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Stress, psychological symptoms, social support and health behaviour among black students in South Africa Karl Peltzer Published online: 12 Nov 2009.

To cite this article: Karl Peltzer (2004) Stress, psychological symptoms, social support and health behaviour among black students in South Africa, Journal of Child & Adolescent Mental Health, 16:1, 19-23, DOI: 10.2989/17280580409486559 To link to this article: http://dx.doi.org/10.2989/17280580409486559

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Journal of Child and Adolescent Mental Health 2004, 16(1): 19–23 Printed in South Africa — All rights reserved

JOURNAL OF CHILD AND ADOLESCENT MENTAL HEALTH ISSN 1682–6108

Stress, psychological symptoms, social support and health behaviour among black students in South Africa Karl Peltzer Human Sciences Research Council, Private Bag X91182, Cape Town 8000, South Africa e-mail: [email protected]

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The study investigated stress events, perceived stress and social support in relation to various common health behaviours among black South African students. The sample included 624 students: 314 Grade 12 Secondary school students and 310 third year social science university students in South Africa. The study found a low prevalence of healthy behaviour, which was inversely related to psychological symptoms and depressive symptoms and positively related to social support and perceived stress. It is suggested that psychological symptoms and social support need to be included in enhancing lifestyle intervention programmes among youth.

Introduction Chronic diseases of lifestyle were responsible for 24.5% of all deaths of all South Africans and 28.5% of those were aged 35–64 years (Bradshaw et al. 1995). The major causes of death contributing to these figures were cerebrovascular diseases (7.2% of all deaths) and ischaemic heart disease (8.7% of all deaths). In a recent, nationally representative survey the Medical Research Council (1998) found that among persons above 15 years, 11% of men and 13% of women were found to either have a blood pressure above 160/95mm Hg, or were taking appropriate medication to lower their blood pressure. A calculation based on these prevalence rates and the census figures published for the South African population 15 years and older leads to an estimate of about 3.3 million hypertensive people in the country. Moreover, 25% of South Africans fell into the overweight category, while 20% fell into the obese category; at 30%, black women have the highest incidence of obesity, 10% of children under the age of two, and 20% of children under the age of six are overweight. Yach (1996) reports that tobacco use among blacks is rising in South Africa. For the country as a whole, lung cancer already accounts for 24% of all deaths from cancer in men and 10.6% of all such deaths in women. In 1995, in the Northern Province, 38% of African men and 2.1% of women were current smokers. In the same study the national current smoker average for African men and women was 53% and 10% (Reddy, Meyer-Weitz and Yach 1996). The two currently (past month) most predominantly used substances among urban, secondary school pupils (mean age = 19.1 years) in the Northern Province of South Africa were alcohol (41.9% in men and 34.3% in women) and tobacco (23.3% in men and 25.7% in women) (Peltzer, Cherian and Cherian 1999b). Flisher et al. (1993b) found among Cape Peninsula high-school students that 18.1% smoked at least one cigarette per day, 26.2% had used alcohol recently (Flisher et al. 1993a). While the full aetiology of any of chronic diseases of lifestyle has yet to be understood, behavioural factors such

as tobacco use, exercise, diet, alcohol consumption and preventive health checks are strongly implicated as risk factors (Steptoe and Wardle 1992). Graham and Uphold (1992) studied health perceptions, safety, life-style practices, nutrition, dental health and care of minor injuries among schoolage boys and girls. Findings indicated that most boys and girls viewed themselves as healthy and managed their own care fairly well in the areas of seat belt use, exercise, and dental health. Nutrition was identified as an area of concern, with 10% of the children skipping breakfast and over half eating snacks with empty calories. Generally, children were found to be knowledgeable in the management of simple injuries and how to respond in the event of an emergency. Boys and girls were similar in all areas of health perceptions and behaviours except for dental health, with boys reporting more regular visits to the dentist than did girls. Peltzer (in print) studied health-related behaviours among black and white South African school-aged children and found areas of concern were: the lack of consistent seatbelt use; among blacks, unhealthy food, eating sweets and drinking soft drinks and, among whites, smoking and drinking alcohol. The character of these adolescent health behaviours would indicate undesirable health processes that may lead to serious health problems (e.g. chronic respiratory diseases and chronic diseases of lifestyle), but they are, in this period of life, still preventable, reversible or at least they could be influenced in a more favourable way. Among black South African university students it was found that more than half did not avoid fat and cholesterol, likewise more than half had not exercised in the past 14 days (Peltzer 2000), more than half did not eat limited salt, two-thirds did not eat fruits daily (Peltzer 2001b), three quarters of the women reported that they did not know how to examine their breasts for cancer and almost 90% had not had a cervical smear test (Peltzer 2001a). Adolescence in particular seems to be a very important period, because it is the time when people are looking for, experimenting with and also establishing the life style, atti-

