FANNY M. CHEUNG

P R E F E R E N C E S IN H E L P - S E E K I N G A M O N G

C H I N E S E S T U D E N T S

ABSTRACT. Chinese university students were asked to indicate their inclination to seek help and the resources for consultation on the 22 problems listed on the Langner Scale. Results showed that the Chinese students were generally not inclined to seek help and when they did, would most often seek help from medical doctors. However, when items were grouped in terms of clinical content, it was found that friends were predominantly preferred for psychological problems while the doctor was preferred for psychophysiological, phy- siological, and ambiguous problems. More female than male students tended to rely on friends and family members while the reverse pattern was found in the preference for doctors. The mental health professional was rarely cited as a resource for any of the pro- blems. The results provide some explanation for observations made in previous studies on symptom presentation and help-seeking behavior among Chinese psychiatric patients.

Studies on Chinese psychiatric patients suggested that Chinese tend to present

somatic symptoms when seeking help for emotional problems (Tseng 1975;

Kleinman 1977). On the other hand, studies among non-patient samples showed

that Chinese frequently admit to psychological symptoms on self-report measures

(Cheung i982 , in press a). However, they would attempt a variety of coping

strategies before seeking professional help (Cheung et al. 1983). There seems to

be a gap between the awareness of psychological problems and the initiative to

seek help from mental health professionals (Cheung 1982). Similar observations

have been made on overseas Chinese in the U.S. and Canada (Sue et al. 1975,

1982; Lin et al. 1978). Chinese tend to refrain from mental health facilities and

instead, rely more upon their families and friends. When professional help is

sought, the medical doctor is the most common resource (Lin et al. 1978;

Cheung et al. 1983).

The type of resources sought for psychological assistance depends on several

factors. Cognitive schema on the cause, nature, and possible solution of different

problems influence a person's problem-solving approach (Cheung et al. 1983).

However, the choice or even the awareness of particular solutions is also affected

by the availability of such resources in the environment. There is an implicit

assumption in Western psychiatry that mental health problems are best helped

by mental health resources. Such an assumption is based on the condition that

mental health resources are accessible and that consumers are aware of their

availability. These conditions are often not met in communities where pro- fessional mental health facilities are recent imports and are in short supply

(Cheung in press b). In these communities, self-help and the primary network

would be more important resources for coping with psychological problems.

In Hong Kong as well as in other societies where little primary mental health

Culture, Medicine and Psychiatry 8 (1984) 371-380. 0165-005X/84/0084-0371 $01.00. © 1984 by D. Reidel Publishing Company.

372 F. M. CHEUNG

care is offered, the medical practitioner is often a frontline professional who deals with mental health problems.

Does the higher utilization of medical facilities over mental health facilities among the Chinese reflect their tendency to somatize? In an earlier study, Cheung (1982) showed that Chinese in urban Hong Kong reported more symptoms on the Psychological subscale of the Langner Scale than on the Psy- chophysiological, Physiological, and Ambiguous subscales. These results indicated a discrepancy between the high level of awareness of psychological symptoms on the one hand, and the high frequency of somatic presentation among Chinese patients on the other hand.

The present study attempts to explain this discrepancy by examining the intentions to seek help and the resources to be approached for the same set of symptoms included on the Languer Scale which was used in the 1982 study. It is expected that the medical doctor would be the most frequently cited profes- sional resource especially for physiological symptoms. Utilization of mental health resources would be low. Instead, greater reliance on friends and relatives would be expected for psychological symptoms.

METHOD

Sub]ects

A total of 255 (125 male and 130 female) first- and second-year students at the Chinese University of Hong Kong participated in the study. The average age was 20. The majority of students at the University came from working-class families.

Instrument

The 22-items on the Langner Scale (Langner 1962) have been translated into Chinese in an earlier epidemiology study (Lee 1976, 1980). In the present study, the Langner Scale items were listed with a preface:

"Suppose the following situations were affecting your daily life, would you seek help or advice from others? If yes, from whom would you seek help or advice?"

The students were asked to check against each item whether they would seek help for that problem and to write down in the space provided the per- son(s) they would seek help from.

