Mental Health, Religion & Culture

ISSN: 1367-4676 (Print) 1469-9737 (Online) Journal homepage: https://www.tandfonline.com/loi/cmhr20

Relationship of religiosity to mental health

literacy, stigma, social distance, and occupational
restrictiveness in Ningxia Province, China

Zhizhong Wang, Hanhui Chen, Harold Koenig & Michael Robert Phillips

To cite this article: Zhizhong Wang, Hanhui Chen, Harold Koenig & Michael Robert Phillips
(2019) Relationship of religiosity to mental health literacy, stigma, social distance, and occupational
restrictiveness in Ningxia Province, China, Mental Health, Religion & Culture, 22:4, 400-415, DOI:
10.1080/13674676.2019.1593338

To link to this article: https://doi.org/10.1080/13674676.2019.1593338

Published online: 26 Jun 2019.

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MENTAL HEALTH, RELIGION & CULTURE
2019, VOL. 22, NO. 4, 400–415
https://doi.org/10.1080/13674676.2019.1593338

Relationship of religiosity to mental health literacy, stigma,

social distance, and occupational restrictiveness in Ningxia
Province, China
a
Zhizhong Wang *, Hanhui Chenb*, Harold Koenig c
and Michael Robert Phillips b,d

a
Department of Epidemiology, Ningxia Medical University, Yinchuan, People’s Republic of China; bSuicide
Research and Prevention Center, Shanghai Mental Health Center, School of Medicine, Shanghai Jiao Tong
University, Shanghai, People’s Republic of China; cSchool of Medicine, Duke University Medical Center,
Durham, NC, USA; dDepartments of Psychiatry and Epidemiology, Columbia University, New York, NY, USA

ABSTRACT ARTICLE HISTORY

Little research has assessed the relationship between religiosity and Received 15 February 2019
mental health awareness in low- and middle-income countries. This Accepted 6 March 2019
study identified a representative sample of 2,425 community-
KEYWORDS
dwelling adults in Ningxia, China and administered the Duke Mental health awareness;
University Religion Index, the Mental Health Knowledge stigma; religious
Questionnaire, the Mental Health Attitude Questionnaire, the Social involvement; mainland
Distance – Personal Questionnaire and the Social Restrictiveness – China; cross-sectional study
Occupational Questionnaire. Religious affiliation per se was not
associated with mental health literacy or attitudes, but higher levels
of religiosity were associated with better awareness of mental health
issues and less social distance and occupational restrictiveness of
those with mental health conditions. However, these relationships
were substantially different in Hui ethnicity respondents (85% of
whom were practicing Islam) and Han ethnicity respondents (15% of
whom practiced Buddhism, Taoism or Confucianism).

Introduction
Research about the relationship between religious involvement and mental health and
about the effect of religious belief on attitudes toward mental illness has increased over
the past few decades (Bonelli & Koenig, 2013; Koenig, 2012b, 2015). Reviews of the litera-
ture suggest an inverse relationship between religious participation and neurosis,
depression, and alcohol use disorders (Bonelli & Koenig, 2013). The US National Comorbid-
ity Survey found that 23.5% of respondents who experienced psychological problems
initially sought help from religious providers, compared to 16.7% who sought help from
psychiatrists and 16.7% who sought help from general medical doctors (Wang, Berglund,
& Kessler, 2003). Another line of research has examined the use of patients’ religious beliefs
in psychotherapy (Baetz & Toews, 2009; Koenig, Pearce, et al., 2015). Other studies report
that among persons with more severe mental disorders, participation in religious activities
was associated with increased use of outpatient mental health services (Harris, Edlund, &
Larson, 2006; Pickard, 2006). However, research among African-Americans found high

CONTACT Michael Robert Phillips mphillipschina@outlook.com

*Both authors contributed equally to this work.
© 2019 Informa UK Limited, trading as Taylor & Francis Group
 MENTAL HEALTH, RELIGION & CULTURE 401

levels of religiosity associated with less use of professional mental health services
(Lukachko, Myer, & Hankerson, 2015).
Relatively little research has focused on the effects of religious belief and practice on
attitudes toward mental health problems in low- and middle-income countries, particu-
larly non-Christian Asian countries (Koenig, 2012a). For example, almost no research on
this topic has been conducted in mainland China where 94% of the 1.3 billion residents
have, at some point in their lives, participated in spiritual activities (Lu, 2014) and over
40% report a religious affiliation (Pew Research Center, 2012), including Buddhism,
Daoism, Confucianism, Islam, Christianity, and a variety of folk religions (Fan, 2003). In
western parts of China (Ningxia and Qinghai) over one-third of the population are actively
practicing Muslims (Chuah, 2004). In fact, mainland Chinese account for 50% of all Bud-
dhists and 73% of practitioners of folk religions in the world. Consequently, research on
the effects of religious belief on attitudes toward mental disorders in China is important
and needed.
Previous small cross-sectional studies in China have assessed the relationship between
religious participation and psychological well-being (Brown & Tierney, 2009), depressive
symptoms (Liu & Koenig, 2013; Wei & Liu, 2013), suicidal ideation (Z. Wang et al., 2013),
cognitive impairment (Su et al., 2014; Zhang, 2010), tobacco use (Wang, Koenig, & Saad,
2015), and mental disorders (Wang, Koenig, Zhang, Ma, & Huang, 2015). Contrary to
research in high-income countries, most of these studies report that greater religious
involvement is associated with more mental distress and psychiatric disorder. The
reason for this may be that when persons in China without any specific religious affiliation
develop psychological problems, they turn to religious activities for the social support and
meaning that such participation provides (Lian, 2012; Wang, Koenig, & Saad, 2016). Alter-
natively, as part of their developing mental disorder they may start believing in reincarna-
tion and/or supernatural forces, and, thus, join religious groups that support or
acknowledge the validity of such beliefs.
To our knowledge no research in China has yet examined the relationship between reli-
giosity and attitudes toward mental illness. The present study addresses this issue by
assessing the relationship between religious involvement, knowledge about mental
illness, and attitudes toward mental illness in a random sample of community-dwelling
adults in Ningxia Province, a relatively poor region of northwest China in which one-
third of the population is Muslim. The questions we aim to address are the following:
Do religious beliefs and participation in religious activities in mainland Chinese increase
or decrease willingness to associate with persons who have mental illnesses? Are
persons with strong religious beliefs more knowledgeable about mental illness and
more willing to accept persons with mental illnesses into their social networks than
persons who do not have strong religious beliefs?

