Parent-Child Relationship Typologies and Associated Health Status Among Older Adults in the United States and China: A Cross-Cultural Comparison.

Background and Objectives: Cultural differences in intergenerational relationships have been well established in prior research. However, cross-national comparison evidence on the parent-child relationship and its health implications remains limited. Research Design and Methods: Data from the 2014 U.S. Health and Retirement Study and the 2015 Health and Retirement Longitudinal Study in China were used (N US, non-Hispanic Whites only = 3,918; N China = 4,058). Relationship indicators included coresidence, living nearby, having weekly contact, receiving assistance with daily activities, providing grandchild care, and financial transfer to/from children. Latent class and regression analyses were conducted. Results: Four classes were identified for non-Hispanic White older Americans: (1) distant and uninvolved (6.58%), (2) geographically proximate with frequent contact and downward support (47.04%), (3) coresident with frequent contact and upward support (13.1%), and (4) geographically proximate with frequent contact (33.28%). Three classes were identified among older Chinese: (1) coresident with frequent contact and upward support (37.46%), (2) coresident/interdependent (25.65%), and (3) geographically proximate with frequent contact and upward financial support (36.89%). For non-Hispanic White older Americans, providing downward support was associated with fewer functional limitations and better cognition. Receiving instrumental support from children was associated with more depressive symptoms, more functional limitations, and poorer cognition among older Chinese. Discussion and Implications: Cultural contrasts were evident in parent-child relationship typologies and their health implications. Compared to the U.S. non-Hispanic Whites, parent-child relationships in China tended to be closer and associated with poorer health status. The findings call for culturally relevant strategies to improve parent-child relationships and ultimately promote the health of older adults.

Dietary Knowledge and Preference Among Middle-Aged and Older Chinese Couples.

This study investigates the interdependence of dietary knowledge and preference and potential rural-urban differences among middle-aged and older Chinese couples. Couple-level data from the 2015 China Health and Nutrition Survey were included (N = 2933). Structural Equation Model examined the actor and partner effects of dietary knowledge on dietary preferences. Findings indicated that greater dietary knowledge was associated with one's healthier diet preferences among both rural and urban residents (P < .01). In rural areas, ones' dietary knowledge was associated with their partners' dietary preferences (P < .01). However, in urban areas, husbands' dietary knowledge was not associated with their wives' dietary preferences (P = .58), whereas wives' dietary knowledge was associated with their husbands' dietary preferences (P < .05). The rural-urban difference indicates the greater decision-making power of men in rural households. A couple-based approach is suggested for dietary interventions and guidelines promoting healthy eating in China, particularly in rural regions.

Immigration-Related Factors and Depression Help-Seeking Behaviors Among Older Chinese Americans.

OBJECTIVES: Asian Americans have the lowest mental health service utilization rate among all racial/ethnic groups. This study investigates how immigration-related factors shape the depression help-seeking behaviors of older Chinese Americans. METHODS: Data were collected from participants who reported experiencing any depressive symptoms in the Population-based Study of Chinese Elderly in Chicago (n = 907). Multinomial logistic regressions were conducted to examine the associations between immigration-related factors and help-seeking behaviors, including not seeking help (23.5%), seeking help from informal source(s) only (40%), seeking help from both informal and formal sources (28.7%), and seeking help from formal source(s) only (8.8%). RESULTS: Older Chinese Americans with lower levels of acculturation (OR = 0.88, 95% CI = 0.79-0.97) and those who lived in Chinatown (OR = 2.34, 95% CI = 1.21-4.52) were more likely to seek help from formal sources only (relative to not seeking any help). CONCLUSIONS: Older Chinese Americans with depressive symptoms predominately relied on informal sources of help, either solely or in combination with formal sources, to address their depressive symptoms. CLINICAL IMPLICATIONS: Leveraging informal support networks and ethnicity-specific resources represents a promising approach for this population.

Racial/ethnic/gender-Based Differences in Health Trajectories Among American Older Adults: 10-Year Longitudinal Evidence from the Health and Retirement Study.

