Two major theoretical perspectives in mental health research informed the current study, the cultural and contextual model of coping (CCMC) [7] and family resilience theory [8]. CCMC is an Individual×Environmental ecological coping model emphasizing that coping occurs within a cultural context [7]. This model advocates examining coping in specific cultural contexts and how cultural coping strategies (i.e., collectivistic coping) may be influenced by environmental variables (i.e., community support) and contribute to psychological consequences under adverse circumstances. Moreover, we aim to examine the underlying mechanism by which cultural coping predicts mental health, highlighting how it may facilitate internal resources (e.g., behavioural compliance) and external resources (e.g., family support) [9]. Guided by the CCMC model, we devised a cultural coping model by examining one of the widely mentioned collectivist coping strategies, forbearance coping, and its potential psychosocial mechanisms and moderators in influencing mental health among Chinese community-dwelling residents. Moreover, informed by family resilience theory, we chose family-level resilience and community-level resilience as important environmental contexts mediating and moderating the influences of forbearance coping.

As a culturally-informed coping strategy, forbearance coping has attracted increasing attention recently [10,11]. Forbearance is defined as the tendency to minimize or conceal problems or concerns so as not to trouble or burden others [11]. According to Ho and Liang [10], forbearance is an applicable and culturally relevant concept in Asian societies. In collectivistic cultures, forbearance represents a high level of benevolence and kindness and the willingness to make sacrifices and endure distress. In Chinese philosophy—Confucianism—forbearance is considered a virtue in which individuals embrace the qualities of kindness and tolerance while considering others’ perspectives [12]. However, current literature does not adequately explain the relationship between forbearance coping and mental health consequences among people from collectivistic cultures. A study conducted among Chinese international students in the US found that the relationship between forbearance coping and psychological distress varied depending on cultural identification [11]. Another study in Hong Kong found that forbearance coping was positively correlated with emotion regulation strategies such as cognitive reappraisal and emotional suppression [10]. Such limited and inconsistent results imply the existence of mediators or moderators that may explain or modulate the relationship between forbearance coping and mental health. Therefore, there is a need for further studies to clarify the role of forbearance coping among Chinese people and its psychosocial correlates in various social contexts [13].

COVID-19 is a highly transmissive infection whose control mainly relies on non-pharmaceutical interventions such as hand hygiene, wearing facemasks, and keeping social distance. Therefore, people’s compliance with such mitigation measures has drawn increasing attention [14]. Individuals’ psychosocial characteristics are believed to influence compliance behaviors and mental health outcomes. Previous studies have found that trait mindfulness, compassion, and problem-focused coping all contributed to compliance with health recommendations during COVID-19 [15,16]. However, given culture may play a critical role in compliance behaviour, less is known about its impact on compliance behaviour during COVID-19 and its mental health impact. Chen et al. [17] argue that collectivism, which encourages conformity and sanctions deviant behaviour, makes collective action easier since individuals emphasize the group’s wellbeing to a greater degree. Based on mobility data from 111 countries, Li et al. [3] found that stay-at-home COVID measures were more strongly predictive of decreased mobility in countries with a high collectivism score than those with a high individualism score. A Chinese study reported that more than 75% of respondents indicated their full compliance with measures such as home confinement and hand sanitizing, and 80% reported compliance with mask-wearing and temperature-taking measures [18]. However, no study has empirically tested cultural-coping strategies and compliance.

Second, the influence of compliance on mental health consequences has not been thoroughly explored. Existing studies have reported inconsistent results. Compliance may induce negative emotions because people may feel forced to comply with certain rules. A Hong Kong study reported an association between compliance with social distancing measures, especially the stay-at-home policy, with lower levels of anxiety, stress and depression [14]. However, a European study produced conflicting results, with higher compliance behaviour predicting lower depression scores but higher anxiety for measures related to personal hygiene [19]. Therefore, more studies are needed to understand compliance and its mental health implications from a cultural coping perspective so that culturally-informed and contextually-specific policy and practical implications can be implemented to enable Chinese people better respond to future public health crises.

