A Qualitative Study of Implementation Challenges of Mental Health Clubhouse Rehabilitation Services in China’s Hunan Province
Abstract
Objective:
Psychosocial rehabilitation has been established as a critical component of client-centered recovery-oriented services for people with serious mental illness. Despite its importance, the implementation of mental health rehabilitation services in low- or middle-income countries has not been well studied. In this study, the authors document the regional challenges of planning and implementing mental health rehabilitation services in clubhouses in Hunan Province in the People’s Republic of China.
Methods:
Participants were purposively selected and consisted of diverse stakeholders, including rehabilitation directors and psychiatric hospital leaders in Hunan Province, China. Information was collected from 33 individuals by using three focus groups, 23 semistructured interviews of key informants, and participant observation. Interview transcripts were coded and analyzed by using standard qualitative methods.
Results:
Implementation challenges were characterized by four themes: skepticism toward psychosocial rehabilitation services, resource shortage, insufficient system integration and incentives, and stigma of mental illness.
Conclusions:
Psychosocial rehabilitation is an emerging public health priority in China. This study on clubhouses in Hunan Province used qualitative methods to inform future directions for service development and research. Early identification of regional implementation challenges is a first step in assessing the applicability of psychosocial rehabilitation services locally in Hunan Province. Successful implementation of clubhouse psychosocial rehabilitation services will benefit not only from strong government commitment but also from developing standard evaluations of evidence-based practices, tackling stigma, and addressing low resource investment.
HIGHLIGHTS
•
Recovery-oriented care has become increasingly important for China's mental health strategy since 2013 reforms mandated psychosocial rehabilitation.
•
Qualitative interviews were used to study the initial challenges in implementation of the international clubhouse model for psychosocial rehabilitation in rural and urban settings in Hunan Province.
•
Major themes were skepticism about rehabilitation services, insufficient system integration and incentives, stigma of mental illness, and resource shortage.
The People’s Republic of China has an estimated 173 million people with a diagnosable psychiatric illness (1). China’s strategy for managing psychiatric illness has been to increase access and adherence to treatment through large-scale public reforms in mental health services (2). In 2012, China’s central government passed a mental health reform law (3, 4) that mandated the availability of prevention, treatment, and rehabilitation services in both urban and rural settings. It became effective in May 2013. The law was an active step to create support for community-based psychosocial rehabilitation services (5).
In China, several psychosocial rehabilitation models have emerged. These models include the international clubhouse model (known as hui-suo in Mandarin), farming programs, workstation programs, and a proposed family-based collaborative care model (6–8), although no survey has been conducted to determine the percentages and uptake of each type of model in different provinces (9, 10). In China, family caretaking has been recognized as transculturally important in the care and rehabilitation of persons with mental illness (7, 8, 11). Because China’s mental health reform law now makes psychosocial rehabilitation mandatory, early identification and scale-up of appropriate models for psychosocial rehabilitation will be a public psychiatry challenge.
The clubhouse model has been used in Hunan Province, with one clubhouse certified by the International Center for Clubhouse Development and other clubhouses introduced after passage of the mental health reform law (12–14). Nationally, a total of six clubhouses in China are internationally accredited (15). International certification requires a clubhouse to send several staff to specific training sites for education in the clubhouse model. The site can then receive accreditation through self-study and on-site visitations. Each part of the process is lengthy and relatively expensive, and accreditation is awarded on a 1- or 3-year basis, based on compliance with the International Standards for Clubhouse Programs (15).
Currently, the use of psychosocial rehabilitation in China is low, varying from 0.3% to 2%; 1.3% of those sampled with serious mental illness use psychosocial rehabilitation services (16). Although use of the clubhouse model is emerging in psychosocial rehabilitation services, no study has characterized the implementation of psychosocial rehabilitation services in China and identified reasons for the low rate of service use. In this study, we used a qualitative case study approach (17, 18) to explore the challenges of implementing psychosocial rehabilitation services in Hunan Province, China.
