Comparison with previous studies

Despite numerous population-based surveys of mental disorders having been conducted across the globe, ^{28,Reference Kessler, McGonagle and Zhao29} comparisons of people with schizophrenia in rural v. urban areas have been relatively rare. One reason is that other large epidemiological surveys ascertained too few individuals with psychotic disorders, used diagnostic methods more suitable for common mental disorders, or did not sample both rural and urban areas. ^{Reference Kendler, Gallagher, Abelson and Kessler30} The few existing studies have generally been hindered by a variety of methodological limitations, such as lacking formal reliability testing for diagnoses ^{Reference Kebede, Alem, Shibre, Negash, Deyassa and Beyero12,Reference Kebede, Alem, Shibre, Negash, Fekadu and Fekadu13} or ascertaining only from treatment settings. ^{Reference Chu, Sallach and Klein14,Reference Drake, Fox, Leather, Becker, Musumeci and Ingram15} Arguably the two most rigorous previous studies were done in Chandigarh, India, and in Butajira, Ethiopia. The Chandigarh study compared outcomes for ‘incident cases’ of non-affective psychoses ascertained via treatment settings in rural v. urban Chandigarh; results suggested that symptomatic outcomes were better in rural than urban areas. ^{Reference Varma, Brown, Wig, Tripathi, Misra and Khare11} The Chandigarh study was limited, however, by small sample size, was restricted to people who received treatment and was done in the 1980s before the recent massive urban migration in many LAMI countries. The more recent study in Butajira ascertained a population-based prevalence sample of individuals with schizophrenia, and also found better symptomatic and functional outcomes among rural than urban residents. ^{Reference Kebede, Alem, Shibre, Negash, Deyassa and Beyero12,Reference Kebede, Alem, Shibre, Negash, Fekadu and Fekadu13} This exceptional study was, however, geographically restricted to one district within Ethiopia, and it is unclear whether its results are generalisable to other districts of Ethiopia or other African populations.

Table 3

Illness/function and lifetime treatment variables by urban, rural and urban v. rural comparison

			Statistic
	Urban (n = 96)	Rural (n = 297)	t (d.f.)	χ2 (d.f.)	P
Duration of illness, years: mean (s.d.)	13.5 (11.7)	11.4 (10.7)	1.58 (355)		0.11
Global Assessment of Functioning score, mean (s.d.)	47.0 (16.2)	45.3 (15.0)	0.93 (390)		0.35
Age at onset, years: mean (s.d.)	31.2 (11.2)	31.6 (11.7)	–0.30 (355)		0.76
Diagnosis, n (%)					0.10Footnote a
Schizophrenia	86 (89.6)	240 (80.8)
Psychotic disorder not otherwise specified	1 (1.0)	23 (7.7)
Delusional disorder	5 (5.2)	10 (3.4)
Schizoaffective disorder	2 (2.1)	11 (3.7)
Schizophreniform disorder	2 (2.1)	10 (3.4)
Brief psychotic disorder	0 (0.0)	3 (1.0)
Prior treatment-seeking for psychological problems (3 categories), n (%)				13.60 (2)	0.0011
In-patient admission	62 (64.6)	130 (43.8)
Only out-patient treatment	12 (12.5)	77 (25.9)
Never treated	22 (22.9)	90 (30.3)
Prior treatment-seeking for psychological problems (detailed categories), n (%)
In-patient admission	62 (64.6)	130 (43.8)			0.03Footnote a
Only out-patient treatment
Out-patient psychiatrist	8 (8.3)	50 (16.8)
Out-patient general Western medicine doctor	3 (3.1)	20 (6.7)
Out-patient traditional Chinese medicine doctor	0 (0.0)	5 (1.7)
Shaman	1 (1.0)	2 (0.7)
Never treated
Only sought help from friends or colleagues	0 (0.0)	4 (1.4)
Only sought help from relatives	0 (0.0)	2 (0.7)
Never sought help	22 (22.9)	84 (28.3)

a. Fisher's exact test.

