Background

Mental illnesses, including depression, bipolar disorder, and schizophrenia, pose a significant public health challenge worldwide, with prevalence rates estimated to affect nearly one in four individuals at some point in their lives [1, 2]. In China, the weighted 12-month and lifetime prevalence rates of any mental illness (excluding dementia) are 9.3% and 16.6%, respectively [3]. Despite the increasing availability of effective treatment options, a considerable treatment gap remains [4]. One substantial barrier impeding individuals from seeking help is the pervasive stigma associated with mental illness [5, 6]. Many individuals fear discrimination and negative judgment from peers, family members, and society at large. This fear can lead to delays in seeking care, increased illness severity, and hesitation to adhere to prescribed treatment protocols, thereby exacerbating the impact of these disorders [7]. Second, the policies and resource allocation of healthcare institutions can also be influenced by discriminatory attitudes. In some regions, funding and resources for mental health services are often insufficient, leading to a decline in service quality. For example, in China, the management of medications and the provision of mental health services in primary healthcare institutions are restricted, resulting in many patients being unable to access timely and effective treatment [8].

The stigma surrounding mental illness can have detrimental impacts on mental health outcomes and quality of life [9], which can be worse than the impact of the mental health condition itself [10]. Delayed treatment due to shame or fear can result in worsening symptoms, increased functional impairment, and a higher likelihood of chronic mental health issues [7, 11]. Furthermore, stigma often contributes to non-adherence to medication regimens, leading to a cycle of relapse and recovery that is both taxing and demoralizing for patients [12]. For some, the compounded effects of stigma and untreated mental illness may culminate in severe situations such as depression and elevated suicide risk [13]. The urgency to manage and combat societal attitudes that perpetuate stigma is clear, as these negative perceptions can have a harmful impact on those living with mental health conditions.

Over the past decades, there has been a surge in the number of anti-stigma initiatives implemented on a global scale, aimed at alleviating the burden of prejudice and discrimination associated with mental illness [14]. These efforts, led by non-profit organizations, health organizations, and academic institutions, seek to educate the public, engage individuals with lived experiences, and promote narratives that highlight recovery and resilience. Strategies such as public campaigns, educational programs, and community movements have garnered notable success in challenging stigmatizing beliefs and promoting acceptance.

In China, Guangzhou also initiated the anti-stigma movement, mainly by training healthcare workers to enhance their knowledge of psychiatry, and this approach has improved discriminatory attitudes towards mental illness [15, 16]. In the past 5 years, China has launched nationwide activities such as “Healthy China initiative“(2019–2030) and “Science Popularization China” to promote health concepts and improve public health knowledge, which has significantly boosted mental health education and awareness. The dissemination of scientific knowledge through diverse channels, including educational videos and articles, has greatly enhanced public access to information about mental illness, which has led to a gradual transformation in societal attitudes. Social media platforms, in particular, have played a crucial role in encouraging open discussion about mental illness, facilitating a cultural shift that emphasizes understanding and support for mental health, rather than stigma or exclusion for those affected.

On October 10, 2022, The Lancet Psychiatry launched a global campaign aimed at ending the stigma surrounding mental illness, reinforcing the need for continued efforts to combat this pervasive issue [14]. Mental health education is one of the important strategies to improve the public’s attitude towards mental illness. Through systematic mental health education, it is possible to effectively reduce prejudice and discrimination against mental illness and enhance the public’s mental health literacy. The Healthy China initiative (2019–2030) encourages healthcare workers to carry out health popularization education in society, and our country has conducted many popular science initiatives regarding mental health. In 2017, we carried out a survey to examine knowledge and attitudes towards mental illness in a Chinse sample population [17], highlighting the need to strengthen health education in rural areas and among the elderly population. With the ongoing Healthy China Action, we would like to conduct another survey to reassess public perceptions of mental health and the level of mental illness knowledge within the community today. This study aims to shed light on the current status of attitudes towards mental illness and the levels of mental health literacy in the Chinese general population, so as to provide a foundational understanding that can guide future anti-stigma interventions and policy developments.