Health disparity by race/ethnicity or gender has been well-documented. However, few researchers have examined health outcomes based on the intersection of individuals' race, ethnicity, and gender or investigated various health dimensions. Guided by an intersectionality framework, this study explores racial/ethnic/gender-based differences in trajectories of multiple health outcomes over a ten-year period among American older adults. Longitudinal data from the Health and Retirement Study (2004-2014) were used (N = 16,654). Older adults (65+) were stratified into six mutually-exclusive groups based on their race, ethnicity, and gender: Non-Hispanic (NH) White Men, NH White Women, NH Black Men, NH Black Women, Hispanic Men, and Hispanic Women. Growth curve models examined the trajectories of three health measures, including cognitive function, physical function limitations (i.e. activities of daily living and instrumental activities of daily living), and depressive symptoms. NH White men and women reported significantly better outcomes in cognition and physical function trajectories than racial/ethnic minority groups. Women in all racial/ethnic groups had more depressive symptoms but better cognition than men. Hispanic women reported the most depressive symptoms. Hispanic women and NH Black women had the worst physical function limitations. NH Black men/women were the most disadvantaged in cognition. Racial/ethnic/gender-based differences were stable over time in all health trajectories. Study findings highlight the utility of an intersectional framework in understanding how multiple social identities intersect to generate protective and/or risk effects on cognitive, mental, and physical health. Multilevel intervention strategies are warranted to reduce the persistent health inequity gap.

Who Cares for Older Adults? A Cross-National Study of Care Sources for Older Adults With Functional Limitations and Associated Determinants.

The study compared care source typologies for older adults in China and the United States. Data from the 2014 U.S. Health and Retirement Study and the 2013 China Health and Retirement Longitudinal Study were used. The respondents included community-dwelling older adults aged 65 years or older with at least one limitation in activities of daily living (ADLs) or instrumental ADLs (IADLs) (NChina = 2476, NUS = 2898). Respondents reported whether they received assistance from spouse, child/grandchild, relatives, others, and formal helpers. Latent class analysis and multinomial logistic regression were applied. Four classes were identified in China and the U.S, separately. In both countries, ADLs and IADLs were strong determinants of care source typologies. Care sources were more diverse and included formal assistance among older Americans. Older Chinese relied largely on their spouses and children/grandchildren for support. Policy efforts are needed to expand formal long-term services and supports, particularly in China.

Insomnia Symptom Trajectory of Spouse Caregivers of Older Adults with Functional Limitations.

OBJECTIVES: This study examined the long-term impact of spouse caregiving on insomnia symptoms, compared to propensity-score matched non-caregivers. METHODS: Health and Retirement Study data between 2006 and 2018 were used. Caregivers (n = 403) were respondents (aged 50+) who assisted their heterosexual spouses in performing (instrumental) activities of daily living at baseline. Non-caregivers were matched using a propensity score matching procedure based on baseline characteristics. Insomnia symptoms were measured every 4 years for both groups. Poisson mixed-effect models estimated the association between caregiver status and insomnia symptoms. RESULTS: Compared to matched non-caregivers, caregivers had similar severity of insomnia symptoms at baseline (ßcaregiver = 0.018, 95% CI = -0.089, 0.124) and reported a similar yearly change rate (ßcaregiver×time = -0.008, 95% CI = -0.017, 0.001). No moderation effects of care-recipients' dementia status and social support were significant. CONCLUSIONS: In this study sample, there is no evidence that spouse caregivers, specifically those who performed light duties, experience more severe insomnia symptoms than non-caregivers. CLINICAL IMPLICATIONS: Spouse caregiving, especially in a light-duty capacity, may not be detrimental to the caregivers' sleep health. More data are needed regarding insomnia in spouse caregivers with heavy duties of care to fully assess the health impact of the caregiving experience.

Memory Trajectories and Disability Among Older Couples: The Mediating Role of Depressive Symptoms.

OBJECTIVES: Using a dyadic approach, this study examined the mediating effect of depressive symptoms on the longitudinal relationships between husbands' and wives' memory trajectories and their prospective disability status. METHODS: Longitudinal data from the Health and Retirement Study 2004-2018 were used. Older (aged 50+) heterosexual couples who had no limitations in the activity of daily living at the baseline (2004) were included (N = 1,310). Latent class growth analysis grouped wives and husbands into distinct memory trajectories in 2004-2014. A structural equation model examined the actor and partner effects of memory trajectories on depressive symptoms in 2016 and disability status in 2018. The mediating effect of depressive symptoms was tested. RESULTS: A total of 4 distinct memory trajectories were found: persistently high, high and slow decline, moderate and slow decline, and low and rapid decline. Only the wife's low and rapid decline memory trajectory predicted her own more depressive symptoms (ß = 0.588, 95% CI: 0.209, 0.967) and her husband's more depressive symptoms (ß = 0.326, 95% CI: 0.004, 0.648). Meanwhile, depressive symptoms had strong and significant actor effects on disability (ß = 0.046, 95% CI: = 0.036, 0.057 for wives; ß = 0.060, 95% CI: = 0.046, 0.074 for husbands). DISCUSSION: The wife's low and rapid decline trajectory was associated with her own and her husband's more depressive symptoms, which in turn increased the disability risk for both partners. Timely identification and treatment of memory decline among wives have the potential to mitigate couples' depressive symptoms and, ultimately, disability risks.

