Stigma of Mental Illness in Hong Kong Families

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Peer-reviewed

Enquiry Article

Experiences of Stigma and Discrimination among Caregivers of Persons with Schizophrenia in Prc: A Field Survey

• Yi Yin,
• Weijun Zhang,
• Zhenyu Hu,
• Fujun Jia,
• Yafang Li,
• Huiwen Xu,
• Shuliang Zhao,
• Jing Guo,
• Donghua Tian,
• Zhiyong Qu

x

• Published: September 26, 2014
• https://doi.org/10.1371/periodical.pone.0108527

Figures

Abstract

In China, caregivers for family unit members with schizophrenia play an important role in treatment and recovery just may experience stigma and discrimination simply because of their family relationship. The object of this study was to mensurate the degrees and correlates of stigma and discrimination experiences among this group. Four hundred twenty-seven caregivers participated in this hospital-based and cantankerous-sectional study in Ningbo and Guangzhou, China. Data were collected past trained interviewers using fixed questionnaires. Stigma and discrimination experiences were measured by the Modified Consumer Experiences of Stigma Questionnaire (MCESQ). Caregivers' social support was measured by the Social Back up Rating Scale. Parametric analysis, nonparametric analysis and multivariate linear regression were used. The hateful (SD) score of MCESQ was two.44(0.45), 2.91(0.71) for stigma experiences and one.97(0.37) for bigotry experiences on a five-signal score ("1 = never" and "5 = very often"). Approximately 65% of caregivers reported that they tried to conceal their family members' illness, and 71% lacked the support of friends. The experience of stigma was significantly negatively associated with the perceived social back up of caregivers (standard β = −0.2,p<0.001). Caregivers who were children of the patients experienced fewer stigmas than other (standard β = −0.18, p<0.001). Urban residence (standard β = −0.12, p<0.01) and patients did not complete master school education (standard β = −0.thirteen, p<0.01) were negatively related with stigmas. In addition, stigma and bigotry was more than experienced in Zhejiang than in Guangdong (p<0.05). In conclusion, this written report performed that caregivers of people with schizophrenia in China experienced full general stigmas and rare bigotry and found the relations with social back up, kinship, patient's educational level and regional differences. More interventions and supports should been given to caregivers who are lack of social support, who live in rural area and who are the patients' parents, spouses or siblings.

Commendation: Yin Y, Zhang Due west, Hu Z, Jia F, Li Y, Xu H, et al. (2014) Experiences of Stigma and Discrimination among Caregivers of Persons with Schizophrenia in China: A Field Survey. PLoS I 9(9): e108527. https://doi.org/10.1371/journal.pone.0108527

Editor: Delphine Sophie Courvoisier, University of Geneva, Switzerland

Received: May 28, 2014; Accepted: August 22, 2014; Published: September 26, 2014

Copyright: © 2014 Yin et al. This is an open up-access commodity distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Information Availability: The authors confirm that, for approved reasons, some access restrictions apply to the data underlying the findings. The data are bachelor upon asking considering of an ethical brake with cooperation hospitals before the survey. The readers can send a asking to corresponding author Dr. Qu Zhiyong (qzy@bnu.edu.cn) to reach the data. Data are available for researchers who meet the criteria for access to confidential information.

Funding: The study was sponsored past the Teaching Foundation of Beijing Normal Academy (http://www.bnuef.org/). DT received the funding. The funders had no office in written report pattern, data collection and analysis, decision to publish, or preparation of the manuscript.

Competing interests: The authors have alleged that no competing interests be.

Introduction

Schizophrenia is i of the most severe mental illnesses in the world. This illness creates burdens for families and affects the quality of life of relatives [one]–[ii]. Patients as well suffer from stigmas, bigotry (the behavioral aspect of stigma), as well as exclusion from customs life in housing, education, employment and social and family relationships [3]–[v]. At the same time, stigmas and bigotry are also mutual among families, who share similar beliefs about inferiority and may experience a lessened sense of humanity [six]. Other research also has shown that family members of serious mental health consumers, particularly caregivers of patients with schizophrenia, often see stigma and discrimination [4], [vii]–[10]. Family stigma negatively impacts caregivers and persons with schizophrenia, creating burdens, enhancing stress and affecting the quality of life [11].

