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Mental health of Malaysian university students: UK
comparison, and relationship between negative mental
health attitudes, self-compassion, and resilience
Yasuhiro Kotera, et al. [full author details at the end of the article]
#The Author(s) 2020
Abstract
Poor mental health of university students is becoming a serious issue in many countries.
Malaysia - a leading country for Asia-Pacific education - is one of them. Despite the
government’s effort to raise awareness, Malaysian students’mental health remains
challenging, exacerbated by the students’negative attitudes towards mental health (men-
tal health attitudes). Relatedly, self-compassion and resilience have been reported to
improve mental health and mental health attitudes. Malaysian students (n=153)
responded to paper-based measures about mental health problems, negative mental health
attitudes, self-compassion, and resilience. Scores were compared with 105 UK students,
who also suffered from poor mental health and negative mental health attitudes, to make a
cross-cultural comparison, to contextualise Malaysian students’mental health status,
using ttests (aim 1). Correlation, path, and moderation analyses were conducted, to
evaluate the relationships among these mental health constructs (aim 2). Malaysian
students scored higher on mental health problems and negative mental health attitudes,
and lower on self-compassion and resilience than UK students. Mental health problems
were positively associated with negative mental health attitudes, and negatively associ-
ated with self-compassion and resilience. While self-compassion mediated the relation-
ship between negative mental health attitudes and mental health problems (high self-
compassion weakened the impacts of negative mental health attitudes on mental health
problems), resilience did not moderate the same relationship (the level of resilience did
not influence the impact of negative mental health attitudes on mental health problems).
Self-compassion training was suggested to counter the challenging mental health in
Malaysian university students.
Keywords Self-compassion .Mental health attitudes .Mentalhealth .Malaysianstudents .Cross-
cultural comparison .Resilience
https://doi.org/10.1007/s10734-020-00547-w
This manuscript has not been published and is not under consideration for publication elsewhere.
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Introduction
Concerning mental health of Malaysian students
Although still under debate, mental health is commonly defined as a dynamic state of internal
equilibrium, entailing the ability to cope with life’s challenges to function in social roles
(Galderisi et al. 2015). Good mental health is related to higher functioning and achievement,
while poor mental health is related to lower productivity and poorer attainment (Royal College
of Psychiatrists 2011). It is no surprise that good mental health and well-being were paid
attention to, as one of the United Nations’17 sustainable development goals (‘Good health and
well-being’; 2015). Poor mental health of university students has been reported in many
countries, commonly recording high rates of depression, anxiety, and high stress (Brown
2018; Mey and Yin 2015). Among American university students, 15% identified as having
depression with 36% taking regular medication (American College Health Association 2008).
In UK-based research, Aronin and Smith (2016) reported that a quarter of students suffered
from some type of mental health problems. Likewise, among Asian university student
populations, 9% of Chinese students had high prevalence of depressive symptoms (Song
et al. 2008), 21% of Japanese students had experienced major depressive episode over a period
of a year (Tomoda et al. 2000), and 41% of Hong Kongese students reported a high level of
anxiety (Wong et al. 2006). These raise concerns as the majority (75%) of long-term mental
disorders start to develop by the age of 25 (Kessler et al. 2007). Poor mental health of
university students does not exclude Malaysia—one of the leading countries for higher
education in Asia-Pacific region (Knight and Sirat 2011;Lee2014). The rate of Malaysian
students who suffer from mental health problems doubled in less than a decade (10% in 2011
to 20% in 2016; Hezmi 2018), for example approximately 30% of medical students in
Malaysia (n=761) reported high prevalence of stress (Yusoff et al. 2010), associated with
depression and anxiety (Rosal et al. 1997; Shapiro et al. 2000).
Though several reasons have been reported for university students’poor mental health
globally (e.g. increased mental distress in youth [Ross et al. 2017]; a lack of personalised
support due to a large cohort [Bathmaker 2003]; social media [Jacobsen and Forste 2011];
financial stress caused by increased tuition fees [Gani 2016]), some of the leading causes of
Malaysian students’mental health problems were related to heavy workload, financial diffi-
culties, and family issues (Ministry of Health 2016;Yusoffetal.2010). A recent restructuring
in Malaysian higher education, categorising public universities into research, field-specific,
and comprehensive (Ministry of Higher Education 2012), may be affecting students’mental
health negatively, as students underwent uncertainty in this transformation, leading to high
anxiety (Mey and Yin 2015).
