Perceived control over physical and mental well-being: The effects of gender,age and social class

Abstract

In a cross-sectional quota based survey 1013 adults (46% male, 54% female; aged 16–65+) in Northern Ireland from ABC1, C2 and DE social class groupings were asked about the perceived influence they have over their physical and mental health, and what types of lifestyle changes can improve health. Findings showed participants perceive that they have more control over their physical compared to mental health, with physical activity being the behaviour most likely to be adopted. Females were more likely than males to make lifestyle changes, including meeting friends, talking about things that were bothering them and trying relaxation techniques. These findings illustrate the need for health promotion to be directed at mental health, and encouraging males to consider adapting healthy lifestyle behaviours.

Keywords

behaviour change depression illness stigma Theory of Planned Behaviour

Introduction

The World Health Organization (2011) estimate that millions of people across the world experience mental health problems, with one in four experiencing a mental illness at some point in their lives. Furthermore approximately 844,000 suicides occur each year (WHO, 2004). While the vast majority of people with a mental illness will not die by suicide (World Federation for Mental Health, 2006), in the United Kingdom 50% of all suicide cases occur in current or former diagnosed psychiatric patients (WHO, 2004). As potential explanations, non-compliance with prescribed treatment, loss of contact with services and stigma associated with help seeking are reported to be common risk factors. The gap between what is needed for mental health services and what is available in various countries remains large. According to the WHO (2011) in their recent Mental Health Atlas publication countries are investing too little in mental health to support and protect their citizens.

In a post-conflict Northern Ireland with a population of 1.7 million people suicide has been shown to be on the increase in recent years. During 2009 260 deaths by suicide were registered, which included 205 males and 55 females; moreover from January to September 2010, a further 176 males and 58 females died by suicide (Public Health Agency, 2011). This is in comparison to earlier years when approximately 150 suicides were reported each year (Department of Health, Social Services and Public Safety, 2006). The role of health promoters in reducing the stigma associated with having a mental health problem, and encouragement for those that may be at risk of suicide to seek help or make important health-related lifestyle changes are aspects that need to be addressed by policy makers.

Unlike physical health, it is argued that mental health has not been accorded the same importance by the public which may in part have contributed to the increased incidence and prevalence of mental health problems. Little empirical evidence has been available in Northern Ireland concerning the public’s understanding of, and attitudes towards, mental health (Health Promotion Agency, 2007). Findings from population surveys have shown that there is a low level of understanding of mental health, and paradoxically individuals are likely to offer help if they were asked for help by someone who was experiencing a mental health problem, but not to seek mental health support themselves (Breslin and McCay, 2006). This unwillingness to seek help was attributed to stigma associated with being labelled as someone experiencing a mental health problem. A psychological explanation for the potential lack of help seeking can be interpreted within a number of psychological theories, one of which is the Theory of Planned Behaviour (TPB) (Ajzen, 1985). The TPB would predict that the amount of behavioural control a person perceives they have, in this case to take care of their mental health, can determine help-seeking behaviours. According to the TPB, a person who perceives they have control over their mental health would be more likely to have an intention to take part in lifestyle behaviours that protect their mental health compared to an individual who may have a low level of perceived control.

In this study we apply the Theory of Planned Behaviour to achieve four aims: (1) to determine with an adult sample, the level of control individuals perceive that they have over their physical and mental health; (2) to establish the nature of any lifestyle/behaviour changes individuals have made to try and improve their mental health; (3) to establish which people are most likely to try activities that may protect their mental health; and finally (4) to offer practical recommendations on encouraging individuals to seek help. As this is a population-based survey we will analyse the sample stratified by gender, age and social class grouping.

Method

Participants

In March 2006 a sample of 1013 adults in Northern Ireland was asked a series of questions relating to mental health in a face-to-face interview. The questions were part of a larger survey assessing attitudes towards mental health (HPA, 2007). Participants were interviewed while at home. The sample consisted of 46% male, 54% female participants, of whom 13% were aged 16–24, 20% 25–34, 30% 35–49, 21% 50–64 and 17% aged 65+. A quota sampling framework was chosen with a representative sample for gender, age and social class grouping based on the Northern Ireland 2001 census. Social class groups were categorized based on occupation of the chief income earner in the household and ranged from the upper middle class to those at the lower levels of income. These included: ABC1, managerial, administrative or professional; C2, skilled manual workers; and DE, semi- and unskilled manual workers and those who depend on government social benefit for their income. Forty-three per cent were in the ABC1 grouping, 21% in C2 and 36% in groups D and E. The survey was administered via separate face-to-face interviews at 45 randomly selected geographical points throughout Northern Ireland. Ethical guidelines were followed, each participant provided consent and were informed that responses would be considered confidential.

