versus town settings, researchers from the Institute of Mental Health in Beijing chose Xicheng and Daxing as two contrasting districts in Beijing city to represent the city and town; these districts were chosen from 16 administrative districts to collect data in early June 2011. The central government and state council are located in Xicheng, a district renowned as a center for politics, economics, culture, and education (Office of Foreign Affairs of the Government of Xicheng District, 2012). Situated at the southern part of Beijing city, Daxing is known for its abundant agricultural resources and has a reputation of being the “green sea of sweet fruit.” It is a district of agriculture, food distribution, and consumer goods and service (Beijing Municipal Daxing District Government, 2012). Researchers from the Institute of Mental Health in Beijing distributed flyers in mental health community clinics or
Downloaded by [Deakin University Library] at 05:22 09 November 2015
4
H.-Y. Hsiao et al.
hospitals governed by the municipal departments of Xicheng and Daxing. Inclusion criteria for participation in this study were mental health providers who (1) are full-time employees with job responsibilities solely involved in mental health service provision and (2) worked in community clinics and psychiatric hospitals. Lack of either one criterion deemed the provider ineligible for participation in the study. Mental health providers include physicians, psychiatrists, and nurses. The research protocol was approved by the university’s Institutional Review Board. Using a purposive sampling method, data were gathered via focus group discussions and a brief survey of collecting sociodemographic information among participants. Given the dearth of relevant research, focus group discussion as a qualitative approach was chosen for its powerful group dynamics to allow probing ideas and concepts and obtain in-depth information. Two focus group discussions with 10 mental health providers each were conducted in Xicheng and Daxing; thus, four focus groups occurred with 40 mental health providers. After informing participants of the purpose of the study and obtaining written consent, two research team members led each focus group. One researcher served as the moderator, and the other served as an observer and took notes. Each session was approximately 90 minutes in length and was held in a private meeting room at the health clinics.
Study Instruments The research team developed a series of guiding questions with structured inquiries, including the following: 1. What do you think about older adults who are confused or have problems remembering things? 2. What do you think of when you hear or read the word dementia? 3. Do you think there are any ways to prevent dementia in elders? 4. What are some of your experiences working with families caring for an elderly family member with dementia? 5. What are some challenges for you? After the initial inquiry, remaining questions were based on the flow of the discussion. In addition, these guiding questions were supplemented with supporting questions that helped participants elaborate on concepts or provide personal stories to explain their opinions. The guiding questions were effective in garnering detailed information from the participants and helped achieve the research objectives. A brief survey was also developed to collect information about sociodemographic characteristics, employment histories, and work experience of
Knowledge, Attitudes, and Clinical Practices
5
mental health providers. All participants completed the survey after focus group discussions. Measures included gender, age, marital status, level of education, medical degree, annual household income, occupation, work position, years of practice, and self-assessed familiarity with the knowledge and skills required to work with patients with dementia.
Downloaded by [Deakin University Library] at 05:22 09 November 2015
Data Analysis Researchers collected data from focus group discussions in the Xichen and Daxing districts. All focus group discussions were video recorded with consent from participants. After collecting data from the four group discussions, the digital videos were downloaded to a researcher’s computer and stored in a secure, password-protected system. The audio portions of the four videos were used for transcription. Taped discussions were subsequently transcribed into Mandarin to produce source documents for analysis and interpretation in 2012. Transcripts were reviewed and analyzed by four members of the research team. The process of framework analysis involves a series of interconnected stages enabling researchers to move back and forth across the data for emergence of a coherent account (Ritche & Lewis, 2003). At Stage 1, the researchers familiarized themselves with all transcripts through immersion in the data and through the process of framework analysis (Ritche & Spencer, 2004); recurring themes within and among group discussions were identified. The original themes (knowledge, attitudes, clinical practice, and experience working with family caregivers) and subthemes identified formed the draft framework at the second stage. Themes and subthemes were refined, combined, and developed through transcript data, which were indexed by coding and annotating the themes from the draft framework on the transcripts. Similarities and differences between initial themes and subthemes became clearer through further immersion, and a refined framework was formed at the third stage to ensure data fit in only one theme. In the last stage, relevant passages of transcripts were extracted from the original transcript and rearranged according to the appropriate thematic reference. During the analysis stage, transcript data were divided and analyzed by city/town group, and charts of themes, research notes, and field notes were reviewed by the research team. Comparisons and contrasts were made between perceptions within and between participant groups (city vs. town).