Malaysian Government’s approach
Today approximately 30% of people in Malaysia aged 16 years or older have mental health
problems (Hassan et al. 2018), with the estimated costs exceeding 80 million USD (Manaf
et al. 2009). To address increasing needs of mental health support, the government launched
the National Strategic Mental Health Action Plan considering (i) accessibility to mental health
services, (ii) collaboration across agencies, (iii) mental health promotion, (iv) development of
mental health staff, (v) first aid, and (vi) research in the next 5 years (2016–2020; Ministry of
Health 2016); however, its effects still remain uncertain. While the Ministry of Education in
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Malaysia envisions more internationally competitive academic outputs (e.g. Vision 2020;
Grapragasem et al. 2014;MinistryofEducation2012), these findings and facts suggest a
need for exploring the mental health of Malaysian students.
Poor help-seeking among Malaysian students
Additionally, students’low help-seeking was considered to undermine their poor mental health
even further (Ministry of Health 2016): 10–35% of people in Malaysia who could benefit from
mental health support, were not receiving support (Crabtree and Chong 2000; Chong et al.
2013). Poor mental health itself is a serious issue; however, it can lead to other diverse
problems, for example it is associated with reduced academic achievement and professional
development (Hashim et al. 2012; Poh Keong et al. 2015), interpersonal conflicts (Clark and
Rieker 1986), sleep disturbance (Niemi and Vainiomaki 2006), low concentration, poor
decision-making (Shapiro et al. 2000), resulting feelings of inadequacy (Yusoff et al. 2010).
These can hinder students’learning and research outputs—a highly valued university priority,
reported by 250 Malaysian academics across 25 universities (Ghasemy et al. 2018).
Negative attitudes towards mental health problems
Poor mental health of Malaysian students may be exacerbated by their negative attitudes
towards mental health problems (Hanafiah and Van Bortel 2015; Yeap and Low 2009).
Negative mental health attitudes refer to beliefs that mental health suffers are weak, incompe-
tent, and unable to take care of themselves (Kotera and Maughan 2020), therefore when
internalised, they can cause feelings of shame (Kotera et al. 2019b). Indeed, negative attitudes
towards mental health among university students are high in many countries (Hyun et al. 2006;
Laidlaw et al. 2016), but particularly high in Asia (Al-krenawi et al. 2009; Gilbert et al. 2007).
Asians are ashamed of disclosing their mental health problems, compared with the other
groups (Haroz et al. 2017). Mental health attitudes (i.e. general attitudes towards mental health
problems, and shame about those problems) were associated with, and predicted, poor mental
health (Kotera et al. 2019a,c). However, to date, these relationships have not been examined in
Malaysian students, indicating a need for exploration. Elucidating these relationships can
inform the impacts of mental health attitudes on mental health in Malaysian students, which
may help develop new approaches to mental health (Kotera and Ting 2019). We hypothesised
that mental health would be associated with mental health attitudes (H1a), and mental health
attitudes would predict mental health (H2).
H1a: Mental health problems would be positively associated with negative mental health
attitudes.
H2: Negative mental health attitudes would positively predict mental health problems.
Self-compassion and resilience
Another contributing factor to Malaysian students’mental health are poor coping strategies
(Ministry of Health 2016). Coping strategies are commonly regarded as behavioural and
psychological efforts to tolerate or minimise negative emotional impacts from stressful events
(Taylor 1998). Studies have reported that self-compassion and emotional resilience (hereafter
‘resilience’) undergird our coping skills, which could reduce mental health problems (Kotera
et al. 2019d; Muris et al. 2018; Williams 2016). Self-compassion refers to a healthy formation
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of self-reassurance, entailing (i) kindness to one’s inadequacy, (ii) understanding that discom-
fort is an inevitable human experience, and (iii) acknowledgement of painful emotions (Neff
2003). These components can help an individual to cope with negative mental health con-
structs including loneliness (Akin 2010) and shame (Gilbert and Procter 2006). Self-
compassion was associated with mental health, and a stronger independent predictor for
mental health than shame and motivation in 144 UK students (Kotera et al. 2019a). Cultivating
self-compassion could lead to better mental health (Kotera et al. 2019c). While previous
research reported that self-compassion mediated the relationship between mental health
attitudes and mental health in a Japanese population (Kotera et al. 2019b), the role self-
compassion plays in this relationship (negative mental health attitudes and mental health
problems) among Malaysian students has not been explored. Considering the cultural similar-
ities to Japan (Hofstede et al. 2010), we hypothesised that (i) mental health problems would be
negatively associated with self-compassion (H1b), and (ii) self-compassion would mediate the
relationship between negative mental health attitudes and mental health problems in Malaysian
students (H3). Exploring these relationships could help to suggest alternative solutions to poor
mental health in Malaysian students, targeting self-compassion (instead of directly engaging
with mental health).
