H. GOLD, M.D., F.R.C.P.(C) Assistant Professor

Department ofPsychiatry Dalhousie University Nova Scotia


Read at The Annual Meeting of The Canadian Psychiatric Association

Quebec City September 29, 1976

rapid growth in university enrollments and in university services Now, in the belt-tightening 1970’s politicians, educators and students are examining and questioning the functions of universities. 10 HE 1960’s

T throughout There


saw a

the world.

many crucial determinants of the outcome and individual benefits of

university education including a stressful interplay of cultural, social and economic factors which affect mental health as well as academic functioning. The years of late adolescence are devoted by the student to learning at the same time as he is forming emotions and ideals into a practical lifestyle, influenced and affected by events in his personal, family and national political existence. All of these form potential stresses which can add to or detract from his studies through their effect on his emotional, and therefore, on his intellectual functioning. Academic achievement and mental health are topics which have been related by a few researchers at individual universities.2, 3, 13, 17, 22, 23 This present paper reports on an on-going study of the mental health of students at universities in different countries and cultures. Findings from Canada and Britain have been presented in earlier papers and will be contrasted to those in Singapore.5-8 Studies in Jamaica, Indonesia, Malaysia and Venezuela are in progress. The effect of national political-economic uncertainties is well illustrated by the difficulties encountered in completing such a project. Postponements and delays are frequent as universities are closed for periods by student unrest or the project is halted by political controls. It was expected, therefore, that the findings in each country would vary not only with culture but also with the political socio-economic situation peculiar to each.15, 18 The resultant stresses would be reflected in the incidence of mental health problems necessitating visits to the university health a


This study began at Dalhousie University, Halifax, Nova Scotia, Canada, in 1969. The freshman undergraduate class enrolling that year was followed until graduation in 1972, having completed an initial questionnaire at first registration. Six universities in Britain formed the next stage. Final year undergraduates at each responded to a questionnaire adapted from that used at Dalhousie University. During the 1973-1974 academic year final year students at the Universities of Nottingham, Birmingham, Sussex, Durham, University College London and University College Cardiff were studied. Various countries in Europe, Africa, Asia and South America were visited. Topics covered in literature reviewed included university student health and mental health, cross-cultural and epidemiological Downloaded from isp.sagepub.com at UNIV NEBRASKA LIBRARIES on March 13, 2015


studies, educational, health

and economic concerns of the lesser developed countries. study Singapore was carried out during the 1975-76 academic year and serves as a bridge between the industrialized and the developing countries in this project. Singapore is an island which became an independent state in 1965. The official languages are Malay, Chinese, Tamil and English; English is the administrative language. The total population of over 2 million live on some 225 square miles and include mainly Chinese, Malay and Indians with Chinese the majority.21 It is a prosperous island with many manufacturing industries and a great emphasis on exporting and the tourist trade. It is geographically as well as economically the crossroads of South East Asia. Thus, there is a constant need for higher technological training and applied skilled labour. The University of Singapore is expanding rapidly and had 5,888 students in 1975-76. The Student Health Clinic was established in 1952 and is situated on an edge of the main campus. There is another smaller university on the island as well as technical colleges and a Teachers Train-



ing College. METHOD

The final year undergraduates at Singapore University were given a questionnaire to complete. It was handed out and collected at the beginning of a lecture hour. The students were told briefly that this was a part of an international study into the health of university students and that their responses would be of use in planning for health needs at the university. They could remain anonymous. The questionnaire was the same one used in Britain with modifications for culture and terminology. A total of 1,382 students were enrolled and 1,171 responded, or 84.7%. The missing 211 students were absent on the study day for their faculty (Table 1). The data obtained gave an overall description of the group, which included epidemiological details, a personality assessment and factors pertaining to use of the Student Health Clinic itself. ,

DESCRIPTION OF SAMPLE: Ethnic Origin: (Table II) Chinese students made up 89% of the group sampled and are thus overrepresented when compared to the general population of Singapore. In contrast Malays are underrepresented. This finding reflects the predominance of the Chinese in the country’s elite. Sex: 544 males and 617 females responded and this response reflects exactly the actual enrollment. ....

Age: Most students were between 22 and 25 years of age in their final year of study. The females were a little younger than the males as the latter had to complete military service before beginning university. Residence: The great majority lived at home throughout university. There was a marked tendency to move out of home in the final year and into a university residence or a rented flat. This finding is related to the fact that 77% of the students were from Singapore itself, 20% from neighbouring Malaysia and only 3% from other countries.