One explanation for stigmas and feelings of guilt is that the origin of illness tin be traced to family [nine]. In addition, social and cultural factors can enhance "genetic risk". Karamlou and Mottaghipour's interviews in Iran showed that cultural differences might influence the experience of stigma in families of psychiatric patients in areas such as concealment, limitation in piece of work and education, genetic attributions, traditional behavior in gild virtually patients, gender differences and so on [12]. Snowden and Yamada also stressed that i source of stigma could not supersede another; it was therefore important to pay more attention to gender, race and immigrant identities in the stigmatized family [13]. In fact, in traditional Chinese club, there is a cultural expectation that families should stay at the infirmary or at habitation to care for patients, leading to much more involvement in the care of people with severe mental illness [fourteen]–[xvi]. Therefore, illness is a family unit issue rather than an private problem [17].

Existing research has discussed the caste to which stigma is experienced or perceived among caregivers in Communist china. For case, Phillips et al. institute that 26% of 952 family members of persons with schizophrenia in v sites around China faced a moderate to astringent degree of stigma, based on interviews [18]. Lee and colleagues performed a study using a focus grouping in Hong Kong suggesting that approximately 40% of patients with schizophrenia reported that their family members were unfairly treated considering of the patients' illness, and over 60% of their family unit members and partners chose to conceal their relationship [nineteen]. Research by Gao and his colleagues indicated that 56% of relatives of patients with schizophrenia kept the disease undercover in Beijing, People's republic of china [20].

Some enquiry worldwide has discussed factors which are related with stigma and discrimination experienced or perceived by family caregivers of patients with severe mental illness. First, unlike social-demographic factors affect perceptions of stigma. Urban residents suffered a higher level of stigma compared with those in rural areas [18], [21]. Furthermore, highly educated families are more sensitive to stigma [xviii], [22]. For example, Shibre and colleagues institute that the urban residents whose age were over 45, perceived more stigma in rural Federal democratic republic of ethiopia [23]. In improver, Charles, Manoranjitham and Jacob found a significant association between stigma scores of patients and relatives in south Bharat and that the relatives' stigma scores were significantly associated with male gender, literacy, rural residence, and belief that illness was due to karma and full patient stigma scores [24]. Second, the clinical history of patients can besides touch on the degree of stigma. A long elapsing of disease will increase stigma [25], and the diagnosis of an illness within 6 months may lead to increased abstention by others [22]. Finally, the psychological states and characteristics of caregivers are other related factors. Magaña et al. discovered that stigma was significantly correlated to depression in Latino family caregivers of persons with schizophrenia [26]. In Ethiopia, information technology was found that caregiver's self-stigma levels were significantly related to their knowledge and the conventionalities in supernatural explanations for the disease [21]. Additionally, high levels of expressed emotion can cause greater stigma [18].

There has been little research into stigma among Chinese family caregivers, although Chinese family caregivers of mentally illness relatives are ordinarily more involved in clinical treatment and care due to traditional family values [thirteen]. Existing inquiry has proposed that stigma is associated with such threats as "genetic contamination" and "losing face" in the Chinese cultural context, but little enquiry has explicitly identified and tested the effects of this threat to family unit lineage among Chinese groups [27], [28]. Well-nigh all existing research about stigma and schizophrenia has used quantitative methods with a lack of systematic assessments; furthermore, petty is known about the specific stigma and bigotry experiences of the caregivers of patients with schizophrenia. Another limitation of prior studies is that their sample selection was based on typical individuals rather than on large-sample, without exploring the breadth and depth of the problem [eleven].

This article will investigate the stigma and bigotry experienced by caregivers in their daily life, such as in education, housing, chore hunting and other social activities in China. In particular, we will explore the correlation between the experience and possible assembly, like social-demographic variables and caregivers' perceived social support.

