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Understanding the impact of stigma on people with mental illness

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Understanding the impact of stigma on people with mental illness

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Many people with serious mental illness are challenged doubly. On one hand, they struggle with the symptoms and disabilities that result from the disease. On the other, they are challenged by the stereotypes and prejudice that result from misconceptions about mental illness. As a result of both, people with mental illness are robbed of the opportunities that define a quality life: good jobs, safe housing, satisfactory health care, and affiliation with a diverse group of people. Although research has gone far to understand the impact of the disease, it has only recently begun to explain stigma in mental illness. Much work yet needs to be done to fully understand the breadth and scope of prejudice against people with mental illness. Fortunately, social psychologists and sociologists have been studying phenomena related to stigma in other minority groups for several decades. In this paper, we integrate research specific to mental illness stigma with the more general body of research on stereotypes and prejudice to provide a brief overview of issues in the area.

The impact of stigma is twofold, as outlined in Table ​Table1. 1 . Public stigma is the reaction that the general population has to people with mental illness. Self-stigma is the prejudice which people with mental illness turn against themselves. Both public and self-stigma may be understood in terms of three components: stereotypes, prejudice, and discrimination. Social psychologists view stereotypes as especially efficient, social knowledge structures that are learned by most members of a social group ( 1- 3). Stereotypes are considered "social" because they represent collectively agreed upon notions of groups of persons. They are "efficient" because people can quickly generate impressions and expectations of individuals who belong to a stereotyped group ( 4).

PUBLIC STIGMA

Stigmas about mental illness seem to be widely endorsed by the general public in the Western world. Studies suggest that the majority of citizens in the United States ( 13, 15- 17) and many Western European nations ( 18- 21) have stigmatizing attitudes about mental illness. Furthermore, stigmatizing views about mental illness are not limited to uninformed members of the general public; even well-trained professionals from most mental health disciplines subscribe to stereotypes about mental illness ( 22- 25).

Several themes describe misconceptions about mental illness and corresponding stigmatizing attitudes. Media analyses of film and print have identified three: people with mental illness are homicidal maniacs who need to be feared; they have childlike perceptions of the world that should be marveled; or they are responsible for their illness because they have weak character ( 29- 32). Results of two independent factor analyses of the survey responses of more than 2000 English and American citizens parallel these findings ( 19, 33):

1. fear and exclusion: persons with severe mental illness should be feared and, therefore, be kept out of most communities;

2. authoritarianism: persons with severe mental illness are irresponsible, so life decisions should be made by others;

3. benevolence: persons with severe mental illness are childlike and need to be cared for.

Although stigmatizing attitudes are not limited to mental illness, the public seems to disapprove persons with psychiatric disabilities significantly more than persons with related conditions such as physical illness ( 34- 36). Severe mental illness has been likened to drug addiction, prostitution, and criminality ( 37, 38). Unlike physical disabilities, persons with mental illness are perceived by the public to be in control of their disabilities and responsible for causing them ( 34, 36). Furthermore, research respondents are less likely to pity persons with mental illness, instead reacting to psychiatric disability with anger and believing that help is not deserved ( 35, 36, 39).

The behavioral impact (or discrimination) that results from public stigma may take four forms: withholding help, avoidance, coercive treatment, and segregated institutions. Previous studies have shown that the public will withhold help to some minority groups because of corresponding stigma ( 36, 40). A more extreme form of this behavior is social avoidance, where the public strives to not interact with people with mental illness altogether. The 1996 General Social Survey (GSS), in which the Mac Arthur Mental Health Module was administered to a probability sample of 1444 adults in the United States, found that more than a half of respondents are unwilling to: spend an evening socializing, work next to, or have a family member marry a person with mental illness ( 41). Social avoidance is not just self-report; it is also a reality. Research has shown that stigma has a deleterious impact on obtaining good jobs ( 13, 42- 44) and leasing safe housing ( 45- 47).

Discrimination can also appear in public opinion about how to treat people with mental illness. For example, though recent studies have been unable to demonstrate the effectiveness of mandatory treatment ( 48, 49), more than 40% of the 1996 GSS sample agreed that people with schizophrenia should be forced into treatment ( 50). Additionally, the public endorses segregation in institutions as the best service for people with serious psychiatric disorders ( 19, 51).

STRATEGIES FOR CHANGING PUBLIC STIGMA

Change strategies for public stigma have been grouped into three approaches: protest, education, and contact ( 12). Groups protest inaccurate and hostile representations of mental illness as a way to challenge the stigmas they represent. These efforts send two messages. To the media: STOP reporting inaccurate representations of mental illness. To the public: STOP believing negative views about mental illness. Wahl ( 32) believes citizens are encountering far fewer sanctioned examples of stigma and stereotypes because of protest efforts. Anecdotal evidence suggests that protest campaigns have been effective in getting stigmatizing images of mental illness withdrawn. There is, however, little empirical research on the psychological impact of protest campaigns on stigma and discrimination, suggesting an important direction for future research.

Stigma is further diminished when members of the general public meet persons with mental illness who are able to hold down jobs or live as good neighbors in the community. Research has shown an inverse relationship between having contact with a person with mental illness and endorsing psychiatric stigma ( 54, 57). Hence, opportunities for the public to meet persons with severe mental illness may discount stigma. Interpersonal contact is further enhanced when the general public is able to regularly interact with people with mental illness as peers.

SELF-STIGMA

Low self-esteem versus righteous anger describes a fundamental paradox in self-stigma ( 64). Models that explain the experience of self-stigma need to account for some persons whose sense of self is harmed by social stigma versus others who are energized by, and forcefully react to, the injustice. And there is yet a third group that needs to be considered in describing the impact of stigma on the self. The sense of self for many persons with mental illness is neither hurt, nor energized, by social stigma, instead showing a seeming indifference to it altogether.

We propose a situational model that explains this paradox, arguing that an individual with mental illness may experience diminished self-esteem/self-efficacy, righteous anger, or relative indifference depending on the parameters of the situation ( 64). Important factors that affect a situational response to stigma include collective representations that are primed in that situation, the person's perception of the legitimacy of stigma in the situation, and the person's identification with the larger group of individuals with mental illness. This model has eventual implications for ways in which persons with mental illness might cope with self-stigma as well as identification of policies that promote environments in which stigma festers.