Methods
The study involved participant observation, focus groups, and in-depth semistructured interviews. We purposively selected initial key informants from a list of mental health hospital leaders in Hunan Province that included approximately 50 members. Twelve informants were selected on the basis of clinical experience with and content expertise in mental health services; they also had to be division leaders and have worked in psychiatry in Hunan, China, for at least 15 years. Of these 12 individuals, three declined because of travel obligations during the study period, leaving nine participants, all hospital directors. We identified all other participants (N=21) by means of referrals from initial key informants, using the snowball sampling method (19).
The interview guide included questions listed in Box 1 and did not change throughout the data collection process. The guide was semistructured and began with open-ended questions to contextualize the interviewee’s role, China’s mental health system, and psychosocial rehabilitation, followed by more detailed questions about the interviewee’s perspective on clubhouses. This inductive method aligns with standard qualitative interviewing (17, 19). Two authors (LL, MD) contacted individuals directly via telephone and invited identified individuals to participate in the study. We used field notes, relevant practice guidelines, and published Chinese mental health literature to triangulate data and identify major themes (1, 2, 9, 20). We terminated data collection once no new themes emerged from in-person interviews and we had interviewed all identified stakeholders deemed important in earlier interviews, reaching a theoretical point of saturation.
BOX 1. Interview guide for assessing views about clubhouses and other mental health services in Hunan Province, China
General Questions About Hunan’s Mental Health System
What is your title at work and what are you responsible for? What do you do in your work that you are most proud of?
How do people receive mental health care in this community? What kind of care do they receive?
Are there programs that attempt to help the patient live more successfully in the community, such as getting a job or going to school?
Are there programs that help patients have better relationships with families, friends, or romantic partners?
Do people have to be sick to receive care? (In parts of the world, early intervention is used with benefit. Does that occur here?) What happens when they get better? (Are there services outside of the hospital that allow them to stay well?)
Are there things that people with mental illness need that they are not getting?
What have you seen work the best? What have you seen that has not worked so well? What do you think might make things better for people with mental illness?
In what way do you think mental health treatment here reflects the values and traditions of society?
Who pays for mental health services? Does the government contribute (county, provincial or national)?
I am interested in your perspective on China’s recent mental health reforms. Are there ways that you think the 2012 reform law has changed the mental health care people receive?
Is there anything I did not ask that would help me better understand your perspective?
Specific Questions About Clubhouses
What is your understanding of the clubhouse model for psychosocial rehabilitation? Do you know facilities that are using the model?
What are the opportunities and challenges of using the clubhouse model here?
How do clients find out about clubhouses? How does a client access and enroll at the clubhouse? Do psychiatric providers directly refer clients to receive rehabilitation?
How are the clubhouses funded? What is the funding used for?
How are the staff recruited to work at clubhouses? Do staff members have training on the clubhouse model?
Study Sites
Data collection took place in Hunan Province, a middle-income region in central China with a population of 67.37 million. It has an estimated 9%−10% prevalence of serious mental illness, which was described in a multistage epidemiological cross-sectional study (21). The most common serious mental illness in Hunan is schizophrenia, followed by bipolar disorder, intellectual disability, and others (21). We chose Hunan Province as the primary site for this study because of ongoing research collaborations among investigators. Changsha, the capital of Hunan, was the site of China’s first psychosocial rehabilitation clubhouse.
Data Collection
One author (LL) conducted all interviews in Mandarin. In total, 23 interviews and three focus groups were conducted. Interview data were collected from October to November 2015. No individuals included in the study sample participated in more than one interview. Observational field notes were collected, along with audio recordings of all interviews. The interviews were fully transcribed in Mandarin by a third party unfamiliar with the research.
Data Analysis
All interviews were coded and organized by using NVivo software (version 10). To minimize bias, two coding researchers trained in qualitative methodology coded approximately 180 minutes of interview material independently (including two full interviews and one focus group) to categorize and determine subthemes for an initial coding framework. Discordance between the two coders was resolved by reviewing field notes and transcriptions to minimize interrater coding disagreement and improve consensus. A single researcher then coded all the remaining interviews and finalized classification of subthemes and themes as described later (22). Researchers then translated subtheme titles and representative Mandarin passages into English.