Methods
Participants
The Epidemiological Investigation and Health System Interventions for Mental Health sur-
veyed a random sample of adults in Ningxia. Details concerning the sampling method
have been described elsewhere (Chen et al., 2014; Cheng, Phillips, Zhang, & Wang,
402 Z. WANG ET AL.

2016). In summary, 7,032 households were selected in 20 primary sampling sites (PSUs) in
the Ningxia Hui Autonomous Region using a probability proportionate to size (PPS)
method. Only 3,981 (57%) of the households were occupied by potentially eligible resi-
dents who were at least 18 years of age, had lived in the household for at least six
months, and had no cognitive or sensory impairment that interfered with the completion
of the interviewer-administered survey. Interviewers visited each household, identified all
householders who met the enrollment criteria, and then randomly selected one house-
holder using a Kish selection table. In 1,556 (39%) of the 3,981 households the selected
participant was not available, unable to complete the survey, or refused to participate.
Overall, 2,425 participants signed informed consent forms and completed the survey.
The survey was conducted from July 18 to October 26, 2013. Four teams were involved
in data collection at the 20 PSUs. Each team consisted of a supervisor, a coordinator, and
6–12 interviewers (students at the School of Public Health of Ningxia Medical University).
Team members were extensively trained before going into the field. After completing the
survey, participants received a gift worth 20 Chinese Yuan (about $3 USD) for their time.
The study was approved by the institutional review board of Ningxia Medical University
(No. 2013-167).

Measures
The survey included several scales: the Chinese version of the Duke University Religion
Index (DUREL; Koenig & Bussing, 2010), the Mental Health Knowledge Questionnaire
(MHKQ; Chen, Wang, & Phillips, 2018), the Mental Health Attitude Questionnaire (MHAQ;
Chen et al., 2018), the Social Distance – Personal Questionnaire (SD-P; Wang et al.,
2011), the Social Restrictiveness – Occupational Questionnaire (SR-O; Wang et al., 2011),
and the 12-item General Health Questionnaire (GHQ-12; Chan, 1993). Demographic
characteristics of participants collected included age, gender, residence (rural vs. urban),
ethnicity (Han vs. Hui), alcohol use (drank alcohol at any time in last month), smoking
(smoked tobacco at any time in last month), and physical health (assessed by an item
in which respondents reported the number of days in the last month that they had
difficulty completing normal activities due to any physical condition).

Religious characteristics
Respondents indicated their religious affiliation as either non-religious or a member of one
of several religions, including traditional Chinese belief systems (Buddhism, Taoism and
Confucianism), Islam, Protestantism, Roman Catholicism, or others. In bivariate analyses,
religious affiliation was dichotomised into those who reported being non-religious
versus those who reported any religious affiliation.
Religiosity was measured using the DUREL, which consists of five items with three sub-
scales. The Chinese version of the DUREL has been validated in Chinese community-dwell-
ing adults (Liu & Koenig, 2013; Wang, Rong, & Koenig, 2014). The first item assesses the
frequency of participation in organisational religious activities (i.e., activities that occur
in groups) on a six-point Likert scale. The second item assesses the frequency of non-
organisational religious activities (i.e., religious activities conducted in private) on a
six-point Likert scale. Items 3–5 assess intrinsic religiosity (i.e., degree of personal religious
commitment or motivation) on three five-point Likert scales. The total score of all five
 MENTAL HEALTH, RELIGION & CULTURE 403

items in the DUREL (with a theoretical range of 5–27) was dichotomised such that persons
with a total score greater than 20 were classified as “highly religious”.

Knowledge and attitudes

The MHKQ and MHAQ were used to evaluate respondents’ knowledge and attitudes about
mental illness. Previous reports from this survey have shown that the MHKQ and MHAQ
have acceptable reliability and validity (Chen et al., 2018). The MHKQ consists of 25
items with yes-no responses and a total score that ranges from 0 to 25, with higher
scores indicating more knowledge about mental illnesses. The original version of MHAQ
had 22 items; after removing one item because it proved to be ambiguous, the remaining
21 items included seven that assessed respondents’ causal beliefs about mental illnesses
and 14 that assessed respondents’ positive and negative attitudes concerning mental ill-
nesses. In the current study, we examined the 14 items about attitudes. Responses are on
four-point Likert scales (1 = “completely agree”, 2 = “agree”, 3 = “disagree”, 4 = “completely
disagree”); the total score for the 14 items is converted into a scale that ranges from 0 to
100 where higher scores indicate a more negative attitude towards mental illnesses.