Methods

1. Study pattern

This report is a cantankerous-sectional and hospital-based survey conducted in Guangzhou, and Ningbo. Guangzhou is too known equally Canton and is the capital letter of Guangdong Province; Ningbo is the second largest city in Zhejiang Province. In 2010, in that location were 12.7 one thousand thousand resident population in Guangzhou and 7.six meg in Ningbo co-ordinate to the 6th Nationwide Population Demography. The survey conducted in iii mental health hospitals in Guangzhou affiliated with Guangdong Mental Health Center and 1 in Ningbo under Ningbo Mental Health Center from June 2012 to July 2012. These centers undertook the master responsibilities for service providing and technique guidance, in which approximately 70% local schizophrenia patients acquired direct and indirect treatment and recovery service.

2. Participants and sample procedures

Before the survey, a focus grouping discussion was conducted to determine the definition of caregivers and sampling procedures in which psychiatrists, researchers, family members participated. According to the purpose and design of the study, only ane primary caregiver for each patient was surveyed and was defined as: (ane) who was regarded by patient as main caregiver; (2) whose cocky-written report care workload percentage among all family members who gave care to the patient should be more xxx%; (three) whose care elapsing was more than than 1-twelvemonth except for patients diagnosed in 2012. And including standard was: (ane) family unit members of people with schizophrenia; (2) age above 18 years old; (3) outpatients or inpatients taken care of by participants had to meet the Chinese Classification of Mental Disorders 3rd edition (CCMD-III) criteria for schizophrenia. CCMD- Three is a clinical guide in China that is widely used to diagnose mental disorders. It is based on International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-ten) and a few variations exist because of cultural differences.

The participants came from two parts: First, the primary caregivers of all the inpatients during the period of investigation were invited by our squad and the nurses were responsible to go in bear upon with them; 2nd, caregivers who accompanied with the outpatient to infirmary in the morning time during the two weeks also were invited to participate in this research.

Sample size adding was based on a conservative estimate 50% (prevalence of stigma), while a 5% error rate was adopted in the calculation. The study would need to have a sample of 384 participants at least. Finally, there were a total of 427 samples for assay in this study.

Cooperative personnel were recruited after beingness fully informed about the research by trained investigators (including graduate students, nurses and intern doctors) in our research team. The investigators conducted face-to-face structured interviews using pretested questionnaire with caregivers in Mandarin or local dialects.

3. Measurements

Stigma and discrimination were measured past the Modified Consumer Experiences of Stigma Questionnaire (MCESQ), which assessed negative reactions experienced considering of relatives with schizophrenia in the past month [29]–[30]. The questionnaire was modified, and one particular nearly unequal handling about wellness insurance was not measured for this written report, given that the health insurance in China was arranged in country-level which combined with New Rural Cooperative Medical Scheme, Urban Residents' Basic Medical Insurance and Urban Employee Basic Medical Insurance, and the medical reimbursement depended on policy at that time. The scale used in our study had 18 items and ii subscales (stigma experience and discrimination experience) that assessed the degree to which an individual had perceived negative social deportment. The "stigma" scale measured the degree to which caregivers dealt with negative attitudes from others because of their relatives' severe mental illness. For case, "I have worried that others volition view me unfavorably considering my family unit member receives psychiatric handling." The "discrimination" scale measured whether caregivers experienced bigotry in working, housing, participation social activities, etc. because of the fact that they were caring for relatives with schizophrenia. One of the examples was "I take been avoided indicating on written applications (for jobs, licenses, housing, school, etc.) that my family received psychiatric treatment for fear that information would be used confronting me or my family." Each item was rated on a five-point Likert scale that was anchored at "1 = never" and "v = very often". A full score of caregivers' stigma and discrimination experience was computed past summing up the individual items after reversely coding opposite scoring item. A higher score therefore indicated higher stigma and discrimination experience. The efficacy of this scale in measuring experiences of stigma has been previously demonstrated [31]. The review of the literature indicated that the boilerplate coefficient for internal consistency for the CESQ was 0.78 [32]. The coefficient for internal consistency in this sample was Cronbach's α = 0.67.

Social support was measured using the Social Support Rating Scale (SSRS), adult and modified past Xiao [33]. This scale consists of 10 items and three major categories that measured subjective support, objective support and the use of differing degrees of back up. For case, "How many shut friends you have that can give you back up and assistance?" was asked to measure out the support from friends. The highest possible score is 66, with a higher score signifying more social support. This calibration is widely used in China with good reliability and validity. The Cronbach's α in this study was 0.724.