Methods

Participants

The questionnaire was administered using the Wenjuanxing platform, with all items set as mandatory fields to ensure data completeness. Participant recruitment employed convenience and snowball sampling methods, replicating the approach detailed in our previous study [17]. Specifically:

  • Initial Seed Selection: We contacted 50 participants from the 2017 survey wave. These individuals were originally selected via convenience sampling based on their accessibility and willingness to participate (including researchers’ relatives and friends).

  • Snowball Recruitment: These initial 2017 participants were asked to forward the survey link via WeChat to their own personal networks (like friends, family) and encouraged to share it further within their circles.

The instructions specified that anyone aged 18 or older could participate, and they could withdraw from the survey at any time. Rather than written informed consent, anonymous electronic informed consent was obtained from the respondents. The survey was conducted from March to September 2024. The study protocol was approved by the Research Ethics Committee of the Second Affiliated Hospital of Xinxiang Medical University (XYEFYLL-2024-44).

Instruments

In line with our previous research [17], we collect basic demographic data, such as age, gender, education level, place of residence, and mental disorder history.

The Mental Health Knowledge Questionnaire (MHKQ) is a valuable tool designed to assess individuals’ knowledge of mental health issues. It comprises 20 self-administered items with scores ranging from 0 to 20, with higher scores indicating greater knowledge of mental health [18].

The Perceived Devaluation and Discrimination Scale (PDDS) is a widely used research tool designed to assess perceived devaluation and discrimination which may be experienced in various social contexts [19]. We used the Chinese version of PDD with a Cronbach’s alpha coefficient of 0.7 while the Cronbach’s alpha coefficient in this study is 0.63. The scale comprises 12 items, each rated on a five-point Likert scale, allowing respondents to indicate the extent of their agreement or disagreement with statements related to devaluation and discrimination. Scores can range from 12 to 60. Higher scores indicate lower levels of perceived discrimination.

Data analysis

Data were analyzed using IBM SPSS v. 25. The statistical methods employed included a general description of the quantitative data. The normality of the data distribution was assessed using the Shapiro-Wilk test, and Levene’s test (α = 0.05) was employed to evaluate the homogeneity of variances between groups. The MHKQ total scores were normally distributed with homogeneity of variances(F = 1.229, P = 0.268), whereas the PDD total scores violated the homogeneity assumption༈F = 56.838, P<0.001༉. Therefore, an independent samples t-test was used for MHKQ, and Welch’s t-test was applied for PDD.The chi-square test is employed for categorical variables like sex and residence. For ordinal variables, the Mann-Whitney U test is employed. Group differences in the total scores of the PDDS and MHKQ were compared by covariance analysis with education as a covariate. The level of significance was set at 0.05.

Results

Sample characteristics

A total of 1061 respondents completed the questionnaires. The mean age of the respondents was (32.44 ± 9.49) years, with a range of 18–67. There were 378 (35.6%) male and 683 (64.6%) female respondents included in the study. The comparison of respondent characteristics between the two groups are summarized in Table 1.

Table 1 Comparison of respondent characteristics between 2017 and 2024
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Response frequencies for the additional items

For the question, “Do you ever have contact with people with mental illness?”, 44.2% (n = 469) replied “Never,” while 55.8% (n = 592) replied “Ever”. A total of 69.7% (n = 739) participants reported learning about mental illness from portrayals in mass media, while 30.3% (n = 322) reported learning from personal encounters with people who have mental illness. In regard to the respondents’ attitudes toward psychotropic drugs, 70.6% (n = 749) considered them effective, 2.5% (n = 27) believed that they would make patients worse, 24.6% (n = 261) believed that they are likely to lead to dependency, and 2.3% (n = 24) considered them ineffective (see Table 1).

Comparison of the total scores of the PDDS and MHKQ between participants from 2017 to 2024

When education was included as a covariate, the adjusted mean total scores for the PDDS and MHKQ were (36.03 ± 0.19) and (16.51 ± 2.53), respectively. Compared with the data from the previous study, significant differences were found in both the MHKQ (t=−5.55, P<0.001, Cohen’s (d) = 0.24, 95%CI[0.152, 0.322]) and PDDS scores (Welch’s t =−8.53, P<0.001, Cohen’s (d)=−0.37, 95%CI[−0.45, −0.29]). The results are displayed in Table 1.