Participants Table 1 reports the sociodemographic characteristics of the study participants. Participants in the Xicheng and Daxing groups were approximately the same age (median = 33 years vs. 33.5 years, respectively). Gender was evenly divided in both groups. Most participants were married (85%
6
H.-Y. Hsiao et al.
TABLE 1 Demographic Characteristics of Participants (N = 40) Xicheng
Downloaded by [Deakin University Library] at 05:22 09 November 2015
Variables Age (median) 20–29 30–39 ≥40 Sex Female Male Education High school College or above Medical doctor degree Yes No Marital status Married Single Annual family income (RMB)
ISSN: 0270-1960 (Print) 1545-3847 (Online) Journal homepage: http://www.tandfonline.com/loi/wgge20
Knowledge, Attitudes, and Clinical Practices for Patients With Dementia Among Mental Health Providers in China: City and Town Differences Hsin-Yi Hsiao, Zhaorui Liu, Ling Xu, Yueqin Huang & Iris Chi To cite this article: Hsin-Yi Hsiao, Zhaorui Liu, Ling Xu, Yueqin Huang & Iris Chi (2015): Knowledge, Attitudes, and Clinical Practices for Patients With Dementia Among Mental Health Providers in China: City and Town Differences, Gerontology & Geriatrics Education, DOI: 10.1080/02701960.2014.990152 To link to this article: http://dx.doi.org/10.1080/02701960.2014.990152
Accepted author version posted online: 27 Jan 2015. Published online: 27 Jan 2015. Submit your article to this journal
Article views: 56
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=wgge20 Download by: [Deakin University Library]
Date: 09 November 2015, At: 05:22
Gerontology & Geriatrics Education, 00:1–17, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 0270-1960 print/1545-3847 online DOI: 10.1080/02701960.2014.990152
Knowledge, Attitudes, and Clinical Practices for Patients With Dementia Among Mental Health Providers in China: City and Town Differences
Downloaded by [Deakin University Library] at 05:22 09 November 2015
HSIN-YI HSIAO School of Social Work, University of Southern California, Los Angeles, California, USA
ZHAORUI LIU Institute of Mental Health, Peking University, Beijing, China
LING XU School of Social Work, University of Texas at Arlington, Arlington, Texas, USA
YUEQIN HUANG Institute of Mental Health, Peking University, Beijing, China
IRIS CHI School of Social Work, University of Southern California, Los Angeles, California, USA
Mental health providers are the major resource families rely on when experiencing the effects of dementia. However, mental health resources and manpower are inadequate and unevenly distributed between cities and towns in China. This study was conducted to examine similarities and differences in knowledge, attitudes, and clinical practices concerning dementia and working with family caregivers from mental health providers’ perspectives in city versus town settings. Data were collected during focus group discussions with 40 mental health providers in the Xicheng (city) and Daxing (town) districts in Beijing, China in 2011. Regional disparities between providers’ knowledge of early diagnosis of dementia and related counseling skills were identified. Regional similarities included training needs, dementia-related stigma, and low awareness of dementia among family caregivers. Culturally sensitive education specific to dementia for mental health providers and a specialized dementia care model for people with dementia Address correspondence to Hsin-Yi Hsiao, School of Social Work, University of Southern California, 1150 S. Olive Street, Suite 1400-1434F, Los Angeles, CA 90015. E-mail: [email protected] 1
2
H.-Y. Hsiao et al.