Social distance and occupational restrictiveness

The SD-P and SR-O were used to assess social distance and social restriction, respectively.
The scales have been employed in a previous study among university students in Chongq-
ing, China (Wang et al., 2011), which found that the scales have acceptable reliability and
validity. Both scales consider respondents’ attitudes about social distance and social restric-
tion for persons with 10 attributes: two neutral conditions (prior appendectomy and current
hypertension), five conditions related to mental health problems (prior suicide attempt,
prior psychiatric hospitalisation, prior serious episode of depression, prior heavy alcohol
use, and prior abuse of illicit drugs), and three other stigmatised conditions (prior imprison-
ment, homosexuality, and current HIV carrier). In the SD-P, respondents rate their willing-
ness to establish four types of personal relationships with persons who have these 10
conditions: spouse, friend, house maid, and house renovator. In the SR-O respondents
rate their beliefs about the appropriateness of four occupations for persons with the 10
conditions: accountant, primary school teacher, policeman, and bus driver. All items are
assessed on a four-point Likert scale, with higher scores indicating respondents’ greater
unwillingness to establish a personal relationship with individuals who have each of the
10 conditions (on the SD-P) or respondents’ stronger belief about the inappropriateness
of an occupational role for individuals who have each of the 10 conditions (on the SR-O).
For each condition the four SD-P measures (for the four relationships) and the four SR-O
measures (for the four occupations) are combined into two overall measures ranging
from 0 to 100 with higher scores indicating respondents’ greater unwillingness to establish
any type of relationship and their stronger belief about the inappropriateness of any type of
occupation for individuals with the condition. The overall social distance score and the
overall occupational restriction score for mental health conditions is the average of the sep-
arate values for the five mental health conditions considered, also ranging from 0 to 100.

Psychological distress
The GHQ is a widely used self-report measure of psychological distress. A Chinese version
of the GHQ has been developed and has solid psychometric properties (Chan, 1993). The
404 Z. WANG ET AL.

current study uses the 12-item version of the scale, and each item is coded on a four-point
Likert scale (0–3 for each item) with a total score ranging from 0 to 36. After accounting for
any missing items, the total score is converted into a revised total score ranging from 0 to
100 with higher scores indicating greater psychological distress. Individuals with revised
total scores higher than 25th percentiles (higher than 36.0 in this sample) were classified
as having “high psychological distress” in the current study.

Statistical analyses
SPSS 20.0 was used for all analyses. Differences between Hui and Han ethnicity participants
in demographic characteristics, psychological stress, knowledge about mental illnesses,
attitudes about mental illnesses, preferred social distance from persons with mental ill-
nesses, and beliefs about appropriate social restriction of persons with mental illnesses
were examined using the Student’s t-test for continuous variables and the chi-square stat-
istic for categorical variables. The bivariate association between continuous variables con-
sidered in the analysis were assessed using Pearson correlation coefficients and (because
some of the measures were not normally distributed) Spearman correlation coefficients.
The bivariate association between the four mental-health-related variables (total scores
of MHKQ, MHAQ, SD-P, and SR-O) and dichotomous variables were assessed using
Student t-tests.
Regression models (general linear modelling) were utilised to examine associations
between each of the four mental-health-related outcomes (the dependent variables in
the models: knowledge, attitudes, social distance, and social restriction) and each of the
four continuous measures of religiosity (the independent variables in the models: the
DUREL total score and the three DUREL subscale scores) (Model 1); these results were
then adjusting for a variety of demographic characteristics (including age, gender, edu-
cational level, urban versus rural residence, Han versus Hui ethnicity, and marital status)
(Model 2); finally the basic results of Model 1 were adjusted both for demographic vari-
ables and for a physical health variable (days unable to undertake normal activities due
to illness in prior month), and current level of psychological distress (GHQ-12 total
score) (Model 3). Due to large ethnic and religious differences between Hui and Han,
we also conducted a stratified analysis using Model 3. Alpha level was set at .05 and –
given the exploratory nature of these analyses – was not corrected for multiple
comparisons.

Results
Demographic, health, and religious characteristics of the sample are presented in Table 1.
The mean age of the 2,425 participants was 46 (ranging from 18 to 90) years and the mean
years of formal education was 7.5 (ranging from 0 to 21) years. Female participants out-
numbered male participants (55.5% vs. 44.5%). Half of the participants were from rural
parts of Ningxia and half from urban parts of Ningxia. There were several statistically sig-
nificant differences in the demographic characteristics between Hui and Han participants.
Compared to Han ethnicity participants, Hui ethnicity participants were significantly
younger, had less education, were more likely to be female, were much more likely to
reside in rural communities, and were much less likely to drink alcohol or smoke. Hui
 MENTAL HEALTH, RELIGION & CULTURE 405

Table 1. Characteristics of the sample.