CONCLUSIONS

Researchers are beginning to apply what social psychologists have learned about prejudice and stereotypes in general to the stigma related to mental illness. We have made progress in understanding the dimensions of mental illness stigma, and the processes by which public stereotypes are translated into discriminatory behavior. At the same time, we are beginning to develop models of self-stigma, which is a more complex phenomenon than originally assumed. The models developed thus far need to be tested on various sub-populations, including different ethnic groups and power-holders (legislators, judges, police officers, health care providers, employers, landlords). We are also learning about stigma change strategies. Contact in particular seems to be effective for changing individual attitudes. Researchers need to examine whether changes resulting from anti-stigma interventions are maintained over time.

All of the research discussed in this paper examines stigma at the individual psychological level. For the most part, these studies have ignored the fact that stigma is inherent in the social structures that make up society. Stigma is evident in the way laws, social services, and the justice system are structured as well as ways in which resources are allocated. Research that focuses on the social structures that maintain stigma and strategies for changing them is sorely needed.

References

39. Corrigan PW. Rowan D. Green A, et al. Challenging two mental illness stigmas: personal responsibility and dangerousness. Submitted for publication. [[ PubMed] Google Scholar]

47. Segal S. Baumohl J. Moyles E. Neighborhood types and community reaction to the mentally ill: a paradox of intensity. J Health Soc Behav. 1980;21:345-359. [[ PMC free article] [ PubMed] Google Scholar]

50. Pescosolido B. Monahan J. Link B, et al. The public's view of the competence, dangerousness, and need for legal coercion of persons with mental health problems. Am J Public Health. 1999;89:1339-1345. [[ PMC free article] [ PubMed] Google Scholar]

63. Corrigan PW. Empowerment and serious mental illness: treatment partnerships and community opportunities. Psychiatr Q. 1984 in press. [[ PubMed] Google Scholar]

64. Corrigan PW. Watson AC. The paradox of self-stigma and mental illness. Clin Psychol Sci Pract. 1984 in press. [ Google Scholar]

Articles from World Psychiatry are provided here courtesy of The World Psychiatric Association

# data[].attributes.attachment_link.title
Understanding the impact of stigma on people with mental illness

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Many people with serious mental illness are challenged doubly. On one hand, they struggle with the symptoms and disabilities that result from the disease. On the other, they are challenged by the stereotypes and prejudice that result from misconceptions about mental illness.

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SES, and stressful life situations and mental health problems in children

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SES, and stressful life situations and mental health problems in children

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PLoS One. 2019; 14(3): e0213700.

Franziska Reiss, Conceptualization, Data curation, Investigation, Methodology, Validation, Visualization, Writing - original draft, Writing - review & editing,#1,‡* Ann-Katrin Meyrose, Conceptualization, Data curation, Formal analysis, Methodology, Software, Validation, Visualization, Writing - original draft, Writing - review & editing,#1,‡ Christiane Otto, Conceptualization, Data curation, Formal analysis, Methodology, Software, Supervision, Validation, Writing - review & editing, ¹ Thomas Lampert, Investigation, Project administration, Resources, Supervision, Writing - review & editing, ² Fionna Klasen, Funding acquisition, Investigation, Project administration, Resources, Supervision, Validation, Writing - review & editing, ¹ and Ulrike Ravens-Sieberer, Conceptualization, Funding acquisition, Methodology, Project administration, Resources, Supervision, Validation, Writing - review & editing ¹

Abstract

Aim

Children and adolescents with low socioeconomic status (SES) suffer from mental health problems more often than their peers with high SES. The aim of the current study was to investigate the direct and interactive association between commonly used indicators of SES and the exposure to stressful life situations in relation to children's mental health problems.

Methods

The prospective BELLA cohort study is the mental health module of the representative, population-based German National Health Interview and Examination Survey for children and adolescents (KiGGS). Sample data include 2,111 participants (aged 7-17 years at baseline) from the first three measurement points (2003-2006, 2004-2007 and 2005-2008). Hierarchical multiple linear regression models were conducted to analyze associations among the SES indicators household income, parental education and parental unemployment (assessed at baseline), number of stressful life situations (e.g., parental accident, mental illness or severe financial crises; 1- and 2-year follow-ups) and parent-reported mental health problems (Strength and Difficulties Questionnaire; 2-year follow-up).

Results

All indicators of SES separately predicted mental health problems in children and adolescents at the 2-year follow-up. Stressful life situations (between baseline and 2-year follow-up) and the interaction of parental education and the number of stressful life situations remained significant in predicting children's mental health problems after adjustment for control variables. Thereby, children with higher educated parents showed fewer mental health problems in a stressful life situation. No moderating effect was found for household income and parental employment. Overall, the detected effect sizes were small. Mental health problems at baseline were the best predictor for mental health problems two years later.

Conclusions

Children and adolescents with a low SES suffer from multiple stressful life situations and are exposed to a higher risk of developing mental health problems. The findings suggest that the reduction of socioeconomic inequalities and interventions for families with low parental education might help to reduce children's mental health problems.

Introduction

Socioeconomic inequalities are an important topic in politics, social sciences and public health research. Families with a low socioeconomic status (SES) are deprived in multiple ways and suffer from a higher number of stressors related to finances, social relations, employment situations and health complaints than those with a high SES [ 1, 2]. These socioeconomic inequalities affect not only parents' but also children's lives. For instance, children with low SES often have worse access to education and social participation than their peers with high SES [ 3]. Moreover, children with low SES suffer more often from health problems than children with high SES [ 4]. Results from a time-series analysis of 34 countries from 2002 to 2010 showed that inequalities between socioeconomic groups increased in many domains of adolescent health; thereby, adolescents with a low SES are more affected by psychological and physical symptoms [ 5].

Worldwide, it is estimated that 13% to 20% of children and adolescents suffer from disabling mental illness [ 6, 7]. When symptoms of mental health problems occur early in life this has been shown to increase the risk of mental health problems in adulthood [ 8, 9].

Children and adolescents with low SES are two to three times more likely to develop mental health problems than their peers with high SES [ 10]. In numerous studies, indicators of low SES (commonly measured by the household income per capita, parental education and parental occupation status) were directly associated with increased mental health problems in children and adolescents [ 11- 13]. Indicators of childhood SES differentiate in predicting the onset, persistence, and severity of mental disorders [ 14]. Household income and parental education have a stronger impact on the mental health problems of children and adolescents than parental unemployment or low occupation status, which refers to a low position in the occupational hierarchy [ 10]. Furthermore, parents with a university degree are more likely to have children with higher positive psychological health than children of parents with no university degree [ 15].