and their family caregivers are urgently needed. Implications for geriatric practitioners and educators are discussed. KEYWORDS dementia, city/town, dementia-related stigma, China
mental
health
provider,
Downloaded by [Deakin University Library] at 05:22 09 November 2015
INTRODUCTION Two thirds of people age 65 years and older with dementia live in developing countries (Albanese et al., 2009). Dementia has become a major public health crisis, especially in China, where more than 70% of older adults live in rural towns and villages (National Bureau of Statistics of China, 2010). The prevalence of dementia is approximately 5.6% for rural towns in China (Stokes & Pan, 2010). Providers tasked with delivering mental health services in hospitals or community clinics, including physicians and nurses, are the major resource that families rely on when experiencing the effects of dementia, particularly in areas in which specialist care for dementia is not available, which is a common occurrence in Western societies (Be´dard, Gibbons, Lambert-Belanger, & Riendeau, 2014; Robinson et al., 2011). As a matter of fact, mental health resources and capacity for dementia care are unevenly distributed between cities and towns in China. Far more financial resources have been put into hospital care in cities than toward developing comprehensive community-based mental health clinics in rural towns (Liu et al., 2011). Accordingly, most physicians cluster in cities, and relatively few professionals work in towns, which indicates that better trained mental health professionals who tend to stay in cities have more exposure to new ideas and advanced knowledge acquired from on-the-job training (Wang, 2012). In China, families residing in towns visit physicians in communitybased clinics more often than hospitals because most residents are excluded from accessing mental health services due to a lack of medical insurance (Jian, Chan, Lu, Reidpath, & Xu, 2010). This is especially true for individuals with dementia. Moreover, physicians in China do not receive formal training or education specific to dementia care as part of their regular curricula in medical school (Wang, 2012). Therefore, knowledge of and attitudes about dementia among mental health providers may affect the quality of dementia care in China. However, based on the literature, little is known about mental health providers’ knowledge, attitudes, and practices regarding dementia in China. Most of the relevant studies on the topic have been conducted in developed regions, such as Europe and North America (Iracleous et al., 2009; Koch, Iliffe, & EVIDEM-ED Project, 2010). Dementia-related stigma, difficulty differentiating between normal aging and dementia, a paucity of specialist diagnostic services, and a lack of confidence and training have been identified by Western scholars as major obstacles preventing providers (e.g.,
Downloaded by [Deakin University Library] at 05:22 09 November 2015
Knowledge, Attitudes, and Clinical Practices
3
physicians) from recognizing and responding to patients with dementia (Bradford, Kunik, Schulz, Williams, & Singh, 2009; Iracleous et al., 2009; Koch et al., 2010). Most studies examining the factors involved with dementia care have been from the perspective of caregivers, patients (Nápoles, Chadiha, Eversley, & Moreno-John, 2010; Reamy, Kim, Zarit, & Whitlatch, 2011; Woo, Mak, Cheng, & Choy, 2011), or primary care physicians and nurses (Fortinsky, Zlateva, Delaney, & Kleppinger, 2010; Harris, Chodosh, Vassar, Vickrey, & Shapiro, 2009). Hence, given the dearth of relevant research and fragmented nature of the mental health system in China, there is a need to examine knowledge, attitudes, and practices of providers whose job responsibilities include mental health service delivery at different levels to improve understanding of dementia care in China. Moreover, because of insufficient and uneven distribution of medical resources in China, regional differences in providers’ knowledge and skills specific to dementia care deserve further investigation. To fill this critical research void, this study used focus group discussions to gain an in-depth perspective of Chinese mental health providers’ attitudes, knowledge, and practices regarding dementia. The objectives of this study were to examine similarities and differences among mental health providers in city versus town settings regarding the following: (1) sociodemographic characteristics and work experiences, (2) knowledge of dementia as a disease, (3) attitudes toward dementia, (4) clinical practices for patients with dementia, and (5) experiences working with family caregivers. Findings and their implications will not only assist mental health practitioners in China in identifying barriers to effective diagnosis and treatment of dementia, as well as training needed to increase quality of care, but will also help geriatric educators improve mental health programs and policies.
METHOD Study Design To reflect the differences in the perspectives of mental health providers in city versus town settings, researchers from the Institute of Mental Health in Beijing chose Xicheng and Daxing as two contrasting districts in Beijing city to represent the city and town; these districts were chosen from 16 administrative districts to collect data in early June 2011. The central government and state council are located in Xicheng, a district renowned as a center for politics, economics, culture, and education (Office of Foreign Affairs of the Government of Xicheng District, 2012). Situated at the southern part of Beijing city, Daxing is known for its abundant agricultural resources and has a reputation of being the “green sea of sweet fruit.” It is a district of agriculture, food distribution, and consumer goods and service (Beijing Municipal Daxing District Government, 2012). Researchers from the Institute of Mental Health in Beijing distributed flyers in mental health community clinics or
Downloaded by [Deakin University Library] at 05:22 09 November 2015
4
H.-Y. Hsiao et al.
