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

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 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

HSIN-YI HSIAO
School of Social Work, University of Southern California, Los Angeles, California, USA
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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 fam-
ily caregivers from mental health providers’ perspectives in city
versus town settings. Data were collected during focus group dis-
cussions with 40 mental health providers in the Xicheng (city) and
Daxing (town) districts in Beijing, China in 2011. Regional dispar-
ities between providers’ knowledge of early diagnosis of dementia
and related counseling skills were identified. Regional similari-
ties included training needs, dementia-related stigma, and low
awareness of dementia among family caregivers. Culturally sen-
sitive 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:
hsinyihs@usc.edu

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, mental health provider,

dementia-related stigma, China

INTRODUCTION

Two thirds of people age 65 years and older with dementia live in develop-
ing countries (Albanese et al., 2009). Dementia has become a major public
health crisis, especially in China, where more than 70% of older adults live
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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 ser-
vices 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 community-
based 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 devel-
oped 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 special-
ist diagnostic services, and a lack of confidence and training have been
identified by Western scholars as major obstacles preventing providers (e.g.,
 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 respon-
sibilities include mental health service delivery at different levels to improve
understanding of dementia care in China.
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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 exam-
ine 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) atti-
tudes toward dementia, (4) clinical practices for patients with dementia, and
(5) experiences working with family caregivers. Findings and their implica-
tions will not only assist mental health practitioners in China in identifying
barriers to effective diagnosis and treatment of dementia, as well as train-
ing 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 admin-
istrative 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 agricul-
ture, 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
 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
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dynamics to allow probing ideas and concepts and obtain in-depth infor-
mation. 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 sociode-
mographic 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.

Data Analysis
Researchers collected data from focus group discussions in the Xichen and
Daxing districts. All focus group discussions were video recorded with con-
sent from participants. After collecting data from the four group discussions,
the digital videos were downloaded to a researcher’s computer and stored
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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 mem-
bers 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 frame-
work 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 ref-
erence. 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 partici-
pants. 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 Daxing

Variables n % n %

Age (median) 33 33.5

20–29 8 40.0 6 30.0
30–39 4 20.0 7 35.0
≥40 8 40.0 7 35.0
Sex
Female 10 50.0 10 50.0
Male 10 50.0 10 50.0
Education
High school 1 5.0 1 5.0
College or above 19 95.0 19 95.0
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Medical doctor degree

Yes 6 30.0 6 30.0
No 14 70.0 14 70.0
Marital status
Married 17 85.0 15 75.0
Single 3 15.0 5 25.0
Annual family income (RMB)
<10,000 2 11.8 1 5.3
10,000–49,999 8 47.1 8 42.1
50,000–99,999 5 29.4 8 42.1
≥100,000 2 11.8 2 10.5

in Xicheng vs. 75% in Daxing). More than 90% of the participants in each
group had received some college-level education, and 30% of both groups
held medical degrees.
Table 2 shows that one half of each group had worked in the mental
health field for approximately 10 years (10 years in Xicheng vs. 10.5 years
in Daxing). Most of the participants in the Xicheng group were community
doctors (60%), whereas job positions in the Daxing group varied, including
clinical physicians in hospitals (45%) and nurses (30%). More than one half
of the participants in both groups had worked with caregivers of family
members with dementia.

RESULTS

Table 3 shows the main themes regarding differences and similarities in

knowledge and clinical practices regarding dementia between the two
groups. Emergent themes found in one group but not the other included
the following: (1) familiarity with dementia as a disease and its effects on
patients’ social networks, (2) sensitivity toward early onset of dementia,
(3) using psychotic symptoms as criteria for treatment, (4) competence in
counseling, (5) need for communication channels between physicians and
 Knowledge, Attitudes, and Clinical Practices 7

TABLE 2 Employment and Working Experience (N = 40)