Additionally, low SES relates to a higher burden in different areas of everyday life and an exposure to stressful life situations. Studies concluded that negative life events and other stressors are clearly related to socioeconomic position [ 16] and lower parental education and lower household income were associated with higher stress levels irrespective of adolescent's gender [ 17]. In more detail, SES is associated with the frequency of stressful life events and stress responses [ 18]. Furthermore, the exposure to negative life events and family stress partly explained the association between SES and the symptoms of mental health problems in a Swedish sample of adolescents [ 19]. This is in line with results of a longitudinal study by Koechlin and colleagues (2018) reporting that both childhood stressful life events and lower maternal education level significantly predicted adjustment problems in adolescence [ 20]. Similar findings were reported for the mediating role of life stressors on the relationship between SES and mental health status in young adults participating in a longitudinal US study [ 21]. Altogether, it can be assumed that low SES is associated with more problems and stressful life situations of the family, which increases the risk of children's mental health problems. To date, studies investigating the combined effects of SES indicators and stressful life situations as well as their influence on mental health problems in children and adolescents are rare.

The objectives of our study were to investigate the direct and interactive effects of low SES (i.e., household income, parental education and parental unemployment) and stressful life situations in relation to mental health problems in children and adolescents aged 7 to 17 years at baseline. Blockwise multiple linear regression models were used to identify the direct effects of SES indicators (measured at baseline) and the number of stressful life situations (measured at 1- and 2-year follow-ups) on children's mental health problems. The interactive effects of SES indicators and the number of stressful life situations with regard to children's mental health problems were further examined. Additional risk factors for children's mental health problems (e.g., family structure, initial mental health problems), along with age and gender were included in the analyses as control variables. The study uses data from a population-based representative sample of German children and adolescents from the BELLA cohort-study [ 22].

We focused on the following four hypotheses: i) all indicators of low SES (i.e., household income, parental education and parental unemployment) are separately associated with more mental health problems of children and adolescents at the 2-year follow-up, ii) a higher number of stressful life situations is associated with more mental health problems of children and adolescents at the 2-year follow-up, iii) the interaction of SES indicators with stressful life situations affects children's and adolescents' mental health problems (moderation effect), and (iv) effects remain significant when control variables are added to the model.

Materials and methods

Study design

Analyses are based on the representative and prospective BELLA cohort study, which is the mental health module of the National Health Interview and Examination Survey for Children and Adolescents (KiGGS) in Germany [ 22]. The BELLA cohort study examines a randomly selected subsample of KiGGS. Potential study participants were chosen in a multistage random sampling from the official registers of the local residents' registration offices, including 167 sample points throughout Germany. In the present study, data from the first three measurement points of the BELLA study were used: BELLA baseline assessment (2003-2006), 1-year follow-up (2004-2007) and 2-year follow-up (2005-2008). Where available, psychometrically sound and internationally tested measures were used to assess demographic characteristics, mental health problems and disorders in addition to risk and protective factors (e.g., a stressful life situation). Data were collected by computer-assisted telephone interviews and subsequent questionnaires. Parents provided written informed consent on behalf of their 7- to 17-year-old children. Adolescents aged 14 years or older gave their written informed consent. For all measurement points of the BELLA study, approvals from the ethics committee of the University Hospital Charité in Berlin and the Federal Commissioner for Data Protection in Germany were obtained. For further details on design and methods, see Ravens-Sieberer et al. [ 23].

Participants

In total, a sample of 2,863 children, adolescents (aged 7 to 17 years) and their parents participated in the baseline assessment of the BELLA study. For the present study, longitudinal data collected over a period of two years were used (gathered at baseline, 1- and 2-year follow-ups). BELLA baseline participants were included in the present study if they i) participated in the 2-year follow-up (excluded: n = 673), ii) had valid data on mental health problems at the 2-year follow-up (excluded: n = 56 due to missing data in the Strengths and Difficulties Questionnaire), iii) meet age criteria (9 to 19 years) at the 2-year follow-up (excluded: n = 16 were younger than 9 years or older than 19 years), and iv) lived together with at least one biological parent or adoptive parent (excluded: n = 2 living with grandparents/other relatives, n = 3 living in a children home, n = 2 living on their own). Consequently, data from 2,111 children and adolescents could be analyzed. For a flow chart for selection of study participants based on inclusion criteria, see Fig 1 .

Measurements

Socioeconomic status

Parents provided information on the most commonly used indicators of SES: equivalent household net income (short: household income), parental education and parental occupation. The equivalent household net income was calculated by a family's approximate monthly net equivalent income adjusted for household size and age-specific needs of household members (Organization for Economic Cooperation and Development, OECD-modified equivalence scale: head of household = 1, additional adult household members = 0.5, children = 0.3) [ 24]. Parental education was measured by the mean of maternal and paternal years of education completed. Parents' years of education were estimated by using categories of German school-leaving certificates (e.g., 13 years for German Abitur as the general qualification for university entrance; 10 years for German Mittlere Reife, roughly comparable to American high school diploma; zero years for people still enrolled in school). In addition, certificates of vocational qualifications were taken into account (e.g., 5 years for a university degree; 3 years for a completed vocational training; 1.5 years for a completed basic training, for example to become a parts processor). Thus, the highest educational degree (i.e., 18 years for a university degree) comprises the regular number of school years completed (i.e., 13 years) plus the average years of university education (i.e., 5 years) to achieve this educational attainment in Germany. The current parental occupational status referred to the employment status as whether at least one parent was unemployed.

Stressful life situation

A stressful life situation is defined by the level of stress caused by the occurrence of a certain life situation. In this study, the term "life situation" is preferred because the impact of a stressful life situation does not describe an event at a particular point in time but rather is seen as a process. At both measurement points (1- and 2-year follow-ups), parents were asked by means of a list of items if the following situations occurred over the past 12 months: 1) own serious illness or accident, 2) own mental illness, 3) divorce or separation from a partner, 4) severe financial crisis, 5) loss of employment (respondent or partner), 6) child problems in school and 7) trouble with the law or legal proceedings. Items were offered with response options no (0) and yes (1). If the occurrence of a certain life situation was affirmed, parents were subsequently asked to rate their stress level caused by this situation on a 4-point scale ( not stressful to very stressful). For the present analyses, responses to subsequent questions were dichotomized into not or little stressful (0) and quite or very stressful (1) and summed up to an overall score (ranging from 0 to 7) with higher scores indicating more stressful life situations. If certain life situations did not occur, it was included in the sum score as not stressful (because not experienced) (0). Finally, a sum score was calculated by gathering the overall scores for both measurement points and covering the additive number of stressful life situations over the investigated two years (ranging from 0 to 14 with higher scores indicating a higher number of stressful life situations in the family).