Analysis

The resources cited in the open-ended answers were grouped under seven cate- gories: family, friend/schoolmate, teacher/adviser, religious personnel, doctor, mental health professional (including psychiatrist, psychologist, or social worker),

PREFFERENCES IN HELP-SEEKING 373

and others. Citation of multiple resources was allowed although infrequent. The percentage of endorsement for each resource category was computed for all 22 items. The raw percentages were then adjusted according to the percen- tage of individuals who would seek any help for each of the 22 items so that the relative preference for each particular resource may be compared across problems.

The Langner Scale items were then regrouped into four subscales derived according to clinical judgment by Crandell and Dohrenwend (1967): Psycho- logical, Psychophysiological, Physiological, and Ambiguous. These four subscales have been used in Cheung's (1982) study: An average endorsement rate for each category of resources was computed for each of the four subscales based on the adjusted percentage on each item. Chi-squared tests were run on the differences between the endorsement of family members, friends, and doctors by the female students, the male students, and the total group. Endorsement for the other groups of resources was too small to warrant inclusion in the comparison.

RESULTS

The overall intention to seek help for each problem was generally low among the female, the male and the total group of students. On all except two items, less than half of the students would seek any help at all even though that problem would be affecting their daily lives. Problems for which students were most

likely to seek help were: (2)"Can't get going" (54.5%), (11) "Fainting" (54.5%), (1) "Feel weak all over" (46.7%), (17) "Clogging in nose and swelling in head" (46.3%), and (3) "Low spirits" (45.9%). Problems for which the students were

least likely to seek help were (14) "Memory not alright" (21.6%), (20) "Nothing turns out right" (24.2%), (6) "Poor appetite" (24.7%), and (8) "Worrying type" (26.3%) (Table I). The tendency to seek help among females differed significantly from that among the males only on two items (No. 2 and 8). On each of these two items, more of the females than males would seek help.

Among those students who would seek help, the medical doctor was their most frequent choice as the resource person (Table II). On 11 of the 22 items, the medical doctor was cited by over half of those who would seek help. On the average, the doctor was chosen significantly more often than friends, who in turn, were favored over family members. Friends were preferred by over half of the help-seeking students on six items. The only problem for which a substantial proportion of students would turn to their family was (6) "Poor appetite"

(47.6%). Some sex differences were observed on the preference for resources (Table

III). Female students were more likely than male students to seek help from friends on five items and from family members on 11 items. Male students, on the other hand, were more likely to prefer the doctor on three items.

374 F . M . CHEUNG

TABLE I ~ r c e n ~ ofs~dentswhowouldseekhelp ~ r the i r ~oblem

Langner scale items Inclination to seek help

Total % M% F%

Psychological subscale

2. Can't get going 54.5 39.5 68.7 * 3. Low spirits 45.9 41.1 50.4 7. Restlessness 34.5 32.3 36.6 8. Worrying type 26.3 18.5 33.6 *

10. Nervousness 42.8 40.3 45.0 12. Trouble sleeping 33.3 30.6 35.9 14. Memory not alright 21.6 25.0 18.3 19. Feeling somewhat apart 34.5 33.9 35.1 20. Nothing turns out right 24.3 23.4 25.2 22. Wonder anything worthwhile 36.9 34.7 38.9

Subscale Average 35.4 31.9 38.8

Psychophysiological subscale

1. Feelweak all over 46.7 41.9 51.1 4. Hot all over 41.6 38.7 44.3

15. Cold sweats 33.7 32.3 35.1 18. Personal worries get me down physically 41.6 43.5 39.7 21. Headaches 47.5 42.7 51.9

Subscale Average 42:2 39.8 44.4

Physiological subscale

6. Poor appetite 24.7 20.2 29.0 11. Fainting 54.5 56.4 52.7 17. Cloggingin nose 46.3 41.1 51.1

Subscale Average 41.8 39.2 44.3

Ambiguous subscale

5. Heart beats hard 40.0 37.9 42.0 9. Shortness of breath 39.6 37.1 42.0

13. Acid stomach 42.4 42.7 42.0 16. Hands tremble 34.1 30.6 37.4

Subscale Average 39.0 37.1 40.8

Full scale Average 38.5 35.7 41.1

* Chi-squared tests between male and female endorsements significant at < 0.05 level.

