Gender differences in mental health literacy among Chinese-speaking Australians in Melbourne,Australia

Abstract

Objective: This study attempted to understand gender differences in knowledge of mental illness, preference for professional help, and medications and treatment methods among Australians of Chinese-speaking background.

Methods: This study adopted a cluster convenience sampling method in which subjects were taken from the four major areas in cosmopolitan Melbourne where most Chinese people are living. A total of 200 Chinese-speaking Australians participated in the study. They were presented with two vignettes describing an individual with acute depression or acute schizophrenia and then questions were asked to assess their understanding of the conditions, preference for professional help, medications and treatment methods.

Results: More female than male respondents could correctly identify the conditions in the two vignettes. Female participants also perceived medications to be relatively more harmful than their male counterparts. In contrast, there were significantly more males than females who adhered to traditional views on the causation of mental illness; had significantly higher percentages of endorsement of ‘deal with it alone’; believed ‘traditional Chinese medical doctor’ and ‘Chinese herbal medicines’ to be helpful to the person in the schizophrenia vignette; and significantly endorsed ‘psychiatric ward’, ‘electro-convulsive treatment’, ‘changing fungshui’ and ‘traditional Chinese worship’ to be helpful for the persons in both vignettes. A combination of factors, which included age, duration of migration and traditional Chinese cultural values, were put forward to explain the above differences.

Conclusions: Campaigns to improve the mental health literacy of Chinese-speaking Australians must take into account the gender differences between male and female Chinese-speaking Australians so that culturally relevant and gender-specific education programmes can be developed.

Keywords

Chinese-speaking Australians cultural beliefs depression knowledge of mental health services mental health literacy schizophrenia

Introduction

Studies have suggested that people with a longer duration of untreated mental health conditions such as psychosis are likely to be less responsive to treatment and require more long-term intensive intervention (McGorry and Jackson, 1999). Moreover, a growing body of clinical evidence has revealed that early detection and intervention in young people with schizophrenia can result in a substantial reduction in morbidity and in better quality of life for these people and their families (Black et al., 2001). Indeed, it has been suggested that recovery from mental illness is greatest at the early stage of the development of the illness (Drake et al., 2000). In the literature, it has been revealed that Chinese people have a longer delay of seeking help from psychiatric services than other cultural groups (e.g. Burnett et al., 1999; Ryder et al., 2000), and several socio-cultural factors have been found to be associated with such a delay. These include (1) influences of the social network, (2) perceptions of the causation of mental illness, (3) stigmatization and (4) lack of recognition of the symptoms as a mental illness.

In a society with collectivist and familial orientations, elders in the family, particularly parents, still hold strong beliefs that they are responsible of taking care of their offspring, disabled or not (Young, 1996). The decision to seek help, therefore, does not rest with the individuals (i.e. young and/or disabled), but incorporates the views of different family members or close relatives and friends. Therefore, how people in a close informal network perceive the symptoms and the mental health services affects the course and nature of the help-seeking pathways. Another possible factor relating to the delay in help seeking is beliefs about the causation of mental illness. In some non-Western cultures, supernatural phenomena, such as witchcraft and possession by evil spirits, are seen as major causes of mental disorders (Jorm, 2000). Tseng (2001) suggests that Asian people have usedsupernatural explanations, natural explanations and somato-medical explanations to understand the cause of a mental disorder. The third possible reason is stigmatization. Kramer et al. (2002) suggest that mental illness is particularly stigmatizing in the Asian cultures. Persons with mental illness and their family members may be reluctant to disclose their problems to others because of a fear of social rejection, social distancing and hostility (Crisp et al., 2000). In the initial stage of the development of a mental illness such as psychosis, these individuals may ignore the presence of the symptoms and ascribe these symptoms to causes other than mental illness. Others may try to manage the symptoms for as long as they can cope. Finally, illness recognition is considered as an important determinant in the help-seeking process. Family members and the ill relatives who do not have sufficient knowledge of mental illness may not be able to recognize the symptoms of a mental disorder. As a result, they do not adequately communicate information to others or may view the symptoms as trivial (McGorry and Jackson, 1999).