Intergenerational Interactions and Relationship Quality: A Daily Study Among Mothers and Their Adult Children.

OBJECTIVES: The parent-child relationship is one of the most long-lasting relationships in human life. Such relationship is particularly adaptive during public health emergencies that threaten human life. However, few studies have examined the effects of daily exchanges in support between aging parents and adult children on the relationship quality during public health emergencies. Using data collected during the coronavirus disease 2019 pandemic, we examined the relationship between daily support and relationship quality among middle-aged and older mothers and adult children. METHODS: Seventy-seven dyads of middle-aged and older mothers (age range: 44-80 years, Mage = 53.78, SDage = 9.57) and adult children (age range: 18-54 years, Mage = 26.61, SDage = 9.46) participated in the study. They reported their daily exchanges with the other (i.e., support they had received from and given to each other) and daily relationship quality (i.e., relationship satisfaction and trust) each day for 14 consecutive days. RESULTS: The perception of being underbenefited on Day N was associated with daily relationship satisfaction on the concurrent day in children but not mothers. It was associated with daily trust toward the relationship partner in both mothers and children on Day N. Both providing and receiving more support on Day N was associated with better relationship satisfaction for both mothers and children on Day N. Only receiving (not providing) more support on Day N was associated with greater trust toward the partner on Day N for both mothers and children. The time-lagged associations were not significant. DISCUSSION: The findings highlight the importance of daily reciprocity and daily support exchanges on relationship quality during a public health emergency.

Participation in mahjong and the associated smoking and alcohol consumption behaviors among Chinese older adults.

This study examined the relationship of playing mahjong with smoking and alcohol consumption behaviors among Chinese older adults. We used a large and nationally representative dataset, the 8th wave of the Chinese Longitudinal Healthy Longevity Survey (CLHLS). Older adults who were 65 years old or above were included in the final analysis sample (n = 10,954). Multivariable logistic regressions were used to examine the associations of playing mahjong with current and former smoking/alcohol consumption status. Additionally, we used negative binomial and multiple linear regressions to investigate the number of cigarettes smoked per day and the amount of alcohol consumed per day. Compared with older adults who did not play mahjong, those who played mahjong at least once per month were more likely to report both current and prior smoking/alcohol consumption habits (all p < 0.05). The sub-analysis revealed that older adults who played mahjong at least once per week tended to smoke more cigarettes per day (all p < 0.05) than those who did not play mahjong at all. When public health practitioners advocate for the health benefits of playing mahjong, they should also consider its associations with smoking/alcohol consumption behaviors among Chinese older adults.

Neo-Antigen-Reactive T Cells Immunotherapy for Colorectal Cancer: A More Personalized Cancer Therapy Approach.

Colorectal cancer (CRC) is the second most common malignancy in women and the third most frequent cancer in men. Evidence has revealed that the survival of patients with metastatic CRC is very low, between one and three years. Neoantigens are known proteins encoded by mutations in tumor cells. It is theorized that recognizing neoantigens by T cells leads to T cell activation and further antitumor responses. Neoantigen-reactive T cells (NRTs) are designed against the mentioned neoantigens expressed by tumor cells. NRTs selectively kill tumor cells without damage to non-cancerous cells. Identifying patient-specific and high immunogen neoantigens is important in NRT immunotherapy of patients with CRC. However, the main challenges are the side effects and preparation of NRTs, as well as the effectiveness of these cells in vivo. This review summarized the properties of neoantigens as well as the preparation and therapeutic outcomes of NRTs for the treatment of CRC.

Social Support and Unmet Needs for Personal Assistance Among Community-Dwelling U.S. Chinese Older Adults: Does the Source of Support Matter?