The current study adds substantially to this previous work. We used a large and representative sample of people with schizophrenia, drawn from a two-stage community study of 12% of the Chinese population. Due to the two-stage design, diagnoses for psychotic disorders could be established via a standardised, clinician-administered diagnostic interview, and masked reassessments of a random sample could be used to assess measurement error. Due to the community-based sampling, we could ascertain a significant number of reliably diagnosed people with schizophrenia who had never been treated. Given the strengths of the design, the threefold difference in employment for rural v. urban areas is unlikely to be a chance or an artifactual finding.

Employment favoured rural areas despite less access to treatment

The rural advantage in employment held even though people with schizophrenia residing in rural settings were disadvantaged relative to their urban counterparts in having less medical insurance and less access to psychiatric treatment. Of note, only 43.8% of people with schizophrenia in rural settings v. 64.6% in urban settings had received psychiatric in-patient treatment (the most prominent form of psychiatric treatment in China) and 30.3% of people with schizophrenia in rural settings v. 22.9% in urban settings had never received formal treatment. Our findings corroborate earlier writings that rural residents face more difficulties in accessing formal psychiatric treatment due to less extensive medical insurance coverage and because such treatment is restricted to psychiatric hospitals that are primarily situated within large urban centres. ^{Reference Phillips17} Although the association between symptomatology and employment remains debated, ^{Reference Marwaha, Johnson, Bebbington, Stafford, Angermeyer and Brugha26} prior studies specifically within rural China suggest that marked symptoms as a result of not being treated ^{Reference Ran, Xiang, Huang and Shan31} are linked to worse employment outcome at 10-year follow-up. ^{Reference Ran, Chen, Chen, Ran, Tang and Lin27} The results indicate greater employment for people with schizophrenia within rural settings despite disadvantages in treatment and suggest that rural contexts may provide considerable accommodating effects.

Sociocultural factors that have an impact on employment in rural and urban settings

Our findings indicate that increased employment opportunities for people with schizophrenia within rural settings were predominantly located within the agrarian sector: 89.6% of rural people with schizophrenia who worked did so either in farming or fishing. Our results corroborate another study of people with schizophrenia within rural China that reported that these individuals were primarily working in less organised, low-skill sectors such as farming or domestic help. ^{Reference Ran, Chen, Chen, Ran, Tang and Lin27} Prior sociological findings suggest the social and contextual conditions that may promote such employment accommodation. ^{Reference Yusuf and Nabeshima32-Reference Fan, Wang, Smyth and Nielsen34} Opportunities for agricultural work are made plentiful because government regulations mandate that farmland be primarily used for individual agriculture and survival often requires maximising its usage. ^{Reference Yusuf and Nabeshima32} Such work has also been described as being flexible seasonally, and even daily, ^{Reference Fan and Keister33} allowing for periodic disability. Involvement of extended kin, including parents, siblings and other relatives, may further aid ill individuals in fulfilling farming or household responsibilities. ^{Reference Fan, Wang, Smyth and Nielsen34} These conditions may have provided the supportive context for rural people with schizophrenia in our study to remain employed, who as indicated by average GAF scores, were still experiencing serious symptoms. Our results also indicated that this rural advantage in agrarian forms of employment slightly favoured women relative to men. This may be attributable to rural women predominantly being limited to agricultural labour due to needing to be close to home because of a traditional focus on housekeeping, whereas rural men may pursue off-farm labour, where an increasing emphasis on education and training may disadvantage people with schizophrenia. ^{Reference Matthews and Lee35}

Table 4

Unadjusted and adjusted Poisson regression of factors associated with employment in individuals with schizophrenia in China

