Attitudes and knowledge for CBT-based psychotherapy among medical students and residents in China: a survey study

Abstract

Background/aim

Psychotherapy training for medical students and residents in China is still in development. To establish an appropriate training program, understanding medical students’ and residents’ current knowledge and attitudes toward psychotherapy is needed.

Methods

One hundred and forty-nine participants, including medical students, residents, and other health providers (HCPs), self-reported their understanding of 18 types of psychotherapy, negative attitude towards cognitive behavioral therapy (CBT), and their attitude towards psychological interventions and counseling in primary care (APIC-PC) through an online survey.

Results

Participants’ understanding of psychotherapy was generally low (M = 26.25, SD = 22.99). Medical students’ (M = 34.42, SD = 22.61) and HCPs’ (M = 37.25, SD = 30.834) understanding was significantly higher than residents’ (M = 20.08, SD = 19.54), F(2, 146) = 8.63, p < .001. Participants from psychiatric departments (M = 33.85, SD = 25.89) understood more psychotherapy than those from non-psychiatric departments (M = 20.98, SD = 19.20), t(147) = 3.46, p < .001. Participants with a bachelor’s degree (M = 2.40, SD = 0.976) scored lower on the Negative Attitude Towards CBT Scale than participants with a graduate degree (M = 2.76, SD = 1.00), t(147) = -2.20, p = 0.029. All participants’ APIC-PC scores were relatively the same and indicated a neutral to slightly positive attitude towards psychotherapy and counseling practices. However, they showed a slightly negative attitude in the “willingness to counsel” subscale (M = 2.65, SD = 0.93).

Conclusion

This study indicated a lack of knowledge of psychotherapy and a lack of psychotherapy courses for medical students and residents, especially those from non-psychiatric departments in China. Our findings suggest an urgent need for psychotherapy and relevant training for Chinese medical students and residents.

Trial registration

The study has been registered at ClinicalTrials.gov (Identifier: NCT06258460, website: httpsregister.clinicaltrials.gov).

Introduction

Psychotherapy, especially cognitive behavioral therapy (CBT), is one of the central treatments for patients with psychiatric disorders and psychosomatic disorders [1, 2]. Specifically, the research found that the main types of psychotherapy (e.g., cognitive behavioral, interpersonal, and psychodynamic therapies) were significantly more effective than care-as-usual treatment when treating adult depression [3]. In addition, behavioral therapy (BT), CBT, interpersonal therapy (IPT), and their combined treatment were found effective in treating most mental disorders [4, 5]. Particularly, CBT methods were most closely related to psychotherapy’s emotional change processes and mechanisms [6]. Hence, CBT is considered as an important treatment for mental disorders. Further, since patients prefer psychological treatments over medical treatment [5], it is important for medical workers (e.g., medical students, physician residents, doctors, and nurses) to learn basic psychotherapy skills, especially some CBT methods [7].

Offering psychotherapy training with a specific focus on CBT to medical workers can benefit their patients. Studies in China found that the doctor-patient relationship is crucial for patients’ outcomes [8], and higher levels of doctors’ empathy are correlated with patients’ lower levels of anxiety and inflammatory factors and higher self-efficacy and sleep quality [9]. Further, patients’ satisfaction is more closely related to doctor-patient communication and respect than facilities, cost, and transportation [10]. Therefore, it is crucial to improve doctor-patient communication by implementing tailored training for medical workers. Research in Beijing showed that psychotherapy training could effectively improve medical doctors’ clinical treatment skills and doctor-patient communication, while patients reported various improvements, such as reduced levels of depression and increased levels of quality of life [11].

Providing psychotherapy training may also help relieve medical students’ pressure and promote their own mental health with a handful of skills. Medical students and residents are generally stressed [12,13,14,15,16], and research found that implementing psychotherapy services can significantly reduce medical students’ levels of distress, depression, anxiety, and suicide risk while increasing their levels of functioning [13].

