healthmedicinet

Background of study location

Selangor is the most developed and urbanized state in Malaysia 24]. The Population and Housing Census of Malaysia 2010 showed Selangor as the most populated
state in Malaysia, constituting of 5.46 million people. The major ethnic group in
Malaysia is the Bumiputera (67.4 %), followed by Chinese (24.6 %), Indians (7.3 %)
and Others (0.7 %). The Household Income Survey (HIS) 2012 showed that the mean monthly
household income of Malaysian citizens was RM 5000 in 2012 25].

Data collection

A cross sectional study was carried out among adults in the community of three districts
in Selangor, which were Hulu Langat, Sepang and Klang from 11
^th
June to 30
^th
December 2012. The sampling frame, maps and Enumeration Blocks (EBs) of the living
quarters (LQ) in this study were obtained from the Department of Statistics Malaysia
(DOS). The study population in this study represents the Malaysian citizens in Selangor
as three out of nine districts were selected and the total population for these three
districts accounts 2.2 Million of population, which is almost 50 % of the total population
of Selangor which consist of 5.4 Million population. The sampling of the households
was done by the Department of Statistics Malaysia (DOS), taking into account of the
total population of people staying in each of these districts. The total number of
Enumeration Blocks and Living Quarters (LQ) that was selected varies according to
districts. The allocation of EB in each district was done proportional to the population
size in the particular districts. In each EB, eight LQs were selected and in each
LQ, two participants were selected. The total number of LQs selected by the DOS in
Hulu Langat was 672, followed by Klang (480 LQ) and Sepang 104 LQ. The inclusion criteria
were Malaysian citizens, adults aged 18 years and above, and staying in the selected
living quarters. The major ethnicity in Malaysia is Malay, Chinese and Indian who
lived in the respective households in each of the districts. Those who were unable
to comprehend either the Malay or English language were excluded from the study. Data
collection was carried out by the main researcher with the assistance from a group
of trained research assistants (RAs). A brief introduction about the study, as well
as the purpose and benefits of taking part in the study were detailed in the information
sheet and all these information were explained to the participants. Informed verbal
consent from the participants was obtained prior to the administration of the questionnaire.
They completed a set of self-administered questionnaires and were assisted when necessary.
The full description on the methodology of this study is detailed in another publication
as they were based on the same study 26]. Ethics approval was obtained from the Medical Research Ethics Committee of the Faculty
of Medicine and Health Sciences, University Putra Malaysia.

Instruments

The questionnaire for this study comprised of items on socio-demography, chronic diseases,
and history of mental health disorders, depression, stressful life events, perceived
stress, domestic violence, self-esteem and religiosity. The questionnaire was in both
Malay and English languages, and had been pre-tested in another location not included
in this study.

Basic socio-demography variables, such as age, gender, ethnicity, religion, marital
status, education level and employment status were assessed in the study. The education
level of the participants was categorized into three categories: Primary (Year 1 to
Year 6), Secondary (Form 1 to Form 5) and Tertiary (Matriculation/Diploma/Degree/Masters/PhD).
The employment status was categorized into three categories: Employed, Unemployed
and Pension. The Generalized Anxiety Disorder-7 (GAD-7) was used in this study to
determine the presence of anxiety. It is a version of PRIME-MD diagnostic instrument
for common mental health disorders and based on the criteria from DSM-IV. The GAD-7
measures generalized anxiety disorder, social anxiety, panic disorder and post-traumatic
stress disorder. It consists of 7 items, with each item scored from 0 to 3, with total
scores ranging from 0 to 21. A cut-off point of 8 and above on the GAD-7 was used
to determine the presence of anxiety in this study as it was demonstrated to have
good reliability (sensitivity of 92 % and specificity of 76 %) 27] besides a recommended cut-off score suggested by Kroenke K et al. 28]. The GAD-7 was first developed and validated by Spitzer et al. among patients attending
primary care clinics 27]. The Malay version of GAD-7 was validated in the primary care setting by Sherina
et al. It has good sensitivity, specificity, concurrent and convergent validity 29]. The GAD-7 was also demonstrated to be a reliable and valid tool to measure anxiety
in the general population 30]. The questionnaire of this study was pilot-tested among 250 respondents (249 responded)
in another district in Selangor. The GAD-7 was found to have good reliability (Standardized
Cronbach’s Alpha?=?0.892 and mean inter-item correlation of 0.541). Hence, the findings
from this study can be generalized to the general population.

Presence of chronic diseases such as heart disease, diabetes, cancer, arthritis and
stroke were self-reported by the participants, based on the diagnosis by doctors or
medical professionals. Similarly, the history of mental health disorders were also
self-reported by the participants, based on the diagnosis made by the doctors or medical
professional.

The Patient Health Questionnaire 9 (PHQ-9) measures the depressive symptoms, based
on the criteria from DSM-IV. The PHQ-9 was first developed and validated by Kroenke
et al. 31]. The instrument is comprised of nine items, with each item scored from 0 to 3, with
total scores ranging from 0 to 27. Participants who had five and above out of nine
symptoms in the PHQ-9 in the past two weeks was diagnosed as having major depression.
Whereas those who had 2, 3, or 4 symptoms was diagnosed as having other depression.
In general, participants who scored 10 and above in the PHQ-9 was categorized as having
depression. The Malay version of PHQ-9 was validated in the primary care setting by
Sherina et al. 32].

For the assessment of stressful life events, seventeen events associated with depression
and anxiety were chosen from Kendler et al. 33]. History of being assaulted, suffering from a serious illness, being abused during
childhood and having unhappy relationships with spouse, children and family were among
the events assessed in this questionnaire.

The Perceived Stress Scale was developed and validated by Cohen et al. 34]. The PSS-10 was used in this study to measure perceived stress. The PSS-10 consists
of ten items, with each of the items rated on a five-point Likert scale (never, almost
never, sometimes, fairly often and very often), with total scores ranging from 0 to
40. The mean score of the total items was used as the cut-off point to classify low
and high perceived stress.

The questionnaires in this study also included items on domestic violence from the
HARK questionnaire 35]. HARK is used as an abbreviation for humiliation, afraid, rape and kick. It is made
up of four items, which includes questions on emotional, psychological, sexual and
physical abuse from current or ex-partners.

For the assessment of self-esteem, the Rosenberg self-esteem scale (RSES) was used.
The RSES was developed by Morris Rosenberg 36]. It is comprised often items, which are rated on a four-point scale (strongly agree,
agree, disagree and strongly disagree), with scores ranging from 10 to 40. For the
classification of low and high self-esteem, the mean score of the total items was
used.

The Duke University Religion Index (DUREL) was used to assess religious involvement
37]. Three major dimensions of religiosity that were assessed in this five-item instrument
were: organizational religious activity (ORA), non-organization religious activity
(NORA) and intrinsic religiosity (IR).

Statistical Analysis

Data entry and analysis was done using the IBM SPSS Statistics version 21.0. There
were varied numbers of missing data in the questionnaire, depending on the study instrument.
Missing data for only that particular instrument were excluded from the analysis.
Age was expressed in mean?±?standard deviation (SD). The association between the independent
categorical variables and anxiety were analyzed using either the Chi square or Fisher’s
exact test. The t-test was used to determine the differences between the continuous independent variable
with anxiety. All the independent variables with p-value??0.25 on the chi-square
and t-test were selected for further analysis. Multivariate logistic regression analysis
using the Enter method was performed to determine the predictors of anxiety. The predictors
of anxiety in this study were selected based on p??0.05.