P R E F F E R E N C E S IN HELP-SEEKING

TABLE II Preferences for resources among students who would seek help

375

Langner Scale Items Adjusted percentage of preferences for r e s o u l ' c e s

Mental health Family Friend Doctor

professional

'Psychological subscale

2. Can't get going 9.4 70.5 0.0 0.0 3. Low spirits 6.8 82.9 0.8 3.4 7. Restlesness 12.5 45.5 2.3 1.1 8. Worrying type 11.9 58.2 3.0 7.5

10. Nervousness 11.0 38.5 40.4 8.3 12. Trouble sleeping 12.9 28.2 62.3 1.2 14. Memory not alright 5.5 34.6 32.7 1.8 19. Feeling somewhat apart 6.8 52.3 2.3 5.7 20. Nothing turns out right 8.1 71.0 0.0 3.2 22. Wonder anything worthwhile 9.6 74.5 1.1 2.1

Subscale Average 9.5 55.6 14.5 3.4

Psychophysiological subscale

1. Feel weak all over 33.6 21.9 46.2 0.0 4. Hot all over 27.4 4.7 69.8 0.0

15. Coldsweats 25.6 4.6 76.7 0.0 18. Personal worries get me down physically 11.3 29.3 59.4 4.7 21. Headaches 17.4 8.3 83.5 0.8

Subscale Average 23.1 13.7 67.1 1.1

Physiological subscale

6. Poor appetite 47.6 7.9 42.9 0.0 11. Fainting 9.4 5.0 91.4 0 . 0 17. Clogging in nose 16.1 3.4 84.8 0.0

Subscale Average 24.4 5.5 73.0 0.0

Ambiguous subscale

5. Heart beatshard 13.7 6.9 84.3 0.0 9. Shortness of breath 11.9 4.0 88.1 0.0

13. Acid Stomach 8.3 5.6 86.1 0.0 16. Hands tremble 19.5 6.9 82.8 0.0

Subscale Average 13.4 5.8 85.3 0.0

Full scale average 15.3 30.2 47.3 1.8

376 F. M. CHEUNG

TABLE III Significant sex differences* in Preferences for resources

Preferences for resources

Subscale Item Preference for: Male Adjusted (%) Female Adjusted (%)

Doctor I 14 Memory not alright 41.9 20.8

II 18 Personal worries get me down physically 70.4 48.1

IV 9 Shortness of breath 93.5 83.6

Friend I 2 Can't get going 63.3 74.4 I 8 Worrying type 47.8 63.6 I 10 Nervousness 28.0 47.5 I 12 Trouble Sleeping 18.4 36.2

II 18 Personal worries get me down physically 14.8 44.2

Family I 3 Low spirits 0.0 12.2 I 8 Worrying type 0.0 18.2 I 12 Trouble sleeping 5.3 19.2 I 19 Feeling somewhat apart 0.0 13.0 I 22 Wonder anything worthwhile 2.3 15.7

II 4 Hot all over 14.6 37.9 II 18 Personal worries get me

down physically 3.8 19.2 II 21 Headaches 3.8 27.9

III 11 Fainting 2.9 15.9 I I I 17 Clogging 5.9 23.9

IV 5 Heart beats hard 4.3 21.8

Chi-square test between male and female percentage significant at ~< 0.05 level. Subscale I = Psychological

II = Psychophysiological III = Physiological IV = Ambiguous

Mental health professionals including psychiatrist, psychologist, or social

worker were rarely mentioned by those who would seek help. These professionals

were mentioned only on 11 out of the 22 items, with the range of endorsement

between 0.8% to 8.3% (Table II). The two items which were slightly more likely

to solicit help-seeking from mental health professionals were items ( I0) "Ner-

vousness" (8.3%) and (8) "Worrying type" (7.5%).

When the items were grouped according to the four subscales, the average

pattern of preferences varied although the average tendency to seek help did not

differ among the subscales. On the Psychological subscale items, friends were

more often sought by both female and male students than the medical doctor

PREFFERENCES IN HELP-SEEKING 377

or family members. On the other three subscales, the medical doctor was pre-

ferred significantly more often than family members while among the three,

friends would be least likely to be consulted for these problems. The role of the doctor was most important while the role of friends diminished on problems related to the Physiological and the Ambiguous subscales. Mental health profes- sionals were not mentioned at all for any item on these two subscales (Table

II).