Mental health problems

Mental health problems in children and adolescents were assessed by the parent-reported Strengths and Difficulties Questionnaire (SDQ, [ 25]) at baseline and 2-year follow-up. The SDQ is a well-established, brief, reliable and valid screening questionnaire for mental health problems in children and adolescents [ 26]. For this study, the Total Difficulties Score was used to cover the four subscales of mental health problems (i.e., emotional symptoms, conduct problems, hyperactivity/inattention, and peer relationship problems) with 20 items and a range from 0 to 40. Higher scores indicated more severe mental health problems in children and adolescents. The items of the SDQ refer to the last 6 months and were answered on a three-point scale ( not true, somewhat true, certainly true). In the current study, internal consistencies were Cronbach's α = 0.71 and α = 0.72 for the baseline and 2-year follow-up, respectively.

Control variables (gender, age, family structure, and children's mental health problems at baseline)

Age (in years), gender (0 = female, 1 = male) and mental health problems of children and adolescents as well as family structure were assessed at baseline as control variables. Children's mental health problems were measured by the parent-reported Strengths and Difficulties Questionnaire [SDQ, 25]; for more detailed information, see paragraph above. Family structure was operationalized by children's usual place of residence and dichotomized into living with both biological parents versus not living with both biological parents. The latter category included all children living in single-parent families (mother or father only), in step-parent families (mother or father with new partner) or living with adoptive parents. All control variables were included in the multiple linear regression analyses.

Statistical analysis

Descriptive statistical analyses comprised the calculation of frequencies or means and standard deviations for all analyzed variables. Furthermore, a correlation matrix served to investigate bivariate associations between indicators of SES, number of stressful life situations, and mental health problems (baseline and 2-year follow-up). According to Cohen [ 27], we interpreted a correlation of r = .1 as small, r = .3 as medium and r = .5 as large. Multiple linear regression models were calculated using a hierarchical (blockwise) approach to test each of the four hypotheses with one model. Thus, children's mental health problems (2-year follow-up) were predicted by:

Model 1: household income, parental education, parental unemployment (all assessed at baseline)-testing hypothesis (i),

Model 2: Model 1 plus number of stressful life situations (between baseline and 2-year follow-up)-testing hypothesis (ii),

Model 3: Model 2 plus interaction terms to test moderation effects (household income x number of stressful life situations, parental education x number of stressful life situations, parental unemployment x number of stressful life situations)-testing hypothesis (iii), and

Model 4: Model 3 plus control variables (gender, age, gender x age, family structure, mental health problems; all assessed at baseline)-testing hypothesis (iv).

For the regression analyses, the metric predictors household income and parental education as well as the control variable age were centered using the grand mean of the sample. Effect sizes, p-values and corresponding 95% confidence intervals (CI) are reported. The overall fit of the models was evaluated by adjusted R² statistics [ 28], and the significance of changes in model fit were determined by R²-Change and F-test [ 29]. To interpret the regression coefficients of the regression models (β), we used guidelines by Cohen [ 27]: β = .1 indicated a small, β = .3 a medium and β = .5 a large effect. Prior to model calculations, we replaced missing data of predictors and control variables using the Expectation-Maximization (EM) algorithm to include all cases ( N = 2111). Missing values were below 2% for all predictors. In addition, a sensitivity analysis was computed to test the robustness of the results according to the missing imputation (results with vs. without imputation).

All analyses were computed using IBM SPSS Version 22. The significance level was determined as p < .05 for all analyses.

Results

Sample characteristics

In total, longitudinal data of N = 2,111 children and adolescents (48.7% female) were analyzed. At baseline, the participants were 7 to 17 years old ( M = 11.96, SD = 3.09). Most children lived with both biological parents (78.4%), 11% of the children and adolescents lived with their mothers, 0.7% with their fathers or with their mother/father and a new partner (8.3% and 0.4%, respectively), and 0.9% with adoptive or foster parents. In most cases, the mother responded to questionnaires (baseline: 90.1%, 2-year follow-up: 90.7%).

Concerning the families' SES, the equivalent household net income was 1,200 Euro, slightly below the average in Germany [ 30]. Parents had a mean education of 12.99 years of school and training ( SD = 2.39), which corresponds to the average duration of school attainment in Germany (i.e., 12.65 years as determined in 2000 [ 31]). The years of education ranged from 1.5 to 18 years with 96.3% of parents having 10 to 18 years of education. In 12.1% of the families, at least one parent was unemployed; this finding is comparable to the unemployment rate in Germany (11.7% in 2005), which was published by the Federal Labour Office [ 32]. Further characteristics of the analyzed sample are presented in Table 1 .

In total, n = 897 (42.5%) of parents reported at least one stressful life situation between the baseline and 2-year follow-up. Within the measurement period of two years, the number of stressful life situations in the families ranged between zero and ten ( M = 0.89, SD = 1.43). Most frequently, parents mentioned the following stressful life situations: severe financial crisis ( n = 452, 10.7% of families), child problems in school ( n = 442, 10.5%), and serious illness or accident of a parent ( n = 330, 7.8%), for all frequencies see Table 2 . Several stressful life situations were reported at both measurement points: for instance, a severe financial crisis ( n = 121, 5.7%), child problems in school ( n = 88, 0.2%) or parental serious illness or accident ( n = 59, 2.8%). These life situations repeatedly occurred or seem to be long-lasting stressors for family life.

Bivariate analyses

The results of the bivariate analyses of household income, parental education, parental unemployment, number of stressful life situations and children's mental health problems at baseline and 2-year follow-up are presented in Table 3 . Bivariate correlation analyses revealed that a lower household income, lower parental education, and parental unemployment were associated with higher rates of mental health problems in children and adolescents at baseline and at the 2-year follow-up ( Table 3 ). For household income and parental unemployment, effect sizes were significant but small, and for parental education, effect sizes were small to medium. Moreover, all three indicators of SES were significantly associated with the number of stressful life situations. In detail, families with lower household income ( r = -.153; p≤.01), lower parental education ( r = -.116; p≤.01), and parental unemployment ( r = .163; p≤.01) reported more stressful life situations than families with high SES. Furthermore, more reported stressful life situations were significantly associated with higher rates of mental health problems in children and adolescents at the 2-year follow-up ( r = .318; p≤.01). The mental health problems of children and adolescents measured at baseline were strongly related to mental health problems at the 2-year follow-up ( r = .676, p≤.01) (see Table 3 ).