Ethics
The Yale University Human Subjects Committee reviewed this study and deemed it exempt from full review. The institutional review board at the Second Xiangya Hospital also determined that the study was exempt from review. All interviewees and focus group members read an informed consent statement and verbally consented to participate.
Results
We recruited 33 participants for the study by using standard qualitative methodology, as described in the Methods section. Table 1 lists participant characteristics.
| Characteristic | N | % |
|---|---|---|
| Gender | ||
| Female | 17 | 52 |
| Male | 16 | 48 |
| Workplace | ||
| Hospital | 17 | 52 |
| Clubhouse center | 9 | 27 |
| University | 5 | 15 |
| Public health facility | 2 | 6 |
| Primary role | ||
| Hospital director | 9 | 27 |
| Psychiatrist or psychologist | 7 | 21 |
| Clubhouse director | 7 | 21 |
| Counselor | 5 | 15 |
| Public health director | 3 | 9 |
| Social worker | 2 | 6 |
| Workplace location | ||
| Urban | 22 | 67 |
| Mid-sized city | 5 | 15 |
| Rural | 6 | 18 |
A total of 23 individual interviews and three focus group interviews were conducted. All interviews used the interview guide and questions, as described in the Methods section. Interviews ranged in length from 47 minutes to 113 minutes, averaging 64 minutes per interview.
Major themes showed that challenges in implementation of psychosocial rehabilitation in China are closely related to skepticism of psychosocial rehabilitation, resource shortage, lack of system integration, and the stigma of mental illness. Themes, subthemes, and related quotes are presented in Table 2.
| Theme | Example quotes |
|---|---|
| Skepticism toward rehabilitation | |
| Caregivers | “Caregivers, they hold a skeptical attitude toward the rehabilitation organizations. They often claim, ‘How helpful would it be? We have already tried all kinds of treatment in so many famous hospitals, but all have failed’” (clubhouse director); “Some family members arrange almost everything for the patients—even feeding, which leads to functional degeneration of the patients” (psychiatrist) |
| Providers | “For stable patients, we often encourage them to find jobs or continue their studies. . . . Generally, we suggest the patients should get back to their normal life quickly if possible [without rehabilitation services]” (psychiatrist); “There is no evidence-based model that fits the local culture and economy in China. Thus, if the government official asked me which model is suitable currently, it is not easy to tell” (hospital director) |
| Insufficient system integration and incentives | |
| Stakeholders | “Doctors are so busy almost every day. . . . Maybe we could involve doctors in our community rehabilitation services, but it will still require further coordination between the related [government] departments” (clubhouse director); “We need to involve the rehabilitation program in hospitals, communities, and the places holding patients in rehab. A whole and integrative system, I think, may truly resolve the problem in reality” (clubhouse director); “Many patients are not yet involved in the rehabilitation service. . . . We tried to contact the officials of local community committees. But we were told that it is not proper to provide the list of the patients who live in the community” (clubhouse director) |
| Leadership | “Officials from different related government departments gave reports about public mental health problems, but no specific implementation plan or willingness to do it [develop services]” (hospital director); “There’s no one who can coordinate different departments related to mental health rehabilitation and make a big plan as a whole. . . . We can’t find a specific department in charge of it” (hospital director) |
| Levels in rehabilitation | “For example, for the patients in a stable stage, it might be better to go to clubhouse, while for those patients who prefer to stay at home, home visiting would be better” (psychiatrist) |
| Rural and urban settings | “We cannot provide specific rehabilitation services according to different type of patients. . . . The government just gives some [limited] financial support to those [patients] who live in the rural areas, have no caregivers, and face financial difficulty” (public health director) |
| Resource shortages | |
| Workforce | “It’s hard to cultivate talented personnel, which is a long process, [and] not accomplished in one stroke. . . . It is not easy to train psychiatrists, nurses, and qualified personnel. . . . There is lack of personnel specialized in psychiatry in China” (psychiatrist); “If you have no specialized background related to mental illnesses, it may be hard for you to approach the population of patients with psychosis. . . . Although there’s a big demand for mental health rehabilitation institutes, few people have the courage to overcome the challenge. . . . This is because there is a lack of related techniques and experiences” (hospital director) |