H1b: Mental health problems would be negatively associated with self-compassion.
H3: Self-compassion would mediate the relationship between negative mental health
attitudes and mental health problems.
Similarly, resilience has also been reported for its protective effects on mental health.
Though its definition is still being debated, it is commonly noted as a comprehensive construct
embracing internal resources and behaviours, which enable people to cope with challenging
life circumstances, and strengthen themselves from such experiences (Grant and Kinman
2014). Resilience directs people’s attention to positives (i.e. strengths and opportunities),
instead of negatives (i.e. weaknesses and vulnerability), by reframing their perspectives
(Russ et al. 2009; Harrison 2013). Indeed, resilient people can be also affected by stressful
events, but they are not overwhelmed by those events lastingly (Tugade and Fredrickson
2004): They acquire new skills to cope with challenges (Carver 1998). Resilience was
associated with better mental health, potentiating self-efficacy, mindfulness, and compassion
(Robertson et al. 2015). This relationship has not been explored in Malaysian students to date
(H1c). Further, in order to evaluate the effects of resilience, the ability to bounce back from
challenges (Smith et al. 2008), we hypothesised that resilience would moderate the relationship
between negative mental health attitudes and mental health problems (H4). Identifying these
relationships could offer helpful insights into a different pathway to good mental health.
H1c: Mental health problems would be negatively associated with resilience.
H4: Resilience would moderate the relationship between negative mental health attitudes
and mental health problems.
Comparison with UK students’mental health
Similar to Malaysian students, university students in the UK also have been reported
to suffer from poor mental health and negative attitudes (Kotera, Conway & Van
Gordon 2019a, Kotera, Green & Sheffield 2019c; University Partnerships Programme
2017). Nearly 90% of first-year students in the UK reported stress and anxiety when
adjusting to university life, this was five times higher than 10 years ago (Bewick and
Stallman 2018; University Partnerships Programme 2017). Half of students within the
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cohort reported struggling with stress resulting from academic work (University
Partnerships Programme 2017). Likewise, though some initiatives have taken place
nationally (e.g. the ‘Time to Talk’campaign led by mental health charities), their
attitudes towards mental health problems were still negative: Students believed that
their family and classmates would consider mental health problems as shameful, and
reported feeling ashamed that they would be thought of as having a mental health
problem (Kotera et al. 2019c). Among diverse subjects in the UK universities, social
work subjects had similar male-female ratio to Malaysian students (86% female; Skills
for Care 2018). Because of these similarities—(i) poor mental health, (ii) negative
attitudes towards mental health problems, and (iii) population being in favour of
female students—this study compared the levels of mental health constructs between
Malaysia and UK, in order to contextualise mental health of Malaysian students.
Appraising the difference between these culturally contrasting groups (i.e.
collectivistic Malaysia and individualistic UK; Hofstede et al. 2010)caninformhow
cultures may relate to mental health and mental health attitudes. Culture-aware
approaches to mental health are essential today, and especially helpful for universities
and policymakers (Gopalkrishnan 2018).
Aims and hypotheses
This study, therefore, aimed to examine the mental health of Malaysian students, considering
negative mental health attitudes, self-compassion, and resilience. First, the levels of these four
constructs (mental health problems, negative mental health attitudes, self-compassion, and
resilience) were evaluated through comparison with UK university students (aim 1). Then,
relationships among those constructs were examined in Malaysian students (aim 2). Four
hypotheses were tested, to address aim 2 (Fig. 1):
H1: Mental health problems would be positively associated with negative mental health
attitudes (a), and negatively associated with self-compassion (b), and resilience (c).