Xicheng Daxing

Variable n % n %

Years of employment (median) 10 10.5

<10 10 50.0 8 40.0
10–19 2 10.0 5 25.0
20–29 4 20.0 2 10.0
≥30 4 20.0 3 15.0
Job type
Community doctor 12 60.0 5 25.0
Clinical hospital physician 2 10.0 9 45.0
Nurse 6 60.0 6 30.0
Work with family caregivers of seniors
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Yes 16 80.0 13 65.0

No 4 20.0 7 35.0
Work with family caregivers of patients with
dementia
Yes 11 55.0 10 50.0
No 9 45.0 10 50.0

TABLE 3 Regional Similarities and Differences Between Xichen and Daxing Groups

Xicheng Daxing

1. Perceived knowledge of dementia as a disease

√
Familiarity with dementia as a disease and its effects on
patients’ social networks
√ √
Insufficient training and education about dementia
2. Providers’ attitudes towards dementia
√ √
Therapeutic nihilism
√ √
Ageism
3. Clinical practice for patients with dementia
√
Sensitivity toward early onset of dementia
√
Using psychotic symptoms as criteria for treatment
√
Competence in counseling
√ √
Need for specialist care
√
Need for communication channels between physicians and
caregivers
√
Advice on dementia prevention reflecting sociocultural
background
4. Experience working with family caregivers
√ √
Low awareness about dementia among family caregivers
√ √
Discriminatory attitudes and behavior toward people with
dementia in public

caregivers, and (6) advice on dementia prevention reflecting sociocultural

background. The main themes regarding similarities in knowledge, atti-
tudes, practices, and experience working with family caregivers between
the two groups were the following: (1) insufficient training and education
 8 H.-Y. Hsiao et al.

about dementia, (2) therapeutic nihilism, (3) ageism, (4) need for spe-
cialist care, (5) low awareness of dementia among family caregivers, and
(6) discriminatory attitudes and behavior toward people with dementia (see
Table 3).

Regional Differences in Knowledge and Clinical Practices

PERCEIVED KNOWLEDGE OF DEMENTIA AS A DISEASE
Familiarity with dementia as a disease and its effects on patients’ social
networks (Xicheng). Having worked with a significant number of patients
with dementia in city settings, most of the providers in the Xicheng group
had high awareness of the causes, signs, and stages of dementia. Two
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providers exemplified this when they pointed out the following:

To me, dementia means that the social functions of the older adults have
partially or fully impaired, which lead to the deterioration in of taking
care of themselves, loss of memory, abnormal behavior, and thinking.

In my community, I had worked with many patients with dementia

having cognitive impairment and behavioral disturbances, like difficulty
performing familiar tasks, disorientation to time and place, and change in
mood. Accompanying psychotic disorder, many demented patients might
start a fire at home or attack a specific family member or neighbors out
of delusions.

These providers acknowledged that behavioral disorders of dementia

would place patients and others in danger, contribute to increased dis-
tress and burden for caregivers, and severely disrupt family, social, and
institutional networks. They, thus, also showed sensitivity to early diagnosis.

CLINICAL PRACTICE FOR PATIENTS WITH DEMENTIA

Sensitivity toward early onset of dementia (Xicheng). Observing an
increasing rate of dementia among city residents as the aging population
increased, providers in the Xicheng group had high levels of sensitivity
toward early symptoms of dementia:

When I suspect a patient has dementia, I will do assessment to con-

firm whether he/she has symptoms of dementia and at what stage. After
diagnosis, this patient will receive a series of medications and treat-
ment. Caregiving, especially for patients’ emotions, is very important after
receiving treatment.

