East Asian Arch Psychiatry 2011;21:73-8

ORIGINAL ARTICLE

Dr Cai-Lian Tam, PhD, MA, BSc, Jeffrey Cheah School of Medicine and Health Sciences, Monash University Sunway Campus, Jalan Lagoon Selatan, 46150 Bandar Sunway, Selangor Darul Ehsan, Malaysia.
Ms Yie-Chu Foo, BSc, School of Health and Natural Sciences, Sunway University College, No. 5 Jalan Universiti, Bandar Sunway, 46150 Petaling Jaya, Selangor Darul Ehsan, Malaysia.
Dr Teck-Heang Lee, DBA, MCom, BA, School of Business, Monash University Sunway Campus, Jalan Lagoon Selatan, 46150 Bandar Sunway, Selangor Darul Ehsan, Malaysia.

Address for correspondence: Dr Cai-Lian Tam, Jeffrey Cheah School of Medicine and Health Sciences, Monash University Sunway Campus, Jalan Lagoon Selatan, 46150 Bandar Sunway, Selangor Darul Ehsan, Malaysia.
Tel: (60-3) 5514 6300 (ext. 44974); Fax: (60-3) 5514 6307; Email: tam.cai.lian@med.monash.edu.my

Submitted: 4 November 2010; Accepted: 24 January 2011

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Introduction

Due to the increasing awareness of psychological health on functioning, possible factors that may affect mental health have been extensively studied.^1,2 According to the World Health Organization (WHO) as cited in the Malaysian National Mental Health Registry,³ mental health is the key to mental disability worldwide, and includes conditions such as depression, schizophrenia, and dementia. The WHO predicted that by 2020, such disorders would increase to 15%.³ Thus, it is crucial to emphasise mental health issues as a means of achieving better lives.

Chen and Paterson⁴ conducted research on 300 adolescents to investigate the relationship of socio- economic status (SES), physical health, and psychological health. Their results suggested that lower incomes may create negative consequences, which lead to poorer mental health states.

Howell and Howell⁵ also conducted a meta-analysis on the relationship between SES and the subjective well- being of individuals from 54 developing countries, and found that economic status alone may not affect a person’s psychological well-being, and that it was essential to consider other factors such as education level (a proxy for wealth or income). The results of this study may serve as a reference for the mental health professionals to plan strategies to improve societal mental health. This is crucial as researchers found that individuals from the low-income homes had a higher tendency to suffer from psychological problems and mental illness due to insecurity related to SES and emotional instability.⁶ Providing insight into such matters can prepare society to respond to its own psychological and emotional needs.

Zimet et al⁷ defined an individual as having mental illnesses if he or she had somatic symptoms, anxiety, insomnia, social dysfunction, or depression, in the absence of an organic cause. In addition, Dalgard et al⁸ explained that mental health can be measured using the 25-item Hopkins Symptom Checklist, which included: anxiety, depression, and common psychosomatic symptoms. Hence, mental health could be understood in terms of how a person was affected by mental health concerns.

Perceived social support is a multidimensional construct that includes the size of the social network, frequency of contact with people within one’s own network, and quality of social support.⁹ Kim et al¹⁰ further explained that social support can be determined by how an individual is loved and cared for, well-regarded, and valued. Comprehending the abovementioned definitions, perceived social support could be understood in terms of quantity, quality, or both.

Socio-economic status is defined differently by different scholars, but always includes a broad spectrum of variables.¹¹ For instance, Thomas et al¹² defined SES as a complex domain which included: income, wealth, education, employment, occupations, and types of housing occupied. It has also been proposed that social prestige and material circumstances are inherent for socio-economic classification.¹² In the current study, 2 elements of SES were to be studied: parents’ income and the individual’s level of education.

Stock et al¹³ studied first-year female university students, including 662 from Spain, 650 from Germany, and 1,031 from Lithuania. The students were asked to rate their frequency of psychosomatic complaints over the past 12 months. It transpired that females had more such complaints than males, which showed that males had better mental health than females. A study on secondary school students in Slovakia indicated that males reported better mental health than females.¹⁴ Another study involving 3,131 adults subjected to a highly structured interview showed no association between gender and mental health.¹⁵

An investigation by Matthews et al¹⁶ in 11,405 respondents showed that males and females differed significantly in their perceived social support. Specifically, 19.4% of males as opposed to 7.9% of females complained of low levels of emotional support, while 16.1% of males compared with 9.6% of females complained of low levels of instrumental support.¹⁶