Due to their special identity as both who need mental health services and who can provide such service to patients [17], medical students’ and residents’ understanding and attitudes toward psychotherapy not only affect whether they will seek psychotherapy but also determine their likelihood and quality of providing psychotherapy to their patients. Studies have found medical students held stigmatized attitudes toward mental health issues [17,18,19,20,21], which prevent them from receiving psychological help [22, 23] and negatively affect patients’ mental disorder remission, treatment adherence, and positive health outcomes [24]. Therefore, improving medical workers’ attitudes and acceptance of psychotherapy is important to promote overall doctors’ and patients’ well-being. Lee et al. (2023) [25] found that 95.2% of medical students in their study believed they could serve as healthy lifestyle role models and provide more effective counseling to their patients if they received sufficient training. Another study also shows that medical students’ positive attitudes toward psychotherapy can be enhanced by training [26], which suggests that understanding medical students’ current attitudes toward psychotherapy and developing tailored training are essential to promote the recommendation and accessibility of psychotherapy.

In addition, Chin et al. (2012) [18] found that even though medical students’ self-perceived psychological skills and knowledge improved after training in psychological treatment, they still held stereotypical, disease-focused views of doctors, and some even believed doctors could not make good counselors. Additionally, students’ perceived effectiveness of psychological treatment and willingness to provide such treatment remained the same before and after the training [18]. The study indicates a need to understand medical students’ conditions to develop better and more tailored psychotherapy training. However, relevant topics of medical students’ attitudes and knowledge of psychotherapy in China are still understudied. To improve general mental health, develop tailored psychotherapy training, and improve medical students’ and residents’ psychological skills, it is urgent to understand their perspectives and attitudes toward psychotherapy.

The present study aims to examine medical students’, residents’, and other health providers’ (HCPs; e.g., doctors, nurses, etc.) knowledge and attitudes towards psychotherapy in China. The study examined participants’ overall knowledge and attitudes towards psychotherapy and differences between different groups categorized by demographic features (e.g., sex, education, and clinical experiences) to better understand the current conditions of medical education of psychotherapy in China.

Hypothesis

Previous research has found that characteristics such as female gender and previous psychiatric experiences were associated with a more positive attitude toward psychiatry and psychotherapy [27,28,29]. Specifically, female doctors and medical students attributed doctor-patient communication more positively, shared relevant information more often, and had higher levels of willingness to learn doctor-patient communication skills compared to male doctors and students, who perceived such communication negatively [27]. Medical students with more psychiatry or psychotherapy experiences demonstrated more positive attitudes toward psychiatry compared to those who were inexperienced [28, 29].

We wanted to examine where there were differences in knowledge and attitudes between male and female participants. Second, considering health care providers (HCPs; e.g., doctors, nurses, and therapists) and medical residents generally have more working experiences than medical students, we expected that HCPs and residents would have more understanding and more positive attitudes toward psychotherapy than medical students. Third, we hypothesized that participants from the psychiatric department would have a better understanding and attitude than non-psychiatric department participants. Finally, we expected participants with higher education qualifications (Master’s or Doctoral Degree) to show more understanding and a more positive attitude than participants with lower education qualifications (Bachelor’s Degree).

The present study aims to understand medical students’ and residents’ basic understanding of common types of psychotherapies, attitudes toward CBT, and the knowledge, skills, confidence, willingness, and curriculum needs in providing psychotherapy. Differences in scores between different groups categorized by demographic features were also examined. 149 participants self-reported a questionnaire through an online survey. The results of the current study can help us better understand the current conditions of medical education in China and provide insights into developing sufficient and tailored medical education, which can also promote the practical application of psychotherapy, especially CBT, in China.

Method

Participants

The current study is part of our broader project, “Evaluating the Effectiveness of Multimodal Psychotherapy Training Program for Medical Students in China,” and all participants recruited for the current study were prepared for the later evaluation project. The evaluation project is a randomized control trial (i.e., randomly assigning participants to either intervention or control groups) with an 8-week follow-up measure. One of the major primary measurements will be Facilitative Interpersonal Skills (FIS), so our sample size assessment and power calculations were based on the primary outcomes of FIS [30, 31]. We assume that the FIS scores in the intervention and control group will increase by 30% and 5% at eight weeks of follow-up. To assess the primary outcome, we estimate 118 participants (59 participants in each group) are required to achieve 80% power (1-beta = 0.80), as significant at the 5% level (alpha = 0.05), of an increase in the primary outcome measure from 5% in the control group to 30% in the intervention group. For the evaluation project, a final target sample size of 160 participants (80 in each arm) will have more than an 80% chance of detecting a significant difference. For the current study, we recruited 149 participants, close to our estimated 160 participants.