Comparison of the results of the PDDS between participants from 2017 to 2024

The total scores of the PDDS ranged from 16 to 59, and the mean score was 36.02 (SD = 5.52). Compared with 2017, except for the item “Most people believe that attending a psychiatric hospital is a sign of personal failure” (F = 8.667, P = 0.07), significant differences were found in the other items (see Table 2).

Table 2 The results of the PDDS between participants from 2017 and 2024
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Comparison of the results of the MHKQ between participants from 2017 to 2024

The total scores of the MHKQ ranged from 2 to 20 and the mean score was 16.51 (SD = 2.53). The mean score for the first section of true or false questions was 13.76 (SD = 1.99), and 181 (17.1%) respondents had perfect scores. Compared with 2017, the current study found significant differences in items 1, 2, 4, 5, 6, 11, and 14 for the first part. In respect to the last four questions, 436 (41.09%) respondents were aware of all four mental health promotion days. Compared with 2017, the public’s awareness rate of International Mental Health Day, International Suicide Prevention Day, and World Sleep Day has increased significantly (all P < 0.05) (Table 3).

Table 3 Comparison of the correct response rate of the MHKQ between participants from 2017 and 2024 (n, %)
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Comparison of the PDDS among demographic variables in 2024

Table 4 shows the mean PDDS scores for different demographic groups. Statistically significant differences were found in gender-matched scores, with females scoring higher than males (F = − 2.06, P = 0.039).

Table 4 Comparison of the PDDS scores among the demographic variables between participants from 2017 and 2024
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Comparison of the MHKQ results among demographic variables in 2024

Table 5 shows the mean MHKQ scores for different demographic groups. Compared with those variables, the respondents’ gender, age, education levels, area of residence, sources of information about mental illness, and contact levels with people with mental illness were found to be significantly related to the total MHKQ scores. The analysis of variance showed that females scored significantly higher than males on the MHKQ (t = − 4.95, P = 0.001). Respondents aged 16–44 scored significantly higher than those above 45 years old on the MHKQ (F = 4.49, P = 0.04). Respondents with higher education levels were found to have greater mental health literacy (F = 34.49, P < 0.001). Urban residents had higher MHKQ scores than rural residents (t = 4.07, P < 0.001). Those who had prior experience of others with mental illness (t = − 4.54, P < 0.001) and who had learned about mental illness through personal experiences (t = − 3.05, P = 0.002) had higher MHKQ scores.

Table 5 Comparison of the MHKQ scores among the demographic variables between participants from 2017 and 2024
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Discussion

Our study indicates potential changes in knowledge of mental health and attitudes toward mental illness among participant compared to data from 7 years ago. However, given the cross-sectional convenience sampling method, these observed differences may primarily reflect variations in sample composition over time rather than definitive societal-level improvements. Since 2019, China has implemented the Healthy China Initiative (2019–2030), which incorporates health promotion efforts, such as requiring healthcare workers to engage in popular science work for career advancement. Many doctors have subsequently participated in community outreach or online health education. Concurrently, media portrayals of mental illness appear to have become more positive. In our sample, these external factors were possibly associated with shifts in knowledge and attitudes, but the study design didn’t directly assess participants’ exposure to or the impact of these initiatives, limiting causal inferences.

Moreover, we all know that the media plays a crucial role in shaping public attitudes towards mental illness. In the past, media coverage often tended to associate mental illness with negative images such as violence and crime, and these stereotypes reinforced the public’s fear and prejudice towards individuals with mental health issues [20]. However, with the advancement of the Healthy China initiative, more and more healthcare workers, including mental health professionals, are beginning to use short videos for public education. This may have contributed to broader awareness in our sample, which implies that professional involvement in mental health advocacy could be valuable for education efforts.Overall, our findings highlight the importance of continued efforts to enhance mental health literacy. Based on the sample data, improving understanding of mental health might encourage individuals to seek psychological assistance when needed. However, further research with representative samples is necessary to generalize these insights to the broader population.