A study was conducted by Cheng and Chan¹⁷ among 2,105 adolescents in Hong Kong using the Multidimensional Scale of Perceived Social Support (MSPSS). This showed that females perceived lower family support but higher support from friends than males.¹⁷ This result could be due to the generally high level of self-disclosure among females. In addition, a study by Prezza and Pacilli¹⁸ found that there was a significant gender difference in family support; males reported having higher levels of social support from the family than their female counterparts. Antonucci and Akiyama¹⁹ reported that females received more support from networks than males. Previous studies^17,19 have found that females generally tend to have higher overall social support, lower family support, and more support from friends than their male counterparts.

Research entailing SES, elements such as parents’ income, and their own educational attainment have been carried out. An investigation was carried out on 939 respondents to measure the relationship between SES as a composite and mental disorders using the revised third edition of the Diagnostic and Statistical Manual of Mental Disorders.²⁰ The study revealed a significant negative correlation between mental disorder and the parents’ composite SES.²⁰ That is, the better the parental SES, the better the individuals’ mental health. In addition, Sundquist and Ahlen²¹ conducted a multi-level study with a sample of 4.5 million Swedish males and females to investigate the relationship of neighbourhood income and mental health. They also found an inverse relationship between the 2 variables. Another national survey in the United States revealed that increases in income tended to improve mental health.²² Thus, generally, there is an inverse relationship between SES and mental health.

When educational attainment was studied as an element of SES, a positive impact was also evident. A study was conducted in a sample of 4,446 individuals aged 25 to 67 years in Norway,⁸ and found that individuals with low education levels had the most mental health problems. Andrews et al²³ probed into the same matter using the Composite International Diagnostic Interview as a measure of mental health among 10,642 Australians aged above 17 years. As compared with those with a bachelor’s degree or higher, individuals with only a high school education were more prone to mood and anxiety disorders.²³

Although most studies found significant associations between an individual’s education level and mental health, a study on 7,171 females and 1,799 males by Lahelma et al²⁴ found no such relationship. Most previous studies also found relationships between SES and mental health. However, this does not prove that SES had a definite bearing on mental health, as others reported contradictory findings. The current research set out to investigate the possible influence of gender, SES, and educational background on the mental health of young adults in Malaysia. The relationship between mental health and other factors has been frequently studied by the scholars in western countries. A few such studies have also been conducted in Asian countries, but were still lacking in the Malaysian context. Social support from others has an important bearing on maintaining mental health and in its improvement if impaired. Therefore, differences in perceived social support between genders merited investigation.

The hypotheses being studied were that: (1) females reported higher level of psychiatric disorder symptoms than males; (2) females perceived higher levels of overall social support than males; (3) females perceived lower levels of family social support than males; (4) females perceived higher levels of social support from friends than males; (5) the higher the parental income, the better the quality of mental health; and (6) there were significant differences in mental health status depending on education levels.

Methods

Participants

The current research involved 303 respondents (151 females, 152 males) aged 16 to 26 years. There were 99 Malays, 100 Chinese, 102 Indians, and 2 from other races. In all, 76 respondents attained the highest education level, which was the Malaysian Certificate of Education (Sijil Pelajaran Malaysia) or equivalent; 44 had the Malaysian Higher School Certificate (Sijil Tinggi Persekolahan Malaysia), A-Level qualifications, or equivalent; 48 had diplomas; 129 had attended an undergraduate programme; and 6 had a postgraduate education.

Procedure

Ethics approval was granted by the university prior to recruitment of subjects. Between September and November 2008, potential respondents were randomly approached in different universities in Selangor state, Malaysia. After they were informed about the purpose of the survey, the response rate was 100%.

Respondents were required to fill out a detailed questionnaire, regarding gender, education, and parental income. Choices for monthly parental income were: ≤ RM 2,000, RM 2,001-4,000, RM 4,001-6,000, RM 6,001- 8,000, and ≥ RM 8,001.