Total Hui Han Hui versus Han
N = 2425 N = 577 N = 1848 statistic (p-value)
Mean (SD) age in years 45.9 (15.3) 43.8 (15.9) 46.5 (15.1) t = 3.75 (<.001)
Mean (SD) years of education 7.5 (5.1) 6.3 (5.1) 7.9 (5.1) t = 6.50 (<.001)
Male, n (%) 1,078 (44.5) 230 (39.9) 848 (45.9) x2 = 6.47 (.011)
Currently married, n (%) 2,104 (86.8) 514 (89.1) 1,588 (86.1) x2 = 3.58 (.167)
Rural resident, n (%) 1,218 (50.2) 402 (69.7) 816 (44.2) x2 = 114.50 (<.001)
Smoker, n (%) 581 (24.0) 91 (15.8) 490 (26.5) x2 = 27.86 (<.001)
Drinker, n (%) 436 (18.0) 48 (8.3) 388 (20.1) x2 = 47.92 (<.001)
Mean (SD) days in prior month unable to engage in 2.8 (8.0) 3.2 (8.5) 2.7 (7.8) t = 1.16 (.243)
usual activities due to physical illness
Mean (SD) total score of GHQ-12 29.4 (14.6) 30.2 (15.1) 29.1 (14.5) t = 1.47 (.142)
Mean (SD) score of organised religious participation 1.7 (1.3) 3.1 (1.8) 1.3 (.6) t = 24.61 (<.001)
item on DUREL
Mean (SD) score on non-organised religious activity 1.4 (1.2) 2.5 (2.0) 1.0 (.3) t = 17.78 (<.001)
item on DUREL
Mean (SD) score of 3 intrinsic religiosity items on 5.5 (4.0) 10.9 (3.9) 3.7 (1.9) t = 42.33 (<.001)
DUREL
Religious affiliation, n (%)
Traditional religion 283 (11.7%) 4 (.70) 279 (15.1) x2 = 2213.40 (<.001)
Muslim 554 (22.8%) 546 (94.6) 8 (.4)
No religious affiliation 1,588 (65.5%) 27 (4.7) 1,561 (84.5)
Mean (SD) total score of Mental Health Knowledge 13.9 (2.5) 13.8 (2.5) 13.9 (2.5) t = 1.34 (.857)
Questionnaire
Mean (SD) total score of Mental Health Attitude 46.4 (9.6) 46.4 (9.4) 46.4 (9.7) t = .12 (.903)
Questionnaire
Mean (SD) total score of Social Distance-Personal 79.3 (16.4) 79.5 (16.1) 79.3 (16.4) t = .30 (.758)
scale for five mental health conditionsa
Mean (SD) total score of Social Restriction- 76.9 (20.9) 77.3 (21.0) 76.8 (20.9) t = .50 (.617)
Occupational scale for five mental health
conditionsa
Note: DUREL: Duke University Religion Index; GHQ-12: 12-item General Health Questionnaire.
The bold values are all statistically significant (i.e., p < .05).
a
The five mental health-related conditions considered include prior suicide attempt, prior psychiatric hospitalisation, prior
serious episode of depression, prior heavy alcohol use, and prior abuse of illicit drugs.

respondents were also more likely than Han respondents to report different types of reli-
gious activity; 85% of Han respondents reported no religious affiliation whereas only 5% of
Hui respondents reported no religious affiliation. There were, however, no significant
differences between Hui and Han respondents in mental health knowledge, attitudes
about mental illnesses, preferred social distance from persons with mental illnesses, or
beliefs about appropriate occupational restrictions of persons with mental illnesses.

Bivariate associations
Table 2 presents the bivariate correlations of continuous measures of participant charac-
teristics, religiosity, and knowledge and attitudes about mental illnesses. The results
shown are for Pearson correlation coefficients; the results of Spearman correlation coeffi-
cients were almost identical (results provided on request). Given the large sample, several
relatively weak correlations (i.e., −.20 < r<+.20) were statistically significant, so we only
consider correlations greater than + .20 or less than −.20 important. As expected, older
individuals had less education and more disability days due to physical conditions.
Current psychological distress was higher in persons who reported more physical disability
and in persons with less education. Different types of religious participation were margin-
ally greater in individuals with lower levels of education (r = −.20 to −.16). The strongest
 406
Z. WANG ET AL.
Table 2. Correlation of demographic variables, religiosity, psychological stress, and knowledge and attitudes about the mentally ill (n = 2217).
Variable 1 2 3 4 5 6 7 8 9 10 11 12
1. Age in years 1.00
2. Years of education −.43 ‡ 1.00
3. Days unable to engage in usual activities due to physical illness .21 ‡ −.23 ‡ 1.00
4. GHQ-12 total score .11‡ −.22 ‡ .27 ‡ 1.00
5. Score of organised religious participation item on DUREL .08‡ −.16‡ .07† .09‡ 1.00
6 Score on non-organised religious activity item on DUREL .17‡ −.20 ‡ .06† .07‡ .65 ‡ 1.00
7. Total score of 3 intrinsic religiosity items on DUREL −.07† −.16‡ .06† .08‡ .64 ‡ .56 ‡ 1.00
8. Total score of all 5 DUREL items −.05* −.16‡ .07‡ .09‡ .83 ‡ .60 ‡ .93 ‡ 1.00
9. Total score of Mental Health Knowledge Questionnaire .04 .04* −.01 .05† −.01 .02 −.01 −.01 1.00
10. Total score of Mental Health Attitude Questionnaire .24 ‡ −.22 ‡ .06‡ .03 .01 .06† −.01 .01 −.03 1.00
11. Average score of Social Distance-Personal scale for the five mental health conditionsa .06† −.01 .03 .01 −.01 −.01 −.02 −.02 −.02 .13‡ 1.00
12. Average score of Social Restriction-Occupational scale for the five mental health .04* −.01 .01 .03 −.02 −.01 −.02 −.02 −.04* .10‡ .56 ‡ 1.00
conditionsa
Note: DUREL: Duke University Religion Index; GHQ-12: 12-item General Health Questionnaire.
Values less than −.20 and greater than +.20 were considered significant and, thus bolded.
a
The five mental health-related conditions considered include prior suicide attempt, prior psychiatric hospitalisation, prior serious episode of depression, prior heavy alcohol use, and prior abuse of
illicit drugs.
*P < .05.
†
P < .01.
‡
P < .001 (two-tailed).
 MENTAL HEALTH, RELIGION & CULTURE 407