H2: Negative mental health attitudes would positively predict mental health problems.
H3: Self-compassion would mediate the relationship between negative mental health
attitudes and mental health problems.
H4: Resilience would moderate the relationship between negative mental health attitudes
and mental health problems.
Negative Mental
Health Attitudes
Mental Health
Problems
Self-CompassionResilience
H2
H3
H4
Fig. 1 Hypothesised framework of this study: Self-compassion mediates, and resilience moderates the relation-
ship between negative mental health attitudes and mental health problems
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Materials and methods
Sample selection
All participants were aged 18 years or older and were studying at a Malaysian
university. One hundred sixty full-time undergraduate students majoring in humanities
subjects, were asked to participate in the study. From this group, 153 (121 females,
31 males, 1 unanswered; Mage =21.24, SD
age =1.59, RNG
age =18–27 years) completed
the self-reported measures about mental health, mental health attitudes, self-compas-
sion, and resilience. Akin to the general Malaysian student population (Statista 2019),
this sample also demonstrated a disparity in favour of female students, though more
male students would achieve more similar gender balance (60% female students in the
general population, while 79% in our sample). One hundred forty-three students were
Malaysian, eight from Bangladesh, and one unanswered. All students were currently
engaged with their studies. Opportunity sampling via tutors’announcements was used
to recruit participants. No compensation was awarded for participation. Informed
consent was obtained from all individual participants included in the study. To ensure
students’safety, academic staff who were familiar with student well-being were
present at the research site, and available mental health support was provided to
students. All study materials were paper-based, written in English, as these Malaysian
students were fluent in English and undertaking modules in English.
UK students were recruited in the same way as the Malaysian students (18 years
old or older, and studying at a UK university at the time of the study) through
opportunity sampling. One hundred and five UK undergraduate healthcare students,
who undertook another study with the same research design (93 females, 12 males;
Mage =30.53, SD
age =9.11, RNG
age =15–58 years; 94 UK nationals; Kotera, Green &
Sheffield 2019c) consented and completed the paper-based survey written in English.
No compensation was awarded for participation.
Materials
Negative mental health attitudes were evaluated using the Attitudes Towards Mental
Health Problems (ATMHP) scale (Gilbert et al. 2007). This 35-item on four-point
Likert scale (‘0’being ‘Do not agree at all’to ‘3’being ‘Completely agree’)evaluates
attitudes towards mental health problems including shame, in four sections: (i) general
negative attitudes, (ii) external shame, (iii) internal shame, and (iv) reflected shame.
Their general negative attitudes (i) consider how their community and family view
mental health problems (e.g. ‘My community/family sees mental health problems as
something to keep secret’). Their external shame (ii) relates to how they feel their
community and family would perceive them if they had a mental health problem (e.g.
‘I think my community/family would look down on me’). Their internal shame (iii)
examines how they perceive themselves if they had a mental health problem (e.g. ‘I
would see myself as inferior’). Lastly their reflected shame (iv) regards their family-
reflected shame (how their family would be seen if they had a mental health problem;
e.g. ‘Myfamilywouldbeseenasinferior’) and self-reflected shame (worries of
reflected shame on themselves, for a close relative having a mental health problem;
e.g. ‘I would worry that others will look down on me’). All of the subscales had
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good Cronbach’s alphas in our sample, indicating high internal consistency
(α=.84–.94).
Mental health problems were measured using the Depression Anxiety and Stress Scale
(DASS21), a shortened form of DASS42 (Lovibond and Lovibond 1995) comprising 21 items
with a four-point Likert scale (‘0’being ‘Didnotapplytomeatall’to ‘3’being ‘Applied to me
very much or most of the time’). The 21 items are allocated to three subscales (seven items
each); depression (e.g. ‘I found it difficult to work up the initiative to do things’), anxiety (e.g.
‘I was worried about situations in which I might panic and make a fool of myself’)andstress
(e.g. ‘I found it hard to wind down’). These subscales had high internal consistency in our
sample (α=.77–.88).