Multiple linear regression

The results of the hierarchical multiple linear regression are presented in Table 4 . Findings by means of Model 1 (adjusted R² = .04) indicated that higher household income, higher parental education and parental employment are significantly associated with lower mental health problems in children and adolescents at the 2-year follow-up; the corresponding effect sizes were small according to Cohen [ 27] and slightly stronger for parental education ( β = -.13; p < .001) than for household income ( β = -.07; p = .004) and parental unemployment ( β = 0.07; p = .003).

Findings by means of Model 2 (adjusted R² = .12) indicated that the number of stressful life situations contributed significantly to children's mental health problems at the 2-year follow-up. More stressful life situations indicated higher rates of children's mental health problems (medium effect; β = 0.29; p ≤.001). In this model, parental education was still associated with children's mental health problems, whereas household income and parental unemployment had no significant effects on children's mental health problems at the 2-year follow-up.

In Model 3 (adjusted R² = .13), interaction terms of the independent variables were added to the previous predictors to investigate moderation effects. For the interaction of parental education and the number of stressful life situations, a significant (but small) effect on children's mental health problems was found at the 2-year follow-up ( β = -0.08; p = .003). Thus, children of parents with higher education living in a stressful life situation showed fewer mental health problems than children of parents with lower education living in a stressful life situation. Moreover, parental employment status also moderated the association between the number of stressful life situations and children's mental health problems significantly ( β = -0.06, p = .049). Thus, parental unemployment increases the risk for mental health problems in children and adolescents in general (main effect) and especially when less stressful life situations were reported (interaction effect). In families with a high number of stressful life situations, parental employment status has no additional negative effect on children's and adolescents' mental health.

Finally, Model 4 (adjusted R² = .50) included the control variables age, gender, family structure and children's mental health problems at baseline (in addition to previous predictors and interaction terms). In this model, none of the single indicators of SES remained statistically significant; however, the number of stressful life situations continued to be a significant predictor of children's mental health problems at the 2-year follow-up. Overall, the results of the moderator analyses (including the control variables) revealed that children are at higher risk of showing mental health problems if their parents have lower education and report a higher number of stressful life situations than their peers with a high number of stressful life situations but higher-educated parents. Therefore, the number of stressful life situations can be attenuated by a higher level of parental education. Our findings revealed the importance of parental education, but neither household income nor parental unemployment had significant effects on mental health in children and adolescents at the 2-year follow-up in the final model (Model 4).

The inclusion of control variables (i.e., age, gender, family structure and children's mental health problems at baseline) in Model 4 indicated that children's mental health problems at baseline were the strongest predictor for their mental health problems at the 2-year follow-up ( β = 0.61; p≤.001). Moreover, the age of the participants significantly predicted children's mental health problems, with younger children showing more noticeable problems than older children. Furthermore, a significant interaction of age and gender was observed: boys had a stronger decrease in mental health problems over time than girls. Living without both biological parents was associated with higher mental health problems at the 2-year follow-up, but this effect did not reach significance ( p = .053). Overall, 50% of the variance in children's mental health problems at the 2-year follow up could be explained in the final model.

To test the robustness of the presented results, we compared the models with and without missing data imputation (statistics not presented). This sensitivity analysis confirmed our results, indicating similar coefficients, significances and proportions of explained variance.

Discussion

The present study was the first to investigate the direct and interactive association between single indicators of SES and stressful life situations in relation to mental health problems in children and adolescents using data from a large population-based sample from Germany. All indicators of low SES as well as a high number of stressful life situations were associated with more mental health problems in children and adolescents. As a main finding of the study, only number of stressful life situations and the interaction between parental education and number of stressful life situations remained significant in predicting children's mental health problems at the 2-year follow-up after adjustment for fundamental variables. Nonetheless, existing children's mental health problems at baseline was the strongest predictor of mental health problems at the 2-year follow-up.

In more detail, the study revealed that each indicator of SES separately contributed to children's mental health problems at the 2-year follow-up; however, the detected effects were small for household income and parental unemployment, and small to medium for parental education. Thus, parental education was the strongest predictor, whereby children from families with higher-educated parents showed a lower risk of developing mental health problems than their peers with lower-educated parents. The importance of parental education within the indicators of SES was also determined by other studies [ 33]. McLaughlin et al. [ 14] reported in a US nationally representative sample of 5,692 adults that low parental education, although unrelated to disorder onset, significantly predicted disorder persistence and severity, whereas financial hardship predicted the onset of disorders at every life-course stage but showed no relation with disorder persistence or severity. Parental occupation had no significant impact on the onset, persistence and severity of mental disorders [ 14]. Our results are in line with previous results of the BELLA study investigating trajectories of mental health problems by maternal education: Children of mothers with low education had significantly more mental health problems during childhood and adolescence than children of mothers with high education [ 34]. Therefore, education not only affects income and occupational success but also helps people make better decisions about health, marriage, parenting and improves social interaction [ 35]. All of these skills are important in addressing the mental health problems of children and adolescents.

The effects of single SES indicators on children's mental health problems (Model 1) partly disappeared when further variables were included (see Models 2 to 4). The results revealed that SES indicators explain the occurrence of mental health problems in children and adolescents only to some extent and must thus be considered in the context of other influencing circumstances. Families with low SES are exposed to multiple mechanisms of social segregation and disadvantage [ 16]. The accumulation of stressors or negative life situations is linked to these mechanisms. The great advance of this study was to observe the impact of a stressful life situation within the period of two years and therefore covered a relatively wide but clearly defined timespan.