correlations were between the three measures of religiosity (r = .56 to .65) and between
the reported level of social distance and occupational restriction of persons with mental
health conditions (r = .56). The mental health knowledge score was not strongly correlated
with any of the other variables, but negative attitudes about the mentally ill and less were
more common in older individuals and less common in individuals with more education.
Bivariate associations among categorical participant characteristics and the four
mental-illness-related measures (MHKQ, MHAQ, SD-P and SR-O) are shown in Table 3.
Respondents’ ethnicity and religious affiliation were not significantly associated with
any of the four measures. Current drinkers were more knowledgeable about mental
health issues than those who were not current drinkers. Negative attitudes about the men-
tally ill were significantly greater in respondents who were not currently married, rural resi-
dents, experiencing high psychological stress, not current smokers, not current drinkers,
and highly religious. Greater desired social distance from persons with mental health con-
ditions was reported in respondents who were women, currently married, and not current
smokers. Belief in higher levels of occupational restriction for persons with mental illnesses
was reported by persons who were currently married.

Multivariate analyses
Table 4 presents the multivariate linear regression analyses assessing the relationship of
the four measures of religiosity (level of participation in organised religious activities,
level of participation in non-organised religious activities, intrinsic religiosity, and the
total of the five items in the DUREL Scale) to each of the four mental health-related
measures (knowledge about mental health issues, attitudes about mental illnesses, level
of social distance from persons with mental illnesses, and beliefs about appropriate
level of occupational restriction for persons with mental illnesses). Model 1 only considers
the specific measure of religiosity, Model 2 adjusts the results for demographic variables,
and Model 3 adjusts the results for both demographic and health status and psychological
stress. As shown in the table, the only statistically significant result was the association
between greater non-organised religious activities and more negative attitudes about
the mentally, and this association became non-significant after adjusting for demographic
variables.
As shown in Table 1, 85% of Han respondents reported no religious affiliation while only
5% of Hui respondents reported no religious affiliation, and the two ethnic groups were
affiliated with different religions. Thus it is certainly possible that “religiosity” has a
different relationship with knowledge and attitudes about mental illness in the two
groups. To assess this possibility, we stratified the Model 3 regression analysis, comparing
the association between each of the four measures of religiosity and each of the four
mental health measures between the two ethnic groups. As shown in Table 5, the associ-
ation between religiosity and knowledge and attitudes about mental health was different
in the two ethnic groups. After adjusting for demographic factors, physical health status,
and the level of current psychological distress, greater mental health literacy was signifi-
cantly associated with high intrinsic religiosity and with a high total DUREL score in Han
respondents, but this was not the case among Hui respondents. Negative attitudes
about the mentally ill was not significantly associated with any of the four measures of reli-
giosity in either the Han or Hui groups. Less reported social distance from those with
 408
Table 3. Bivariate associations between dichotomous participant characteristics and mental illness-related variables.
Total score of Social Distance- Total score of Social Restriction–