This study examines the relationship between social support sources and unmet needs among U.S. Chinese older adults. Data were from the Population Study of Chinese Elderly in Chicago. Unmet needs were assessed by indexes of activities of daily living (ADL) and instrumental activities of daily living (IADL). Three specific sources of social support (spouse, family members, and friends) were included. Multivariable logistic regression models were conducted. Approximately 17% of the 3,157 respondents reported having unmet ADL/IADL needs. U.S. Chinese older adults with less overall social support were more likely to have unmet ADL needs (odds ratio [OR]=0.91, 95% CI=0.83-0.99) and IADL needs (OR=0.84, 95% CI=0.81-0.88). Family and friend support were associated with a lower likelihood of having unmet ADL needs. Support from spouse, family, and friends was associated with a lower likelihood of having unmet IADL needs. The findings highlight the importance of informal social support in addressing unmet needs .

Health Behavior Patterns and Associated Risk of Memory-Related Disorders Among Middle-Aged and Older Chinese Couples.

Objectives: Studies on the interdependence of couples' health behaviors and subsequent cognitive outcomes remain limited. Methods: Longitudinal data from the China Health and Retirement Longitudinal Study (2011-2018) were used (N = 1869 heterosexual couples). Latent class analysis identified the dyadic pattern of health behaviors in 2011 (i.e., alcohol consumption, smoking, and physical inactivity). Stratified Cox models examined the association of latent classes with risk of developing memory-related disorders in 2013-2018. Results: Three classes were identified: class 1 (21.25%, only husband smoke, and both active), class 2 (47.55%, both inactive, neither drink nor smoke), and class 3 (31.20%, both drink and smoke, and both active). Couples' sedentary lifestyle was associated with an increased risk of memory-related disorders among both husbands and wives. Conclusion: Couples were moderately concordant in their physical activity but weakly in smoking and drinking. Couple-based interventions, especially promoting physical activity, may reduce cognitive aging among middle-aged and older Chinese couples.

Depressive Symptom Trajectories and Cognition Among Older American Couples: A Dyadic Perspective.

OBJECTIVES: This study examined whether trajectories of depressive symptoms of one spouse are associated with the other spouse's memory. METHODS: Longitudinal data from the Health and Retirement Study (2004-2016) were used (N = 5690 heterosexual couples). Latent-class growth analysis and structural equation models examined the actor and partner effects of depressive symptom trajectories on memory. RESULTS: Four depressive symptom trajectories were identified (i.e., persistently low, increasing, decreasing, and persistently high). Compared to the low trajectory group, the increasing and persistently high trajectories were associated with worse memory for both men and women. While none of the wives' depressive symptom trajectories was significantly associated with husbands' memory (p > .05), husbands' decreasing trajectory was linked to wives' better memory (ß = 0.498, 95% CI = 0.106, 0.890). DISCUSSION: Older adults with increasing and persistently high depressive symptoms may experience worse memory. Psychosocial interventions targeting depressive symptoms among older men may be beneficial to their spouses' memory.

Food Insecurity and Mental Health Trajectories during the COVID-19 Pandemic: Longitudinal Evidence from a Nationally Representative Survey.

Food insecurity and mental disorders are pressing public health issues during COVID-19. Empirical evidence on the extent to which food insecurity affects mental health outcomes of American adults as the pandemic unfolds remains limited. Longitudinal data from the Understanding Coronavirus in America survey collected biweekly between April and December 2020 were used (N=4,068). Respondents were asked about their food insecurity experiences and stress, anxiety, and depressive symptoms. Linear mixed-effect models were estimated. Food insecurity was associated with higher levels of stress, anxiety, and depressive symptoms. Stress, anxiety, and depressive symptoms declined among food-secure U.S adults. However, mental health trajectories of respondents with various food insecurity categories remained stable or worsened over time. The mental health gap between food-secure and food-insecure groups widened over time. Food insecurity has substantial mental health implications amidst the pandemic. Screening for and addressing food insecurity may alleviate the mental health burden borne by food-insecure people.

Public Discourse and Sentiment Toward Dementia on Chinese Social Media: Machine Learning Analysis of Weibo Posts.