Self-compassion was evaluated using the Self-Compassion Scale-Short Form (SCS-
SF), a shortened version of the Self-Compassion Scale. While noting the recent
debates on how to measure self-compassion (López et al. 2015), SCS-SF was chosen
for this study for its wide usage and participant-friendliness (Raes et al. 2011). SCS-
SF comprises 12 five-point Likert items (Raes et al. 2011) including ‘Itrytobe
understanding and patient towards those aspects of my personality I don’t like’,to
which participants respond on the five-point response: ‘1’being ‘Almost never’to ‘5’
being ‘Almost always’.Forthenegativeitems(1,4,8,9,11,and12),thescoreis
reversed. SCS-SF had high internal consistency in our sample (α=.72).
Lastly, the Brief Resilience Scale (BRS) was used to measure the level of resil-
ience. Though measurement of resilience was being debated (Cosco et al. 2017), BRS
was one of the most frequently used resilience measures, focusing on how an
individual deals with difficulties (Smith et al. 2008), which fitted with students who
were undertaking their studies. This six-item scale evaluates the ability to bounce
back from adversity (Smith et al. 2008). The six items including ‘I have a hard time
making it through stressful events’are responded on the five-point Likert scale (‘1’
being ‘Strongly disagree’to ‘5’being ‘Strongly agree’; reverse scoring for the items
2, 4, and 6). BRS demonstrated high internal consistency in our sample (α= .70).
Procedure
All data collected were first screened for outliers and the assumptions for parametric tests.
Second, in order to evaluate the mental health of Malaysian students (aim 1), the scores were
compared with 105 UK undergraduate healthcare students, using ttests. Third, to appraise the
relationships among those four mental health constructs (aim 2), correlations between mental
health problems, negative mental health attitudes, self-compassion, and resilience were mea-
sured (H1). Finally, path analysis and moderation analysis were conducted to examine i)
whether negative mental health attitudes would predict mental health problems (H2), and ii)
whether self-compassion would mediate, and resilience would moderate the relationship
between negative mental health attitudes and mental health problems (H3 and H4). IBM
SPSS version 25 and Process macro version 3 were used for these analyses.
Results
No score was identified as an outlier, using the outlier labelling rule (Hoaglin and Iglewicz
1987). Table 1summarises the mean and standard deviation for mental health problems,
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negative mental health attitudes, self-compassion, and resilience in both Malaysian and UK
students.
Evaluating the levels of Malaysian students (aim 1)
Because some of the sub/scales were not normally distributed as assessed by Shapiro-
Wilk (p< .05), all of the scores were square root-transformed to satisfy the assumption
of normality, followed by ttests to compare the two groups. Homogeneity of
variances for all scores was maintained, assessed by Levene’s test for equality of
variances (p> .05). Malaysian students had higher levels of mental health problems
(depression 95% CI, 2.78 to 7.28, t(256) = 4.41, p< .0001; anxiety 95% CI, 4.88 to
9.12, t(256) = 6.51, p< .0001; stress 95% CI, 0.75 to 5.19, t(256) = 2.63, p= .009), and
negative mental health attitudes including shame (community attitudes 95% CI, 0.91
to 2.51, t(256) = 4.19, p< .0001; family attitudes 95% CI, 0.76 to 2.36, t(256) = 3.82,
p= .0002; community external shame 95% CI, 1.99 to 4.13, t(256) = 5.65, p<.0001;
family external shame 95% CI, 1.46 to 3.54, t(256) = 4.73, p< .0001; internal shame
95%CI,0.28to2.44,t(256) = 2.48, p= .014; family-reflected shame 95% CI, 3.58 to
6.32, t(256) = 7.12, p< .0001; self-reflected shame 95% CI, 3.06 to 4.22, t(256) = 7.15,
p< .0001), and lower levels of self-compassion (95% CI, −0.32 to −0.06, t(256) =
2.86, p= .005) and resilience (95% CI, −0.45 to −0.17, t(256) = 4.37, p< .0001), than
UK students.
Correlations between mental health, mental health attitudes, self-compassion,
and resilience in Malaysian students (H1)
Pearson’s correlations were used to examine relationships between mental health problems,
negative mental health attitude, self-compassion, and resilience in Malaysian students
(Table 2).