In our detailed comparison using the PDDS, we found that, apart from the item “Most people believe that entering a mental hospital is a sign of personal failure,” which showed no significant differences between groups, all other items revealed notable intergroup differences. This indicates that discrimination against mental health facilities may persist in the study participants, potentially dissuading individuals from seeking early treatment.

More than 6 decades ago, many countries in Europe and America began the process of de-institutionalization, shifting away from traditional mental health hospitals [21]. In China, there have been significant efforts to rename psychiatric hospitals (e.g., changing the name of psychiatric hospitals to alternatives such as “brain hospital,” Anding Hospital or Kangning Hospital, etc.) or to transform these hospitals into general hospitals. The health administration of China requires general hospitals to set up departments of psychiatry, a decision which might prove instrumental in diminishing the stigma associated with visiting mental healthcare facilities.

In addition, closer examination of the MHKQ within our sample revealed increased awareness of important dates such as International Mental Health Day, International Suicide Prevention Day, and World Sleep Day compared to previous data. These findings may indicate the potential influence of health education initiatives. Notably, awareness of the International Day against Drug Abuse and Illicit Drug Trafficking approached 90% in our participants. However, it is evident that other mental health-related observances, particularly International Suicide Prevention Day—showed lower recognition rates in this sample, would benefit from stronger promotional efforts to bolster public awareness.

Further analysis of demographic differences within our sample revealed that female participants tend to exhibit greater acceptance and understanding in attitudes towards mental illness. This finding is in agreement with previous research [15, 22, 23] suggesting that societal expectations often encourage female to display empathy and compassion.

Consequently, female participants in our sample may be more inclined to adopt supportive and understanding attitudes when confronted with the struggles of others, which explains why females exhibit higher levels of tolerance towards mental health issues [24].

Furthermore, our results indicated higher levels of mental health knowledge among female respondents compared to males, consistent with earlier studies highlighting gender disparities in mental health awareness [15, 25]. Notably, in both surveys, the proportion of female respondents was higher. This may reflect a greater engagement with health-related topics or a higher willingness to participate in such research among the female in our sample, rather than a general population trend.To address this sampling imbalance, it could be beneficial for future studies to implement strategies aimed at increasing male participation, such as targeted outreach, tailored communication, or incentivized engagement.

In addition, within our sample, we found greater mental health literacy among urban populations, people under 45 years old, and individuals with higher education levels. This observation aligns with prior research [17, 26, 27], which suggests that urban residents have greater access to education compared to their rural counterparts. In the study population, higher education levels foster more opportunities for individuals to engage with mental health resources and education. Therefore, there is a pressing need to prioritize mental health education, particularly in rural areas where knowledge gaps may still exist.

Finally, it is essential to acknowledge the limitations of this study. First and foremost, this research was not a cohort study; therefore, the findings may not reflect long-term trends. In addition, the study used self-reported instruments which can be subject to social desirability bias and may not always accurately reflect participants’ true feelings or behaviors. Moreover, convenience sampling limits the sample’s representativeness. This is because the final sample depends on the social networks of the initially selected participants, which restricts generalizability. Additionally, the use of an online questionnaire led to demographic imbalance, with females and younger individuals overrepresented. Future research employing probabilistic sampling could more accurately describe attitude distributions across sociodemographic groups. Lastly, we used an electronic version of informed consent, meaning that it was not possible to ensure that every participant was fully clear about the research purposes; however, the participants completed the questionnaire voluntarily and were aware of their right to withdraw from the study at any time.

Conclusions

In conclusion, our survey results observed positive differences in attitudes and knowledge levels within the specific groups studied between the 2017 and 2024. These differences suggest a potential change in mental health literacy among these surveyed groups. However, because the study used a cross-sectional convenience sampling design, the differences may reflect variations in sample composition rather than definitive societal-level trends over time. Sustained efforts focused on education and advocacy remain crucial, aiming to reduce stigma and support mental health literacy across diverse demographics. Future initiatives could explore incorporating engaging modalities like drama and performances into public education. This approach may enhance the reach and effectiveness of activities aimed at populations such as those in rural areas or older adults. Further research with representative samples and longitudinal designs is needed to assess population-level trends and causal links.