Clearly, mental health providers in Xicheng city recognized the impor-

tance of early detection of dementia, timely treatment, and caregiving from
 Knowledge, Attitudes, and Clinical Practices 9

family members. However, the phenomenon of underdiagnosis of dementia

was prevalent among providers in the rural town of Daxing.
Using psychotic symptoms as criteria for treatment (Daxing). Due to lim-
ited medical resources and education, some providers in the Daxing group
were unaware of the causes and stages of dementia. Physicians in the Daxing
group often used psychotic symptoms as criteria for providing treatment to
patients with dementia, “I am not quite sure what causes dementia. Isn’t
it the problems of brain? We have few patients with dementia; therefore,
we lack practical experience” and “Most hospitals in towns refuse to admit
patients who have minor cognitive problems; therefore, family carers should
send older adults with dementia to the hospital only if they have aggressive
behaviors with symptoms of psychotic disorders.”
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Daxing providers tended to view cognitive problems as a low priority

relative to physical health problems among patients with dementia. Lack of
knowledge about dementia might partially explain why they did not have as
much competence in counseling as the Xicheng providers had.
Competence in counseling (Xicheng). Providers in the Xicheng group
expressed empathetic attitudes toward and exhibited confidence about com-
municating with patients and family caregivers. Two Xicheng providers
discussed their experience dealing with caregivers:

We will communicate with family members who get angry at patients’

behavioral disorders and explain to them that dementia is an illness [that]
causes such behavioral problems.

When I know a patient who has dementia, I will show my caring attitude
toward him or her. I will educate his/her family caregivers to take care of
patients with love and do not get mad about their behavioral problems.

Providers in Xicheng acknowledged that counseling family caregivers

regularly and guiding them on how to care for patients with dementia was
critical because family caregivers face major emotional and social burdens.
On the contrary, Daxing providers knew little about counseling skills and
expressed a need for communication.
Need for communication channels between physicians and caregivers
(Daxing). Providers in the Daxing group expressed difficulty discussing or
explaining diagnoses with patients or caregivers. One Daxing respondent
noted the following:

We really need a channel that assists us to cope with family caregivers’

stress and frustrations. We do not know how to deal with the para-
doxical situation now. As a matter of fact, dementia is incurable and
irreversible. However, for family members, any treatments or support
we provide seem to give them hope that the situation of family mem-
bers with dementia would get better. We do not know how to console
hopeless family members.
 10 H.-Y. Hsiao et al.

The common opinion among Daxing providers concerning communica-

tion was a need to develop methods for facilitating communication between
physicians and caregivers to cope with frustration and stress. The regional
differences were identified not only in the type of clinical practice provided
for patients, but also in the providers’ advice on dementia prevention.
Advice on dementia prevention reflecting sociocultural background
(Daxing). Advice from providers in the Daxing group featured elements of
a typical lifestyle for older adults in towns. Suggestions, such as embroidery
and playing mahjong, were connected to life skills and culture, “Most older
adults in rural towns have techniques of embroidery for garments or shoes.
If some have early signs of dementia, I will suggest [to] them to keep doing
those things they are familiar with to prevent dementia” and “I heard from
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others that playing mahjong could exercise our brains, so I think it is a good
way to avoid occurrence of dementia.”
In contrast to the Daxing providers’ advice, Xicheng providers thought
social engagement, healthy diet, and stress management played key roles
for dementia prevention, which, to a large extent, were quite similar to the
prevention advice provided by physicians in Western societies. The two fol-
lowing suggestions from urban providers address this belief, “I will suggest
older adults watch their diet, walk or jog backward, and ease stresses emo-
tionally. Nevertheless, the most important thing is being aware of dementia”
and “If older adults don’t have financial burdens, they could engage in
productive activities to prevent dementia.”
Suggestions made by providers in city versus town settings reflected a
contextual background of contact experience with patients with dementia.
Despite all these regional differences, Daxing and Xicheng also showed some
similarities.