	Unadjusted		Adjusted
	Relative risk (95% CI)	P	Relative risk (95% CI)	P
Rural v. urban residence	3.52 (2.50–4.97)	<0.001	3.27 (2.11–5.07)	<0.001
Female v. male gender			0.94 (0.86–1.03)	0.1637
Age			0.99 (0.99–1.00)	0.0953
Global Assessment of Functioning			1.00 (0.99–1.00)	0.8289
Province
Shandong			–	–
Gansu			1.01 (0.90–1.13)	0.8992
Qinghai			1.12 (0.97–1.30)	0.1305
Zhejiang			0.95 (0.74–1.21)	0.6779
Insurance status
Self-pay			–	–
Cooperative medical service			0.95 (0.83–1.08)	0.4341
Free medicare			0.79 (0.47–1.34)	0.3891
Medical insurance			0.99 (0.51–1.92)	0.9742
Treatment status
No treatment			–	–
Out-patient treatment			0.92 (0.84–1.01)	0.0843
In-patient admission			0.94 (0.84–1.06)	0.3219
Duration of illness			0.99 (0.99–0.99)	0.0243
Marital status
Unmarried			–	–
Married			1.11 (0.99–1.23)	0.0669

These generally accommodating features of rural settings are contrasted by the competitive labour market in urban China, whereby modern market dynamics predominate and employment opportunities heavily favour young, educated and skilled workers. ^{Reference Solinger and Keister36} The constraints that productivity and technology place on employment prospects generally for people with schizophrenia ^{Reference Marwaha, Johnson, Bebbington, Stafford, Angermeyer and Brugha26} are reflected by the small proportion in our sample working in professional/managerial positions (5/370, 1.4%). This emphasis on modern wage-earners in urban China thus particularly disadvantages employment opportunities for those with any health conditions, especially those experiencing symptoms of schizophrenia. In addition, financial disincentives provided via benefit systems that are more likely to be accessible in urban areas might contribute to the lower urban employment rate. Yet another factor may be more exposure to employer-based discrimination in urban settings. ^{Reference Marwaha, Johnson, Bebbington, Stafford, Angermeyer and Brugha26} In agrarian jobs, discrimination may be mitigated by more informal hiring practices based on kinship-networks and fewer formal requirements for employment. ^{Reference Rao, Angell, Lam and Corrigan37}

Although we have put forth some potential explanations along the lines of supportive accommodation in rural areas, we caution that much more work is required to fully understand these sociocultural factors. It may turn out that supportive accommodation does not properly characterise the factors that contribute to employment in rural areas. For example, the increased employment in rural areas may also be driven by dire necessity. For women, in particular, it is possible that these individuals with schizophrenia were required to work in order to avoid becoming destitute or ostracised. In that scenario, employment may still have beneficial effects for social integration, but this might also be associated with potentially adverse effects of coercion. The data available in this study do not indicate whether women in rural areas could choose whether or not to work, or how they felt about their work.

Study limitations and strengths

Study limitations include the cross-sectional design, which precluded causal inference or controlling for important baseline variables (such as pre-morbid employment). ^{Reference Ran, Chen, Chen, Ran, Tang and Lin27} Also, although broad definitions of employment are frequently utilised, ^{Reference Marwaha, Johnson, Bebbington, Stafford, Angermeyer and Brugha26} more refined measures of employment (for example hours worked, income) would have yielded more detailed information. However, our study is one of the few to corroborate patient report of employment with relative data. Another limitation is that although the GAF accounted for effects of symptoms on impairment, it did not assess specific symptom domains (i.e. positive or negative symptoms), which have sometimes been associated with functional outcomes. ^{Reference Marwaha, Johnson, Bebbington, Stafford, Angermeyer and Brugha26} Study strengths included the unprecedented use of clinician-administered semi-structured interview to reliably diagnose psychotic disorders within a large, representative psychiatric epidemiology study. Other study strengths include its stratified random sampling, high response rate and that it encompassed both urban and rural areas in a single middle-income country.