Demographic and background information nerveless in this study for caregivers and their relatives included age, gender, marital status (unmarried, married, divorced/widowed), kinship (spouse, kid, parent, sibling, other), education level (≤primary schoolhouse, middle school, high school, higher and above), province of residence (Guangdong, Zhejiang), settings (rural, urban), employment condition (employed, unemployed, retired), family income (yuan per twelvemonth), duration of caring (twelvemonth), and other items related to the illness, such as the duration of disease and phase of illness (prodromal phase, acute stage, remission).

4. Information analysis

Data was double-entered into EpiData version 3.1 (EpiData Clan, Odense M, Denmark). And so, data was imported into STATA version 12.0 for Windows (Stata Corp, College Station, Texas United states of america) for data completeness, outlier clearance and data analyses. Descriptive analyses were used to report stigma and bigotry status, degree of social support, social-demographic status and the status of the patient's illness. Normality of the stigma experience score, discrimination feel score and total MCESQ score were checked using Skewness-Kurtosis test. Scores of stigma experience and total MCESQ scores met the standard of normal distribution. Since the discrimination score was not normally distributed and it could non be normal after logarithmic transformation and exponential transformation, non-parametric examination and robust regression were used for the analysis of discrimination score. Therefore, (1) Pearson analysis, T-test and ANOVA was used to identify the relationships amongst stigma experience, social support and other factors; (2) in terms of discrimination experience, bivariate analyses were conducted using Spearman analysis, Ranksum-test and Kruskal-Wallis examination; (3) bivariate test almost MCESQ score was the same as that of stigma score; (four) multiple linear regressions were used to clarify the associates of the stigma experience score and total MCESQ score. (5) robust regression was conducted to analyze related factors of bigotry feel score. Finally, the presence of multi-collinearity was likewise checked.

v. Ethics argument

The written report was approved by the Institutional Review Board of the School of Social Evolution and Public Policy at Beijing Normal University. Approved exact informed consent was used rather than signature or fingerprint one because participants regarded the latter every bit sensitive issues in local culture and information technology might lead to high refusal charge per unit. The consent was read past the investigators earlier starting the interviews to keep every study participant exist informed of the enquiry purpose, procedures, potential risks and benefits of participation, confidentiality protection, the right to turn down or withdraw then on. The interview was started or stopped at the participant request. Our ethics committee canonical this consent process.

Results

1. Socio-demographic characteristics

Tabular array 1 and Table 2 summarize the social and demographic characteristics of caregivers. 229(53.half-dozen%) caregivers in Guangdong and 198(46.4%) caregivers in Zhejiang were included in this written report. The average age of caregivers was 50.88 years (min = twenty, max = 83, standard deviation [SD] = 12.62), about half (52.0%) were male. In terms of family kinships, 54.vi% of primary caregivers were parents of patients, 26.five% were spouses, 10.v% were children, six.three% were siblings and 2.1% were other relatives. Nigh three-quarters (74.iii%) had less than nine years of education. Merely 17.6% were unemployed. 53.four% of caregivers lived in rural areas. Average of caring yr was 7.26(SD = 3.37). Family income was 46,551 RMB (virtually 7,389 U.S. dollars, 1 USD ≈ 6.iii RMB, June 2012) per year on average. The score of social support was range from 14 to 51 and hateful score was 28.76 (SD = seven.08).

As shown in Tabular array 1 and Tabular array 3, the sample consisted of patients aged between 12 and 75 years old with a mean age of 35.53(SD = 11.63). More than one-half (56.ii%) of patients was female, and 43.8% were male. The majority had a low educational level (62.five%) and was unemployed (69.six%). The majority (60.seven%) of patients was in the acute phase, near a quarter (24.1%) was in the remission phase, and the remainder (15.ii%) was in prodromal phase. On boilerplate, the elapsing of disease was 7.38(SD =half dozen.23) years.