All participants (N = 149) recruited from this project were mainly medical students and residents with some other HCPs in China. Detailed inclusion criteria are presented in Table 1.

Table 1 Participant inclusion criteria

The study took place in Zhejiang province. Most of the participants were affiliated with hospitals or medical schools in Zhejiang province (90.6%). Of the rest of the participants, 10 were from Jiangsu province (6.7%), 2 were from Anhui province (1.3%), 1 from Henan province (0.7%), and 1 from Shanghai city (0.7%). All participants voluntarily signed up for a psychotherapy training program, and the surveys were taken before the training began.

Procedures

After consent, participants received an online survey and first reported their demographic information.

In the same online survey, participants were asked to report their knowledge of several psychotherapies to measure their understanding of psychotherapy. There were 18 psychotherapies, including supportive psychotherapy, psychodynamic therapy, psychoanalysis, and short-term therapy, cognitive-behavioral therapy (CBT), dialectical-behavioral therapy (DBT), acceptance and commitment therapy (ACT), interpersonal therapy (IPT), (systematic) family therapy, mindful-based psychotherapy, group therapy, emotionally focused therapy, game therapy, humanistic therapy, hypnotherapy, gestalt therapy, positive psychology, and existential therapy. The participants would indicate whether they had heard of these therapies by choosing the option “yes” or “no.” If they reported “yes,” then they rated their level of understanding on a 0–10 scale (0 the lowest and 10 the highest). Example question was: “Have you ever heard of supportive psychotherapy? Please choose ‘Yes’ or ‘No.’ If you choose ‘Yes,’ please indicate the extent of your understanding from 0–10.” The total score of psychotherapy knowledge is 180, and we regarded 90 as a mid-point, and scores below were considered a low level of psychotherapy understanding (See Supplementary file 1).

We adapted Parker and Waller’s (2017) [32] Negative Attitudes towards CBT scale and added two more items: “too complicated to understand” and “too much focus on large and/or complex psychological issues.” Each item was scored from 1 to 7, where the highest score, 7, indicated the strongest negative attitude towards CBT, and the lowest score, 1, indicated the least strong negative attitude towards CBT (See Supplementary file 2).

Finally, we used Chin et al. (2011) [33] Attitude to Psychological Interventions and Counseling in Primary Care (APIC-PC) survey to measure participants’ “skills and knowledge,” “confidence to counsel,” “willingness to counsel,” and “curriculum needs.” Each item was scored from 1 to 5, and participants’ final scores were the mean scores of each item. If the score was larger than 3, it indicated participants’ more positive attitudes or knowledge of psychotherapy. If the score was lower than 3, it indicated participants’ more negative attitudes or less knowledge of psychotherapy. Specific items are illustrated in Table 6.

Data analysis

Each participant’s overall understanding score was the sum of all items in the understanding survey. Participants’ overall scores of their attitude towards CBT were the mean of all 18 items. Their APIC-PC scores were categorized into mean scores of each factor: “skills and knowledge,” “confidence to counsel,” “willingness to counsel,” and “curriculum needs.”

Then, several independent t-tests were carried out to measure the differences in scores in three domains between groups characterized by sex, highest education qualification, and departments. One-way ANOVA was used to examine the differences in participants’ understanding and attitudes toward psychotherapy between medical students, residents, or HCPs.

Results

All 149 participants responded and completed the whole survey (i.e., response rate 100%). Participants’ demographic information was collected (Table 2), including age (M = 25.7, SD = 3.9, range 21–44), sex (71.1% female), identity (30.2% medical students, 59.1% medical residents, 10.7% HCPs), highest academic qualification (53.4% graduate degree), and their departments (40.9% psychiatric department), see detailed information in Table 1.

Table 2 Participants’ demographic features

Understanding

All participants’ understanding scores were low (M = 26.25, SD = 22.99; Table 3). There was no difference between male participants’ understanding (M = 26.61, SD = 22.92) and female participants’ scores (M = 26.10, SD = 23.12), t(147) = 0.12, p = .91. As the maximum score of the understanding survey was 180, participants’ average scores were considered as very low, which could be attributed to lack of psychotherapy training and accessibility.