As depicted by the CCMC model, the family belief system and meaning-making process may function as mechanisms of change that account for the impact of coping strategies on mental health. Family resilience can be defined as the capacity of the family to withstand and rebound from stressful life challenges [20]. Walsh [8,20] identifies the family belief system as the first category of the family resilience subsystem, and meaning-making of adversity is the primary and pivotal process. As argued by Walsh [20], the family can gradually forge a sense of coherence through shared efforts to make loss-related challenges comprehensible, manageable, and meaningful to tackle [21], which in turn depathologize intense reactions and reduce individuals’ negative emotions. Forbearance coping is suggested as conducive to maintaining interpersonal relationships, family harmony and cohesion, in turn facilitating family resilience and individual psychological health [10]. Moreover, the meaning-making process may help to comprehend individual and collective sacrifices, tolerance and endurance in forbearance coping, leveraging psychological distress.

The literature shows that family resilience significantly contributes to individual mental health among breast cancer survivors [22] and youth with ADHD [23]. However, another study conducted in the US failed to reveal the protective role of family resilience among youth who experienced wildfires [24]. In a Singapore study, nurses with experience of the SARS epidemic reported that Chinese families solicited family values and beliefs such as being cooperative and united as sources of resilience [25]. There may be contextual specificity for the functions of the family resilience process and other variables that may function as moderators strengthening or suppressing the influences of family resilience systems.

Community resilience is a community’s ability to anticipate and prepare for threats, absorb and cope with negative impacts, and recover and grow from disasters through community members’ deliberate, purposeful, and collective efforts [26]. A growing number of studies have emphasized the pivotal role of community resilience in the context of significant adversity, such as natural disasters [27] and public health crises [28]. Studies have generally supported a protective function served by community resilience characterized as trust, reciprocity and mutual support among neighbours, community authorities and non-government organizations coordinating and providing various forms of support and a sense of belonging and attachment toward the community [27,29]. Community resilience has been found to be negatively associated with adverse mental health outcomes among the general population following disasters in China [30].

It is particularly important to study community resilience in China in response to public crises because the geographic community in China is a basic unit of social, political and administrative organization [31]. During the COVID-19 pandemic, communities in China have been vitally important in providing social services to residents. However, previous studies have focused on the direct effect of community resilience only; its moderating effect on community members’ mental health remains understudied. As informed by the CCMC, environmental factors such as community resilience may function as moderators interacting with psychosocial coping processes in predicting mental health outcomes [7]. Masson et al. [29] identified the buffering effect of community resilience for people experiencing a flood disaster. Shi et al. [32] revealed that community resilience amplified the positive relationship between residents’ participation in community-based epidemic prevention and their perceived effectiveness of these measures. Park and Bae [33] demonstrated that higher levels of perceived community resilience among residents buffered the detrimental impact of mental health symptoms on quality of life. However, very few studies have explored the moderating role of community resilience in association with family resilience and cultural coping in the context of public health crisis such as COVID-19.

Guided by the CCMC model, this study explored forbearance coping and its interconnections with individual-, family-, and community-level psychosocial processes in determining mental health consequences among Chinese community-dwelling residents in the post-pandemic regularized prevention and control era. We proposed a moderated mediation model (Figure 1), suggesting that the culturally oriented coping strategy of forbearance might have impacted individual pandemic prevention compliance behaviours and the family-level resilience process of making meaning from adversity, which in turn predicted psychological distress. We also hypothesized that community resilience could have functioned as a moderator, interacting with individual and family coping processes to determine mental health outcomes. To facilitate understanding, we provided a summarised table listing the included variables (Table 1). By delineating the ecological cultural coping and resilience processes experienced by Chinese people, culturally sensitive, ecological supportive and resilience-oriented administrative policies and healthcare services can be devised and implemented for future public crises, such as transmitted diseases.