2. Descriptive analyses of stigma and discrimination

Table 4 shows the MCESQ scores for each item. The hateful scores for the MCESQ scale were as follows: 2.44 for the overall MCESQ score (SD =0.45) (between "seldom" and "sometimes"); 2.91 for stigma experiences (SD = 0.71) (nearly "sometimes"); and i.97 for bigotry experiences (SD = 0.37) (nearly "seldom").

The mean score of "I have avoided telling others outside of my firsthand family that my family member has received psychiatric treatment" was above 3, and 64.9% answered "sometimes" to "always". This finding indicates that caregivers themselves would similar to conceal the fact that a family member was receiving treatment for mental illness. Moreover, seventy.7% of caregivers lacked the support of friends. The mean score for "friends understanding and supportive" was 2.eighty, showing that caregivers lacked understanding and support from friends. Additionally, because of their family situation, more than than one-half (62.three%) of caregivers had lowered their expectations for accomplishments in life. Nearly one-half (48.2%) of caregivers reported that they had been unfavorably treated and 38.0% had shunned/avoided by others who knew nearly their family unit member's disease. Furthermore, 36.0% of caregivers had heard others proverb unfavorable or offensive things nigh their family members. Notwithstanding, caregivers of persons with schizophrenia seldom experienced discrimination when watching news in the mass media, renting a firm, searching for a job, acquiring education, joining social activities, applying for a license, in legal proceedings and in dealing with government officials. The near frequent areas in which bigotry occurred while working with co-workers and supervisors (38.4%) and writing paper awarding for jobs, licenses, housing, school and so on (37.nine%).

3. Bivariate correlations

Table i, 2 and 3 nowadays the bivariate analyses for stigma experience mean scores, discrimination feel mean scores, and MCESQ hateful scores with peradventure associates.

Pearson assay found the age of caregivers was significantly positively related to stigma (r = 0.12, p<0.05). Different family kinship with patients also associated with caregivers' feel of stigma. As demonstrated in Table 2, parents and spouses suffered significantly more than stigmas than siblings, children and other family unit members (F = 8.16, df = 4, p<0.001) and children experienced fewest. Additionally, the relationship between kinship and MCESQ scores was also statically significant (F = 7.85, df = iv, p<0.001). Besides, their living areas were too related to their stigma experience and the total MCESQ scores. As showed, the mean stigma scores of Zhejiang was 3.08 (SD = 0.05), significantly more than that in Guangdong (Mean = 2.76, SD = 0.04, t = 4.56, p<0.001). Caregivers from rural areas also reported more than stigma experiences than those from urban (t = 2.08, p<0.05). SSRS scores were negatively associated with stigma experience (r = −0.24, p<0.001) and MCESQ scores (r = −0.21, p<0.001). Notwithstanding, caregivers' gender, educational level, marital status, and family unit income were not statically significantly related to MCESQ scores.

The bivariate analysis suggested that the stigma experience of caregivers was negatively correlated with patient historic period (r = −0.16, p<.001), educational level (F = three.89, df = 3, p<0.01) and related to marital status (F = 4.27, df = ii, p<0.05) and phase of illness (F = 3.xxx, df = 2, p<0.05). Caregivers experienced more stigmas when patients were young, singled, highly educated and in the acute phase. Patient gender, employment status and duration of disease did non announced to influence caregivers' experience of stigma. Similarly, mean score of MCESQ was negatively related to patients age (r = −0.15, p<0.01) and associated with phase of illness (F = iii.78, df = 2, p<0.05).

The caregivers' experience of discrimination was just significantly correlated with province (Z = −ane.97, p<0.05). However, the relations betwixt discrimination and other patient and self-factors were non significant.