Z. WANG ET AL.
Total score of Mental Health Knowledge Total score of Mental Health Attitude Personal scale for 5 mental health Occupation scale for 5 mental health
Questionnaire Questionnaire conditionsa conditionsa
Variables n Mean (SD) t (p) n Mean (SD) t (p) n Mean (SD) t (p) n Mean (SD) t (p)
Gender
Male 1078 13.9 (2.5) 1.43 (.232) 1078 46.1 (9.7) 1.66 1001 78.2 (16.5) 8.37 1014 76.2 (21.2) 2.35
Female 1347 13.8 (2.5) 1346 46.6 (9.6) (.198) 1216 80.2 (16.1) (.004) 1260 77.5 (20.6) (.125)
Currently married
Yes 2104 13.7 (2.6) 1.29 (.255) 2103 43.9 (9.9) 25.09 1921 79.7 (16.2) 8.10 1975 77.4 (20.9) 6.61
No 321 13.9 (2.5) 320 46.8 (9.5) (<.001) 295 76.8 (16.8) (.004) 298 74.0 (21.1) (.010)
Residence
Urban 1207 13.9 (2.5) .52 (.469) 1206 45.4 (9.8) 23.70 1114 80.0 (15.7) 3.62 1141 77.5 (20.2) 2.04
Rural 1218 13.8 (2.5) 1218 47.3 (9.4) (<.001) 1103 78.7 (16.9) (<.057) 1133 76.3 (21.6) (.153)
Ethnicity
Hui 577 13.8(2.5) 1.79 577 46.4 (9.4) .02 529 79.5 (16.1) .09 536 77.3 (21.0) .25
Han 1848 13.9 (2.5) (.182) 1847 46.4 (9.7) (.903) 1688 79.3 (16.4) (.758) 1738 76.8 (20.9) (.617)
b
High psychological distress
Yes 674 14.0 (2.4) 1.87 673 47.2 (9.3) 6.02 610 80.1 (16.4) 1.85 624 77.1 (21.3) .09
No 1751 13.8 (2.5) (.172) 1751 46.1 (9.7) (.014) 1607 79.0 (16.3) (.174) 1650 76.8 (20.8) (.753)
Current smoker
Yes 581 13.9 (2.5) .20 581 45.6 (9.6) 5.36 540 78.0 (16.4) 4.84 549 76.1 (21.5) 1.06
No 1844 13.9 (2.5) (.652) 1843 46.6 (9.6) (.021) 1677 79.7 (16.3) (.028) 1725 77.2 (20.7) (.303)
Current drinker
Yes 436 14.1 (2.5) 4.27 436 44.8 (10.1) 15.19 407 78.2 (15.3) 2.20 412 75.4 (20.7) 2.63
No 1989 13.8 (2.5) (.039) 1988 46.7 (9.5) (<.001) 1810 79.6 (16.5) (.138) 1862 77.3 (21.0) (.105)
Religious affiliation
Yes 837 13.9 (2.5) .56 837 46.4(9.3) .01 772 79.1 (16.4) .27 783 76.7 (21.0) .16
No 1588 13.8 (2.5) (.455) 1587 46.4(9.8) (.956) 1445 79.4 (16.3) (.600) 1491 77.1(20.8) (.683)
c
Highly religious
Yes 204 13.9 (2.5) .31 204 47.9 (8.1) 5.21 187 78.9 (15.5) .10 188 75.5 (22.0) .90
No 2221 13.9 (2.4) (.576) 2220 46.3 (9.8) (.023) 2030 79.3 (16.4) (.750) 2086 77.0 (20.8) (.341)
Note: The bold values are all statistically significant (i.e., p < .05).
a
The five mental health-related conditions considered include prior suicide attempt, prior psychiatric hospitalisation, prior serious episode of depression, prior heavy alcohol use, and prior abuse of
illicit drugs.
b
High psychological distress is present if converted total score of Chinese version of 12-item General Health Questionnaire (GHQ), which has theoretical range of 0–100, is greater than 36.
c
Persons classified as “highly religious” are those with a total score on the Duke Religion Index (DUREL), which has a theoretical range of 5–27, of greater than 20.
 MENTAL HEALTH, RELIGION & CULTURE 409

Table 4. Multivariate linear regression analysis of four measures of religiosity and level of mental health
knowledge, attitudes about mental illnesses, and social distance and social restriction of the mentally ill
among residents of Ningxia, China, 2013a.
Model 1 Model 2 Model 3
B (SE) [R2] B (SE) [R2] B (SE) [R2]
Total score of Mental Health Knowledge Questionnaire (MHKQ) (N = 2425)
Participation in organised religious activities −.01 (.04) [.00] −.01 (.04) [.01] −.01 (.04) [.01]
Participation in non- organised religious activities .04 (.04) [.00] .04 (.04) [.01] .04 (.04) [.01]
Intrinsic religiosity −.01 (.01) [.00] .00 (.01) [.01] .03 (.01) [.01]
Total score of 5-item DUREL .00 (.01) [.00] .00 (.01) [.01] .00 (.01) [.01]
Total score of Mental Health Attitude Questionnaire (MHAQ) (N = 1845)
Participation in organised religious activities .09 (.15) [.00] −.20 (.15) [.08] −.20 (.15) [.08]
Participation in non-organised religious activities .50 (.16)† [.00] .02 (.16) [.08] .02 (.16) [.08]
Intrinsic religiosity −.03 (.05) [.00] −.07 (.49) [.08] −.07 (.05) [.08]
Total score of 5-item DUREL .01 (.03) [.00] −.05 (.03) [.08] −.04 (.03) [.08]
Average score of Social Distance-Personal (SD-P) scale for 5 mental health conditionsb (N = 1686)
Participation in organised religious activities −.03 (.27) [.00] .14 (.27) [.02] −.12 (.27) [.02]
Participation in non- organised religious activities −.07 (.29) [.00] −.06 (.29) [.02] −.07 (.29) [.02]
Intrinsic religiosity −.11 (.08) [.00] −.07 (.09) [.02] −.07 (.09) [.02]
Total score of 5-item DUREL −.06 (.06) [.00] −.03 (.06) [.02] −.03 (.06) [.02]
Average score of Social Restriction-Occupational (SR-O) scale for 5 mental health conditionsb (N = 1736)
Participation in organised religious activities −.38 (.34) [.00] −.26 (.35) [.01] −.27 (.35) [.01]
Participation in non- organised religious activities −.20 (.36) [.00] −.20 (.37) [.01] −.21 (.37) [.01]
Intrinsic religiosity −.10 (.11) [.00] −.06 (.11) [.01] −.06 (.11) [.01]
Total score of 5-item DUREL −.07 (.07) [.00] −.05 (.08) [.01] −.05 (.08) [.01]
Note: DUREL: Duke University Religion Index.
a
In all three models 4 separate regression analyses are conducted, one for each of the four measures of religiosity. Model 1
includes the religious measure alone; Model 2 adjust results for demographic variables (age, gender, educational level,
urban versus rural residence, Han versus Hui ethnicity, and marital status); and Model 3 adjusts results for demographic
variables and for the level of physical health and psychological stress in the prior month.
b
The 5 mental health-related conditions considered include prior suicide attempt, prior psychiatric hospitalisation, prior
serious episode of depression, prior heavy alcohol use, and prior abuse of illicit drugs.
*p < .05.
†
p < .01.