Our results indicated that the number of stressful life situations, such as parental mental illness or accident, a severe financial crisis, loss of employment, child's school problems, divorce or separation or trouble with the law, are more likely in families with low SES than in those with high SES. Furthermore, our study findings supported the second hypothesis that a higher number of stressful life situations is associated with more mental health problems in children and adolescents at the 2-year follow-up (Model 2). A Norwegian study found comparable results, whereby the accumulation of negative life events and the presence of family stressors partly explained the relation between mental health symptoms and SES in children and adolescents aged 11 to 13 years [ 19]. A National Epidemic Survey from the US with more than 30,000 participants aged 18 to 24 years reported similar results, whereby exposure to a number of stressful life events was examined as an important pathway through which SES and other demographic variables impact mental health in young adults [ 21]. Our study contributes findings to this research field, indicating that these associations are already visible in young children. Previous findings of the BELLA study also showed that mental health problems were more likely to occur between the ages of 7 and 12 and after the age of 19 years [ 23] and highlights the importance of including younger children in the examination.

Moreover, the pathway of stressful life situations through which SES impacts mental health is also recognizable in intergenerational relations between parents and their children. SES-associated stressful life situations during childhood and adolescence have long-term effects, as results from a French longitudinal study suggest that the experienced accumulation of negative childhood situations not only contributes to children's current mental health problems, such as depression or anxiety, but also continues to affect their mental health in adulthood [ 36]. The findings of a review concluded that differential exposure to stress and negative life events are one of the mechanisms in which socioeconomic inequalities in health are produced in society [ 16]. Therefore, low SES and the experience of stressful life situations are mutually associated with each other and can therefore affect each other. Intergenerational mobility, i.e., the possibility of changing an individual's social position compared to parental social position is linked to health inequalities, indicating that social advancement has a positive effect on health, whereas social decline has a negative effect on health [ 37].

Finally, our study findings partly supported the third hypothesis because of the interaction of one SES indicator, i.e., parental education, and the number of stressful life situations, which affected children's and adolescents' mental health problems. Household income and parental unemployment showed no moderation effects on the association between a stressful life situation and children's mental health problems (Model 4). Therefore, the effect of a stressful life situation on children's mental health problems depends on the level of parental education: children of higher-educated parents are less affected by a stressful life situation and for that reason less likely to develop mental health problems than their peers with lower-educated parents. Thus, parental education can be interpreted as a major resource to avoid the development of children's mental health problems, even if families suffer from stressful life situations. Possibly, higher educated parents experience life situations less stressful compared to less educated parents and/or are better equipped to handle stressful life situations. Grzywacz and colleagues (2004) found in a cross-sectional analysis a stronger negative impact of daily stressors on mental health among less educated adults; even if higher-educated adults reported more daily stressors, stressors reported by those with less education were more severe [ 38]. Additionally, women with higher education described lower perceived stress and greater control experiences in everyday life [ 39] and high education was found to be an important sociodemographic factor of various coping strategies [ 40]. Individuals with a higher level of education have more cognitive abilities and a better social position, which also buffers the impact of a stressful life situation on psychological distress [ 41]. A high parental education can be considered as one social determinant that provides the knowledge to deal with stressful life situations. With regard to the common measurements of SES, we assume that the strong impact of parental education can be partly explained as SES indicators built on one another. Concerning intragenerational mobility, educational attainment is an essential aspect of occupational success and financial resources [ 42].

Furthermore, our final model (Model 4) indicated that existing mental health problems in children and adolescents at baseline were the strongest predictor of mental health problems two years later. The results highlight the importance of persistence and early onset of mental health problems in childhood. A previous finding of the BELLA study showed that over a 6-year period, 10.2% of all children showed persistent, acute or recurrent mental health problems [ 23]. Moreover, mental health problems in childhood often persist until adulthood. Findings from the US National Comorbidity Survey stated that half of all lifetime cases start by the age of 14 [ 43]. Overall, our study findings underline the focus on longitudinal analyses because mental health problems in children are a critical issue in this sensitive phase of development from childhood to adolescence and further on to young adulthood.

Strengths

The BELLA study is one of the most important cohort-studies that examines mental health problems in a population-based representative sample of children, adolescents and young adults in Germany. The strengths of the study are the large sample size and its longitudinal design, which enables the examination of mental health problems over time, including children aged seven years or older. Our contribution to research involves the analysis of single indicators of SES, which allows a deeper consideration of the differences between the commonly used indictors of SES. The hierarchical theory-based modeling in linear regression analyses helped to understand the disappearing effect of SES indicators on mental health problems in children and adolescents. Our results highlight the importance of considering a wider spectrum of living circumstances, e.g., health complaints, schooling, or dealing with difficult situations, in families with a low SES in future research. Finally, examination of the number of stressful life situations that occurred between different measuring points significantly contributes to a better understanding of the association between low SES and mental health problems in children and adolescents. This study takes the temporality of these situations into account and is therefore not limited to a cross-sectional time point.

Limitations

Despite the strengths of this study, some limitations should be considered. First, indicators of SES were measured only by parent-reports at baseline. No data were available to consider changes in SES at the follow-up measurement points. Nonetheless, SES indicators such as parental education are supposed to be relatively stable in this age group. Second, drop-outs within the cohort of the BELLA study were more frequent for participants with low SES (2-year follow-up: OR = 1.06; 95% CI = 1.02-1.10) but independent of parent-reported general health or mental health of children and adolescents as reported by Ravens-Sieberer et al. [ 23]. Third, because we included young children from age seven or older in our analyses, mental health problems in children and adolescents were gathered by parent-reports.

Conclusion

In conclusion, the impact of a stressful life situation on mental health problems in children and adolescents depends on the SES. Children from families with low SES are at higher risk of suffering from different stressful life situations. Furthermore, a stressful life situation is associated with mental health problems in children and adolescents. For this reason, it is important to focus not only on the indicators of SES, such as household income, parental education or parental occupation, but also on the broader current life situation with various burdens of stress in analyses on the mental health of children and adolescents. For future research, it would be interesting to examine other indicators (besides SES) that affect the association between a stressful life situation and children's mental health, e.g., personal and social resources (e.g., social support or self-efficiency). In terms of opportunities for intervention and prevention, the aspect of parental education turned out as the most critical issue. Children with less educated parents obviously need more support in dealing with stressful life situations (e.g., parental illness or accident or severe financial crises) than their peers in a comparable situation but with higher-educated parents.

Supporting information

S1 Data
Socioeconomic status, stressful life situations and mental health.
(XLS)

Acknowledgments

The authors thank all of the children, adolescents, their parents and young adults who participated in this study for their time and involvement. We are very grateful to all the researchers and students who worked on this project and made it possible, especially to: Claus Barkmann, Anne-Catherine Haller and the BELLA study Group. We would like to thank the Robert Koch-Institute and the Charité Berlin for their ongoing support and cooperation.