| Public and private financial resources | “The governmental funding is likely to increase gradually year by year, but the increment is not that big. . . . We have to pay staff the salary, . . . pay some for the medical insurance and subsidies” (clubhouse director); “It’s very difficult to establish or run a clubhouse . . . , because it only has inputs but no outputs. So no companies are willing to put the investment into this kind of clubhouse in the long term” (clubhouse director) |
| Access | “Transportation is a problem due to traffic jams. . . . Some patients living far away from here may spend 1–2 hours to get here” (social worker) |
| Stigma toward mental illness | |
| Community stigma | “Most people don’t understand [persons with mental illness]. They think a rehabilitation clubhouse means that all the persons in it . . . are dangerous and even likely to kill people or do bad things. So people ask us [the clubhouse] to move out of their community” (counselor) |
| Family stigma | “Some parents know that a child is ill and he may be at home for a few years. Yes, it may affect his reputation, and he will be kept at home for several years [instead of going to clubhouses or treatment]. Therefore, this view influences his visits [to the clubhouse] and affects his timely visit” (clubhouse director) |
Skepticism Toward Rehabilitation Models
Hospital participants, including mental health hospital leaders and inpatient attending psychiatrists, voiced skepticism about the efficacy of psychosocial rehabilitation. In particular, participants were concerned that the clubhouse model might only benefit a small group of stable patients and would have limited applicability in China. Similarly, psychiatrists and hospital leaders stated that they were skeptical about sending patients to clubhouse facilities that were not certified and that could not make any guarantees about the quality of their services. They preferred to send patients home to the care of their families.
Rehabilitation directors emphasized the need for more outreach to promote and educate patients and providers about psychosocial rehabilitation services. Caregivers were perceived as distrusting the model and preferring home care, which made recruitment of new clubhouse members difficult. Rehabilitation directors reported contacting family members multiple times and resorting to recruiting families at pharmacies to find new clubhouse participants. Despite these efforts, many clubhouses had difficulty maintaining regular attendance.
Insufficient System Integration and Incentives
Clinical staff at hospitals and clubhouse centers emphasized that government needed to play a leadership role in disseminating and promoting psychosocial rehabilitation. In fact, although many government agencies wanted to help coordinate services (including civil affairs, police department, public health, and others), no single agency or official was charged with this role. Public health directors and hospital directors voiced concern about the lack of shared leadership and limited options for psychosocial rehabilitation. Clubhouse directors speculated that psychosocial rehabilitation models may have limited success because individual hospitals and rehabilitation centers are unable to develop a coordinated continuum of care from inpatient hospitals to community settings.
Clubhouses struggled to engage psychiatrists to refer patients. Clubhouse directors mentioned that referrals would be more likely if collaborations were established with psychiatric hospitals. Clubhouse directors described having limited ability to reach well-known psychiatrists at mental health hospitals to promote the clubhouse model. Moreover, hospital directors had limited knowledge of psychosocial rehabilitation resources available in the community.
In addition, clubhouse directors described not being able to identify patients in the community because public health officials declined to share lists of patients collecting government-subsidized psychiatric medications. Instead, clubhouse staff advertised clubhouse offerings outside of public health facilities and pharmacies, with limited success.
In Hunan, the clubhouse model provides only one level of care. Several clubhouse directors remarked that many people with active symptoms of severe mental illness were not eligible for psychosocial rehabilitation. The clubhouse model allows those with stable or less severe psychiatric illness to be enrolled in psychosocial rehabilitation. However, once their psychiatric illness was stabilized, individuals did not want to participate in unpaid psychosocial rehabilitation programs; instead, they chose to earn money through menial jobs to support their families financially.
Similarly, interviewees also described the limited integration of psychosocial rehabilitation resources between urban and rural settings; they noted that rural settings would benefit from having psychosocial rehabilitation rather than psychiatric treatment focused solely on hospitalization.