This study was particularly interested in examining the knowledge of mental illness among male and female Chinese in Melbourne, Australia. In it, the term ‘mental health literacy’ is used, which denotes ‘knowledge and beliefs about mental disorders which aid their recognition, management or prevention’ (Jorm, 2000). Inherent in this concept is the assumption that individuals who have a higher level of mental health literary will be more willing to seek professional help for themselves and/or for people whom they know may be suffering from a mental health problem. A growing number of studies have been conducted to examine the mental health literacy of different cultural groups such as the Australians, Japanese, Germans and Chinese (Gaebel et al., 2002; Jorm, 2000; Jorm et al., 1997; Wong et al., 2010). These studies have identified certain demo-sociocultural factors that explained the mental health literacy found among these various cultural groups. Indeed, Lauber et al. (2003) have argued that demographic variables are crucial to our understanding of attitudinal and epidemiological studies. One such variable that is of interest to the study of mental health literacy is ‘gender difference’. A study conducted by Jorm et al. (2005) on the mental health literacy of Australians found that women rated lifestyle (e.g. getting out and about more) and psychological factors (e.g. consulting psychologists) as being slightly more helpful than did men. The study conducted by Wang et al. (2007) on Canadians regarding depression literacy has revealed that men had poorer depression literacy than women and were more likely to endorse the use of alcohol to cope with difficulties. In Germany, Gaebel et al. (2002) found that women were better informed about the causes of schizophrenia than men. There were also more women than men who endorsed interventions such as ‘more education and information on mental illness’ and ‘more opportunities for contact with the mentally ill’ as helpful to a person with schizophrenia. Barry and Grilo (2002) explored Asian Americans’ willingness to seek help from psychological services and found that female participants and those who were older were more willing to seek or to recommend psychological services. To conclude, previous studies appear to suggest that (1) females appear to have better mental health literacy than males and (2) females tend to endorse psychological explanations about the cause of mental illness and to adopt psychological interventions more so than men.

However, there are some interesting variations in the findings on gender difference in mental health literacy between the above studies and the ones conducted on the Chinese population. Boey (1999) found that Chinese male participants were more willing to use mental health services than their female counterparts. Furnham and Chan (2004) found that more Chinese male than female participants tended to favour psychological explanations (e.g. social stress) of schizophrenia and disagreed with a biological explanation. A study conducted by Tang et al. (2007) on Chinese in mainland China found that female Chinese participants had a greater tendency to seek help from non- psychiatric facilities than male Chinese participants. These included traditional Chinese medicine, general hospitals, qigong practice, folk healing and visiting famous religious places to pray. To summarize the above findings, (1) Chinese males seem to endorse psychological explanations more so than Chinese females and (2) Chinese females appear to endorse non-medical interventions more so than Chinese males. How does one account for these differences in the findings? Do cultural values play a part in shaping the understanding of mental illness and the differences in the preference for professional help, medications and treatment methods between Chinese men and women? To what extent do contextual factors in a society influence the above differences between Chinese men and women? Answers to these questions will inform the development of culturally relevant and gender-specific mental health promotion and intervention strategies to improve the mental health literacy of Chinese people.

Objectives

To understand gender differences in mental health literacy among Australians of Chinese-speaking background in Melbourne, Australia.

To explore gender differences in the preference for certain culture-specific professional help, medications and treatment methods regarding schizophrenia among Australians of Chinese-speaking background.

Method

Sample

Australia has a large Chinese-speaking population, which when including those who were born in other countries but speak Chinese in their family homes, amounts to about 3.4% (669,000) of the total Australian population (Australian Government Department of Immigration and Citizenship, 2006). This study adopted a cluster convenience sampling method in which subjects were taken from the four major areas in cosmopolitan Melbourne where most Chinese people are living: Box Hill, Doncaster, Monash and Preston. The participants were recruited through the social service organizations serving the Chinese population in these four areas. Posters introducing the research (i.e. a survey on psychological health of Chinese-speaking Australians) were put up on the exhibition boards of these organizations. The selection criteria for participants was an age of 18 and above, Australians or immigrants of Chinese-speaking background, and first-generation migrants who are living in Melbourne, Australia. Potential participants who were interested in the study then approached the research team for further information. Participation in this study was voluntary. Those who decided to participate in the survey had to sign a consent form and were later given the self-administered questionnaire to complete. This research was endorsed by the human ethics committee of The University of Melbourne. Each questionnaire took about 40 minutes to complete.

The survey questionnaire

The questionnaire was written in Chinese and contained two parts: sociodemographic characteristics of the respondents and mental health literacy (early depression and early schizophrenia).