Family Background: (Table III) While 85% of the students replied that their parental marriage was intact, nearDownloaded from isp.sagepub.com at UNIV NEBRASKA LIBRARIES on March 13, 2015

86 had a widowed parent. The largest group claimed the head of the family to salaried employee (39%). Over 22% stated their parent was retired, 14% were employees of 25 or less. Overall, the majority came from the upper work echelon, but 203 students (17.3%) did not know the family income. One-third of the students claimed to be irreligious. Another third was Protestant, 15% were Buddist, 10% Catholic. Family size was also of interest. Very few students were the only child or one of two. The majority had 4 to 7 or more siblings. However, rank in the family was important as more students were the first or second child than other rankings and the numbers decreased with birth rank.

ly 13%



Clinic Use (a) 785 students (67%) in the sample had been to the Student Health Clinic. They came mostly for physical ailments. About 3% claimed an emotional problem to be the cause of their use of the clinic. Of the non-users, 66% were not ill, 43% had their own general practitioner, and many were unhappy about the clinic’s location and hours. (Table IV) (b) The clinic records for the 1975-76 year give the following diagnosis for the entire university population.ll

1 he contrast in the two sets of data will be discussed later.

Factors Relating to Clinic Use A. General Use While all ethnic groups used the clinic, the students of Malay and Ceylonese origin were proportionately the main users.12, 24 Students living in university residences or with relatives were proportionately greater clinic users than those living at home in their second and third years. Those in their fourth year (final year honours) tended to visit more if they lived in university residences or in rented flats. Again, the finding that those away from home utilized the clinic more than the local students is supported by the Malaysian students’ greater use of the clinic than those ’

from Singapore. While the use of the clinic could students who claimed that religion was


be related to religious in their lifestyle


affiliation, were more

those often


Those who stated that they were healthy before beginning university were clinic users significantly more than their previously sickly classmates. This probably means that the ill students already had their own doctors. Finally, clinic users describe themselves as very sensitive and shy. All of the foregoing were significant at the level p>.01. Age, sex, faculty of study, family income, parents’ occupation and marital status, sibling number and birth rank were all non-significant factors when associated with clinic use. -


Use for Psychological Complaints There were few factors distinguishing students who reported having psychological difficulties from their peers. They complained of headaches and being sickly before entering university and came often from one parent homes. Students disDownloaded from isp.sagepub.com at UNIV NEBRASKA LIBRARIES on March 13, 2015


claiming a firm religious belief tended to admit to emotional problems, as did those living away from home by second year. They described themselves, to a significant as sensitive, shy, quiet, lonely, seclusive, sad, uncertain, nervous extent, (p>.01) people with few friends. C. Britain and Canada: Singapore users in the Canadian and British studies were similar in most respect. In Britain, 81.1 % of the 1603 sampled visited their university clinics, reporting an average 13.7% use for emotional difficulties. (range between universities was 7.4% - 24.5%) These students were most often in Arts, Social Science and Pure Science, were female and living off-campus. They had little religious affiliation and described themselves in the same terms as the Singapore students. The Dalhousie study of 888 students found a 71.2% use of the clinic with 18.3% having an emotional component. There was no difference by sex but they too lived away from home, and off campus, with personality characteristics similar to those in Britain and Singapore.




Of the 1171 Singapore students 67% were Student Health Clinic patients. Of these 3.2% felt their complaints had an emotional basis. The clinic statistics differ markedly with 25.32% of diagnosis being psychosomatic and psychiatric. Clinic use did not correlate positively with sex or the faculty of study. However, the latter may be affected by the relatively poor response of the Arts and Social Science group. The students who did admit to psychological problems were disusers they tinguished mainly by their personality self-assessments. Like other clinic lived away from home but came more often from broken homes. (p = .02) Singapore students claimed a religious belief more frequently than did the Canadian or British students. A large number did not know the family income, many students did not give their age and most remained anonymous, some blanking out the name they had written on the form. Many students commented on their Health Service at the University of Singapore. Generally, they asked for emphasis on physical ailments, more medications, and complained about psychological interpretations of their symptoms. Their reluctance to admit to or deal with emotional conflicts is made obvious by the difference in statistics of categories of clinic use given above.