DISCUSSION

The results showed that Chinese university students were generally not inclined to seek help for their problems. Even when the problems may be affecting their daily lives, less than half of the total group of students would seek help at all. Female students were not more inclined to seek help than male students except

for two psychological problems. For those students who would seek help, the medical doctor was the most

often cited resource. Mental health professionals were rarely mentioned even when the problem was psychological in nature. Considering that this group of students was enrolled in the Introductory Psychology course and should have a preliminary awareness of the mental health profession, their low preference rate was particuarly indicative of the general public's underutilization of mental health facilities in Hong Kong.

Within the primary social network, friends were cited as a resource more

often than family members. The stronger preference for friends may be a re- flection of the developmental stage of students in their late teens and early twenties. However, the reliance on friends was restricted to more psychological problems. When the problems were grouped according to their content, the dominant influence of friends was seen only on the Psychological subscale. On the Psychophysiological, Physiological, and Ambiguous subscales, friends were consulted even less than family members. This differentiation may fit the Attri- bution Theory of the Health Belief Model expounded by King (1982) in her D. Phil. thesis in which she tried to match health behavior with one's expectancy on the course of action. The concept of "explanatory models" has been discussed at length by Kleinman (1980) and Mechanic (1972, 1977).

The resource chosen for consultation depends on the students' interpretation of the nature of the problem and their expectation that a particular resource may be helpful. The students would turn to their friends for problems which were related to their moods, personal adjustment, and existential concerns. In these situations, the role of the doctor was greatly diminished. When the problem involved somatic consequences, especially if specific symptoms were manifested (such as fainting, shortness of breath, acid stomach, etc.), then the doctor

378 F. M. CHEUNG

would become the primary resource for help (Table IV). This separation in the

roles of friends for psychological problems and doctors for somatic problems

may explain why Chinese patients tend to present more somatic complaints to

their doctors even when their problems may include psychological features.

If they perceive their problems to be primarily psychological in nature, they

would be unlikely to consult their doctors, and would have approached their

friends instead. On the other hand, friends and peers would be perceived to lack

the expertise and experience to deal with specific symptoms, especially those of

physiological nature. The distinction between the roles of the primary social

network and the medical doctor would also help to understand the delay among

ethnic Chinese patients in seeking help for mental health problems (Lin et al.

1978). The first level of consultation for psychological problems would remain

within the patients' primary network.

TABLE IV Problems for which friends or doctors would be consulted

Items Friend as preferred resource % Would seek help Adjusted preference %

3 Low spirits 45.9 82.9 22 Wonder anything worthwhile 36.9 74.5 20 Nothing turns out right 24.3 71.0

2 Can't get going 54.5 70.5 8 Worrying type 26.3 58.2

19 Feeling somewhat apart 34.5 52.3

Items Doctor as preferred resource

11 Fainting 54.5 91.4 9 Shortness of breath 39.6 88.1

13 Acid stomach 42.3 86.1 17 Clogging in nose 46.3 84.7 5 Heart beats hard 40.0 84.3

21 Headaches 47.4 83.5 16 Hands tremble 34.1 82.8 15 Cold sweats 33.7 76.7 4 Hot all over 41.6 69.8

12 Trouble sleeping 33.3 62.3 18 Personal worries get me

down physically 41.6 59.4

It is particularly relevant to note that the mental health professional was

not recognized as an alternative resource for professional consultation even

among university students. This lack of recognition is understandable given the lack of availability of mental health services in Hong Kong. It appears that

utilization of mental health facilities would be prevalent only in communities in which they are more readily available in primary care such as in the U.S. or

PREFERENCES IN HELP-SEEKING 379

the Netherlands. Even in Britain, delay in referral from primary medical care to mental health services was well documented (Goldberg and Huxley 1980).