Table 3 Participants’ understanding of psychotherapy

Analysis showed that both HCPs’ and medical students’ average understanding scores were higher than medical residents: medical students (M = 34.42, SD = 22.61), medical residents (M = 20.08, SD = 19.54), or other HCPs (M = 37.25, SD = 30.834), F(2, 146) = 8.63, p < .001, which is contradictory to our hypothesis. HCPs might have more working experiences than students and residents, so their scores of understanding were relatively higher. However, HCPs’ average score was still low compared to the maximum 180 scores, which indicated the lack of psychotherapy implementation in hospitals. Medical residents had the lowest mean score, which indicated their lack of knowledge. They might have less time and accessibility to learn compared to medical students and HCPs.

In contrast to our hypothesis, there was no difference between undergraduate (M = 25.31, SD = 22.57) and graduate groups (M = 27.08, SD = 23.47), t(147) = −0.47, p = .642, which also indicated a lack of knowledge of psychotherapy and a lack of psychotherapy courses in universities.

Align with our hypothesis, we found that participants from the psychiatric department (M = 33.85, SD = 25.89) had higher scores than participants from non-psychiatric departments (M = 20.98, SD = 19.20), t(147) = 3.46, p < .001. This indicated that more psychiatric experiences may enhance medical students’ and residents’ knowledge of psychotherapy. Still, the low average score suggested that even working in a psychiatric department, participants did not learn psychotherapy-relevant knowledge or receive relevant training (Fig. 1).

Fig. 1

Understanding of psychotherapy

Note. Shown are each subgroup’s scored understanding of psychotherapy, which contains 18 items, with each item scored from 1−10 and the maximum of the whole survey scored 180. The higher scores indicate more understanding of psychotherapy. The subgroups are categorized into sex (male and female), identity (medical students, medical residents, and HCPs), educational level (undergraduate and graduate), and department (psychiatric department and non-psychiatric departments). The “HCPs” was referred to as “healthcare providers” (e.g., doctors, nurses, etc.)

Negative attitude towards CBT

In contrast to our hypotheses, there were no significant differences between participants’ attitude towards CBT and their sex, identities, or their assigned departments (Table 4). We only found a significant association between participants’ highest education qualification, and their scored negative attitude towards CBT, t(147) = −2.20, p = 0.029. Participants with a bachelor’s degree (M = 2.40, SD = 0.976) scored lower than participants who had completed or were completing a graduate program (M = 2.76, SD = 1.00), which means participants who were less educated perceived CBT as less negative, whereas more educated participants viewed CBT more negatively (Fig. 2).

Table 4 Participants’ negative attitude toward CBT

Fig. 2

Negative attitude towards CBT

Note. Shown are each subgroup’s scored negative attitude towards CBT, which contains 18 items scored from 1−7 and calculates participants’ mean scores of overall negative attitude towards CBT. The higher scores indicate more negative attitude towards CBT. The subgroups are categorized into sex (male and female), identity (medical students, medical residents, and HCPs), educational level (undergraduate and graduate), and department (psychiatric department and non-psychiatric departments). The “HCPs” was referred to as “healthcare providers” (e.g., doctors, nurses, etc.)

APIC-PC scores

Results showed that participants had neutral but slightly positive attitudes toward psychotherapy and relatively balanced knowledge of psychotherapy, as indicated by their mean sub-scale scores of “skills and knowledge” (M = 3.05, SD = 1.22), “confidence to counsel” (M = 3.20, SD = 0.74), and “curriculum needs” (M = 3.48, SD = 1.17; Table 5). However, the scores of “willingness to counsel” (M = 2.65, SD = 0.93) were below 3, suggesting participants had low levels of willingness to deliver psychotherapy. We found 5 sub-items scored below the mid-point 3 (i.e., numbers 2, 3, 4, 5, and 6) while others were slightly above 3 (Table 6). Please see Supplementary file 3 for detailed APIC-PC scores for each items.

Table 5 All participants’ average score of 4 item domains in APIC-PC

Table 6 All participants’ average score of each item (APIC-PC)

The score of “skills and knowledge” (M = 3.05, SD = 1.22) indicated that participants only had general but not high levels of psychotherapeutic skills. Participants might have received some psychotherapy knowledge, but as they did not go through professional systematic training, they did not have high levels of practicing skills.

Participants’ attitudes toward establishing a psychological curriculum (M = 3.49, SD = 1.17) were slightly above 3, showing participants’ neutral but slightly positive attitudes toward the psychological curriculum. This reflected participants’ perceived general needs of receiving the psychological curriculum.