Funding Statement

This article is part of a dissertation project and received no specific funding for this work. The BELLA study has been financially supported by the German Science Foundation. The funder had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Data Availability

All relevant data are within the manuscript and its Supporting Information files.

References

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Articles from PLOS ONE are provided here courtesy of PLOS

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Socioeconomic status, stressful life situations and mental health problems in children and adolescents: Results of the German BELLA cohort-study

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Children and adolescents with low socioeconomic status (SES) suffer from mental health problems more often than their peers with high SES. The aim of the current study was to investigate the direct and interactive association between commonly used indicators ...

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African Americans and Mental Health Stigma

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African Americans and Mental Health Stigma

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African Americans and Mental Health Stigma: Mental Health in a Minute

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Overcoming the stigma around mental illness

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Overcoming the stigma around mental illness

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Overcoming the stigma around mental illness. | Michaela Mulenga | TEDxCasey

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Culture of Silence: Overcoming the Cultural Barriers of Mental Illness

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Culture of Silence: Overcoming the Cultural Barriers of Mental Illness

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Published by: LifeWorks,

Though an awful lot has been done to break down the barriers and stigma of mental illness, in certain cultural communities where it's still taboo, openly talking about and dealing with mental health issues can be a serious challenge. While every culture-and how they deal with mental health issues-is different, the suggestions below can help you or a loved one better navigate cultural concerns as you steer your way back to improved mental health.

State your needs. Even if those around you want to help, they might not know how. If people offer help, be specific about how they can support you. Do you want them to sit down and listen? Make you a meal? Research medical help in your community? Talk to your family? Being concise and clear will not only make your allies feel more useful, but will also help you get much-needed support during this difficult time.

Find supportive help. Don't let the fear of being labeled with a mental illness, or fear of interacting with the members of the medical profession keep you from seeking support and treatment. If you feel that family and close friends won't accept your situation, research further shows a field such as isolation can make a tough situation even worse. Instead of going it alone, look to your family doctor or another health professional for the support and resources you need to get your mental and emotional health back on track.

Name it. Aside from helping to develop a treatment plan, a diagnosis gives you words to talk about your experience in a way other people can understand and relate to. It's also a reminder that you're not alone: many out there are coping with the same illness and similar issues.

Watch your words. Be careful not to equate yourself with your condition. "I am depressed," sends a very different message than, "I am dealing with depression." Though it used to be common to hear someone referred to as a schizophrenic, it would seem strange to say, "She is a cancer." Why? Because people shouldn't be defined by their illness. Phrases like, "she is living with schizophrenia," or, "he was diagnosed with depression," help to separate the disease from the person.

Tell it like it is. If you're comfortable speaking out, you may want to educate the people around you about how hurtful insensitive comments about mental illness can be. A support group can be a good testing ground for finding your voice in a caring setting. For some people, telling their story, and working publicly to change cultural perceptions, can be a vital part of the healing process. This may include letters to the editor of a magazine or newspaper or giving talks to spiritual, community, or cultural groups about your journey and the challenges you encountered on the path to better mental health.

Trust yourself. You're probably the best judge of the difficulties you may face in your cultural community. While it's important to get help for yourself and help loved ones try to understand what you're going through, only you can decide who, when, and how much to tell those around you about your condition.

Seek and ye shall find. Studies suggest one in five North Americans has been touched by some type of mental illness. Countless resources out there-books, internet sites, magazines, and videos-can help you connect to valuable information. Chat rooms and message boards on mental health concerns may also help you get in touch with a more supportive community-possibly even of people from your cultural background-who've been in your shoes and understand what you're going through.

Don't take it personally. As hard as it can be not to feel shamed when your community may still try to shut out or dismiss your mental health challenges, remind yourself that mental illness is not something you chose. While it may be difficult, do your best to focus your energy on coping with your illness rather than worrying about what others think of you.

Dealing with mental illness is challenging on its own. But when you're also facing an uphill cultural battle, it can be overwhelming. By finding the social and medical support you need and working to counteract cultural stigma around mental illness, you'll help restore your own well-being and make the journey for others facing a similar situation that much easier.

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Culture of Silence: Overcoming the cultural barriers of mental illness | US

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Published by: LifeWorks, Though an awful lot has been done to break down the barriers and stigma of mental illness, in certain cultural communities where it's still taboo, openly talking about and dealing with mental health issues can be a serious challenge.

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Cultural Barriers to Mental Health Treatment Among Hispanics/Latino(a)s

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Cultural Barriers to Mental Health Treatment Among Hispanics/Latino(a)s

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By: Mary Martinez

In January of this year, Vecinos began offering integrated mental health services in its static and mobile health clinics. The response thus far from our clients has been favorable, but we at Vecinos remain concerned about the many barriers Hispanics/Latinos face in seeking mental health services. They are far less likely to seek treatment for mental health issues than non-Hispanic whites.

A 2014 Fact Sheet published by the American Psychiatric Association noted that 36 percent of Hispanics with depression received care compared to 60 percent of non-Hispanic whites and that Hispanics were more frequently undertreated for depression. The American Psychological Association (APA) found that only one percent of psychologists identified themselves as Hispanic even though Hispanics represent 20 percent of the U.S. population as a whole. The APA additionally reported that both language barriers and values created barriers to treatment for Hispanics experiencing mental health issues.

This corresponds with many studies citing the lack of culturally and linguistically competent mental health providers. The majority of mental health professionals do not speak Spanish, nor have they been sufficiently educated in Hispanic/Latino(a) culture. This often results in miscommunication and misinterpretations that can be very frustrating to the Hispanic/Latino(a) client. Previous negative experiences related to language barriers, discrimination, or poor treatment were also cited as reasons Hispanics/Latino(a)s gave for not seeking treatment, along with a lack of confidence in the ability of services to meet their needs.

There is also a significant disconnect between American models of psychotherapy and the needs and values of the Hispanic/Latino community. American models of therapy, which are Euro-centric, value individual traits and independence while Hispanic/Latino(a) culture values family unity, loyalty to family and friends, and one's role in the community. Hispanics/Latino(a)s are more likely to turn to family or friends when they have a problem or feel depressed or anxious. They are also more likely to consult a member of the clergy or even a local healer.