Table 1 Comparison between Malaysian students and UK students in mental health problems, negative mental
health attitudes, self-compassion, and resilience (ttests)
Measured Construct (RNG) Malaysian students (n=153) UK students (n= 105) t
MSD MSD
Depression (0–42)*** 15.36 10.09 10.33 7.14 4.41
Anxiety (0–42)*** 17.41 8.93 10.41 7.80 6.51
Stress (0–42)** 18.68 9.15 15.71 8.53 2.63
Community attitudes (0–12)*** 6.86 3.34 5.15 3.04 4.19
Family attitudes (0–12)*** 4.10 3.55 2.54 2.68 3.82
Community external shame (0–15)** 8.72 4.47 5.66 3.96 5.65
Family external shame (0–15)** 4.86 4.74 2.36 3.17 4.73
Internal shame (0–15)* 7.82 4.36 6.46 4.30 2.48
Family-reflected shame (0–21)*** 10.93 5.57 5.98 5.36 7.12
Self-reflected shame (0–15)*** 7.59 4.95 3.37 4.20 7.15
Self-compassion (1–5)** 3.12 0.54 3.31 0.50 2.86
Resilience (1–6)*** 3.05 0.46 3.36 0.68 4.37
*p<.05, **p<.01, ***p< .001 significant difference between Malaysian students and UK students (higher
values are in italics)
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Table 2 Correlations between mental health problems, negative mental health attitudes, self-compassion, and resilience in Malaysian students (n = 153)
1234567891011121314
1GN –
2Age −.12 –
3 Depression .05 .03 –
4 Anxiety .05 −.03 .61** –
5 Stress .10 .03 .75** .72** –
6 Community attitudes −.01 .004 .17* .24** .23** –
7 Family attitudes −.04 −.02 .28** .34** .25** .49** –
8 Community external shame −.09 −.05 .29** .30** .29** .52** .40** –
9 Family external shame −.05 −.08 .48** .38** .39** .30** .54** .54** –
10 Internal shame .09 −.11 .39** .28** .33** .28** .26** .56** .50** –
11 Family-reflected shame −.01 −.14 .17* .19* .18* .27** .25** .63** .45** .61** –
12 Self-reflected shame .03 .04 .25** .24** .28** .31** .26** .28** .32** .41** .32** –
13 Self-compassion −.18* .12 −.61** −.45** −.52** −.24** −.31** −.30** −.38** −.40** −.23** −.19* –
14 Resilience −.04 .03 −.46** −.40** −.43** −.09 −.26** −.25** −.34** −.30** −.09 −.11 .46** –
Gender (M = 1, F = 2); **Correlation is significant at the 0.01 level (2-tailed). *Correlation is significant at the 0.05 level (2-tailed)
Higher Education (2021) 81:403–419 411
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All of the mental health subscales (depression, anxiety, and stress) were positively related to
negative mental health attitudes, and negatively related to self-compassion and resilience. H1
was supported. Demographics were not related to any of the sub/scales, except for gender and
self-compassion (male students tended to have more self-compassion than female students).
Mediation and moderation in negative mental health attitudes and mental health
problems (H2–H4)
To assess mediation and moderation in Malaysian students’mental health, using the model 5
in the Process macro (Hayes 2013), negative mental health attitudes (predictor variable), self-
compassion (mediator variable), resilience (moderator variable), and mental health problems
(outcome variable) were entered. To avoid multicollinearity issues, the predictor variable was
centred prior to regression analyses. ‘Negative mental health attitudes’were calculated by
totalling the subscale scores of the Attitudes Towards Mental Health Problems scale (Gilbert
et al. 2007). Likewise, ‘mental health problems’were the total score of DASS 21 (Antony et al.
1998).
Negative mental health attitudes were a significant predictor of mental health
problems (p< .001). H2 was supported. The indirect effect of negative mental health
attitudes on mental health problems through self-compassion was significant, b= .17,
BCa CI [.10, .26], which accounted for 61% of the total effect, indicating a large
effect. The total effect of negative mental health attitudes on mental health problems,
including self-compassion, was significant, b= .28, p< .001. Both of the paths from
negative mental health attitudes to self-compassion (b=−.04, p< .001), and from self-
compassion to mental health problems (b=−4.33, p< .001) were significant. Self-
compassion partially mediated the relationship between negative mental health atti-
tudes and mental health problems. H3 was supported. Lastly, there was no significant
interaction effects of negative mental health attitudes and resilience (b=−.57, p= .22):
Resilience did not moderate the relationship between negative mental health attitudes
and mental health problems (Fig. 2). H4 was rejected.