Limited staffing and other resources determined the adoption of an online convenience sampling strategy. We used Survey Monkey, one of China’s three largest online survey platforms, to administer an online questionnaire between late 2020 to early 2021. The online questionnaire includes the following variables: demographic information (i.e., age, gender, employment, family income, educational attainment, residence type, and marital status), forbearance coping, psychological distress, community resilience, family meaning making of adversity and compliance with anti-pandemic measures. Detailed descriptions of the adopted measurements are described in the measurements section. The inclusion criteria for participants are as follows: 1) participants must be older than 18 years; 2) able to understand Chinese; 3) possess a mobile device and live in Guangdong province; and 4) provide consent to participate in the research. Sample size was calculated using G*power, with a conservative small effect size of 0.02 [11], an α value of 0.05 and an expected power of 0.80, resulting a minimum sample size of 395. We adopted multistage cluster convenience sampling to enlarge the coverage of sampling areas. We randomly selected ten cities in the province and contacted one gatekeeper in each selected city, asking them to disseminate the survey link among their social networks. Online consent was obtained before completing the questionnaire. Questionnaire completion took around 12 minutes, and 402 people completed it. Table 2 summarises respondents’ demographic information. Relatively more respondents were female (56.2%). Most respondents were aged between 35 and 54 years (57.7%), working as a clerk/service industries/retail or professional/manager/administrative staff (73.6%), completed tertiary education (71.7%), had a monthly income of less than 16,000 yuan (70.6%) and married (70.9%). Respondents’ IP addresses revealed that residents in almost all the major cities in Guangdong province, such as Guangzhou, Shenzhen, Zhuhai, Foshan, Dongguan, Zhanjiang, Jieyang, Jiangmen, Shantou, and Huizhou, were included. The study was approved by the Institutional Review Board, Department of Psychology, Renmin University of China [#22-023].

Data analysis was performed using SPSS 26 (IBM Corp., Armonk, NY, USA). First, descriptive statistics and frequencies were calculated to summarize respondents’ demographic information and means and standardized deviations (SDs) of the studied variables. Second, zero-order bivariate correlation analyses were performed to explore relationships between the variables. Third, a multiple-step hierarchical regression analysis was performed to examine the relationships between forbearance coping, compliance behaviours, family meaning-making of adversity and community resilience and psychological distress as guided by the CCMC conceptualization [7]. In the first step, demographic variables such as age, gender, education, family income, and employment were entered. Forbearance coping and compliance behaviours were entered in the second step. Family meaning-making and community resilience were entered in the third and fourth steps, respectively. A conventional threshold of statistical significance of 0.05 was chosen to interpret the results [41]. Finally, a moderated mediation model was specified and tested using SPSS PROCESS macro [42]. The Model 14 template was used to examine the moderating effect of community resilience in the mediating models of compliance behaviours and family meaning-making. Bootstrap analysis with 5,000 resamples was used to test the significance of the mediation effects [43]. Following Aiken and West [44], all interactions were probed at one standard deviation above (+1 SD) and one standard deviation below (-1 SD) the mean of the moderator. All continuous predictors were mean centred prior to calculating the interaction terms.

The study is not without limitations. First, a cross-sectional research design limits the interpretation of causal effects. The higher levels of psychological distress make it more likely that respondents adopt forbearance coping and lower levels of family meaning-making. Future longitudinal studies are strongly advocated to further examine the causal effects of forbearance coping, family meaning-making and psychological health. Second, the study relied on convenience sampling. Although we ensured data collection covered ten major cities in Guangdong province, this strategy limited the generalizability of the findings to Chinese residents in other provinces. Additionally, data collection occurred during the pandemic, which may impact the relationships between forbearance coping, compliance, family resources, and mental health outcomes. Preventive measures of COVID-19 including social distancing, quarantine, home confinement, and mask-wearing have undoubtedly caused prolonged stress and mental health challenges. This situation may have amplified the impact of forbearance coping on employing compliance behaviours, leveraging family resources, and their mental health consequences due to the fact that collective preventive strategies were key to the success of the prevention strategies. Therefore, caution should be exercised when generalizing these findings to other distress contexts.