Questionnaire

A series of questions was developed based on the perceived behavioural component of the Theory of Planned Behaviour (Ajzen, 1985). The survey included four questions. Two assessed the respondent’s perceived control over physical and mental well-being: ‘How much influence do you think people can have on their own physical well-being by the way they choose to live their lives?’ and ‘How much influence do you think people can have on their own mental well-being by the way they choose to live their lives?’ Four responses were available for each question: 1 – a lot of influence, 2 – a little influence, 3 – no influence at all or 4 – I do not know.

To obtain an indication of how many participants tried intentionally to influence their health, respondents were asked whether, in the past year, they had tried to make any changes to their lifestyle, even in the short term to improve their physical or mental health. Respondents could answer ‘yes’ or ‘no’. If they responded ‘yes’ they were provided with a list of lifestyle behaviours that could potentially improve physical and/or mental well-being. For physical health these were: tried to give up smoking; tried to lose weight; cut down on fatty foods; reduced the amount of alcohol I drink; took up regular physical activity; tried to eat more fruit and vegetables. For mental well-being these included: took up regular physical activity; tried to get out and see friends more; talked to people about things that were bothering me; tried some relaxation techniques.

Prior to the fieldwork a pilot test was conducted to confirm the suitability and face validity of the questions for the participants.

Statistical analysis

Percentage scores are presented for each question by gender, age and social class grouping. To assess the associations between gender, age and social class, separate Pearson’s Chi Square (χ²) statistical tests were calculated. The minimum probability interval for statistical significance was set at p < .05. All analyses were conducting using the Statistical Package for the Social Sciences, Version 16.

Results

Perceived influence over physical health: gender, age and social class

When participants were asked: ‘How much influence do you think people can have on their own physical well-being by the way they choose to live their lives?’ the majority of respondents (93%) said ‘a little’ or ‘a lot’ of influence (see Fig. 1). Only 3% said no influence at all, while 5% reported that they did not know. There were no differences across gender or age groups but across social class statistically significant differences were evident – 89% of the DE group said ‘a little’ or ‘a lot’, compared to 96% of the ABC1 group and 93% of the C2 group, the DE group also gave a higher proportion of ‘don’t know’ responses (7%) than the ABC1 (3%) and C2 groups (4%) (χ² = 18.2, d.f. = 6, p < .01).

Figure 1.

Perceived control over physical and mental well-being.

Perceived influence over mental health: gender, age and social class

When asked: ‘How much influence do you think people can have on their own mental well-being by the way they choose to live their lives?’ 79% said ‘a little’ or ‘a lot’ of influence (see Fig. 1). Eleven per cent reported no influence and 10% reported that they did not know. There were no differences by gender or age; but across social class statistically significant differences were again evident – 76% of the DE group said ‘a little’ or ‘a lot’ of influence, compared to 81% of the ABC1 and C2 groups, the DE group also gave a higher proportion of ‘none at all’ responses (13%) than the ABC1 (10%) and C2 groups (9%) (χ² = 12.6, d f = 6, p < .05).

Further analysis was conducted to establish if there was a statistically significant difference between the mean scores for perceived influence over physical and mental health. In order to establish if a difference was present, those who rated that they had ‘a little’ or ‘a lot’ of influence over their physical and mental health only were compared (this reduced the sample to N = 793), wherein a statistically significant difference was shown (t = −13.32, d.f. = 792, p < .01). Therefore participants perceived that they had more control over their own physical than mental health.

Lifestyle changes to improve health

Seventy-two percent of those surveyed reported that they had personally made lifestyle changes that impacted on their physical health (Table 1). This compared to only 41% who reported that they had made changes to benefit their mental health. Those most likely to have made lifestyle changes benefiting their mental health were female (57%), those aged 35–49 (30%) and those in the ABC1 social class group (48%). Those least likely were males aged between 16–24 and 65+ and those in the C2 social class grouping.

Table 1.

A comparison across gender, age and social class of those who made lifestyle changes to improve physical or mental health

	1013 sample (%)	Male (%)	Female (%)	Age 16–24 (%)	Age (25–34) (%)	Age (35–49) %	Age 50–64 (%)	Age 65+ (%)	ABC1 (%)	C2 (%)	DE (%)
Activities to improve physical health	72	43	58**	12	22	31*	20	15	46*	21	33
Activities to improve mental health	41	43	57**	13	22	30*	22	13	48*	18	34

Note: Statistical significance: *p < .05; **p < .01. due to rounding, figures may not equal 100.