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tudes, concepts, beliefs and habits that may have long-term influences on their health (Geckova et al. 2001). The rapid social, physical and mental development that occurs during adolescence is important as many of the health behaviours, which become manifest in adulthood, such as smoking, have their origins during younger years. The use of illicit drugs and alcohol and other forms of risk taking during adolescence may not only have an immediate impact on morbidity and mortality, but may also contribute to actions which cause injuries. Thus, behaviours such as tobacco use, food choices, and physical activity are also measured as indicators of adolescent ‘health’ because of their importance as determinants of future health status (e.g. as a cause of chronic diseases such as heart disease and cancer) (Nutbeam 1997). Poor health behaviours of some students are a cause of concern in relation to health (Rigotti, Lee and Wechsler 2000) and, in addition, symptoms of depression and anxiety are of concern among students and are associated with poor academic performance and limited participation in scholarly activities (Reifman and Dunkel-Schetter 1990). Some research indicates that depression and/or anxiety may be associated with alcohol use and tobacco use (Al-Subaie 1998, Green and Pope 2000). Allgöwer, Wardle and Steptoe (2001) found as part of the European Health and Behaviour Survey among university students that depressive symptoms were significantly associated with lack of physical activity, not eating breakfast, irregular sleep hours and not using a seat belt in both men and women and, additionally among women, with smoking, not eating fruit, and not using sunscreen. Low social support was independently associated with low alcohol consumption, lack of physical activity, irregular sleep hours and not using a seat belt in men and women. There is a lack of studies on health behaviours such as diet, physical activity, seat belt use, preventive health check ups and sleep hours among African populations. It is also of interest how these health behaviours are related to stress, social support and psychopathology. There is evidence that personal health behaviours are associated with psychological symptoms and psychological well-being (Allgöwer et al. 2001), so the nature of the interrelationship of these factors is of great interest; especially among an African sample this has not been studied. Thus, this study investigated stress events, perceived stress and social support in relation to various common health behaviours among black South African students. Since there may be important differences in the development of health behaviours and psychological variables associated with them between different age or school levels, this study investigated senior secondary school and third year university students. Data from the study could contribute to more effective lifestyle intervention programmes among students should data on stress, minor psychiatric morbidity and other factors be included. Method Sample The sample included 624 students: 314 grade 12 secondary school students chosen at random from three rural schools