In addition to language and values, some of the other barriers preventing Hispanics/Latino(a)s from seeking mental health services include negative perceptions about mental health care. The National Alliance of Mental Health's web page on Latino Mental Health notes (NAMI) the Hispanic/Latino community's lack of information and misunderstanding about mental health. In general, the Hispanic/Latino(a) community does not talk about mental health issues and many do not seek treatment because they don't recognize the signs and symptoms of mental health conditions such as depression or anxiety nor do they know where to find help.

This lack of information and communication also increases the stigma associated with seeking help for mental health issues. Many Hispanics/Latino(a)s do not seek treatment for fear of being labeled as " locos " (crazy). Others see it as a source of shame and don't want their community to find out, even though one in five people in the United States is affected by mental illness. Utilizing mental health services also raises privacy concerns. Many Hispanics/Latino(a)s do not know that mental health information is confidential and cannot be shared with anyone without the patient's consent.

The barriers

Some of the biggest barriers to seeking mental health services are economic and structural. The percentage of Hispanics/Latino(a)s in the United States without health insurance ranges between 32 and 37%, compared with 16% for all Americans. Hispanics/Latino(a)s without health insurance are forced to rely on community agencies which may be limited or non-existent, especially in rural areas. In addition, anxiety about legal status and fear of deportation for themselves and/or members of their families, keep many Hispanics/Latino(a)s from seeking help. Even when there is a willingness to utilize mental health services, the lack of transportation and/or money is prohibitive, as well as not knowing where to find such services.

The National Alliance for Mental Illness (NAMI) has some great resources for both mental health providers and Hispanic/Latino(a) clients seeking mental health services. To improve the odds of getting a culturally-sensitive mental health provider, ask questions to get a sense of the provider's level of cultural sensitivity. Don't be afraid to ask questions such as:

Have you treated other Latino(a)s?

Have you received training in cultural competence or on Latino(a) mental health?

How do you see our cultural backgrounds influencing our communication and my treatment?

Make sure you can work with this person and that you communicate well. Let the provider know about your culture and values. For example, if you want your family to be included as part of your treatment, say so. If your lack of medical insurance or finances is preventing you from seeking services, contact a local health or mental health clinic to see what services you qualify for. Vecinos is available to see patients or to provide referrals.

References

Aguilar-Gaxiola, S., Loera, G., Méndez, L., Sala, M., Latino Mental Health Concilio, and Nakamoto, J. (2012). "Community-Defined Solutions for Latino Mental Health Care Disparities: California Reducing Disparities Project," Latino Strategic Planning Workgroup Population Report. Sacramento, Ca: UC Davis, 2012. https://health.ucdavis.edu/newsroom/pdf/latino_disparities.pdf

Dingfelder, S. F., "Closing the Gap for Latino Patients," American Psychological Association Monitor, January 2005. https://www.apa.org/monitor/jan05/closingthegap

"Latino/Hispanic Communities and Mental Health." Mental Health America. http://www.mentalhealthamerica.net/issues/latinohispanic-communities-and-mental-health. Accessed 8 April 2019.

"Latino Mental Health." National Alliance of Mental Health (NAMI). https://www.nami.org/Find-Support/Diverse-Communities/Latino-Mental-Health. Accessed 10 April 2019.

Rastogi, M., Massey-Hastings, N., & Wieling, E. "Barriers to Seeking Mental Health Services in the Latino/a Community: A Qualitative Analysis." Journal of Systemic Therapies, 31(4), 1-17. doi:10.1521/jsyt.2012.31.4.1, 2012. https://guilfordjournals.com/doi/10.1521/jsyt.2012.31.4.1

"Substance Abuse and Mental Health Services Administration, Racial/ Ethnic Differences in Mental Health Service Use Among Adults." HHS Publication No. SMA-15-4906. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2015. https://www.integration.samhsa.gov/MHServicesUseAmongAdults.pdf

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Cultural Barriers to Mental Health Treatment Among Hispanics/Latino(a)s -

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By: Mary Martinez In January of this year, Vecinos began offering integrated mental health services in its static and mobile health clinics. The response thus far from our clients has been favorable, but we at Vecinos remain concerned about the many barriers Hispanics/Latinos face in seeking mental health services.

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By Mental Health First Aid USA on July 11, 2019

What comes to mind when you think about culture? For a lot of us, we immediately think of what's right in front of us: unique languages, different clothing and diverse food. But a society's culture also impacts a person's beliefs, norms and values. It impacts how you view certain ideas or behaviors. And in the case of mental health, it can impact whether or not you seek help, what type of help you seek and what support you have around you.

According to research published by The Commonwealth Fund, minorities in the United States are less likely to get mental health treatment or will wait until symptoms are severe before looking. In fact, only 66 percent of minority adults have a regular health care provider compared to 80 percent of white adults. Hispanic and Asian populations report the lowest rates of having a regular doctor or provider, at 58 percent and 60 percent.

It's important that we understand the role culture plays in mental health care so we can support our loved ones and encourage treatment when it's needed most.
Here are four ways culture can impact mental health:

1. Cultural stigma. Every culture has a different way of looking at mental health. For many, there is growing stigma around mental health, and mental health challenges are considered a weakness and something to hide. This can make it harder for those struggling to talk openly and ask for help.

2. Understanding symptoms. Culture can influence how people describe and feel about their symptoms. It can affect whether someone chooses to recognize and talk about only physical symptoms, only emotional symptoms or both.

3. Community Support. Cultural factors can determine how much support someone gets from their family and community when it comes to mental health. Because of existing stigma, minorities are sometimes left to find mental health treatment and support alone.

4. Resources. When looking for mental health treatment, you want to talk to someone who understands your specific experiences and concerns. It can sometimes be difficult or time-consuming to find resources and treatment options that take into account specific cultures factors and needs.

These are only a few ways culture can impact the perception of and treatment for mental health. Every culture and person is different and face a unique journey to recovery.

You can help address the mental health of minorities by understanding the role culture plays in mental health and by becoming trained to help those around you. Mental Health First Aid gives people the skills to identify signs of mental health and substance use challenges and action steps to take to help them get treatment. Find a Mental Health First Aid course near you and #BeTheDifference in the life of someone who may need your support today.

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Four Ways Culture Impacts Mental Health - Mental Health First Aid

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What comes to mind when you think about culture? For a lot of us, we immediately think of what's right in front of us: unique languages, different clothing and diverse food. But a society's culture also impacts a person's beliefs, norms and values. It impacts how you view certain ideas or behaviors.