The sex differences found in the present study suggest a possible difference in resource utilization among Chinese males and females. Females were more likely than males to rely on their friends and family members as a resource for help. Males, on the other hand, tend to approach the medical doctor more often

than the females. Similar sex differences have been observed among psychiatric

patients in the U.S. (Horwitz 1977). But there, females were more likely to seek help from both their primary network and professional resources. No sex dif-

ference was found in the utilization of just medical professionals however. An interesting distinction in the preference for different resources was found

between females and males on item (18) "Personal worries get me down phy-

sically". The statement consists of both a psychological element in the first

part and a physical element in the second part. The female students were pro-

bably relating to the psychological element when more of them would turn to friends or family members for help. The male students may be focussing on the

physical element when a larger majority of those who would seek help would

turn to the medical doctor. This distinction renders further support to the im- portance of understanding the person's own interpretation of his or her problem and beliefs about the alternative resources.

Given the strong reliance among Chinese students on their primary social network for what they perceive as psychological problems, the importance of

working with the family and peers in the provision of community mental health services for the Chinese as recommended by Lin et al. (1978) should be em- phasized. When mental health problems are articulated in a psychological idiom,

family members and friends would be the primary level of intervention before

the problems are filtered through to the attention of medical doctors. When

mental health problems are articulated in psychophysiological or physiological terms, the physician would be the primary source of consultation. Only a small

proportion of the problems will eventually reach the mental health professional.

The interface among mental health professionals, physicians, and the client's

social network should be a primary orientation in the provision of mental

health services in Chinese communities.

Dept. of Psychology, The Chinese University of Hong Kong

REFERENCES

Cheung, F. M. 1982 Psychological Symptoms among Chinese in Urban Hong Kong. Social Science and

Medicine, 16: 1339-1344.

380 F. M. CHEUNG

Cheung, F. M. in press (a) Cross-cultural Considerations for the Translation and Adaptation of the

Chinese MMPI in Hong Kong. In J. N. Butcher and C. D. Spielberger (eds.) Ad- vances in Personality Assessment, Vol. 4. Hlllsdale, N. J.: Lawrence Erlbaum Associates.

Cheung, F. M. in press (b) An Overview of Psychopathology in Hong Kong - with Special Reference to

Somatic Presentation. In W. S. Tseng and D. Wu (eds.) Chinese Culture and Mental Health. New York: Academic Press.

Cheung, F. M., Lee, S. Y., and Y. Y. Chan 1983 Variations in Problem Conceptualizations and Intended Solutions among Hong

Kong Students. Culture, Medicine, and Psychiatry 7: 263-278. Crandell, D. L. and Dohrenwend, B. P.

1967 Some Relations among Psychiatric Symptoms, Organic Illness, and Social class. American Journal of Psychiatry 123: 1527-1538.

Goldberg, D. and Huxley, P. 1980 Mental Illness in the Community. London: Tavistock.

Horwitz, A. 1977 The Pathways into Psychiatric Treatment: Some Differences Between Men and

Women. Journal of Health and Social Behavior 18: 169-178. King, J. B.

1982 Health Beliefsl Attributions, and Health Behaviour. D. Phil. Thesis, University of Oxford.

Kleinman, A. M. 1977 Depression, Somatization and the "New cross-cultural Psychiatry". Social Science

and Medicine 11: 3-10. Kleinman, A. M.

1980 Patients and Healers in the Context of Culture: An Exploration of the Borderland Between Anthropology, Medicine, and Psychiatry. Berkeley: University of Cali- fornia Press.

Langner, T. S. 1962 A Twenty-two item Screening Score of Psychiatric Symptoms Indicating Impair-

ment. Journal of Health and Human Behavior 3: 269-276. Lin, T. Y., Tardiff, K., Donetz, G., and Goresky, W.

1978 Ethnicity and Patterns of Help-seeking. Culture, Medicine and Psychiatry 2: 3-13.

Mechanic, D. 1972 Social Psychologic Factors Affecting the Presentation of Bodily Complaints.

New England Journal of Medicine 286: 1132-1139. Mechanic, D.

1977 Illness Behavior, Social Adaptation and the Management of Illness. Journal of Nervous and Mental Disease, 165: 79-87.

Sue, S. and McKinney, H. 1975 Asian-Amercians in the Community Mental Health Care System. American

Journal of Orthopsychiatry 45: 111-118. Sue, S. & Morishirna, J. K.

1982 The Mental Health of Asian Americans. San Francisco: Jossey-Bass. Tseng, W. S.

1975 The Nature of Somatic Complaints Among Psychiatric Patients: The Chinese Case. Comprehensive Psychiatry 16: 237-245.