Regional Similarities in Knowledge, Attitudes, Clinical Practices, and

Experience Working With Family Caregivers
PERCEIVED KNOWLEDGE OF DEMENTIA AS A DISEASE
Insufficient training and education about dementia. On-the-job train-
ing received by providers in the Xicheng group focused on assessment and
treatment of mental illness, and they discussed concerns about insufficient
training regarding dementia as a disease. One provider spoke on this issue, “I
didn’t take any courses teaching [about] dementia. Trainings I have received
so far are all about psychiatric assessment and treatment for severe mental
illness like schizophrenia.”
Similarly, a lack of training and knowledge caused providers in the
Daxing group to experience difficulty detecting and diagnosing dementia, as
well as timely treatment, as exemplified by the following statement, “Most
doctors here do not have enough knowledge about dementia as a dis-
ease. Sometimes we thought these patients ha[d] some psychiatric problems,
 Knowledge, Attitudes, and Clinical Practices 11

and thus did not give them correct treatment” and “We knew little about
dementia as a disease and could not tell the differences between dementia
and psychiatric illness.”
Clearly, it is challenging for most providers in both groups to distinguish
dementia from other mental illness. Therefore, they expressed a training or
education need for dementia. In addition to knowledge of dementia, they
exhibited similar attitudes toward dementia.

PROVIDERS’ ATTITUDES TOWARD DEMENTIA

Therapeutic nihilism. Therapeutic nihilism, a belief that it is meaning-
less to provide patients with dementia diagnosis or available treatments
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because they may cause more harm than good (Koch et al., 2010), was
a common feeling among all providers. One Xicheng provider stated the
following:

It’s really challenging to provide care for this group of population in the
clinical setting unless they are at home cared by family members. I have
negative impressions about them and don’t have enough confidence to
cope with this group of patients in hospitals in urban cities.

Additionally, a Daxing provider noted the following, “As far as I know, there
is no way to cure dementia. The most important thing is to care for those
patients in family settings.”
Most of the providers doubted the usefulness of interventions and per-
ceived that there were limited options for treatment. Providers in both groups
thought family members should take full responsibility for caring for a patient
with dementia to promote the patient’s quality of life.
Ageism. In the context of dementia care, ageism has been defined
as negative attitudes associated with aging as a degenerative or disabling
process (O’Connor & McFadden, 2012), a common sentiment among par-
ticipants. Two providers (Xicheng and Daxing, respectively) spoke on this
notion:

I always think that it is natural to have memory loss in late age. I generally
do not think that is a disease.

In rural towns, it’s very common that older people will become for-
getful. I believe when people reach [a] certain age, it’s very normal to
have symptoms of aging like memory loss. I don’t think there are any
associations between memory loss and a disease.

Providers in city and town settings considered memory loss and func-
tional loss, to a lesser extent, to be normal phenomena of minor concern
when compared with other mental or physical illnesses.
 12 H.-Y. Hsiao et al.

CLINICAL PRACTICE FOR PATIENTS WITH DEMENTIA

Need for specialist care. In this clinical setting, primary physicians are
the first resources for patients with dementia and their family caregivers.
There is no specialist team or mental health service targeted for this patient
population. In relation to this reality, a Xicheng provider stated the following:

I think there should be a system for assisting patients with dementia.

When a primary care physician finds a patient with signs of dementia
in a clinic, you could refer him or her to a specialized institution for
diagnosis and treatment. Then, these people could be referred to nursing
homes for care services.
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Another participant from the Daxing group commented on this topic, as well:

We really need a specialized team trained with knowledge of dementia

in the clinical settings. Neither government nor management in hospitals
have a policy or plan regarding dementia care. Currently, all physicians
in communities are providing primary care, so we don’t have such kinds
of resources available, like assessing stages of symptoms for demented
patients and mentoring their caregivers.

Both groups expressed a strong desire for central government officials

to develop specialist care and referral systems for patients with dementia.
They also had similar experiences working with family caregivers of people
with dementia.