The score of “confidence to counsel” (M = 3.20, SD = 0.74) showed that participants were generally confident about providing counseling services, but they were less confident about their knowledge of psychology history. In addition, participants were generally unwilling to provide counseling, indicated by their “willingness to counsel” scores (M = 2.65, SD = 0.93).

Opposed to our expectations, participants’ sex, identity, education level, and assigned departments were not associated with their scores across four domains (“skills and knowledge,” “confidence to counsel,” “willingness to counsel,” and “curriculum needs”) of attitude toward psychotherapy (Table 7). Results suggested all participants’ attitudes toward psychotherapy were relatively the same. All participants might have similar training experiences, making them have similar perspectives toward psychotherapy.

Table 7 APIC-PC scores of each subgroup

Discussion

Participants of this study were recruited before attending psychotherapy training. All participants reported a low understanding of psychotherapy, and medical residents showed even lower understanding. However, participants from psychiatric departments scored higher than those from non-psychiatric departments. All participants had a general and slightly positive attitude toward CBT. Specifically, participants with a bachelor’s degree demonstrated a more positive attitude than those with graduate degrees such as master’s or doctoral degrees. Regarding attitudes toward psychological interventions and counseling in primary care, results tended to be in between. These findings suggest a lack of understanding and skills in psychological treatment among medical workers, which illustrates that medical education in psychotherapy in China is insufficient.

As regards levels of psychotherapy knowledge, results showed that all participants generally lacked knowledge about psychotherapy. No significant difference was found between males and females and undergraduate and graduate groups. Given that all participants had a decent education and worked or studied in the health system, this result may indicate that the comprehension level of psychotherapy-related knowledge in the Chinese population is less optimistic, which calls for more popularization work. This is consistent with previous research on the development of mental health care in China [34]. Although psychotherapy has been rapidly developed since the 1980s in China’s healthcare system, educational system, and social institute, psychotherapy education still lacks an appropriate understanding of psychotherapy and the development of basic psychotherapy training and practical skills [35]. According to Chinese Undergraduate Medical Education Standards - Clinical Medicine Specialty (2022 edition) [36], psychotherapy training was not emphasized in undergraduate medical studies, as the manual only mentioned students should understand “medical psychology” as part of humanity subject and apply “psychological support and other palliative care methods to achieve humanitarian purposes, improve the quality of death of patients.” Additionally, mental health training was still scarce in primary health care and general medical care, and high-quality psychotherapy training programs were usually offered to postgraduate [11, 37], which indicates a need to develop undergraduate psychotherapy training as a part of medical education. Further, the prevalent societal stigmatization of mental health issues in China [38, 39] may also hinder the popularization of psychotherapy training, which indicates an urgent need to reduce stigmatization. For example, physicians’ disclosure of their past experiences and treatment of mental illness can reduce medical students’ stigmatization of mental health, improve their positive attitudes toward psychiatry, and motivate them to seek help [40]. Hence, more psychoeducation and public disclosure of mental health issues can enhance public positive attitudes toward psychotherapy and foster relevant education.

One of our findings showed that both HCPs and medical students’ average understanding scores were higher than medical residents’. According to general clinical experience, the more clinical practice medical residents have, the higher the likelihood that psychotherapy demands exist among them, which might motivate them to gain psychotherapy-relevant knowledge. However, our results did not confirm this expectation. One possible explanation was the medical residents’ heavy workload [41, 42], which may result in less time and fewer chances to learn about psychotherapy. Medical residents may also experience more frequent medical disputes compared to students [43, 44], which may cause more frequent burnout [42] and reduce their energy in learning new psychotherapy skills. One promising finding that fits the hypothesis is that participants from psychiatric department scored higher than those from non-psychiatric settings. Psychotherapy is one of the conventional treatment methods in psychiatry. Psychiatric participants may learn more about psychotherapy through direct observation or through conversations with colleagues. Notably, their knowledge of psychotherapy remains relatively insufficient.