Discussion The findings in the three countries differ in several areas. Many more Singapore students lived at home, came from large religious families but were unaware of the family income. Families were not only large but often only had one parent.18 These students seemed reluctant to give data, such as their age. Were they fearful of losing their anonymity? While there were many complaints that the clinic was inconveniently located very few lacked confidence in the secrecy of their medical records. Some of the differences may be cultural - Chinese as opposed to British and Canadian - while others are related to the economic development of Singapore. There are over three times as many females as males in Arts and Social Science in Singapore University, but many more males in Engineering. Women predominate in Science and in Business, Accountancy and Law. These findings differ from the two other studies. Other studies mention certain characteristics of the Chinese Singaporean Downloaded from isp.sagepub.com at UNIV NEBRASKA LIBRARIES on March 13, 2015


student.1, 24 Authoritarian family

structure plus an emphasis on education causes these young people to study rather than to play at university. In general, the students are examination and achievement oriented with little interest in things psychological.12 These characteristics are emphasized by the country’s demand for trained technocrats. The absence of a sociology department, and of psychiatry in the medical school seem to highlight this point.. In contrast the students studied in Britain and Canada were very interested, in general, in their personality self-assessment. Many asked for more help with psychological problems rather than denying their existence as in Singapore. However, in all universities it was obvious that the students wished to be heard first, then treated as indicated by their complaints. Too much emphasis by physicians on the physical or the psychological drew equal condemnation. Thus, the theoretical orientation of clinic personnel remains crucial.8 Studies of utilization of a medical clinic or of incidence and prevalence of mental illness are inevitably open to biased reporting unless the researcher remains alert. Patients have a well known ability to fit into the clinical picture the examiner is visualizing. A search for psychological problems in university students must guard against too wide a definition of mental ill health in that age group. Several recent studies of adolescents have shown that adolescent turmoil is not the norm.9, 15, 20 We need not expect every young person to have pathological emotional upsets, but also we must be wary of what we do label as illness. A study of university students in various countries and from varying cultures emphasizes this point. ’rhe Singapore University students are the same age as those in Canada and Britain. Mainly Chinese, they have different cultural expectations and outlooks. But, beyond that, they are also products of their particular unique society. They are molding themselves to fit into a work oriented, industrialized, burgeoning and wealthy developing city state while remaining devoted children of large authoritarian families. The psychological traumas of ego identity and psychosocial moratoriums are outside this ethic.4 Yet, the study reported here reveals that these students are becoming more like their western counterparts. Males and females have an equal incidence of psychological disorders and clinic visits. Women are enrolling in the traditionally male dominated fields of Business and Engineering. This is a change in the last decade.13 A surprising number do not adhere to their parents’ religion despite living at home in such a rigid culture. Furthermore, a slow but steady increase in student unrest and drug abuse points to an erosion of fear of authority. Perhaps a further study in five years will yield results more comparable to those in Britain and Canada. Meanwhile, the students’ insistence on anonymity, to the extent of omitting age, as well as name, their lack of knowledge of family finances, and their insistence on physical treatment only, illustrate how different these young people are from those presenting at university health clinics in Canada and Britain. University students become the future of a country. However, they must learn skills which are of use to that country without losing their cultural identity. This is the problem in many developing countries where the educated young adult no longer fits into his family and his environment. It would seem, however, that the graduate from Singapore University in 1976 will not have this difficulty. REFERENCES


E.: The Role

of Occupational Medicine in the Promotion of Mental Health in the University Student. Singapore, University Health Service, University of Singapore, 1970. 2. Crown, S., Lucas, C. J., Supremaniam, S.: ’The Delineation and Measurement of Study


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. Psychiatry. 1973, 123: 381. Difficulty in University Students.’ Brit. J Davies, D., Stengel, E.: ’The Effects of Anxiety on Students’ Progress.’ Annual Proceedings of the British Student Health Association, 1966. 4. Erikson, E.: Identity: Youth and Crisis: New York, W. W. Norton and Company, Inc., 3.

1968. 5.