mental health conditions was significantly more common in Han respondents with greater
participation in organised religious activities, higher levels of intrinsic religiosity or a higher
total score on DUREL; in the Hui group this association was only significant for the intrinsic
religiosity variable. Finally, less reported occupational restrictiveness of those with mental
health conditions was significantly associated with higher intrinsic religiosity or a higher
total DUREL score in Han respondents but with greater participation in non-organised reli-
gious activities in Hui respondents.

Discussion
Stigma and discrimination contribute to the burden caused by mental illness and can sig-
nificantly disrupt help seeking, treatment, and rehabilitation (Byrne, 1997). A study con-
ducted thirty years ago found that certain population groups respond to mentally ill
individuals with rejection, suspicion, and fear (Madianos, Madianou, Vlachonikolis, & Ste-
fanis, 1987). More recent studies indicate that this type of stigma and discrimination
towards the mentally ill remains an important global health and human rights issue
(Crabb et al., 2012). These negative attitudes also exist among medical professionals: a
study among Sri Lankan doctors and medical undergraduates found that they tended
to blame the mentally ill for their condition (Fernando, Deane, & Mcleod, 2010). Studies
410 Z. WANG ET AL.

Table 5. Multivariate linear regression analysis of four measures of religiosity and level of mental health
knowledge, attitudes about mental illnesses, and social distance and social restriction of the mentally ill
among Han and Hui residents of Ningxia, China, 2013a.
Han Hui
B (SE) [R2] B (SE) [R2]
Total score of Mental Health Knowledge Questionnaire (MHKQ) (Han, N = 1846; Hui, N = 577)
Participation in organised religious activities .03 (.09) [.01] −.01 (.07) [.01]
Participation in non- organised religious activities .25 (.17) [.01] .08 (.06) [.01]
Intrinsic religiosity .07 (.03)* [.01] .02 (.03) [.01]
Total score of 5-item DUREL .05 (.02)* [.01] .00 (.02) [.01]
Total score of Mental Health Attitude Questionnaire (MHAQ) (Han, N = 1845; Hui, N = 577)
Participation in organised religious activities −.51 (.35) [.08] −.14 (.25) [.08]
Participation in non- organised religious activities −.39 (.65) [.08] .15 (.23) [.08]
Intrinsic religiosity −.21 (.11) [.08] −.13 (.11) [.08]
Total score of 5-item DUREL −.17 (.09) [.08] −.06 (.08) [.08]
Average score of Social Distance-Personal (SD-P) scale for 5 mental health conditionsb (Han, N = 1686; Hui, N = 529)
Participation in organised religious activities −1.26 (.62)* [.03] .37 (.46) [.03]
Participation in non- organised religious activities −2.11 (1.16) [.03] −.55 (.41) [.03]
Intrinsic religiosity −.47 (.20)* [.03] −.40 (.20)* [.03]
Total score of 5-item DUREL −.40 (.15) † [.03] −.23 (.14) [.04]
Average score of Social Restriction-Occupational (SR-O) scale for 5 mental health conditions (Han, N = 1736; Hui, N = 536)
b

Participation in organised religious activities −1.20 (.79) [.01] −.78 (.60) [.04]
Participation in non-organised religious activities −2.09 (1.47) [.01] −1.05 (.53) † [.04]
Intrinsic religiosity −.67 (.26) † [.01] −.25 (.26) [.03]
Total score of 5-item DUREL −.52 (.20) † [.01] −.34 (.19) [.04]
Note: DUREL: Duke University Religion Index.
The bold values are all statistically significant (i.e., p < .05).
a
Four separate regression analyses are conducted, one for each of the four measures of religiosity. Results are adjusted for
demographic variables (age, gender, educational level, urban versus rural residence, and marital status) and for the level
of physical health and psychological stress in the prior month.
b
The five mental health-related conditions considered include prior suicide attempt, prior psychiatric hospitalisation, prior
serious episode of depression, prior heavy alcohol use, and prior abuse of illicit drugs.
*p < .05.
†
p < .01.