4. Regression Analyses

Three models (encounter Table 5) were investigated in this commodity, i for the caregivers' stigma feel score (Model one), one for the caregivers' discrimination feel score (Model 2) and another for the caregivers' MCESQ scores (Model iii). Models included simply those associate variables that were related with the relevant stigma score, discrimination score and MCESQ score at p<0.05. The first and third models yielded significant overall probability levels, accounting for 14.2% and 10.5% of variance in the dependent variables. Candidate factors for the 3 multivariate models were selected on the basis of their significant partial correlation with the corresponding scores (Table 1, Tabular array 2 & Tabular array three). Model 1 and Model iii indicated that the degree of caregivers' social support was significantly negative related to the caregivers' stigma (standard β = −0.20, p<0.001) and total MCESQ scores (std. β = −0.17, p<0.001). Furthermore, children of patients suffered significantly fewer experiences of stigma than spouses, parents and other relatives who were caregivers (std. β = −0.18, p<0.001). In addition, if patient did not or merely complete primary school, the caregivers experienced fewer stigmas (std. β = −0.13, p<0.01). Moreover, people living in urban areas experienced fewer stigmas (std. β = −0.12, p<0.01). Furthermore, caregivers from Zhejiang reported more than stigmas (std. β = 0.15, p<0.005), discrimination (unadjusted B = 0.67, p<0.05) and MCESQ scores (std. β = 0.13, p<0.01) than people from Guangdong.

Give-and-take

This report found that the family unit caregivers of patients with schizophrenia generally experienced stigmas in daily life and discrimination experiences are comparably fewer. This finding was based on the bodily reported experiences of caregivers rather than answers to questions almost hypothetical situations. Our results showed that caregivers normally avoided telling others that their family members were receiving schizophrenia treatment. Furthermore, caregivers felt that it was difficult to obtain support from friends. Experiences of bigotry amongst caregivers were rare, particularly in terms of housing, interactions with officials, license applications, pedagogy and social activities. Additionally, some caregivers thought they were discriminated against in the workplace. During China's planned economy menstruum, information technology was "work unit of measurement" (Danwei) that provided all the welfare to families and individuals, including wages, schooling, housing, etc., thus there are a lot of people who nevertheless want to seek help from work unit of measurement to solve the problem of many families [34]. Such phenomena notwithstanding exist. For instance, when family unit member suffer from serious affliction, caregivers will apply to his/her enterprises and institutions for special economical aids or caring leaves. To our experience, information technology is hard to conceal a family member's mental illness from employers, because caregivers have to explain the reasons when they enquire for leave. Similar situations occurred when caregivers were filling out application forms (for jobs, licenses, housing, school, etc.). Caregivers worried that disclosing a family fellow member's mental disease might hurt their family member or themselves. A lack of trust in professionals could issue in a fear of disclosing information.

Our written report also institute that this type of feel of stigma and discrimination is associated with caregivers' social support, kinship, patients' education level and living areas.

First, we posited that social support was significantly related to caregivers' experiences of stigma. People with loftier levels of social support experienced fewer stigmas. This broadens Mueller et al.'south finding that social support can modify perceived stigmatization in mental ill group [35]. Informal and formal social support from mental health professionals and other families can play a positive role in care-giving and help caregivers overcome negative information, get through difficult times and draw on inner strength [36]. At the aforementioned time, caregivers with loftier social support near likely live in a friendly and open environment. Other people give the caregivers helps, understanding and assistances rather than looking downward on them or delivering socially stigmatizing data.

2d, in our report, we also found that kinship of caregivers with patients related with experiences of stigma. In particular, children perceived fewer stigmas than other family unit caregivers. Existing research has found that parents, especially mothers, are the main caregivers of adult family members who have schizophrenia [37]. Corrigan and Miller'south review suggested that parents often blamed themselves for causing their child'due south illness [38]. Our study also demonstrated that one-half of people with schizophrenia were cared for by parents. Different Guanxi (social network) have different degrees of influence on one'southward daily life, which is well-known as Chaxu geju (the differential mode of association) [39]. Considering of traditional culture, Chinese parents always consider children as members of their family, even if they are married [twoscore]. In China, mental illness ofttimes harmed family honor and was associated with "loss of face" [41]. Presently, Chinese parents suffer increased distress and pressure level because of the i-child policy [42]. However, with reduced family unit sizes, more and more children alive away from their parents later on marriage, making it easier for a kid to keep a parent'southward severe mental illness secret than it is for a parental caregiver to keep a kid'south mental illness clandestine. Except that, young adult receive more than education and oftentimes leave their hometown to work in brand-new area. Therefore, adult children of person with mental illness experienced fewer stigmas.