EXPERIENCE WORKING WITH FAMILY CAREGIVERS

Low awareness about dementia among family caregivers. Both groups
observed that it was common for the general public, including family
caregivers, to assume that changes in cognitive function were part of the
normal aging process. A participant in the Xicheng group said as much in
the following statement, “Under most circumstances, urban family members
treated older adults with dementia symptoms like children and disciplined
their behaviors without seeking help from doctors. They considered changes
in patients’ behavior or memory loss as a process of normal aging.” A Daxing
provider concurred, “People do not pay special attention to dementia. Many
people in rural towns consider patients with dementia as psychotic with
aggressive behaviors, such as beating or biting.”
From the providers’ perspectives, it was difficult for family members in
city and town settings to differentiate between normal aging/mental illness
and dementia, which may delay diagnosis and treatment.
Discriminatory attitudes and behavior toward people with dementia.
In Xicheng and Daxing, a lack of awareness of dementia as a disease
 Knowledge, Attitudes, and Clinical Practices 13

among family members of patients or members of the public resulted in

discriminatory attitudes or behavior against people with dementia. Two
providers (Xicheng and Daxing, respectively) related their knowledge of
these attitudes:

In some public places, when pedestrians see people with dementia with
walking difficulties, faces covered in spit, and a sloppy appearance, they
will keep their distance.

Most rural family members of patients with dementia had limited edu-
cation and were unaware of dementia as a disease. When they [were]
confronted with threatening behavior from their siblings with dementia,
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rural caregivers felt frightened and locked the patient with dementia at
home to avoid embarrassment in front of neighbors.

Providers in both groups described a structural stigma against people

with dementia, seen as possibly reflecting badly on the entire family and, in
turn, causing embarrassment and shame to the other family members.

DISCUSSION

The findings of this study provide compelling evidence for the differences
in knowledge about dementia and clinical practices between mental health
providers in city (Xichen) and town (Daxing) settings. Major discrepancies
found between city and town settings reflect the uneven distribution of medi-
cal resources and manpower in China. Significantly more financial resources
have been directed toward hospital care in cities than toward developing
comprehensive, community-based mental health services in rural towns (Liu
et al., 2011). Regarding perceived knowledge about dementia as a disease,
the results showed that frequent contact with patients with dementia in the
city inspired great confidence among providers in the Xicheng group, in
terms of recognizing the early signs and stages of dementia that signifi-
cantly affect patients’ social networks and create burdens for caregivers.
Providers in city settings had high levels of sensitivity regarding the detection
of early-onset dementia and subsequent responses to postpone institution-
alization. They showed competence in communication with patients with
dementia and their family caregivers and provided consolation. In contrast,
providers in the Daxing group tended to use behavioral disorders as cri-
teria for treatment, placing less emphasis on cognitive problems relative
to physical issues. As Liu et al. (2011) indicated, in rural towns with lim-
ited medical resources, only people with severe mental illness and acute
conditions are typically provided medication by rural providers and admit-
ted to the hospital; those with early-onset dementia are often referred back
 14 H.-Y. Hsiao et al.

to their communities for follow-up care. Moreover, providers in the Daxing

group had challenges in discussing or explaining diagnoses or treatment with
patients and caregivers, which exhibits, to geriatric educators in China, the
need for caregiver counseling programs for mental health providers in town
settings.
Providers in both groups shared similarities in educational needs, atti-
tudes about dementia, and experiences working with family caregivers.
Comments from both groups signified gaps in the mental health system and
services for people with dementia in China. All providers acknowledged
insufficient knowledge about how to perform early diagnosis and treatment,
as well as the general lack of mental health professionals, and indicated a
strong desire for training needs. For mental health providers in rural town
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setting, the results of this study provide implications for geriatric education
with an emphasis on clinical features of dementia and diagnostic criteria
for major neurocognitive disorders caused by dementia to avoid or post-
pone future actions, such as institutionalization. However, providers in the
city setting will need hands-on training specific to specialized knowledge
of dementia. Moreover, dementia-related stigma was apparent in comments
made by providers in both groups. Therapeutic nihilism and ageism resulted
in a failure to recognize dementia as a disease, which may affect timely diag-
nosis and treatment in both cities and towns. Among family caregivers and
the general public in both settings, there was also a structural stigma against
people with dementia. Fear and negative images remain associated with
dementia; therefore, people in both settings were reluctant to engage with
individuals who have dementia, and avoidance was highlighted as a common
reaction to the presence of a person with dementia. These findings align with
studies conducted in Western societies (Bradford et al., 2009; Wu, Emerson
Lombardo, & Chang, 2010). Moreover, Wu et al. (2010) noted that Chinese
families associate the symptoms of dementia with the process of aging. They
view people with mental illness, including dementia, as bringing shame to
the entire family. With the Confucian value of filial piety, which emphasizes
children’s responsibility in taking care of older adults, unique challenges,
specifically for the Chinese population, result in cultural barriers that prevent
older adults from timely seeking mental health services. These barriers also
signify the need for culturally sensitive dementia education and care ser-
vices to reduce the stigmatization of dementia. Culturally sensitive dementia
education should include dementia-care capacity building, increased con-
tact with people with dementia and their family caregivers, and enhanced
awareness of dementia as a disease among medical professionals. It is also
critical to raise awareness and educate the public about dementia and avail-
able treatments and services, especially through the media and publications
with China’s governmental support.
Given that service models and facilities in hospitals varied significantly
across regions in China (Wang, 2012), the lack of a specialized model
 Knowledge, Attitudes, and Clinical Practices 15