Instruments

The General Health Questionnaire

The 12-item General Health Questionnaire (GHQ-12) was used in the study. It is a measure of current mental health and addresses somatic symptoms, anxiety and insomnia, social dysfunction, and depression. The respondents rated these with regard to their own health on a 4-point Likert scale (1 = ‘better than usual / not at all’; 2 = ‘same as / no more than usual’; 3 = ‘worse / rather more than usual’; 4 = ‘much worse / much more than usual’). The scores of all 12 items were added to obtain the overall score; higher scores reflected more symptomatology or lower health status. The GHQ had high internal consistency with Cronbach’s alpha values of 0.37 to 0.79, and the test-retest coefficients of the instrument were highly significant.²⁵

Multidimensional Scale of Perceived Social Support

This scale consisted of 12 items in which respondents were required to rate each on a 7-point Likert scale from 1 (never) to 7 (always). It contained 3 subscales, namely the family subscale, the friends subscale, and the significant other subscale. The family subscale score was obtained by summing the scores of items 3, 4, 8, and 11, dividing by four. Similar scoring was applied for the friends subscale (including items 1, 2, 5, 6, 7, 9, and 12) and the significant other subscale (including items 1, 2, 5, and 10). For the overall perceived social support score, all item scores were summed and divided by 12. Higher scores meant higher perceived support. The MSPSS has strong reliability that ranged from 0.77 to 0.92, good internal consistency,²⁴ and construct validity.²⁶

Statistical Analyses

In order to analyse gender differences in mental health and social support, independent sample t tests were used. Crosstab analyses were used for gender differences in each subject’s own education level and the range of respective parental incomes, while the Kruskal-Wallis test was used for gender difference in parents’ exact amount of income. The latter test was also used to analyse parents’ range of income and the subjects’ own education levels, while correlation tests were applied for parents’ exact amount of income.

Results

Gender Difference in Mental Health

There was no significant difference between males (mean [standard deviation] GHQ score, 23.3 [5.8]) and females (24.5 [5.6]) in terms of their mental health (t = –1.8; p > 0.05). Summing the two, 29.7 was yielded as the clinical cut-off score. Scores of 29.7 or above were coded as clinically relevant, while lower scores were regarded as normal.

Gender Difference in Perceived Social Support

Overall perceived social support, and perceived family support, support from friends, and significant other support were assessed using independent sample t test, and that the significant and non-significant gender differences are shown in Table 1. Females perceived significantly higher levels of overall social support than males (t = –2.7; p < 0.05).

Gender Difference in Socio-economic Status

Crosstab analyses were for gender and level of parental education, and different parental income ranges yielded no significant differences (Table 2). The same was true after applying the Kruskal-Wallis test to the exact amounts of parental income, with no significant difference being found (χ² = 1.98; p > 0.05). Hence, there appeared to be no difference between males and females in terms of their parental incomes.

Parents’ Income and Mental Health

The Kruskal-Wallis test was conducted to examine the association between parental income and mental health. In addition, bivariate correlation was conducted between parental income and mental health. Results indicated that there was no significant difference in mental health across parental incomes (χ² = 5.0; p > 0.05), but a significant relationship with the individual’s mental health (r = –0.1; p < 0.05) was found. The negative correlation indicated that the higher parental income, the fewer the number of identified symptoms.

Differences between Education Levels and Mental Health

Applying the Kruskal-Wallis test to examine differences between education level of individuals and their mental health, the differences were insignificant (χ² = 0.7; p > 0.05).

Discussion

The current study aimed to examine gender differences in mental health and perceived social support, relationships between parental income and mental health, and differences in mental health across education levels. Females perceived significantly higher social support, social support from friends, and social support from persons other than males. There were no significant differences between genders in terms of mental health and perceived social support from family, and between individual education levels and mental health.

The analysis of mental health between genders revealed no significance. The original hypothesis proposing higher levels of psychiatric symptoms in females was rejected. This was contrary to some previous research indicating that women had higher prevalence of psychosomatic complaints¹³ and distress¹⁴ than males, but the findings were consistent with that of Aneshensel et al.¹⁵ The common factor in the current study and that by Aneshensel et al¹⁵ was that their samples included working adults, which differed from the other investigations^13,14 that only included students. Conceivably, being a student or working individual could affect gender differences in mental health.

One possible explanation for the insignificant findings in the present study could be related to cultural differences. Asians are generally regarded as gaining more benefits from social support without requiring explicit expression of relevant problems, which is in contrast to individualistic societies such as Europe and North America.¹⁰ The sample in the current study represented Malaysian inhabitants, who adopted the collectivistic culture. Thus, the lack of sufficient differences between genders with respect to mental health could have been moderated by their collectivistic nature on perceived social support.