Negative Mental
Health Attitudes
Mental Health Problems
Self-Compassion
Resilience
-.04***
-4.33***
.28***
Negative Mental Health
Attitudes x Resilience
-3.14**
-.57
Fig. 2 Mediation of self-compassion, and moderation of resilience in the relationship between negative mental
health attitudes and mental health problems: Statistical diagram. **p< .01, ***p< .001. The confidence interval
for the indirect effect is a BCa bootstrapped CI based on 5000 samples
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Discussion
This study explored mental health problems, negative mental health attitudes, self-compassion,
and resilience in Malaysian students and UK students. Their mental health problems and
negative mental health attitudes were higher than UK students, while their self-compassion and
resilience were lower than UK students. Malaysian students’mental health problems were
associated with their negative mental health attitudes, self-compassion, and resilience. Nega-
tive mental health attitudes predicted their levels of mental health problems. Self-compassion
partially mediated the relationship between negative mental health attitudes and mental health
problems, while resilience did not moderate the relationship.
Comparison between Malaysian and UK students
Our comparative evaluation of mental health between Malaysian students and UK students,
highlighted the serious nature of mental health status in Malaysia. Consistent with previous
findings (Hezmi 2018; Ministry of Health 2016), Malaysian students scored higher on all the
subscales for mental health problems and negative mental health attitudes than UK students,
who were also known to have challenging mental health and negative mental health attitudes
(Kotera, Green & Sheffield 2019c). Because poor mental health is linked with diverse negative
consequences (e.g. academic performance, relational conflicts, low concentration, and feelings
of inadequacy (Clark and Rieker 1986;Hashimetal.2012; Shapiro et al. 2000;Yusoffetal.
2010), solutions for this problem need to be explored and implemented. The high levels of
negative mental health attitudes in Malaysian students may be related to low awareness of
mental health in the country (Su Lin 2018). In Malaysian universities, it may be the case that
mental health issues are still stigmatised; thus, students feel shameful to talk about them. On
the other hand, there are various initiatives and movements taken place in the UK, encouraging
people to talk about mental health issues (e.g. ‘Mental Health Crisis Care Concordat’; Welsh
Government 2016). The number of students who have sought out mental health support in the
UK increased by more than 50% in the past 5 years (Spitzer-Wong 2018). Negative mental
health attitudes delay people to seek out help, which can lead to poor clinical outcomes (Brown
2018). Particularly shame related to others had a greater difference (p< .01) from UK students,
than internal shame (p< .05). This was consistent with previous research, comparing Asian
students and British students (Gilbert et al. 2007). This difference may lie in the cultural
difference of collectivism/individualism: Collectivism prefers tightly connected society, where
people expect their group members to take care of them in return for loyalty, whereas
individualism perceives a society loosely connected, where individuals only take care of
themselves and their immediate families (Hofstede et al. 2010). Collectivistic Malaysian
students are more concerned with how other people would see them if they had a mental
health problem, while individualistic UK students are more concerned of how they would see
themselves (Kotera et al. 2019b). This may suggest that collective understanding (a shared
perspective held by the peers of a university community) rather than individual understanding
of mental health would be beneficial to Malaysian students.
Correlations between mental health, attitudes, self-compassion, and resilience
Malaysian students’mental health problems scores were positively related with negative
mental health attitudes, and negatively related with self-compassion and resilience. Consistent
Higher Education (2021) 81:403–419 413
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
with previous research, these correlations may imply the importance of having good mental
health. Though the causal directions were not certain, students with good mental health tended
to have positive attitudes (less shame) about mental health problems, more compassion
towards themselves, and resilience. For example, common humanity (one component of
self-compassion) relates to understanding of life’s challenges and noticing that we all have
similar problems. Such understanding can help develop their resilience, as well as educate
them that resilience is not a fixed trait (which many students seem to assume), rather is a
quality that can be developed, resulting in better student mental health (Burke and Scurry
2019). These findings may suggest that Malaysian students can benefit from potentiating their
self-compassion and resilience, to improve their mental health and mental health attitudes.