Mental health literacy. This instrument was adapted from that used by Jorm et al. (2005) to study the mental health literacy among Australian samples. The original English version was translated into Chinese and back- translated into English by a professional translator. The depression and schizophrenia vignettes were written to satisfy the diagnostic criteria for depression and schizophrenia according to DSM-IV and ICD-10. After reading the vignettes, respondents were asked a series of questions to assess their recognition of the disorders: their awareness of mental illness; and beliefs about the helpfulness or harmfulness of different professions, medications and treatment methods. In the first section of this instrument, after the description of the vignette, the participants were asked to provide written answers to two questions: ‘Do you think the person needs help or not? (Yes/No format) and ‘What mental health issue do you think the person is having?’. The main part of the questionnaire was then broken down into three sections. Essentially, the participants were asked to rate each type of (1) professional, (2) medication and (3) treatment as ‘helpful’, ‘harmful’ or ‘not sure’ in relation to the mental health issue faced by the person in the vignette. Based on a literature review (e.g. Kleinman, 1986) and the authors’ clinical experience of working with Chinese people, the list of options was extended to include additional items to explore the cultural dimension of the participants’ beliefs about professional help, medication and treatment methods. For example, under ‘professional help’, ‘Chinese medical doctor’ and ‘Chinese traditional healer’ were added. Under ‘medication’, ‘Chinese herbal medicine’ was introduced. Under ‘treatment methods’, ‘taking Chinese nutritional foods/supplements’, ‘qiqong’, ‘changing fungshui’ and ‘traditional prayer’ were included.

Statistical analyses

Frequencies were used to describe the demographic characteristics of Chinese-speaking Australians in Melbourne. Since both gender and Mental Health Literacy Scale were categorical variables, cross-tabulations and χ ² tests were used to determine whether differences existed in knowledge of mental illness, preference for professional help, and medications and treatment methods between males and females. T-tests were also used to examine the gender difference in the perception of the causation of mental illness held by Chinese-speaking Australians.

Results

Table 1 shows the demographic characteristics of the sample. Females tended to be younger and had lived in Australia longer than males. More males had achieved post-secondary qualifications and held full-time jobs. The majority of both genders came from Hong Kong and China, and over 70% were married. Finally, more females than males had higher family incomes and claimed to be more proficient in English. The respondent sample resembles the Chinese-speaking Australians described in the census data (Australian Government Department of Immigration and Citizenship (DIAC), 2006) but with two differences: the male-to-female ratio was higher in this sample (54.8% vs. 45.2%) and there were more unemployed people (11.2%) (Australian Government DIAC, 2006).

Table 1.

Mean and percentage of demographic characteristics of respondents (N = 200)

	Male (n = 61)	Female (n = 139)
	M	M
Age (years)	56.78	45.45
Living in Australia (months)	118.47	130.28
	%	%
Education
Primary school	0	3.8
Secondary school	8.5	13.5
Senior secondary school	23.4	33.8
Diploma	31.9	24.1
Degree	27.7	18.8
Masters or higher	8.5	6.0
Place of origin
China	62.2	40.6
Hong Kong	26.7	39.1
Vietnam	0	6.8
Singapore/Malaysia	2.2	6
Taiwan	8.9	5.3
Others
Marital status
Single	21.7	7.5
Married	73.9	70.7
Widow	2.2	4.5
Divorced	2.2	15.8
Co-habitating	0	1.5
Family income per year (AUS$)
0–20,000	33.3	20.8
20,001–40,000	25	30.2
40,001–60,000	22.2	22.9
60,001–80,000	8.3	14.6
> 80,001	11.1	11.5
Language
Cantonese	62.2	76.1
Putonghua	37.8	21.6
Hakka	0	0.7
Chiu Chou	0	0.7
Others	0	0.7
English ability
Very poor	20.5	11.6
Poor	38.6	31.2
Average	22.7	49
Good	15.9	5.8
Very good	2.3	2.2
Employment
Full time	39.5	15.4
Part time	10.5	26
Waiting for a job	13.2	22.8
Unemployed	31.6	27.6
Retired	5.3	2.4
Housewife	0	5.7

Only a small percentage of males and females could identify the vignettes as either a condition of schizophrenia or depression (Table 2), with females being more successful. Regarding the perception of the causation of mental illness, there were significantly more males than females who adhered to traditional views such as ‘while the ancestors have committed certain mistakes, the offspring have to bear the punishment’ and ‘imbalance of yin-yang’ (F = 5.52, df = 1, p = 0.02). Significantly more males than females perceived ‘deal with it alone’ (p = 0.01) and ‘traditional Chinese medical doctor’ (p = 0.00) to be helpful to the person in the schizophrenia vignette (Table 3).