Another potential study limitation is that the sampling strategy did not enable ascertainment of rural migrants who have illegally relocated to urban areas for work opportunities. Phillips et al's study ^{Reference Philips, Zhang, Shi, Song, Ding and Pang18} selected respondents by household or computerised registry, ascertainment methods that would heavily bias towards respondents who held ‘official’ urban hukou status via official recognition of their residence. This resulted in the vast majority of study respondents residing in their assigned hukou area. Nevertheless, this sampling strategy points towards the study sample remaining valid for identified rural respondents, and being representative of urban respondents who did not illegally migrate from rural settings.

Future directions

We intend these findings to spur investigators to study the pathways by which contextual factors have an impact on people with schizophrenia. With this in mind, we pose four broad questions that follow naturally from the data presented here and could be a useful focus for future research.

First, what features of the rural context in China (and perhaps elsewhere) explain the higher employment in rural areas? Future research might focus on the specific contextual mechanisms - including neighbourhood, household and daily social interactions - that could lead to more supportive accommodation of employment for people with schizophrenia in rural areas. As we have noted above, such research might also reveal that ‘supportive accommodation’ does not properly characterise the contextual effects. Future research should also focus on the local interpretation of being employed in rural v. urban contexts, as holding a job in a rural v. an urban setting may confer significantly different meanings (and better educated, urban patients may very well not be satisfied with the type of employment that might be available in rural contexts).

Second, are rural settings generally more conducive than urban settings to social integration for people with schizophrenia in China? Across the many approaches to conceptualising and measuring social integration, or closely related outcomes such as social inclusion and participation in civil society, employment looms large in every approach. The rural advantage might pertain not only to the key domain of employment, but also to other domains of social integration. Furthermore, this question might pertain not only to China, but also to many other countries.

Third, are there striking rural v. urban differences in employment in countries other than China? Some previous findings tend to support this view, but as noted earlier, data are scant. As a corollary, are there also rural v. urban differences for other domains of social integration in other countries?

Fourth, what proportion of individuals with schizophrenia in LAMI countries do not receive any treatment, and what are the implications of receiving no treatment for the outcome of their illness? Although not a focus of this study, our finding that 28.5% of people with schizophrenia in the overall sample never received formal treatment provides one of the few available estimates of the proportion of people with schizophrenia who remain untreated in LAMI countries, thus significantly contributing to the literature on global mental health and underscoring the scarcity of psychiatric resources in LAMI countries. ^{Reference Saxena, Thornicroft, Knapp and Whiteford38} But due to the cross-sectional nature of our study, and the lack of in-depth information about the duration and quality of treatments received, it remains difficult to make any strong inferences about causal relationships between treatment and outcome. We hope that future studies will shed more light on this question.

As a final note, our findings may also have relevance to the earlier debates about differential outcome of psychoses in LAMI v. high-income countries. ^{Reference Hopper, Harrison, Janca and Sartorius1,Reference Jablensky, Sartorius, Ernberg, Anker, Korten and Cooper5} Work in rural settings was found to be mainly agrarian and low-skilled, whereas in urban settings it was mainly skilled and service-related. There might be similarities here to the different types of work available in previously defined ‘developing’ v. ‘developed’ contexts, for example, more formal employment in ‘developed’ contexts. Thus, while classifying sociocultural environments in such a fashion is no longer as salient within contemporary societies, ^{Reference Cohen, Patel, Thara and Gureje6} our findings might still aid understanding of the prior reported advantages in employment that residence within LAMI countries conferred when compared with high-income countries.

In conclusion, this study suggests that for people with schizophrenia in China, those in rural settings generally retain opportunities to participate in employment, whereas those in urban settings do not. This result poses important questions about how a rural social context might increase the opportunities for these individuals to use their capacities for productive work, and perhaps also limit their opportunities not to work. Systematically examining these questions could provide key insights into the conditions that enable people with schizophrenia to take up essential roles in different contexts.