BACKGROUND: Dementia is a global public health priority due to rapid growth of the aging population. As China has the world's largest population with dementia, this debilitating disease has created tremendous challenges for older adults, family caregivers, and health care systems on the mainland nationwide. However, public awareness and knowledge of the disease remain limited in Chinese society. OBJECTIVE: This study examines online public discourse and sentiment toward dementia among the Chinese public on a leading Chinese social media platform Weibo. Specifically, this study aims to (1) assess and examine public discourse and sentiment toward dementia among the Chinese public, (2) determine the extent to which dementia-related discourse and sentiment vary among different user groups (ie, government, journalists/news media, scientists/experts, and the general public), and (3) characterize temporal trends in public discourse and sentiment toward dementia among different user groups in China over the past decade. METHODS: In total, 983,039 original dementia-related posts published by 347,599 unique users between 2010 and 2021, together with their user information, were analyzed. Machine learning analytical techniques, including topic modeling, sentiment analysis, and semantic network analyses, were used to identify salient themes/topics and their variations across different user groups (ie, government, journalists/news media, scientists/experts, and the general public). RESULTS: Topic modeling results revealed that symptoms, prevention, and social support are the most prevalent dementia-related themes on Weibo. Posts about dementia policy/advocacy have been increasing in volume since 2018. Raising awareness is the least discussed topic over time. Sentiment analysis indicated that Weibo users generally attach negative attitudes/emotions to dementia, with the general public holding a more negative attitude than other user groups. CONCLUSIONS: Overall, dementia has received greater public attention on social media since 2018. In particular, discussions related to dementia advocacy and policy are gaining momentum in China. However, disparaging language is still used to describe dementia in China; therefore, a nationwide initiative is needed to alter the public discourse on dementia. The results contribute to previous research by providing a macrolevel understanding of the Chinese public's discourse and attitudes toward dementia, which is essential for building national education and policy initiatives to create a dementia-friendly society. Our findings indicate that dementia is associated with negative sentiments, and symptoms and prevention dominate public discourse. The development of strategies to address unfavorable perceptions of dementia requires policy and public health attention. The results further reveal that an urgent need exists to increase public knowledge about dementia. Social media platforms potentially could be leveraged for future dementia education interventions to increase dementia awareness and promote positive attitudes.

Perceived social support and help-seeking among U.S. Chinese older adults who reported elder mistreatment.

This study aimed to examine the associations between perceived social support and help-seeking among U.S. Chinese older adults who reported elder mistreatment (EM). Data were from the Population Study of Chinese Elderly in Chicago. Perceived social support and informal/formal help-seeking intentions and behaviors were measured. Descriptive statistics, multiple linear regressions, and multinomial logistic regression analyses were performed. A total of 450 participants reported EM. Mean age of the sample was 72.73 ± 8.03 years old. Perceived social support was associated with an increase in intentions of seeking help from informal sources. Compared with not seeking help, older Chinese-American adults with any EM who perceived social support were more likely to seek help from informal and formal sources. The potential role of social support in increasing help-seeking was highlighted. Culturally tailored interventions that provide social support might promote help-seeking among U.S. Chinese elder immigrants who experienced EM.

Does the Microbiota Composition Influence the Efficacy of Colorectal Cancer Immunotherapy?

Colorectal cancer (CRC) is the second most common malignancy globally, and many people with CRC suffer the fate of death. Due to the importance of CRC and its negative impact on communities, treatment strategies to control it or increase patient survival are being studied. Traditional therapies, including surgery and chemotherapy, have treated CRC patients. However, with the advancement of science, we are witnessing the emergence of novel therapeutic approaches such as immunotherapy for CRC treatment, which have had relatively satisfactory clinical outcomes. Evidence shows that gastrointestinal (GI) microbiota, including various bacterial species, viruses, and fungi, can affect various biological events, regulate the immune system, and even treat diseases like human malignancies. CRC has recently shown that the gut microorganism pattern can alter both antitumor and pro-tumor responses, as well as cancer immunotherapy. Of course, this is also true of traditional therapies because it has been revealed that gut microbiota can also reduce the side effects of chemotherapy. Therefore, this review summarized the effects of gut microbiota on CRC immunotherapy.

Functional disabilities and changes in sleep quality and duration among older adults: results from a longitudinal study in China, 2005-2014.

PURPOSE: We examined the associations of activities of daily living (ADL) and instrumental activities of daily living (IADL) with changes in sleep-related measurements among Chinese older adults from 2005 to 2014. METHODS: Four waves of longitudinal data from the Chinese Longitudinal Healthy Longevity Survey (CLHLS; 2005-2014; n = 42,417) were used. Two sleep-related measurements were included: sleep quality and meeting the recommended daily sleep duration (7-8 h). We used Cox two-state regression models to examine the different states of sleep quality and duration. RESULTS: Approximately 43.6% of observations were between 81 and 95 years old, and 35.9% were between 65 and 80 years old. Around 54.8% of observations were female. Older adults with more ADL and IADL limitations had a higher risk of experiencing declines in sleep quality and the transition from meeting to not meeting the recommended sleep duration over time (all p < 0.01). CONCLUSION: ADL and IADL limitations are significant risk factors for the development of sleep-related issues over time among Chinese older adults. Functional limitations need to be included in intervention strategies focused on sleep hygiene and studies examining changes in sleep patterns over time.