The current study found that females perceived higher levels of overall social support and social support from friends than males, which was in accordance with Cheng and Chan’s study.¹⁷ One possible reason was due to gender differences in self-disclosure. Studies by Davidson and Duberman²⁷ and Reisman²⁸ revealed that females across all ages had a higher tendency to disclose matters to friends. Females become involved in more in-depth communication through willingness to express their problems and stress. Another study¹⁸ revealed that compared with males, females had larger social networks, more sources to draw support from, and were more satisfied with friends.

In this study, no significant difference for perceived family social support between gender was found, which was contrary to our third hypothesis and prior findings¹⁷ that females perceived less social support than males. Cheng and Chan¹⁷ explained that the lower perception of family support by females as stemming from the possibility that adolescent females are taught to value closeness with parents. This makes them more frustrated than their counterpart males, at a time that they need / want to express their independence. However, further research is still required to clarify independence issues in perceived support from family.

Our study revealed no significant difference between mental health and different categories of parental income. However, when the parent’s exact income was used instead of ranges, a positive relationship existed and seemed to support the fifth hypothesis. This finding was supported by Lahelma et al²⁴ who found that individuals who experienced economic difficulties consistently had higher rates of common mental disorders compared with those who had less economic difficulties.

The association between parental income and mental health can be further understood using the social causation model that was supported by a study examining the association between SES and depression or distress.²⁹ The social causation model proposed that mental illnesses are an effect of poor socio-economic circumstances. It therefore seems reasonable to view better mental health as an effect of higher parental income, which is a component of SES. Thus, those capable of attaining resources could maintain good mental health. In short, there was a relationship between parental income and mental health.

When considering the mental health of individuals in terms of education status, the current research showed no significant difference across education levels of the participants. Thus, the last hypothesis was not supported, which was comparable to the findings of Lahelma et al.²⁴ At this stage of life, parental education may be more influential than an individual’s own education, as the educational achievements of parents affect their occupation, and consequentially contribute to income.²⁴

As compared with females, males perceived lower levels of social support from people generally and from friends in particular. This may indicate that males really receive less social support or alternatively they crave for more social support. Sufficient social support could be included as precautions and interventions for males affected by mental illness.

The parental income but not the participant’s own education level, which was correlated with mental health, shows that parents have a role in the mental health of late adolescents and young adults. One possible explanation is that this group of individuals is still at the initial stage of gaining their own SES that could provide them with different kinds of living conditions. Therefore, they are still considerably dependent on their parents or relevant adults, and their own educational background has little influence on their mental health. Hence, while their own SES should be the target of interventions for western young adults, parental SES should be a better target for young individuals in Malaysia.

The strengths of this study were its focus on the equality of female and male respondents as well as their ethnicity. The instruments used to measure the variables were established in terms of reliability and validity. The sample size was also sufficient to yield significant results. However, the participants were mostly from the Selangor state of Malaysia, and hence not representative of the whole nation.

Future research should also explore other socio- economic components, including parental education status, parental occupation, and physical living conditions so as to arrive at a more holistic perspective of what might affect mental health. Cultural influences in perceived social support, mental health and SES all have important implications and warrant studies to analyse perceived social support and SES functioning, and how they might be manipulated to improve and / or maintain good mental health.

Our study in young adults showed that generally there were gender differences for perceived social support, but not for mental health status. There was also a relationship between parental income and mental health. Conversely, there was no significant difference in mental health across subjects with differing education levels. These results reflect the importance of social support, especially in females. The latter appear to benefit more due to their associated larger social networks and correspondingly more sources for support. Besides, the various components of SES affect mental health differently and thus could be viewed individually, though they are not mutually exclusive. It should also be appreciated that the present study was exploratory, and that more research is necessary before its findings are taken as conclusive.