Peltzer

in the central region of the Northern Province and 310 third year social science university students from the University of the North chosen at convenience in a class room setting. The secondary school students were 113 (36%) males and 201 (64%) females in the age range of 15 to 24 years (M age 18.9yr, SD = 2.1) and the university students were 91 (29.4%) males and 219 (70.6%) females in the age range of 17 to 39 years (M age 23.8yr, SD = 4.0). Distribution by ethnicity showed 423 (84%) Northern Sotho, 50 (10%) Tsonga and 30 (6%) other. The income of the child’s father was reflected as follows: none 77.5%, ZAR1–999 per month 7.4%, ZAR1 000–2 999 per month 5.6%, ZAR3 000–6 999 per month 7% and above ZAR7 000 per month 2.4%. The income of the child’s mother was reflected as follows: none 76.5%, ZAR1–999 per month 8.8%, ZAR1 000–2 999 per month 5.3%, ZAR3 000–6 999 per month 6.8% and above ZAR7 000 per month 2.2%. Measures A 31-item Students Stress Scale was used, which is an adaptation of Holmes and Rahe’s Social Readjustment Rating Scale (Zimbardo 1992) of items in relation to interpersonal events (e.g. ‘Death of a close family member?’), study (e.g. ‘Failing an important subject?’), financial (e.g. ‘Change in financial status?’), illness (e.g. ‘Major personal injury or illness?’) and other factors (e.g. ‘Pregnancy?’, ‘Sex problems?’). Students were asked to answer either ‘yes’ or ‘no’. The scores ranged from 0–31, with a mean item score of 9.95 (SD = 5.7). The Student Stress Scale has been validated with South African secondary school students previously (Peltzer, Cherian and Cherian 1999a). Cronbach alpha for the Student Stress Scale was 0.83 for this sample. A 14-item Perceived Stress Scale (Cohen, Kamarck and Mermelstein 1983) designed to assess the extent to which an individual perceives various life events as stressful was also used. Answers were given on a 5-point scale anchored by 0 (never) and 4 (very often). Scores are obtained by reversing the scores on the seven positive items, and then summing across all 14 items. The scores ranged from 0–56, with a mean score of 24.5 (SD = 8.7). The Perceived Stress Scale has been validated with South African secondary school students previously (Peltzer, Cherian and Cherian 1999a). Cronbach alpha for the Perceived Stress Scale was 0.70 for this sample. A 20-item Self-reporting Questionnaire (SRQ) (WHO 1994) measured minor psychiatric morbidity using 10 depressive (e.g. ‘Do you feel unhappy?’), 5 anxiety (e.g. ‘Are you easily frightened?’), and 5 somatic complaints (e.g. Do you have uncomfortable feelings in your stomach?). Students were asked to answer either ‘yes’ or ‘no’. Each of the 20 questions is scored 1 or 0; a score of 1 indicates that the symptom was present during the past month; a score of 0 indicates that it was absent. The scores ranged from 0–20, with a mean item score of 6.3 (SD = 4.8). The Self-reporting Questionnaire has been validated with South African secondary school students previously (Peltzer, Cherian and Cherian 1999a). Cronbach alpha for the Self-reporting Questionnaire was 0.86 for this sample. Depending on the criteria, culture and language, different cut-off scores are selected in different studies, but most often the cut-off score

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of 7 or above indicates the existence of a probable psychological problem (Sartorius and Janca 1996). In the only study with the Self-reporting Questionnaire in a community sample in South Africa by Rumble et al. (1996), with a sample of 481 rural black adults, a cut-off score of 8 was established. Social support was assessed by two items: (1) having someone to talk things over with when there are problems and (2) friends caring about you, rated with 1 = agree and 0 = disagree. Finally, a 20-item Self Health Appraisal Questionnaire (Lawrence and Schank 1993) was included. The following 15 personal health behaviours were investigated in this analysis: physical examination in the past two years, dentist in the last two years, eyes checked within the past two years, know how to do a breast self-examination, ever had a mammogram, habitual (always) seatbelt use, never drinking and driving, no habitual (daily) alcohol use, non-smoking of cigarettes, never used illicit drugs, four or more times a week physical activity, 8–10 hours sleep time, habitual (daily) breakfast, diet includes the basic four food groups and protected sex. Ratings of each behaviour were transformed into binary outcomes, with the ‘healthy’ option being coded 1 and the ‘unhealthy’ option being coded 0. The English version was pilot-tested twice on a sample of 20 students, and the test-retest reliability was 0.80. Cronbach alpha for the 14 item (mammogram was excluded as it only applies to women) ‘Health Behaviour Index’ was 0.68 for this sample. Procedure Trained postgraduate research assistants administered the English version of the questionnaires to the students. Students filled in the questionnaires voluntarily after informed informal (or verbal) consent in the presence of the research assistants and were free to ask questions for clar-