Table 2.

Percentage and mean of respondents giving the correct label to the schizophrenia vignette, recognizing that the person needed help, and adhering to certain causes of mental illness (by gender)

	Depression		Schizophrenia
	Male	Female	Male	Female
	%	%	%	%
Correct label	25	75	24	76
Needing help
Yes	50	66.3	100	98.5
No	50	33.3	0	1.5
Causes	M	M	F (df =1)	p
Biological	3.60	3.64	0.08	0.77
Psychosocial	3.79	3.86	0.39	0.53
Traditional	2.23	1.92	5.52	0.02

Table 3.

Percentage of respondents rating each type of professional as ‘helpful’ and ‘harmful’ for the person in the schizophrenia vignette (by gender)

	Depression				p	Schizophrenia				p
	Male		Female			Male		Female
	Helpful	Harmful	Helpful	Harmful		Helpful	Harmful	Helpful	Harmful
Doctor	97.4	2.6	96.9	3.1	ns	100	0	96.3	3.7	ns	ns
Pharmacist	82.4	17.6	73.9	26.1	ns	88.2	11.8	68.2	31.8	ns	ns
Counsellor	100	0	99.1	0.9	ns	100	0	100	0	ns	ns
Social worker	97.8	2.2	100	0	ns	100	0	99.1	0.9	ns	ns
Hot-line telephone counsellor	100	0	93.8	5.2	ns	100	0	99.0	1.0	ns	ns
Psychiatrist	97.4	2.6	70.0	3.8	ns	100	0	99.2	0.8	ns	ns
Clinical psychologist	100	0	100	0	ns	97.8	2.1	91.7	8.3	ns	ns
Close family	100	0	96.4	3.6	ns	100	0	98.2	1.8	ns	ns
Close friends	100	0	94.3	5.7	ns	97.3	2.7	97.7	2.3	ns	ns
Naturopath	95.8	4.2	86.8	13.2	ns	94.5	5.5	91.3	8.7	ns	ns
Religious practitioner	96.7	3.3	96.1	3.9	ns	96.2	3.8	84.6	15.4	ns	ns
Deal with it alone	43.8	56.3	46.2	53.8	ns	44.0	56.0	18.3	81.7	0.01	ns
Traditional Chinese medical doctor	77.3	22.7	79.2	20.8	ns	94.7	5.3	55.3	44.7	0.00	ns
Traditional healer	7.7	92.3	2.7	97.3	ns	3.7	96.3	2.6	97.4	ns	ns

Female respondents generally perceived medications to be relatively more harmful than male respondents (Table 4). While there were about similar percentages of males and females who could identify antidepressants and anti- psychotics to be helpful for the person in the respective depression and schizophrenia vignettes, there were significantly more males than females who perceived ‘Chinese herbal medicines’ to be helpful to the person in the schizophrenia vignette (p = 0.01).

Table 4.

Percentage of respondents rating each type of medication as ‘helpful’ and ‘harmful’ for the person in the schizophrenia vignette (by gender)

	Depression				p	Schizophrenia				p
	Male		Female			Male		Female
	Helpful	Harmful	Helpful	Harmful		Helpful	Harmful	Helpful	Harmful
Vitamins, minerals	84.6	15.4	80.4	19.6	ns	83.3	16.7	69.6	30.4	ns
St. John’s Wort	14.3	85.7	10	90.0	ns	12.5	87.5	17.4	78.3	ns
Pain relievers	23.1	76.9	7.9	92.1	0.03	26.3	73.7	6.8	93.2	0.01
Antidepressants	76.0	24.0	72.6	27.4	ns	88.0	12.0	84.2	15.8	ns
Antibiotics	8.3	91.7	6.5	93.5	ns	30.0	70.0	5.1	94.9	0.00
Sleeping pills	57.1	42.9	49.4	50.6	ns	82.1	17.9	47.4	52.6	0.00
Anti-psychotics	66.7	33.3	45.2	54.8	ns	92.9	7.1	87.4	12.6	ns
Tranquilizers	51.9	48.1	45.2	54.8	ns	70.8	29.2	60.5	39.5	ns
Chinese herbal medicines	57.1	42.9	41.3	58.7	ns	70.0	30.0	37.0	63.0	0.01