in China also find that health professionals and community residents often hold negative
attitudes towards mental illness and lack knowledge about mental health (J. Wang et al.,
2013; Xiao et al., 2016). Thus, success in rehabilitating individuals with mental illnesses in
China depends, in part, on changing the attitudes of family members, community
members and health professionals. In localities with many religious practitioners one
potential avenue for doing this is to activate religious belief systems that emphasise
caring for the disadvantaged.
In the present study we found that religious affiliation per se was not related to mental
health literacy or to attitudes about the mentally ill. However, higher levels of religiosity
were significantly associated with more negative attitudes about the mentally ill, though
this relationship became non-significant after adjustment for demographic variables.
Our most dramatic finding was that the “valence” of religiosity – that is, the way religi-
osity is associated with mental health literacy and attitudes about the mentally ill – is quite
different in the Han and Hui ethnic groups. The vast majority of the Han group have no
religious affiliation, so persons who do report religious beliefs and practices are a relatively
select group, a group that is associated with greater knowledge about mental illness and
less social distance and occupational restrictiveness of persons with mental health con-
ditions. However, in the Hui ethnic group almost everyone is a practicing Islam so the
relationship between the level of religiosity and other external variables such as
 MENTAL HEALTH, RELIGION & CULTURE 411

knowledge and attitudes about the mentally ill are much less evident than in the Han
group, and more likely to be obscured by other factors that affect these attitudes such
as age, gender, education, and marital status.
These findings only provide partial support for the suggestion that religious believers
are more accepting than non-believers of persons with mental illnesses (Yao, 2006). The
presumed explanation for this hypothesis is that religious individuals are more willing
to help disadvantaged groups in the population. The history of the development of
mental health services in China supports this view: the first officially authorised mental
health care service facilities were established in the Tang Dynasty (618-907 AD) in
temples run and staffed by Buddhist monks (Liu et al., 2011), and the first modern psychia-
tric hospital in China was established in 1898 by the American Christian missionary John
Kerr. This is also the stance taken in Islam: Muslim scholars during the Middle Ages rejected
the notion that mental illness was caused by demonic possession and viewed mental dis-
orders as conditions that were physiologically based (Haque, 2004; Youssef & Youssef,
1996), views that led to the establishment of the first inpatient psychiatric facility in the
world in Baghdad in 705 AD by al Razi (Murad & Gordon, 2002).
There is, however, another possibility explanation for greater awareness and sensitivity
to mental health issues in the religiously active. Religious involvement is positively associ-
ated with successful coping, treatment engagement, and help-seeking behaviour (Smolak
et al., 2013). Religious individuals are more likely to use mental health services, which pre-
sumably results in a better understanding of mental illness. At least one study has reported
that those with higher levels of private religious activity and higher levels of intrinsic reli-
giosity were more likely to have accessed some form of mental health service (Pickard,
2006). And religious involvement may increase social integration and strengthen an indi-
vidual’s social network (Smith, 2003), making it possible for positive attitudes and views to
spread more easily in religious groups.
The present study’s findings are important for several reasons. This is the first study to
our knowledge to examine the association between religious involvement and mental
health awareness in a community-based sample in mainland China. Second, this study
examined the association between religious involvement and mental health awareness
in different ethnic groups with religious affiliations that are often overlooked in previous
studies about religion and mental health, including Islam (in most Hui ethnicity respon-
dents); the traditional Chinese religions of Buddhism, Taoism and Confucianism (in a min-
ority of Han respondents); and no reported religious affiliation (in the majority of Han
respondents). Finally, given the religious awakening happening in China (Stark & Liu,
2011) and large numbers of individuals with mental disorders who need treatment in
the community (Shen et al., 2006), the present findings help identify a potential supportive
role that religious practitioners and religious institutions could play in the provision of
community-based mental health services.

Limitations
First, the cross-sectional design means that we are only able to report associations
between religiosity and mental health awareness and attitudes; it is not possible to deter-
mine whether this is a causal relationship. Second, the sample selected for this study was
from only one province in China where over 30% of the population is Muslim, so
412 Z. WANG ET AL.

generalising these results to other areas of China must be done with caution. Third, we
have combined results for five distinct conditions into the assessment of social distance
and occupational restriction of persons with mental health conditions (prior suicide
attempt, prior psychiatric hospitalisation, prior serious episode of depression, prior
heavy alcohol use, and prior abuse of illicit drugs); it is certainly possible that the results
for the five separate conditions would be different from each other. Finally, similar to
the overall Ningxia population, there were three times as many Han respondents as Hui
respondents, so differences in the variables identified as statistically significant in the stra-
tified regression results between Han and Hui respondents (Table 5) may be due to the
relatively small number of Hui respondents.

Conclusions
This is the first study of the relationship between religiosity and mental health literacy,
stigma, social distance, and occupational restrictiveness in mainland China. In a represen-
tative community-based sample from a province with a substantial proportion of Muslim
residents, we found that religious affiliation per se was not related to mental health literacy
or to attitudes about the mentally ill. However, different measures of the level of religiosity
(based on a validated Chinese version of the five-item Duke University Religion Index)
were associated with individuals’ willingness to include persons with mental health con-
ditions in their social networks, and with individuals’ beliefs about the appropriateness
of the participation of persons with mental health conditions in different occupations.
There were, moreover, substantial differences in these relationships between the largely
Muslim Hui respondents and the Han respondents, only a minority of whom reported
any religious affiliation.

Disclosure statement
No potential conflict of interest was reported by the authors.

Funding
This work was supported by China Medical Board [Grant number 11-063].

ORCID
Zhizhong Wang http://orcid.org/0000-0002-0612-3218
Harold Koenig http://orcid.org/0000-0003-2573-6121
Michael Robert Phillips http://orcid.org/0000-0002-5973-2439

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