A Qualitative Study of Implementation Challenges of Mental Health Clubhouse Rehabilitation Services in China’s Hunan Province

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.

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.

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.

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.