Finally, significantly more males than females considered ‘psychiatric ward’ (p = 0.05), ‘electro-convulsive treatment’ (p = 0.01, p = 0.00), ‘changing fungshui’ (p = 0.05, p = 0.00) and ‘traditional Chinese worship’ (p = 0.05, p = 0.03) to be helpful for the persons in the depression and schizophrenia vignettes, respectively (Table 5).

Table 5.

Percentage of respondents rating each type of intervention as ‘helpful’ and ‘harmful’ for the person in the schizophrenia vignette (by gender)

	Depression				p	Schizophrenia				p
	Male		Female			Male		Female
	Helpful	Harmful	Helpful	Harmful		Helpful	Harmful	Helpful	Harmful
Physical activity	100.0	0	99.2	0.8	ns	95.6	4.4	100	0	ns
Read about problem	88.6	11.4	86.7	13.3		100	0	90	10.0	ns
Get out more	67.4	8.7	58.6	9.0		90.3	9.7	78.4	21.6	ns
Learn relaxation	100	0	100	0		97.1	2.9	97.9	2.1	ns
Cut out alcohol	95.0	5.0	95.0	5.0		97.4	2.6	95.1	4.9	ns
Psychotherapy	100	0	100	0		100	0	100	0	ns
Cognitive behavioural treatment	100	0	98.9	1.1		100	0	98.0	2.0	ns
Hypnosis	95.2	4.8	68.3	31.7	0.01	95.0	5.0	55.3	44.7	ns
Psychiatric ward	43.5	56.5	23.1	76.9	0.05	87.5	12.5	67.6	32.4	0.05
Electro-convulsive treatment	70.0	30.0	28.2	71.8	0.01	77.8	22.2	28.6	71.4	0.00
Occasional drink	28.0	72.0	14.9	85.1		19.2	76.9	20.3	79.7	ns
Taking Chinese nutritional foods/supplements	66.7	33.3	73.3	26.7	ns	52.4	47.6	48.8	51.2	ns
Qigong	71.4	28.6	76.1	23.9	ns	78.3	21.7	74.4	25.6	ns
Changing fungshui	11.4	27.3	3.0	27.8	0.05	15.2	21.7	3.0	35.1	0.00
Traditional Chinese worship	29.4	70.6	9.8	90.2	0.05	13.8	86.2	2.7	97.3	0.03

Discussion

In this study, more female than male Chinese-speaking Australians could correctly identify the two vignettes, particularly the schizophrenia vignette. This is consistent with findings of mental health literacy observed in other cultural groups (Gaebel et al., 2002; Jorm et al., 1997; Wong et al., 2010). A combination of factors, including differences in age, duration of residence in Australia and the perception of mental illness between male and female participants in this study, may serve to explain this phenomenon. In Chinese culture, mental illness is heavily stigmatized (Fung et al., 2007). Traditional beliefs suggest that mental illness is a result of demon possession, improper child-bearing practice and the wrongdoing of ancestors (Wong et al., 2004). In schizophrenia, psychotic conditions are considered even more stigmatizing because these conditions are perceived as signs of madness and denote a sense of unpredictability, danger, and bizarre and uncontrollable behaviours (Fung et al., 2007). Hence, there is a strong cultural disposition not to disclose one’s mental illness and to express personal and social distress in an idiom that is more socially acceptable (Kleinman, 1986), such as psychosocial causes relating to inability to deal with stress, traumatic childhood experience, and personality deficits (Pearson, 2003; Phillips et al., 2000; Wong et al., 2004). In this sample, male Chinese-speaking Australians were much older and had a relatively shorter duration of stay than female Chinese-speaking Australians. Therefore, they might be less acculturated and have stronger adherence to traditional values (Lai and Chau, 2007). Consequently, they might fail to correctly identify the conditions in the two vignettes.