Types of behaviours/activities to improve mental health

With regard to activities that are perceived to improve mental health, taking up regular physical activity (25%) was the most common. There was no difference between males and females in relation to adopting physical activity; however those in the 65+ group and DE social class grouping were the least likely to report adoption of physical activity (Table 2). Females were significantly more likely than males to report going out to see friends more often (26% compared to 19%), talk to people about issues that were bothering them (22% compared to 12%) or try some relaxation techniques (10% compared to 6%). The 16–24 (19%) and 65+ (17%) age groups were least likely to try to reduce levels of stress when compared to the other groups. Participants aged 16–24 (5%) and 65+ (3%) were least likely to try some relaxation techniques, all the other age groups were at the same level (10%). The ABC1 group (11%) were also more likely to try relaxation techniques when compared to the C2 (8%) and DE groups (5%).

Table 2.

A comparison across gender, age and social class of the types of lifestyle changes adopted to improve mental health

Base 1013	All (%)	Male (%)	Female (%)	Age 16–24 (%)	Age 25–34 (%)	Age 35–49 (%)	Age 50–64 (%)	Age 65+ (%)	ABC1 (%)	C2 (%)	DE (%)
Took up a regular physical activity	25	24	27	33	37	25	21	12***	30	26	20**
Tried to get out and see friends more	23	19	26**	28	24	19	24	23	25	18	23
Talked to people about things that were bothering me	17	12	22***	20	22	16	18	11	18	15	18
Tried some relaxation techniques	8	6	10*	5	10	10	10	3*	11	8	5*
Other	2	1	2	1	2	1	2	3	1	1	2

Note: three levels of statistical significance are shown in the tables: *p < .05; **p < .01; ***p < .001.

Discussion

We aimed to determine the level of control individuals perceive they have over their physical and mental health and whether specific behaviours are adopted to prevent or improve mental health. We also aimed to establish who are the people most likely to try or not to try activities that may protect their mental health which we explored by comparing the responses from different gender, age and social class groupings with the consequence of offering practical advice for promoting mental health.

Findings showed that a high proportion of adults perceived that they had control over their physical health. This did not differ by gender or age; however those in the lower DE social class grouping were least likely to have this view. This finding is consistent with previous health promotion research and may be explained in part by the individuals in the DE grouping having less awareness of lifestyle healthy behaviour change (HPA, 2007), or knowledge of mental health literacy (Griffiths et al., 2011; Thompson et al., 2004). When compared to responses for physical health, fewer people perceived that they have control over their mental health (93% compared to 79%). A similar trend for social grouping was found wherein the DE group reported lower levels of perceived control over mental health. Furthermore the DE group gave a higher proportion of ‘none at all’ responses than the ABC1 and C2 groups adding further support to the view that the DE group are less aware of the control they could have over their health through the types of activities they can engage in. This finding is consistent with previous research on views towards mental health (Jorm, 2000) and when interpreted within the framework of the Theory of Planned Behaviour (Ajzen, 1985) those with a low level of perceived behavioural control in activities to maintain a positive mental health will be less likely to have the intention to engage in health enhancing activities.

When asked if they have made any lifestyle changes to improve physical health, even in the short term, 72% responded that they have done so compared with only 41% who have adapted lifestyle behaviours to improve their mental health. This finding indicates that making lifestyle behaviour changes is more likely to be for improving physical health than for improving mental health. These figures for behaviour change are predictably lower than that for the perceived control question. This finding is consistent with the Theory of Planned Behaviour, as the relationship between perceived behavioural control and intention is higher than for behavioural control and actual behaviour change (Ajzen, 1985). However the trend between those who are likely to change and those who are not is not clear for all groupings. It would appear that females aged between 35–49 years old and a member of the ABC1 social class grouping will be more likely to engage in behaviours with the intention of improving mental well-being, while males aged 16–24, or 65+ and belonging to the C2 grouping are least likely to engage in actual behaviours that will improve mental well-being. The relative lack of engagement by males in mental health promoting behaviours is not new as this group has been highlighted as a ‘hard to reach’ target group who do not access the available health provision (Day et al., 2001). The social class differences also support the points made above in relation to awareness surrounding mental health and well-being. What remains unclear, or inconsistent in our findings, is that the C2 social class grouping of males has shown that they perceive they have control over their mental health when compared to the DE group, yet there is a lower percentage of the C2 group engaging in health enhancing behaviours. A potential explanation is that the intentions of the C2 group to engage in healthy behaviours to enhance mental well-being out-weighed the actual number of people who did engage in the behaviours. This highlighted the importance of understanding the non-causal relationship or intention–behaviour gap that exists between having an intention to take part in an activity and actually getting around to doing the activity.

