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Participants were from a population-based epidemiological study of mental disorders in the province of Ningxia, located in western China, where the Hui ethnicity makes up 35% of the total population (6.4 million)[27]. Inclusion criteria were: aged 18 years or older and in residence for at least six months at their current address. Exclusion criteria were: unconsciousness caused by brain injury, brain tumor and/or craniotomy or dementia; being in the acute phase of a cerebrovascular accident; experiencing a severe illness that prevented communication; having any obvious cognitive disabilities; or currently suffering from deafness, aphasia or other language barriers.
Participants were selected in three stages. First, 62 primary sample units (PSU) were selected from 2,209 villages and 393 neighborhood communities using a probability proportionate to size (PPS)[28] method. Second, depending on the total number of households in the selected PSU, 60 to 210 households were identified from each PSU using a systematic sampling method, resulting in a total of 6,890 households being selected. Third, interviewers visited each household and used a Kish selection table[29]to randomly select one eligible participant from each household. Interviewers were unable to reach the household member selected in 414 cases, resulting in a total sample of 6,476 participants who were approached to conduct a face-to-face interview from July 2011 to January 2013. Of those, 5,810 participants (89.7%) completed the interview. The present study consisted of 2,770 participants who completed the Part II interviews described below. Face-to-face, computer assisted personal interviews (CAPI) [30] were carried out by lay interviewers from Ningxia Medical University. Interviewers were trained in a 7-day training session by our research team. The training covered general interviewing techniques, review of the questionnaire, post-interview editing and in- and out-of-classroom exercises for interviewers. 90 trainees passed the final test and were selected to be interviewers. The interview schedule was divided into two parts. Part I, which was administered to all respondents, included the core WHO-CIDI diagnostic interview for mental disorders. Part II included assessments of risk factors, services sought, religious involvement, and assessment of additional disorders that were either of secondary importance or were too time consuming to assess in the full sample [31]. Selection of subjects to complete Part II was controlled by the CAPI program, which divided respondents into three groups based on their Part I responses. First, all respondents who (1) met lifetime criteria for at least one mental disorder assessed in Part I, (2) met sub-threshold lifetime criteria for a mental disorder and sought treatment for it at some time in their life, or (3) either ever made a plan to commit suicide or attempted suicide, were selected to complete Part II of the evaluation. Second, a probability sample was selected of 59% of respondents who did not meet criteria for membership in the first group, but gave responses in Part I indicating that they (1) ever met subthreshold criteria for Part I disorders, (2) ever sought treatment for any emotional or substance abuse problem, (3) ever had suicidal ideation, or (4) used psychotropic medications in the past 12 months to treat emotional problems. Third, a 25% random sample of respondents without mental disorders or emotional problems was selected to receive the Part II evaluation [31].
In order to eliminate the influence that the stigma towards mental illness might have and encourage participants to report their mental symptoms, the survey was designed as anonymous. The potential risks and benefits of the survey were described by the interviewer and the participants were asked to provide their consent by checking a box on computer screen with the response (1 = I agree to participate in the study; 5 = I do not agree to participate in the study). If the response was “I do not agree”, the CAPI program was immediately terminated automatically. The consent document was recorded as one of the variables in the dataset file by computer program. The study was approved by the Institutional Review Board of the Ningxia Medical University.
Twelve-month prevalence of mental disorders (Anxiety disorders include agoraphobia, generalized anxiety disorder, obsessive-compulsive disorder, panic disorder, social phobia, specific phobia, and neurasthenia; Mood disorders include unipolar depressive disorder and bipolar disorder; Alcohol use disorders) were assessed. The WHO Composite International Diagnostic Interview (WHO-CIDI) [32] was used to diagnose mental disorders according to the International Classification of Disease 10th Edition (ICD-10) diagnostic criteria. The Training and Recourse Center of CIDI in Beijing provided the Chinese version of the WHO-CIDI-CAPI and training program. Culture adaptation and modification research found it was a good instruction in validation [33]. High concordance was found between the clinical evaluation for mental disorder and the Chinese version CIDI diagnoses [34], and consequently has been widely used in epidemiological studies in China[35,36].
As a section of full CIDI, religious participation and the importance of religion were measured by asking: “How often do you usually attend religious activities?” (more than once a week, about once a week, one to three times a month, less than once a month, never) and “In general, how important are religious or spiritual beliefs in your daily life?” (very important, somewhat, not very, or not at all important). High religiosity was defined as both (1) attending religious activities at least 2–3 times per month and (2) religious or spiritual beliefs being very important in daily life. Religious affiliation was determined by asking “What is your religion?” Socio-demographic information was collected using the demographic section of the CIDI. Demographic characteristics included age, gender, education, marital status (married vs. unmarried), residence (rural vs. urban), ethnicity (Han as majority vs. Hui as minority in China), experience of migration from other areas of China (yes vs. no), and geographical region (developed vs. undeveloped). Physical health variables included overall self-reported physical health (good vs. poor), self-reported chronic body pain (yes vs. no), type II diabetes (yes vs. no), and hypertension (yes vs. no).
Analyses were performed using the Statistical Analysis System (SAS) 8.2 software (SAS Institute Inc. Cary, NC, USA). Differences in socio-demographical characteristics between Hui and Han ethnicities, and associations between participant characteristics and mental disorders, were examined using one-way-analysis of variance for continuous variables, and the chi-square statistic for categorical variables, Wilcoxon-Mann-Whitney test for religious attendance and importance. No weighting program applied during the comparison analysis. The data were not weighted for comparison analysis. Three separate unconditional logistic regression models were used to examine associations between religious involvement and mental disorders. In summary, model 1 included the religious involvement variable; model 2 included the religious variable and socio-demographic characteristics; and physical health variables were added in model 3. Analyses were stratified by ethnicity and age (under age 50 and age 50 or over) for model 3. Religious affiliation was recorded as a binary variable (with vs. without a religious affiliation). Odds ratio with 95% confidence interval were calculated for all models. Given the exploratory nature of these analyses, statistical significance level was set at 0.05, without corrections for multiple comparisons.
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