Indeed, a similar argument can be used to explain why male Chinese-speaking Australians were found to have a significantly higher percentage of endorsement of the helpfulness of ‘Chinese medical doctors’, ‘Chinese herbal medicines’ and ‘changing fungshui’. Being first-generation Chinese immigrants from different parts of Asia and having lived in Australia for a relatively shorter period of time, male Chinese-speaking Australians who were older and relatively less acculturated might be more inclined to endorse traditional methods of treatment for a person with mental illness. These findings appear to contradict a previous study that suggested that Chinese women were more ready to seek help from non-psychiatric facilities including Chinese medicine doctors (Tang et al., 2007).

However, male Chinese-speaking Australians in this sample had a significantly higher endorsement than females for ‘deal with it alone’ for the person in the schizophrenia vignette. In a patriarchal society, Chinese males are considered as the head of a household and strong and powerful (Goodwin and Tang, 1996). Inherent in this traditional role is a need for a male figure to assume responsibilities for taking care of all family members. The male participants who were considerably older might have internalized this image, thereby endorsing ‘deal with it alone’ as an option for handling the vignette conditions.

In this study, it appears that female Chinese-speaking Australians in Melbourne than males tended to see certain aspects of the medical model of treatment to be more harmful for persons with schizophrenia and depression. Generally speaking, when compared to their male counterparts, they perceived all types of medication to be more harmful to the persons in both vignettes. They also considered medical treatments such as psychiatric ward and electro-convulsive treatment to be more harmful, whereas the males tended to see these treatments as more helpful for the persons in the vignettes. As explained above, men who were more traditional might show a greater preference than women for traditional Chinese methods of treatment such as ‘changing fungshui’ and ‘traditional Chinese worship’. On the other hand, women in general and those who were more educated might be more willing to seek and read medical information about the advantages and disadvantages of different medications and medical treatments. Consequently, women in this sample might rate certain medications and psychiatric treatments to be more harmful than men.

Given that male Chinese-speaking Australians were less able to identify the mental illnesses described in the vignettes, had a tendency to deal with mental illness alone, and tended to endorse traditional Chinese treatment methods, it is not far-fetched to suggest that they may delay seeking help from formal psychiatric services for treatment. Moreover, even if they become vaguely aware of the fact that there was something wrong with them, they may prefer to deal with it alone or to seek help from traditional Chinese alternative sources. One important point that springs up from this discussion is the need to develop certain mechanisms to engage male Chinese-speaking Australians as early as possible in receiving formal psychiatric service. While GPs can still play a critical role in providing the necessary initial mental health assessment and interventions for these males, Chinese medical doctors and religious practitioners can be educated to understand symptoms of certain major psychiatric illnesses and to provide information on mental health for this group of people because they may be the first point of contact whom male Chinese-speaking Australians can trust and approach for help.

Another way of helping this group is to improve their mental health literacy so that they become more aware of the need to seek help from formal psychiatric services. One useful and effective strategy for disseminating mental health information is mental health first aid training (MHFA) (Kitchener and Jorm, 2004). This is a de-stigmatizing strategy which helps an individual with or without a mental health concern to acquire knowledge about mental illness, which presumably is to be used to help people around himself or herself. When adopting this mental health first aid training programme, it will be useful to incorporate some of the findings of the present study, particularly targetting male Chinese-speaking Australians. For example, males may benefit from a clearer delineation of symptoms of certain major psychiatric illnesses because of their relative lack of recognition of mental illness. Also, it may be beneficial for them to understand their endorsement of ‘deal with it alone’ and ‘more readily accepting different traditional Chinese cultural practices’ and the implications of such endorsements.

Limitations

This study adopted a cluster convenience sampling method and sampled Chinese-speaking Australians in Melbourne, Victoria. Therefore, the findings may not be generalized to Chinese-speaking people living in other parts of Australia and overseas. As in any community-based study, participation in the survey may depend on certain demographic and socioeconomic characteristics. The percentages in this study could have been overestimated or underestimated. Finally, this was a cross-sectional study that relied on self-report, thus recall and reporting biases were a possibility.

Conclusion

This study has identified a number of differences in the recognition of mental illness and the preference for professional help, medications and treatment methods that are held among male and female Chinese-speaking Australians in Melbourne, Australia. Campaigns to increase the mental health literacy of male and female Chinese-speaking Australians will need to take into account these differences so that a culturally relevant and gender-specific education programme can be developed.

Footnotes

Acknowledgements

The authors would like to express their sincere thanks to Professor Anthony Jorm for his generous support in the early stage of the research process.

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