The percentage of participants disclosing that they took part in activities to look after their mental health and what specific activities they participated in was low (25%). Therefore caution must be expressed when interpreting responses by gender, age and social class. The activity most likely to be adopted for improving mental health was the taking up of regular physical activity. There were no differences between males and females in relation to reported adopting of these physical activities. However those in the 65+ group and DE social class grouping were least likely to adopt physical activity. Females were more likely than males to go out and see friends more often, talk to people about things that were ‘bothering’ them or to try relaxation techniques, while the 16–24 and 65+ age groups were least likely to try to reduce levels of stress or try some relaxation techniques.

These findings indicate that activities that may help with looking after mental health or provide distraction differ between males and females, with females being more likely to engage in these activities. The behaviour males engage in at a similar level to females is physical activity, a behaviour that can be performed without speaking about mental health problems, or what is bothering them. Hence these are activities that do not attract attention from others while helping to cope with mental health but at the same time allowing the individual to avoid stigma. Females tend to engage in both types of behaviours. Therefore gender should be taken into consideration when developing interventions to enhance mental well-being.

The findings presented here have some practical implications. Since the survey was completed a two-phased mental health public information campaign has been adopted in Northern Ireland. Phase 1 has taken a population approach with a focus on education in an attempt to raise awareness of mental health. The aims were to de-stigmatize mental health and encourage help-seeking behaviour. The campaign consisted of national television advertisements, radio broadcasts, poster boards and leaflet distribution across Northern Ireland. The second phase of the campaign was targeted towards males as this is the group most at risk of suicide, with self-care and help-seeking behaviour being encouraged in the campaign. Research is currently ongoing to evaluate the outcome of this campaign and to monitor in the population ways in which individuals seek help or cope when experiencing mental health problems.

Our study has some limitations. First, single-item questions were used in the survey. The use of single items may not have assessed the complete nature of intentions and behaviour. Given the full length questionnaire assessing attitudes to mental health (HPA, 2007) we opted for single items in order to minimize participant drop out. Future research could include a shorter survey with a validated assessment tool. Second, the wording of the question, ‘How much influence do you think people can have on their own mental well-being by the way they choose to live their lives?’ requires some clarification. We intended this question, supported by our pilot study findings, as a way of enquiring about a participant’s own life. However, it is possible that participants perceived this not to be about them personally but as referring to other people in general. This raises an interesting question as to how individuals respond to mental health questions regarding themselves or referring to others. If a participant perceives the question to be related to them will they have a different response compared to perceiving the question to be about seeking help for others? As stigma has been predicted to influence help seeking, perhaps responses are moderated by whether the help is for them personally or others. This is worth investigating further as it may influence our interpretations of what we know about help-seeking intentions and behaviour via survey-based research.

In summary these findings show that fewer respondents believe people can control their mental health compared to their physical health. Using the Theory of Planned Behaviour to predict intentions and adopting healthy behaviours, the relatively low perceived control by respondents over mental health outcomes would indicate that preventative lifestyle or treatment behaviours will not be engaged in as much. Therefore mental health promotion efforts should focus on bridging the gap between understanding the role of stigma surrounding mental health, how stigma influences intentions to seek help and how a person can make the transition from intention to seek help to actually seeking help. As outlined in Northern Ireland, the development of public mental health awareness programmes may be a first step in developing intentions to seek help. It is also evident from this study that targeting those who have lower perceived intentions to look after their mental health is required – in particular, males, the youngest and oldest in the population, and DE social class groupings. Finally, according to WHO (2011), countries across the world are investing too little in mental health to support and protect their citizens. The findings from this study lead us to suggest that further effort is required to increase mental health literacy in the population in an effort to reduce the gap a person perceives they have over their physical and mental health in an effort to promote help seeking.

Footnotes

Acknowledgements

This research was funded in part by the Department of Health, Social Services and Public Safety as part of the Protect Life – A Shared Vision: The Northern Ireland Suicide Prevention Strategy and Action Plan 2006–2011, the Health Promotion Agency in Northern Ireland and the Sport and Exercise Science Research Institute at the University of Ulster, Northern Ireland.

Competing Interests

None declared.

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