Resource Shortages
Interviewees described financial, cultural, and systemwide challenges in delivering rehabilitation. Clubhouse directors reported limited specialized training in psychosocial rehabilitation, low employee income, and the need for additional financial investment in rehabilitation. Clubhouse staff typically include the director and one to five other staff. Staff help clients with arts and crafts, cooking, and some simple activities, such as gluing books together and folding paper boxes. Many clubhouse directors mentioned that staff working in psychosocial rehabilitation are recruited from the department of disabilities and geriatric care centers or are asked by superiors to work in the clubhouse even though they had no prior training in health or psychiatry. Only one clubhouse was certified by the International Center for Clubhouse Development. This clubhouse had a private foundation grant from Hong Kong and paid for international certification through the grant. The certified clubhouse was more successful than others in recruiting patients and managing programs. It also benefited from local publicity and collaboration with nearby hospital physicians who were aware of the quality of its psychosocial rehabilitation services. In the certified clubhouse, 20–40 members came to the clubhouse daily, whereas zero to 20 came to the clubhouses that were not certified.
Clubhouses were funded by public-sector organizations such as the Ministry of Public Health, public safety (police), civil affairs, and other governmental agencies. Because government funding was used to pay rent and staff, most clubhouses did not have funding for program development and publicity. Although they knew about the international standards for clubhouse certification, the interviewees mentioned that the cost of training and certification was prohibitively high.
Clubhouse directors discussed their low operational budget for employee wages and clubhouse facilities. Clubhouses were often located on the second floor because the rent was lower, and clubhouse members had difficulty finding them because of limited public street signs. Funding through charities and the private sector was limited because clubhouse programs are free to the public and do not produce financial returns on investment for companies or investors.
Clubhouse directors also discussed structural barriers to access, such as transportation and family finances. Reported concerns included not wanting a family member to travel on a bus alone, needing to travel on several bus lines, and having limited money to buy bus tickets. Attendance varied because of weather, with poor attendance on rainy days.
Stigma Toward Mental Illness
Stigma was a theme discussed in many interviews. On a societal level, many people with mental illness had difficulty finding jobs in the community. Rehabilitation directors shared their difficulty in establishing partnerships with private companies to hire someone with a mental illness. In addition, staff members at rehabilitation centers talked about workplace safety concerns and described vivid depictions on television of mental illness and violence.
Many interviewees discussed the theme of family stigma; families worried about being judged by the community and hid their child with mental illness at home. Family members feared that a diagnosis of mental illness could hurt an individual’s marriage prospects and affect how neighbors viewed the family. Although psychosocial rehabilitation workers attempted public outreach, family members were reluctant to bring individuals to a clubhouse. After hospitalization, family members preferred to care for patients whose symptoms were not stable at home. Clubhouse directors shared that family members often recognized behavioral changes and psychosis in their child but did not seek treatment until the symptoms became more severe. On a more extreme level, some families abandoned patients at state hospital facilities and did not claim them when they were ready to be discharged.
Discussion
To our knowledge, this is the first study of its kind to apply a qualitative case study design to assess the challenges in implementing the recovery-oriented clubhouse model in China. No known studies have assessed the efficacy of and evidence base for the clubhouse model in mainland China. The only published English-language study of the clubhouse model in a Chinese patient-care context was conducted in Hong Kong (23). This study provides an important insight into the early receptivity of the clubhouse psychosocial rehabilitation model by psychiatric providers and administrators in a low- or middle-income country, and it outlines some specific struggles faced by Chinese providers and other health care leaders involved in care delivery at clubhouses.
We identified stigma as a core theme of implementation challenges. Stigma has been previously described in the literature in China and other countries as a barrier to accessing mental health care (24–26). Stigma is a social phenomenon that can diminish with more public knowledge about mental illness (27), and psychoeducation can be helpful in reducing family- and patient-related stigma. Similarly, helpful elements in reducing provider-level stigma include engagement with service users, testimony from service users, myth busting about common misperceptions of mental illness, and didactic sessions on stigma and discrimination (28). Although China has begun to invest in and implement public awareness campaigns as a strategy to reduce stigma, more investment in public awareness may reduce some barriers to access to psychosocial rehabilitation programs (29).