Perfusion measurement in brain gliomas using velocity-selective arterial spin labeling: comparison with pseudo-continuous arterial spin labeling and dynamic susceptibility contrast MRI.

OBJECTIVES: To evaluate the performance of velocity-selective (VS) ASL among patients with untreated gliomas by comparing with both pseudo-continuous (PC) ASL and dynamic susceptibility contrast-enhanced perfusion-weighted imaging (DSC-PWI). METHODS: Forty-four consecutive patients with newly diagnosed glioma who underwent preoperative perfusion MRI including VSASL, PCASL, and DSC-PWI between 2017 and 2019 were retrospectively evaluated. Visual inspection was performed to evaluate the tumor signal intensity relative to gray matter based on 1-5 score criteria and weighted kappa was used to evaluate the pair-wise concordance between VSASL or PCASL and DSC-PWI. The relative tumor blood flow (rTBF) was measured from sampling intra-tumoral areas of hot-spot on the blood flow map and normalized against the contralateral normal gray matter blood flow. Linear regression and Bland-Altman analyses were performed to evaluate the correlation and agreement of rTBF measurements between ASL methods and DSC-PWI. The ROC analysis was constructed to determine the diagnostic performance of three perfusion methods for grading gliomas. RESULTS: TBF maps derived from VSASL were more comparable with DSC-PWI than PCASL on visual inspection (weighted kappa of 0.90 vs 0.68). In quantitative analysis, VSASL-rTBF yielded higher correlation with the values from DSC-PWI than PCASL-rTBF (R2 = 80% vs 47%, p < 0.001 for both). Both ASL and DSC-derived rTBF showed good distinction between low-grade and high-grade gliomas (p < 0.001). Compared to PCASL, VSASL yielded superior diagnostic sensitivity, specificity, and accuracy in glioma grading. CONCLUSIONS: VSASL showed great promise for accurate quantification of TBF and could potentially improve the diagnostic performance of ASL in preoperative grading of gliomas. KEY POINTS: • VSASL demonstrated a greater agreement with DSC-PWI than with PCASL on visual inspection and perfusion quantification. • VSASL showed a higher diagnostic sensitivity, negative predictive value, and accuracy than PCASL for glioma grading. • With the advantages of insensitivity to transit delay and no need of prescribing a labeling plane, VSASL could potentially improve the diagnostic performance of ASL for a more accurate, noninvasive quantification of TBF in patients with glioma.

Mental health-related stigma and attitudes toward patient care among providers of mental health services in a rural Chinese county.

BACKGROUND AND AIMS: The increasing prevalence of mental illness and low treatment rate presents a pressing public health issue in China. Pervasive stigma is a significant barrier to mental health recovery and community inclusion. In particular, stigmatizing or supportive attitudes held by healthcare providers could either perpetuate or mitigate self-stigma of people with mental illness. Moreover, mental health resources are unevenly distributed in China, with most of them concentrated in urban centers and provincial capitals. This study explores healthcare providers' attitudes toward mental illness and the challenges they faced at work in a rural Chinese county. METHOD: Four focus groups were conducted with 36 healthcare providers from a three-tier mental healthcare system in a rural county in southwestern China. Focus group discussions were recorded and transcribed verbatim. The team employed a conventional content analysis approach for data analysis. All transcripts were double-coded by three bilingual team members who are native Chinese speakers. Coding discrepancies were resolved by consensus. RESULTS: Healthcare providers recruited from the county, township, and village levels varied in educational background, professional qualification, and experience of working with people with mental illness. Five thematic categories identified across four groups include (1) barriers to mental healthcare delivery, (2) keys to mental health recovery, (3) providers' attitudes toward providing care, (4) providers' perception toward patients and family members, and (5) providers' perception of training needs. CONCLUSIONS: This is a unique study that included healthcare providers from a three-tier healthcare system. Findings signal the importance of understanding healthcare practitioners' experiences and views to inform the design of training initiatives in rural or low-resource communities.