ification. Anonymity and confidentiality were assured. No time limit was given, but on average students took 15 minutes to answer all the questions. Permission was obtained from the relevant authorities. Results Table 1 shows the relationship between health behaviour, stress events, perceived stress and psychological symptoms. The prevalence of healthy behaviours was on average 5.8 (SD = 2.3) from a total of 14 healthy behaviours (mammogram was excluded). Most participants reported that they never used illicit drugs (94.1%), never engaged in drink driving (86.1%), are non-smokers (84.5%), that their diet includes the basic four food groups (60.1%) However, low prevalence rates were reported among women for having had a mammogram (4%), physical activity (21.1%), eye check up (24.2%), protected sex (27.1%), habitual seat belt use (28.8%), normal sleep hours (30%), physical exam (34.6%), and habitual breakfast (43.1%). There were 37 (11.8%) secondary school and 48 (15.5%) university students with scores on the Self-reporting Questionnaire-20 of 11 or more, indicating a clinically significant psychological disorder, and 91 (29%) secondary school and 43 (14%) university students with scores of 8 or more, indicating a possible significant psychological disturbance. The mean scores for males was 5.7 (SD = 3.7) and for females 6.4 (SD = 5.1). Stress events (r = 0.31, P < 0.001), perceived stress (r = 0.13, P < 0.05) and social support (rho = 0.31, P < 0.001) were associated with the Self-reporting Questionnaire-20 score. The overall health behaviour was positively associated with perceived stress and inversely related with psychological symptoms and depressive symptoms of the SRQ. The number of stress events experienced were associated with

Table 1: Analysis of Variance (ANOVA) between health behaviour, stress and psychological symptoms Item

Physical exam past 2 years Dentist past 2 years Eyes checked within the past 2 years Know breast self-exam Ever had mammogram (female only) Habitual seat belt use (always) Never drink driving No habitual alcohol use (daily) Non-smoking of cigarettes Never used illegal drugs# Physical activity (4 or more times/week) Normal sleep hours (8–10) Habitual breakfast (daily) My diet includes the basic four food groups Protected sex Total health behaviour

#

Percent

34.6 28.8 24.2 20.7 04.2 28.8 86.1 80.2 84.5 94.1 21.2 30.0 43.1 60.1 27.1 M = 05.8 SD = 2.3

Stress events F 34.80*** 04.97* 00.65 01.33 00.01 00.00 –16.19*** 00.09 –07.86** 00.15 08.02** 01.97 00.03 00.38 00.10 r = 00.07

Cannabis, Cocaine, Morphine; *** P < 0.001, ** P < 0.01, * P < 0.05

Perceived stress F 21.73*** 33.78*** 57.56*** 43.82.*** 10.26*** 15.00*** –04.06* 00.76 01.24 00.90 07.74** 04.73* 01.63 08.41** 39.84*** r = 00.35*** r =

SRQ F 13.90*** –06.44* –11.46*** 00.29 –13.69*** –10.09** 01.95 02.36 01.82 –06.47* 00.02 00.35 –07.96** –14.17*** 00.00 –00.13**

SRQ depression F 15.64*** –15.67*** –22.77*** –09.67** –10.43*** –20.60*** 01.94 01.39 00.32 00.67 01.84 –07.50** –12.37*** –11.39*** –05.04* r = –00.21***

Social support X2 07.61* 15.88*** 14.74*** 08.76* 04.77 09.62** 04.05 39.74*** 09.51** 01.66 02.12 07.83* 02.11 16.10*** 00.47 F = 03.43*

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Peltzer

physical exam in the past two years, physical activity, drink driving, smoking cigarettes, and depressive symptoms of the SRQ (r = 0.26, P < 0 001). Perceived stress was positively associated with most of the individual health behaviours including eyes checked, protected sex, knowing how to exam the breast for cancer (for women only), having consulted the dentist or having had a physical exam in the past two years, habitual seat belt use, diet, having had a mammogram (for women only), physical activity and normal sleep hours. Minor psychiatric morbidity, as measured by the SRQ as well as depression symptoms from the SRQ, were inversely associated with two-thirds of the healthy behaviours such as habitual seat belt use, diet, habitual breakfast, having had a mammogram, eyes checked and dentist consulted in the past two years. In addition, depressive symptoms were also associated with unprotected sex, abnormal sleep hours and not knowing how to self-exam one’s breast (for women only). Having had a physical examination in the past two years was associated with minor psychiatric morbidity. Social support was positively associated with the health behaviour index and in particular with no habitual alcohol use, diet, dental and eyes check up, non-smoking and habitual seat belt use. Table 2 shows the health behaviour index, stress and psychological symptoms by gender. Female students reported more healthy behaviours (6.1) than male students (5.3) and male students had experienced more stress events than female students. There were no significant gender differences regarding minor psychiatric morbidity, depressive symptoms, perceived stress and gender. Social support was positively associated with the health behaviour index (F = 3.41, P = 0.033) and inversely related with the SRQ (F = 23.82, P < 0.001), depressive symptoms (F = 7.85, P < 0.001), and perceived stress (F = 12.00, P < 0.001). Table 3 shows the health behaviour index, stress and psychological symptoms by school level. University students reported more healthy behaviours (6.7) than secondary school students (5.0) and university students had experienced more stress events and scored higher on the Perceived Stress Scale than secondary school students. However, secondary school students reported more psychological symptoms including depressive symptoms than university students.