Third, patients' educational activity level was another relative factor. Caregivers reported significantly more stigma experience when their family unit member with schizophrenia was highly educated. Our finding is consistent with previous findings [eighteen], [22]. This issue might be explained in this manner: educational activity level is one of most important predictors for ane'south social and economical status. Also, social culture and traditional norm give more expectation to people who perceived highly educational activity. Once the aberrant situation occurred, the gaps between reality and expectation may make the family members become more sensitive to others' attitude and behaviors and feel "lose face".

4th, the urbanization and residence province as well associated with their stigma and discrimination experience. The region and setting can capture the factors which are hard to measure, like civilization, law, institution in local areas. Cultures in Guangdong (Lingnan Civilization) and Zhejiang (Wuyue Civilization) provinces both appreciate family values and association traditions [43], and the two areas have similar levels of economic development (in terms of Gross domestic product), just the difference was meaning. In our study, caregivers had more than stigma and discrimination feel in Zhejiang province and rural areas. This kind of regional disparity also reveals that objective living environment is important associates of stigma and discrimination experience.

Information technology was also needed to pay attention to the association between stigma experience with the phase of illness and the age of caregivers and patients, although their relations were only statistically significant in bivarite analysis. Caregivers experienced more stigmas in the patients' acute phase in which patients' abnormal behavior is often and hands observed by neighbors, friends and other people. Therefore, stigma will be more readily experienced past such caregivers. Then, caregivers' age was positively associated with caregivers' experiences of stigma and patients' historic period was negatively related to stigma experiences. It echoes the result in other research that the elder group encountered more bigotry considering elderberry caregivers might provide a long period of intendance for their developed children [44] or other relatives; they are as well more than sensitive to stigma from others. Furthermore, stigma led to a poor quality of life for long-time caregivers [i]. Therefore, a lifelong perspective regarding caregivers' experiences is necessary.

Finally, there was no evidence from our written report to support the thought that gender, marital status, duration of illness or caregiver's pedagogy level had relationship with experiences of stigma or discrimination in the target area of China. Nosotros did not observe any gender differences in scores of stigma and experiences of discrimination, similar to previous research [23]. Additionally, although half of patients were single, marital status did not touch on caregivers' experiences of stigma in the regression analysis. One possible explanation for the lack of a correlation between caregivers' educational level and experiences of stigma or bigotry is that near participates in our samples did not or but complete middle school. Furthermore, duration of the affliction was not related to the stigma and bigotry experience in the short period which might be explained that schizophrenia is variable and chronic.

Also, it is important to highlight four possible limitations of the nowadays written report. Get-go of all, we conducted our research in Zhejiang and Guangdong provinces, two of the most economically adult areas in Cathay. Therefore, our results may not correspond the stigmatization of all caregivers in China, considering variations in indigenous groups and regional cultures. 2d, the MCESQ was originally used amid consumers or persons with mental illness. Nevertheless, the reliability and validity of the modified scale in our study appeared to exist good. Third, the 3 models in our study were based on the results of bivariate correlation analysis rather than on theory, so they might not apply to other samples, at the aforementioned fourth dimension, it cannot reveal causal relation. Quaternary, we conducted face up-to-face structured interview rather than fill up questionnaires by themselves in the data collection procedure, which may atomic number 82 to a social desirability bias.

Conclusions

Caregivers of people with schizophrenia experienced considerable stigmas, which were related to social back up, kinship, patients' educational level and regional factors. Discrimination was rarely reported by caregivers, merely province difference was pregnant. Information technology is suggested that more than social back up should requite to those caregivers whose family members are suffering from severe mental illness.

Acknowledgments

The authors desire to thank the hospitals and medical personnel who gave support in the research pattern and data drove.

Author Contributions

Conceived and designed the experiments: YY WZ JG DT ZQ. Performed the experiments: WZ ZH FJ YL HX SZ JG DT ZQ. Analyzed the data: YY ZQ. Contributed reagents/materials/analysis tools: YY WZ ZH FJ YL HX SZ JG DT ZQ. Contributed to the writing of the manuscript: YY WZ ZH FJ YL HX SZ JG DT ZQ.

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