References

1. Göz F, Karaoz S, Goz M, Ekiz S, Cetin I. Effects of the diabetic patients’ perceived social support on their quality-of-life. J Clin Nurs 2007;16:1353-60.
2. Springer A, Parcel G, Baumler E, Ross M. Supportive social relationships and adolescent health risk behavior among secondary school students in El Salvador. Soc Sci Med 2006;62:1628-40.
3. National Mental Health Registry. Preliminary report of the National Mental Health Registry 2003. Website: http://www.nmhr.gov.my/documents/preliminaryReport.pdf. Accessed 10 Jan 2011.
4. Chen E, Paterson LQ. Neighborhood, family, and subjective socioeconomic status: How do they relate to adolescent health? Health Psychol 2006;25:704-14.
5. Howell RT, Howell CJ. The relation of economic status to subjective well-being in developing countries: a meta-analysis. Psychol Bull 2008;134:536-60.
6. Najman JM, Aird R, Bor W, O’Callaghan M, Williams GM, Shuttlewood GJ. The generational transmission of socioeconomic inequalities in child cognitive development and emotional health. Soc Sci Med 2004;58:1147-58.
7. Zimet GD, Dahlem NW, Zimet SG, Farley GK. The multidimensional scale of perceived social support. J Peers Assess 1988;52:30-41.
8. Dalgard OS, Mykletun A, Rognerud M, Johansen R, Zahl PH. Education, sense of mastery and mental health: results from a nation wide health monitoring study in Norway. BMC Psychiatry 2007;7:20.
9. Chou KL. Assessing Chinese adolescents’ social support: the Multidimensional Scale of Perceived Social Support. Pers Individ Dif 2000;28:299-307.
10. Kim HS, Sherman DK, Taylor SE. Culture and social support. Am Psychol 2008;63:518-26.
11. 1 Winkleby MA, Jatulis DE, Frank E, Fortmann SP. Socioeconomic status and health: how education, income, and occupation contribute to risk factors for cardiovascular disease. Am J Public Health 1992;82:816-20.
12. Thomas B, Hardy S, Cutting P. Stuart and sundeen’s mental health nursing: principles and practice. London: Elsevier Health Sciences; 2004.
13. Stock C, Kücük N, Miseviciene I, Guillén-Grima F, Petkeviciene J, Aguinaga-Ontoso I, et al. Differences in health complaints among university students from three European countries. Prev Med 2003;37:535-43.
14. Sleskova M, Salonna F, Madarasova Geckova A, van Dijk JP, Groothoff JW. Health status among young people in Slovakia: comparisons on the basis of age, gender and education. Soc Sci Med 2005;61:2521-7.
15. Aneshensel CS, Rutter CM, Lachenbruch PA. Social structure, stress, and mental health: Competing conceptual and analytic models. Am Sociol Rev 1991;56:166-78.
16. Matthews S, Stansfeld S, Power C. Social support at age 33: the influence of gender, employment status and social class. Soc Sci Med 1999;49:133-42.
17. Cheng ST, Chan AC. The multidimensional scale of perceived social support: dimensionality and age and gender differences in Hong Kong adolescents. Pers Individ Dif 2005;37:1359-69.
18. Prezza M, Pacilli MG. Perceived social support from significant others, family and friends and several socio-demographic characteristics. J Community Appl Soc Psychol 2002;12:422-9.
19. Antonucci TC, Akiyama H. An examination of sex differences in social support among older men and women. Sex Roles 1987;17:737- 49.
20. Miech RA, Caspi A, Moffitt TE, Bradley R, Wright E, Silva PA. Low socioeconomic status and mental disorders: a longitudinal study of selection and causation during young adulthood. Am J Sociol 1999;104:1096-131.
21. Sundquist K, Ahlen H. Neighbourhood income and mental health: a multilevel follow-up study of psychiatric hospital admissions among 4.5 million women and men. Health Place 2006;12:594-602.
22. Ettner SL. New evidence on the relationship between income and health. J Health Econ 1996;15:67-85.
23. Andrews G, Henderson S, Hall W. Prevalence, comorbidity, disability and service utilisation. Overview of the Australian National Mental Health Survey. Br J Psychiatry 2001;178:145-53.
24. Lahelma E, Laaksonen M, Martikainen P, Rahkonen O, Sarlio- Lähteenkorva S. Multiple measures of socioeconomic circumstances and common mental disorders. Soc Sci Med 2006;63:1383-99.
25. Goldberg D. General health questionnaire. Berks, United Kingdom: NFER-NELSON Publishing Co. Ltd.; 1981.
26. Eker D, Arkar H. Perceived social support: psychometric properties of the MSPSS in normal and pathological groups in a developing country. Soc Psychiatry Psychiatr Epidemiol 1995;30:121-6.
27. Davidson LR, Duberman L. Friendship: communication and interactional patterns in same-sex dyads. Sex Roles 1982;8:809-22.
28. Reisman JM. Intimacy in same-sex friendships. Sex Roles 1990;23:65- 82.
29. Link BG, Lennon MC, Dohrenwend BP. Socioeconomic status and depression: the role of occupations involving direction, control and planning. Am J Sociol 1993;98:1351-87.