or system for diagnosis, treatment, and referral of people with dementia

created an obstacle to providing quality care. The results of this study high-
lighted the importance of the dementia care model through collaborations
among academic institutions, communities, and mental health providers.
Academic institutions, such as medical schools, need to provide education
specific to dementia as part of the regular curricula to educate mental health
professionals about clinical features of dementia, the differences between
dementia and normal aging, diagnosis, medical treatment, advance research
on dementia, stigma-related issues, and person-centered communication, as
well as caregiving skills. Mental health providers in communities will make
home visits to families, teach them caregiving skills, inform them about avail-
able treatments and services in communities, and provide counseling and
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emotional support for families. A dementia care model is essential for those
without medical insurance coverage in rural towns.
There are limitations to this study. First, although data were collected
in two districts with distinct characteristics, Xicheng and Daxing, these two
districts are located in Beijing, a capital city with significant development.
Daxing, though characterized by agriculture, may not be representative of
all rural towns. Second, mental health providers were recruited from hos-
pitals or clinics in Xicheng and Daxing, which may not be representative
of providers in all cities and towns in China. Third, there may be a recall
bias, in that responses from all providers were based on reflections regard-
ing patients with dementia. Fourth, the study used a purposive sampling
method to recruit mental health providers at different levels. Therefore, sam-
ples in city versus town settings might not be completely comparable. Levels
of perceived knowledge about dementia as a disease or caring skills var-
ied greatly between the two groups. Participants with more contact with
patients with dementia had greater levels of awareness about the issues
surrounding dementia than general mental health providers, who may also
provide treatment for patients with dementia. Results from this study stress
the importance of pursuing more qualitative research on process-type issues
(e.g., how patients are referred to mental health clinics and how family
caregivers provide care) among various stakeholders in providing dementia
care in China’s mental health system. In addition, future qualitative research
should seek an in-depth perspective on various training needs (e.g., special-
ized knowledge and care of dementia or communication with patients and
family caregivers) among mental health providers, social workers, adminis-
trators in nursing homes, policy makers, and caregivers. Quantitative studies
using larger samples in city and town settings could examine mental health
providers’ knowledge, attitudes, and clinical practice relevant to dementia
care to generate more representative results that allow for generalization to
larger populations in both settings.
In conclusion, using qualitative methods, this study highlighted simi-
larities in terms of mental health providers’ practices and identified major
 16 H.-Y. Hsiao et al.

disparities between knowledge and skills specific to dementia care between

providers in cities and rural towns in China. Our findings provide impli-
cations for practitioners seeking to improve mental health education and
services for people with dementia in China.

ACKNOWLEDGMENTS

Special thanks go to Jie Deng and Mian Liu who assisted with data collection
in Beijing and data analysis.
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