Importance of self-compassion to mental health
Our path and moderation analyses illustrated the importance of self-compassion to the mental
health of Malaysian students. Self-compassion was the key protecting factor for their mental
health. Cultivating self-compassion can reduce mental health problems and negative mental
health attitudes (Gilbert and Procter 2006). Malaysian universities can benefit from incorpo-
rating self-compassion training into their curriculum. For example, three weekly 45-min group
sessions with everyday homework (20 min of guided meditation over 2 weeks) of self-
compassion training improved students’mental health and self-compassion (Haukaas et al.
2018). Considering their high shame relating to others, self-compassion training emphasising
on the connectedness (e.g. common humanity) would help maximise the effects on their
mental health. Students would be able to learn that many others also have similar problems and
stop shaming and criticising themselves for disclosing their mental health issues. This training
can counter a key contributing factor to poor mental health of university students—loneliness
(McIntyre et al. 2018), additionally, the connectedness component of self-compassion can also
contribute to a reduction in loneliness (Akin 2010). Because transitional times were related to
lower levels of mental health (Cvetkovski et al. 2017), such training would be especially
helpful to be implemented in the beginning and/or towards the end of their university life.
Future research should evaluate the effects of self-compassion training, focusing on the
connectedness, on mental health of Malaysian students.
Although this study offered novel insights into mental health of Malaysian students, several
limitations need to be considered. First, opportunity sampling was used for student recruitment,
which thwarted the generalisability of the findings. Moreover, students were recruited from a
single academic institution—the institutional bias might have been present (e.g. student recruit-
ment profiles, institutional focus on teaching and research, student support). Second, although the
comparison with UK students helped to evaluate the levels of mental health in Malaysian students,
future research could compare findings with students from more diverse countries. Further, this
study compared the Malaysian humanities students and the UK social work students for their
similarities; however, comparing with students in the same discipline would capture the cultural
difference more accurately. Third, self-report measures might have had limited accuracy to
evaluate mental health issues because of social desirability bias (Latkin et al. 2017). Moreover,
cultural differences in survey responding, potentially further affected by the survey written in
English, might have been present (e.g. self-enhancement bias in the UK sample; Harzing 2006).
Future research can benefit from using implicit tests provided in Malay or biological measure-
ments in order to counter these biases. Finally, while this study illuminated the relationships, the
causality of these effects has not been evaluated. A longitudinal study would help to elucidate the
414 Higher Education (2021) 81:403–419
Content courtesy of Springer Nature, terms of use apply. Rights reserved.
temporal patterning of the observed relationships and to develop approaches addressing the
causality.
Conclusion
Mental health awareness in Malaysia has been increasing, especially among university
students (e.g. the National Strategic Mental Health Action Plan; Ministry of Health 2016).
Malaysian students’mental health is exacerbated by their negative attitudes towards mental
health problems, leading to low help-seeking. This was the first study to evaluate and explore
mental health of Malaysian students, in relation to negative mental health attitudes, self-
compassion, and resilience. Malaysian students had higher levels of mental health problems
(depression, anxiety, and stress) and negative mental health attitudes (negative attitudes with
external, internal, and reflected shame), and lower levels of self-compassion and resilience,
when compared with UK students. Their mental health problems were positively associated
with negative mental health attitudes, and negatively associated with self-compassion and
resilience. While self-compassion mediated the relationship between mental health problems
and negative mental health attitudes, resilience did not moderate the same relationship.
Considering their high shame concerning others, the effects of self-compassion training
focused on connectedness should be evaluated, while considering cultural adjustments to
Malaysian students. The findings in this study will inform researchers, educators, and students
in Malaysia of novel means to counter the challenging mental health of Malaysian students.
Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which
permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give
appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and
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exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy
of this licence, visit http://creativecommons.org/licenses/by/4.0/.
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Affiliations
Yasuhiro Kotera
1
&Su-Hie Ting
2
&Siobhan Neary
3
*Yasuhiro Kotera
Y.Kotera@derby.ac.uk
1
Human Sciences Research Centre, University of Derby, Kedleston Road, Derby, Derbyshire DE22 1GB,
UK
2
Center for Language Studies, Universiti Malaysia Sarawak, Jalan Datuk Mohammad Musa, 94300 Kota
Samarahan, Sarawak, Malaysia
3
International Centre for Guidance Studies, University of Derby, Kedleston Road, Derby DE22 1GB, UK
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