Another research finding was related to the limited evaluation of clubhouse psychosocial rehabilitation services. All clubhouses except one lacked international certification and had unclear training guidelines, which suggests variable quality of the psychosocial rehabilitation services provided and potential deviation from evidence-based practices for recovery and psychosocial rehabilitation. Although several studies have described the process for measuring the implementation of community support programs and for assessing the fidelity of psychosocial rehabilitation models, we found that no formal evaluation process was used to standardize the care delivered in the clubhouses in Hunan Province (30–32). Future research should address evaluation and fidelity of service delivery to evidence-based practices and further assess the use of clubhouse psychosocial rehabilitation in the Chinese context.
Some limitations of the study include that the study was conducted in one province in China and was primarily centered in the city of Changsha. As a result, it is difficult to ascertain whether the study is relevant to locations outside of Hunan Province because China has regional variations in psychosocial rehabilitation models (33). The interviews were conducted over a short time frame, and clubhouses varied in stage of development and implementation. In addition, we did not individually interview patients and service users. Moreover, the interview guide did not introduce the concept of recovery, and the word rehabilitation was used synonymously with recovery. Although by Western definitions recovery extends beyond rehabilitation services, we assessed the implementation of rehabilitation services through the clubhouse model as related to going to work and finishing school (34). We found that individuals with mental illness would rather earn money through a menial job to help with their family’s financial needs than participate in unpaid clubhouse psychosocial rehabilitation programs. This finding is congruent with established cultural findings in China that individuals make fewer autonomous decisions; family decision making is more prevalent, which is important for recovery programs to consider (35, 36). Finally, we did not assess other types of psychosocial rehabilitation models, including workstations and farming communities.
As a low- or middle-income country, China has made significant progress in its reform of mental health services in recent years. This progress largely reflects the Chinese government’s central role in China’s recent mental health reform, including psychosocial rehabilitation. It is important to acknowledge the importance of leadership in instituting change and that policy initiatives have led to large expansions in psychosocial rehabilitation services and structural reorganization in an attempt to improve access to and coordination of psychiatric care (37).
Additional aspects of psychosocial rehabilitation should be evaluated in future qualitative studies. More narrowly focused research questions about location of service delivery, transitions between levels of care, tiered levels of care, user experience, other psychosocial rehabilitation models, and social stigma will provide additional data about the cultural adaptability of psychosocial rehabilitation in China. Addressing mental health workforce development and educational training will be crucial as cities and provinces across China attempt to expand and implement psychosocial rehabilitation programs (38, 39).
Conclusions
Psychosocial rehabilitation is emerging as a public health priority in China. In this study of clubhouses in Hunan Province, we used qualitative methods to inform future directions for service development and research. Early identification of regional implementation challenges is a first step in assessing the applicability of psychosocial rehabilitation services in local settings such as Hunan Province. Successful implementation of clubhouse psychosocial rehabilitation services will benefit not only from strong government commitment but also from developing standard evaluations of evidence-based practices, tackling stigma, and addressing low resource investment.
Acknowledgments
The authors acknowledge Xinran (Richard) Hu, M.D., M.P.H., and Xuan Ouyang, M.D., Ph.D., for their help in facilitating and guiding data collection and for their input on the literature review.
Footnote
The Yale Global Mental Health Program, Bertram H. Roberts, M.D., Memorial Fund, and Yale New Haven Hospital medical staff fund helped fund Dr. Li’s time for study design, research analysis, and manuscript preparation. Second Xiangya Hospital supported Dr. Deng’s research time, NVivo software acquisition, and transcription services used in study analysis.
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History
Received: 30 November 2018
Revision received: 18 January 2019
Revision received: 6 March 2019
Accepted: 15 March 2019
Published online: 30 April 2019
Published in print: August 01, 2019
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Competing Interests
The authors report no financial relationships with commercial interests.
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