hospitals governed by the municipal departments of Xicheng and Daxing. Inclusion criteria for participation in this study were mental health providers who (1) are full-time employees with job responsibilities solely involved in mental health service provision and (2) worked in community clinics and psychiatric hospitals. Lack of either one criterion deemed the provider ineligible for participation in the study. Mental health providers include physicians, psychiatrists, and nurses. The research protocol was approved by the university’s Institutional Review Board. Using a purposive sampling method, data were gathered via focus group discussions and a brief survey of collecting sociodemographic information among participants. Given the dearth of relevant research, focus group discussion as a qualitative approach was chosen for its powerful group dynamics to allow probing ideas and concepts and obtain in-depth information. Two focus group discussions with 10 mental health providers each were conducted in Xicheng and Daxing; thus, four focus groups occurred with 40 mental health providers. After informing participants of the purpose of the study and obtaining written consent, two research team members led each focus group. One researcher served as the moderator, and the other served as an observer and took notes. Each session was approximately 90 minutes in length and was held in a private meeting room at the health clinics.
Study Instruments The research team developed a series of guiding questions with structured inquiries, including the following: 1. What do you think about older adults who are confused or have problems remembering things? 2. What do you think of when you hear or read the word dementia? 3. Do you think there are any ways to prevent dementia in elders? 4. What are some of your experiences working with families caring for an elderly family member with dementia? 5. What are some challenges for you? After the initial inquiry, remaining questions were based on the flow of the discussion. In addition, these guiding questions were supplemented with supporting questions that helped participants elaborate on concepts or provide personal stories to explain their opinions. The guiding questions were effective in garnering detailed information from the participants and helped achieve the research objectives. A brief survey was also developed to collect information about sociodemographic characteristics, employment histories, and work experience of
Knowledge, Attitudes, and Clinical Practices
5
mental health providers. All participants completed the survey after focus group discussions. Measures included gender, age, marital status, level of education, medical degree, annual household income, occupation, work position, years of practice, and self-assessed familiarity with the knowledge and skills required to work with patients with dementia.
Downloaded by [Deakin University Library] at 05:22 09 November 2015
Data Analysis Researchers collected data from focus group discussions in the Xichen and Daxing districts. All focus group discussions were video recorded with consent from participants. After collecting data from the four group discussions, the digital videos were downloaded to a researcher’s computer and stored in a secure, password-protected system. The audio portions of the four videos were used for transcription. Taped discussions were subsequently transcribed into Mandarin to produce source documents for analysis and interpretation in 2012. Transcripts were reviewed and analyzed by four members of the research team. The process of framework analysis involves a series of interconnected stages enabling researchers to move back and forth across the data for emergence of a coherent account (Ritche & Lewis, 2003). At Stage 1, the researchers familiarized themselves with all transcripts through immersion in the data and through the process of framework analysis (Ritche & Spencer, 2004); recurring themes within and among group discussions were identified. The original themes (knowledge, attitudes, clinical practice, and experience working with family caregivers) and subthemes identified formed the draft framework at the second stage. Themes and subthemes were refined, combined, and developed through transcript data, which were indexed by coding and annotating the themes from the draft framework on the transcripts. Similarities and differences between initial themes and subthemes became clearer through further immersion, and a refined framework was formed at the third stage to ensure data fit in only one theme. In the last stage, relevant passages of transcripts were extracted from the original transcript and rearranged according to the appropriate thematic reference. During the analysis stage, transcript data were divided and analyzed by city/town group, and charts of themes, research notes, and field notes were reviewed by the research team. Comparisons and contrasts were made between perceptions within and between participant groups (city vs. town).
Participants Table 1 reports the sociodemographic characteristics of the study participants. Participants in the Xicheng and Daxing groups were approximately the same age (median = 33 years vs. 33.5 years, respectively). Gender was evenly divided in both groups. Most participants were married (85%
6
H.-Y. Hsiao et al.
TABLE 1 Demographic Characteristics of Participants (N = 40) Xicheng
Downloaded by [Deakin University Library] at 05:22 09 November 2015
Variables Age (median) 20–29 30–39 ≥40 Sex Female Male Education High school College or above Medical doctor degree Yes No Marital status Married Single Annual family income (RMB)