Gold, J. H.: ’Utilization of the Student Health Clinic.’ J. Am. Coll. Health Assoc. 1973,


H.: British Student Health: A ’Comparative Analysis of Use and Services offered Six Universities.’ Annual Proceedings of the British Student Health Association, 1975. Gold, J. H.: ’Social Stress and Mental Health: A Crossculture Study of University Students.’ Canadian Sociology and Anthropology Association Meeting, Laval University, Quebec City, 1976. Hudgens, R. W.: Psychiatric Disorders in Adolescents. Baltimore, The Williams & Wilkins Company, 1974. I.D.R.C. : Education research priorities: a collective view. Ottawa, IDRC - 068e, 1976. Kadri, Z. N.: Personal Communication, 1976. Kadri, Z. N.: ’A Twelve-Year Survey of Schizophrenia in a South-East Asian University. J. Am. Coll. Health Assoc., 1975, 23:313. Kadri, Z. N.: ’Personality appraisal of South-East Asian University Students.’ J. Am. Coll. Health Assoc., 1966, Dec.: 131. Kidd, C. G., Caldbeck-Meenan, Y.: ’A Comparative Study of Psychiatric Morbidity Among Students at Two Different Universities.’ Brit. J. Psychiatry, 1966, 112:57. Leighton, A. H.: ’The Erosion of Norms.’ Aust. NZ J. Psychiatry, 1974, 8 : 223. Masterson, J. F.: The Psychiatric Dilemma of Adolescence. Boston, Little, Brown & Co., 1967. McMichael, P. M.: ’Self-Reported Emotional Illness, Its Consequences and Correlates A Study of First Year Edinburgh Students.’, 1973, Nov., mimeographed paper. Murphy, J. M., Leighton, A. H.: Approaches to Cross-Cultural Psychiatry. Ithaca, New York, Cornell University Press, 1965. Development Centre of the O.E.C.D.: The Challenge of Unemployment to Development and the Role of Training and Research Institutes in Development. Paris, 1971. Offer, D., Offer, J. B.: From Teenager to Young Manhood. New York, Basic Books Inc., 1975. Paxton, J. (Ed.): The Statesman’s Year-Book, 1973/1974. London, The Macmillan Press Ltd., 1973. Payne, J.: ’Review of Literature on Student Wastage.’ Annual Proceedings of the British Student Health Association, 1969. Savonen, K.: ’Development of Preventive Measures in the Finnish Student Health Service.’ Annual Proceedings of the British Student Health Association, 1965. Teoh, J. I. : ’Psychological Problems Among University Students in an Area of Rapid Socio-Cultural Change.’ Aust. NZ J. Psychiatry, 1974, 8: 109.


Gold, J.


7. 9. 10. 11.

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many crucial determinants of the individual outcome and benefit of education including the stressful interplay of cultural and socioeconomic factors which are of growing importance in the inflationary 1970’s. An epidemiological study of university students from 1969 - 1972 in Canada, 1973 1974 in Britain, and 1975 in Singapore, attempted to identify stresses leading to mental ill-health in these students. Singapore was chosen as an example of a culture bridling the developed Northern and developing Southern nations of the world. Cultural differences affecting the results of the study are discussed as is the role of Downloaded from isp.sagepub.com at UNIV NEBRASKA LIBRARIES on March 13, 2015 social change. a








’&dquo; ~*’

66 did not Based on

reply to this question. Office of Population Consensus and Surveys, Classification of Occupations. London,







possible by



Fellowship (1973-1975)



grants from The Dean’s M.R.C. Fund, Dalhousie University. The assistance of K. L.

Weldon, Ph. D., Department of Preventive Medicine, Dalhousie University, is gratefully acknowledged. The project could not have been accomplished without the great effort and co-operation of Dr. Z. N. Kadri, Physician and Head, UniverDownloaded from isp.sagepub.com UNIV NEBRASKA LIBRARIES on March 13, 2015 Service and atMr. Foo Choo sity of Singapore’s Health Keng.


Uniaersitdt Studenten und geistiges Wohlbe finden: Kanada, Grossbritannien und Singapur. Es existieren viele entscheidende Determinante der individuellen Ergebnisse und Vorteile einer Universitatsausbildung einschliesslich der kulturellen und sozialwirtschaftlichen Umstande die im Inflationsjahrzehnt 1970 zunehmende Bedeutung haben. Eine epidemiologische Untersuchung von Universitit Studenten im Jahre 1969-1970 in Kanada; 1973-1974 in Grossbritannien, und in 1975 in Singapur versuchte die verschiedenen Drucke die zu Geisteskrankheiten in Studenten f3hren zu identifizieren. Singapur wurde als Beispiel einer Kulturbrücke zwischen den industriellen Staaten des Nordens und den Entwicklungslandern des Sudens ausgesucht. Die Kulturunterschiede und ihr Einfluss auf die Resultate der Untersuchung, sowie die Rolle sozialer Umwalzung werden diskutiert.

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University students and mental health. Canada, Britain and Singapore.

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