Table 2: Health behaviour, stress and minor psychiatric morbidity by gender

Discussion The study found a low prevalence of healthy behaviour, which was inversely related to psychological symptoms and depressive symptoms and positively related to perceived stress. Psychological symptoms as measured by the SRQ as well as depression symptoms from the SRQ were inversely associated with two-thirds of the healthy behaviours such as habitual seat belt use, diet, habitual breakfast, having had a mammogram, eyes checked and dentist consulted in the past two years. Allgöwer et al. (2001) also found in a study among European university students that depressive symptoms were related to a number of unhealthy behaviours such as not eating breakfast, short or long sleep hours, not using a seat belt and lack of physical activity in both men and women. Inconsistent with the literature is that alcohol and tobacco use was not related to psychological symptoms in this sample (Al-Subaie 1998, Green and Pope 2000). There were 11.8% secondary school and 15.5% university students with scores on the Self-reporting Questionnaire-20 of 11 or more, indicating a clinically significant psychological disorder, and 29% secondary school and 14% university students with scores of 8 or more, indicating a possible significant psychological disturbance. Peltzer et al. (1999) found similar prevalence rates among grade 11 secondary school students in the Limpopo Province , namely 12.6% 11 or more symptoms and 21.7% with a Selfreporting Questionnaire-20 score of 8 or more. The study further found that social support was positively associated with the health behaviour index and inversely related with the SRQ, depressive symptoms and perceived stress. In particular, social support was associated with no habitual alcohol use, diet, dental and eyes check up, nonsmoking, habitual seat belt use and normal sleep hours. Allgöwer et al. (2001) also found among European university students that social support was related with habitual seat belt use, normal sleep hours and non-habitual alcohol use. The finding that protective health behaviours were related to social support is consistent with other studies The study found that psychological symptoms including depressive symptoms might be indicative for a detrimental effect on various health behaviours and social support indicative for reinforcing healthy behaviours. Therefore, it is suggested that psychological symptoms, social support, as

Table 3: Health behaviour, stress and psychological symptoms by school level Scale

Scale Health index Stress events Perceived stress SRQ SRQ depression

M 5.3 11.4 23.8 5.7 2.4

Male SD 2.0 6.0 7.9 3.7 1.7

*** P < 0.001, ** P < 0.01, * P < 0.05

Female M SD 6.1 2.5 9.3 5.4 25.1 8.9 6.4 5.1 2.6 2.6

t –3.96*** 3.59*** –1.63 –1.42 –0.69

Health index Stress events Perceived stress SRQ SRQ depression

Senior secondary University school students students M SD M SD 5.0 1.8 6.7 2.5 8.5 5.1 10.7 5.8 19.6 7.7 28.2 7.6 7.2 4.3 5.6 5.0 3.1 2.1 1.9 2.4

*** P < 0.001, ** P < 0.01, * P < 0.05

t 9.18*** 3.72*** 12.46*** –3.69*** –6.30***

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well as stress-management need to be included in enhancing lifestyle intervention programmes among youth. It is not clear why perceived stress seemed to increase various health behaviours, which needs further investigation. These data are cross-sectional and no conclusions about causality can be drawn. However, it is implausible that failure to use a seat belt, not having breakfast or not consulting the dentist in the past two years causes psychological symptoms. In these cases, the failure of protective behaviour may result from anxiety or depression and a lack of concern about long-term consequences (Allgöwer et al. 2001). The study was based on a questionnaire survey and is therefore dependent on the reliability of self-report data. Most behaviours were indexed by single-item measures rather than more detailed inventories and different cutoff points in the classification of health behaviours might have altered the associations with variables. Moreover, the social support measure included only two items and results have to be interpreted with caution. Acknowledgements — The financial assistance of the University of the North towards this research is hereby acknowledged.

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