This is the first study to apply the CCMC in Chinese people under a significant public health crisis. Moreover, we have expanded this cultural coping model by revealing its underlying mechanisms (via behavioural compliance and family meaning-making processes) and illuminating the moderating role of the external environmental influences (i.e., community resilience). The findings strongly suggest that culturally endorsed forbearance coping strategies might have double-edged effects on the mental health of Chinese people and are strongly influenced by environmental factors such as family meaning-making and perceived community resilience. The study also extends community resilience research by identifying the significant moderating effect of community resilience in shaping the coping processes in the COVID-19 context, highlighting the importance of building up collective-level community resilience in the face of life-threatening [29]. Finally, the study is the first to consider the interconnections of community-level and family-level resilience through a cultural coping lens. The results indicate that community and family resilience synergistically dilute the mental health burden generated by adopting forbearance coping in response to COVID-19 stressors.

Practically speaking, forbearance coping strategies adopted by Chinese community-dwelling residents could facilitate compliance and cooperative behaviour, which are conducive to community-level anti-COVID-19 measures. However, individuals’ mental health may be adversely affected at the same time. Thus, mental health services for community residents, especially during a period of prolonged stress, should be provided. On the one hand, there is a great need in the community for professional mental health services, especially in a public crisis context. Social workers and community workers should be trained to raise their awareness of possible mental health crises [51]. On the other hand, remote mental health services using mobile phones and the internet may be designed and provided to improve the accessibility of such services. Second, we found that family meaning-making positively mediated the negative impact of forbearance coping only when people perceived the community as resilient to possible adversities. Community leaders are strongly advised to strengthen connections between residents by organizing informal meetings to provide information about the community’s readiness for adversity [49,50]. In addition, Yip et al. [50] highlighted the important role of civic-mindedness and responsibility. For example, campaigns have been initiated in Singapore to create a culture and societal norm where people clean up after themselves as acts of graciousness and consideration for others during COVID-19. Moreover, it is necessary to take effective emergency education measures to cultivate community residents’ awareness of and response to emergency prevention and focus on stimulating their internal kinetic energy for emergency participation. Lastly, it is necessary to ensure the availability of essentials such as food, water, and preventive medical devices within the community to ensure full preparation for any secondary crises induced by the public health crisis. All such measures are critical for building community resilience to benefit residents’ psychological adaptation when facing future public adversity.

COVID-19 is a highly transmissible infection, primarily controlled through non-pharmaceutical interventions such as hand hygiene, wearing facemasks, and maintaining social distance. Therefore, community-based and collective response strategies are crucial for managing such public health crises. The capacity of community public health risk management to respond to future pandemics or other disasters is gaining consensus among scholars and policymakers. For example, WHO has initiated the Public Health and Social Measure Initiative to empower countermeasures for epidemic and pandemic preparedness and prevention at individual, community and national levels [52]. In China, the central government has also urged to establish responsive and resilience risk management systems in the community [53]. This study emphasizes the importance of building resilient communities and family units, as well as supporting mental health among community residents, providing quantitative evidence for future policy interventions and the implementation of pandemic and disaster prevention measures in China.

Previous studies have generally overlooked the perspective of a social-ecologically oriented and culturally-informed coping model in explaining psychological health among Chinese community-dwelling residents during COVID-19. Guided by the Cultural and Contextual Coping Model [7], our study tested an inconsistent mediation effect (i.e., double-edged effect) for forbearance coping in predicting the psychological distress of Chinese community-dwelling residents during the post-pandemic era. The study results showed an unexpected negative influence of forbearance coping on psychological health. Nevertheless, forbearance coping facilitated personal compliance with COVID-19 mitigation measures and improved psychological health. More importantly, meaning-making of adversity within families partially mediated the negative effect of forbearance on mental health only when respondents perceived higher levels of community resilience. Therefore, there is an evident need for community-based family-oriented mental health services during public health crises, and collective strategies that strengthen community resilience should also be emphasized.