Prenatal Social Support, Postnatal Social Support, and Postpartum Depression

Prenatal Social Support, Postnatal Social Support, and Postpartum Depression RI-HUA XIE, RN, MSC, PHD, GUOPING HE, MD, DIANA KOSZYCKI, PHD, CPSYCH, MARK WALKER, MD, AND SHI WU WEN, MB, PHD

PURPOSE: To assess the association of antenatal and postnatal social support with postpartum depression (PPD). METHODS: We carried out a prospective cohort study of 534 pregnant women between February and September 2007 in Hunan, China. The association between prenatal and postnatal social support with PPD was examined. RESULTS: A total of 103 (19.29%) women had PPD. Women with low prenatal and postnatal social support had higher rates of PPD. For prenatal support, PPD was 28.20% in the lowest quartile versus 9.90% in the highest quartile (adjusted odds ratio [OR]: 3.38, 95% confidence interval [CI] Z 1.64,6.98). For postnatal support, PPD was 44.10% in the lowest quartile versus 5.40% in the highest quartile (adjusted OR: 9.64, 95% CI Z 4.09, 22.69). CONCLUSIONS: Lower or lack of social support is a risk factor of PPD. The association between postnatal social support and PPD is much stronger than that of prenatal social support. Ann Epidemiol 2009;19:637–643. Ó 2009 Elsevier Inc. All rights reserved. KEY WORDS:

Postpartum Depression, Edinburgh Postnatal Depression Scale, Social Support, Antenatal,

Postpartum.

INTRODUCTION Postpartum depression (PPD) is a subtype of major depression with onset within 6 months after childbirth (1). The reported rates of PPD range from 10% to 20% (2–6). It is a serious problem that affects a woman’s health and wellbeing, marital relationship, as well as the offspring’s health and well-being (7–10). The etiology of PPD remains elusive, although epidemiologic studies have identified several risk factors such as perinatal stressors, psychosocial stressors, and demographic, socio-economic and socio-cultural factors (4, 6, 9, 11). Psychosocial studies suggest that lack of social support is an important risk factor for PPD, whereas strong social ties serve as a buffer against depression during the postpartum period (12). Dimensions of social support include subjective support, objective support, and support availability (13). Subjective support reflects an individual’s level of satisfaction of being From the OMNI Research Group, Department of Obstetrics and Gynecology, University of Ottawa, Canada (R.-H.X., S.W.W.); Huaihua Medical College, Hunan, P.R. China (R.-H.X.); Ottawa Health Research Institute, Clinical Epidemiology Program, University of Ottawa, Canada (R.-H..X., M.W., S.W.W.); Central South University, Hunan, People’s Republic of China (R.-H.X., G.H. S.W.W.); Stress and Anxiety Clinical Research Unit, Institute of Mental Health Research, University of Ottawa, Canada (D.K.). Address correspondence to: Dr. Shi Wu Wen, OMNI Research Group, Department of Obstetrics and Gynecology, University of Ottawa, Faculty of Medicine, 501 Smyth Rd, Box 241, Ottawa, Ontario, Canada, K1H 8L6. Tel.: 613-737-8899, ext 73912; Fax: 613-739-6266. E-mail: swwen@ ohri.ca. Received September 30, 2008; accepted March 2, 2009. Ó 2009 Elsevier Inc. All rights reserved. 360 Park Avenue South, New York, NY 10010

respected, supported, and understood by key individuals in their interpersonal environment. Objective support reflects the degree of practical support the social network is able to provide (including monetary or other living necessities). Support availability refers to the availability and effectiveness of social supports for dealing with a life event (e.g., childbirth) (13). Although social support is a variable of importance in PPD research, studies on the association between social support and PPD suffer from methodological limitations. Many studies have used cross-sectional or case-control designs (12, 14–16). Although some studies have used prospective cohort design (17–23), most of them measured social supports only once. Studies comparing effects of social support levels measured at different time points during the perinatal period and risk of PPD are limited. Moreover, there is a paucity of research addressing which dimension(s) of support is associated most strongly with depression risk. Understanding the impact of social support and dimensions of support at different time periods in pregnancy may have important implications for the prevention and treatment of PPD. The objective of this study was to use a prospective cohort study to examine the associations of prenatal social support, postnatal social support, and components of social support with PPD. METHODS We recruited study subjects between February and September 2007 at Hunan Maternal and Infant Hospital, the First Affiliated and the Third Affiliated Hospitals of the Central South University in Changsha, Hunan, People’s 1047-2797/09/$–see front matter doi:10.1016/j.annepidem.2009.03.008