Regarding negative attitude towards CBT, it was found that all participants scored comparatively low. In other words, their attitudes toward CBT tended to be positive. This may be directly related to the sample in this study, whose willingness to participate in the survey and subsequent training suggests a more positive attitude. Moreover, no significant associations were found between participants’ attitudes toward CBT and their sex, identities, or their assigned departments. To some extent, this finding supports the explanation that low degrees of psychotherapy understanding rather than subjective perception contributes to the general positive attitude toward CBT. The exclusive significant difference is that participants with a bachelor’s degree scored lower in negative CBT attitudes than those who had completed or were attending a graduate program. This difference may be derived from recency effects. According to Chinese Undergraduate Medical Education standards - Clinical Medicine Specialty [36], at least some courses of psychological support or treatment were mentioned in undergraduate programs, whereas these courses are either less or not implemented in graduate programs. Still, previous research showed that medical workers with higher levels of education usually showed lower levels of doctor-patient communication and trust [8, 44, 45]. More educated physicians may have more experience working with more severe cases or at emergency frontlines, where they may experience heavier workload, more frequent burnout, more frequent medical disputes, and even disgrace [42,43,44]. These experiences may lead to their negative views of doctor-patient communication, trust [46], and even treatments, such as CBT. Other factors, such as personality, were found to be correlated with attitude toward psychotherapy [29, 47]. Furthermore, Kuhnigk et al. (2006) [28] found that medical students who rated the educational program more positively also showed more positive attitudes toward psychiatry. It is possible that education programs in more developed areas were more advanced than programs from developing areas in China [48]. However, given that psychotherapy training offered by universities in two areas were relatively the same [48] and manualized [36], future research should further examine the relationship between attitudes towards psychiatry and rating of the educational program.

Finally, the study showed that participants’ attitudes toward psychological interventions and counseling in primary care scored near the middle level. In the aspects of skill and knowledge, confidence to counsel, and curriculum needs, participants scored a little above average, whereas they scored a little lower than average in the aspect of willingness to counsel. This indicates that participants generally thought they had certain but not enough knowledge and skills about psychotherapy, general but not strong enough confidence to practice counseling, and a more positive demand for future curriculum. Meanwhile, the willingness to counsel was weak. Although medical students demonstrated general positive attitudes toward psychotherapy, their perceived stigma and lack of accessibility made them less likely to provide psychotherapy services for their patients [19]. This research finding may explain our participants’ low-scored willingness to deliver psychotherapy. Moreover, there was no difference among participants of different genders, education, identities, or departments, indicating they shared similar perspectives toward psychological interventions and counseling in primary care.

The limitations of this study are important to note. First, the sample population of this study is relatively small and simple. Since most of the participants were from Zhejiang province, and we only recruited a limited number of them, the generalizability of the current study was restrained. Future studies should recruit more participants from diverse regional areas. There is a potential selection bias that all participants voluntarily signed up for this survey study and followed a psychological training program, which suggests their more positive attitude and higher levels of willingness to study psychotherapy than those who didn’t sign up. Therefore, future studies need to expand the sample to those not signing up. Second, participants were mainly from Zhejiang and surrounding areas, which may not be representative samples for the whole nation. Third, there were more female participants (71.1%) than male participants, which resulted from participants’ voluntary sign-up of the study. As the current study is part of the broader project that intended to implement psychotherapy training, the fact that female participants outnumbered male participants may suggest females may be more interested in learning psychotherapy than males. However, the larger amount of female participants also limits the generalizability of the findings to males. Future research should balance the number of male and female participants. Finally, many results were inconsistent with the hypotheses, which may indicate the limitations of quantitative analysis based on self-report. It’s better to combine qualitative interview methods or measurements with high reliability and validity to understand the specific reasons behind our findings [18].

The findings of the current study have meaningful insights into future research and implications of developing sufficient and tailored medical education of psychotherapy in China. Specifically, training of basic psychotherapy knowledge is urgently needed to improve medical workers’ attitudes toward psychotherapy, whose negative attitudes may negatively affect the effectiveness of patients’ psychological treatments. Additionally, universities should provide more comprehensive training in psychological treatment, especially CBT, for students, and hospitals can offer psychotherapy-relevant events for residents, doctors, and nurses in order to enhance medical workers’ basic psychological skills (e.g., high-quality doctor-patient communications). Policymakers can also advocate for the public to pay attention to mental health and relevant services to facilitate people’s positive attitudes towards psychotherapy and help-seeking behaviors. Future research should focus on developing interventions and training for medical workers and the public to improve overall well-being in China.