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List of Abbreviations and Acronyms PPD Z Postpartum depression SSRS Z Social Support Rating Scale EPDS Z Edinburgh Postnatal Depression Scale SD Z Standard Deviation OR Z Odds Ratio aOR Z Adjusted Odds Ratio 95%CI Z 95% Confidence Interval

Republic of China, during their prenatal visits at 30–32 weeks of gestation. Married primiparous women of 20–45 years of age who came to the participating hospitals for prenatal care (including childbirth) and planned to stay in Changsha city during the postpartum period were invited to participate in the study. Participating women gave signed informed consent. Women with a multi-fetal pregnancy, a current or lifetime history of bipolar disorder, schizophrenia or other psychotic illnesses, a major chronic disease, or obstetric and pregnancy complication (severe preeclampsia/eclampsia, placenta previa, placental abruption, major postpartum infection, still birth, major birth defects, or birth weight !1,500 grams) as recorded in medical charts were excluded, because these conditions may increase PPD risk (11) and bias our findings. Research nurses conducted face-to-face interviews with participating women to collect relevant clinical and demographic data. A standardized data form was used to record obstetric and demographic data at 30–32 weeks of gestation. Social support level was measured with the Social Support Rating Scale (SSRS) at 30–32 weeks of gestation and was measured again at the postpartum visit that was scheduled 2 weeks after childbirth. The SSRS used in this study was developed by Xiao (13), based on the unique environmental and cultural conditions in China. This scale consists of 10 items, with three dimensions: subjective support (4 items), objective support (3 items), and support availability (3 items). The highest possible score for subjective support is 32: Item 1 with the highest score of 4, Item 3 with the highest score of 4, Item 4 with the highest score of 4, and Item 5 with the highest score of 20. The highest possible score for objective support is 22: Item 2 with the highest score of 4, Item 6 with highest score of 9, and Item 7 with the highest score of 9. The highest possible score for support availability is 12: Item 8 with the highest score of 4, Item 9 with the highest score of 4, and Item 10 with the highest score of 4. The highest possible total score for this scale is 66 (Appendix). This scale can be used in the general population for individuals 14 years of age or older. It has been used widely in the Chinese population and has shown high validity and reproducibility (13). The Chinese version of the Edinburgh Postnatal Depression Scale (EPDS) was administered 2 weeks postpartum to assess PPD. A score of 13 or higher was used as the cut-off for

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PPD (24). Previous studies have shown the reliability and validity of the EPDS in identifying depression, and it has been applied widely in both research and clinical settings (25). The sensitivity (0.82) and specificity (0.86) of the Chinese version of the EPDS is comparable to the original scale (24). We first compared the distribution of demographic characteristics between women who completed the 2-week postpartum follow-up with those who did not. We then described the perinatal characteristics of the study subjects, including prenatal and postnatal social support levels, and compared PPD rates in women with different levels of prenatal and postnatal social support. Adjusted odds ratio (aOR) and 95% confidence interval (CI) for PPD were estimated with multiple logistic regression models, with PPD as the dependent variable and social support as the independent variable. SSRS scores were stratified into quartiles, with the highest quartile as the reference group. Potential confounding variables included in the regression model were maternal age, education, household income, planned pregnancy, the number of abortion, model of delivery, Doula, and fetal gender. The selection of confounding variables that were entered into the multiple logistic regression models was based on a combination of preliminary analysis of data collected in this study and biological rationale. Full model with all independent variables being included in the final model was used. The regression models were run first for the SSRS total scores and then for the SSRS subscale scores (i.e., subjective support, objective support, and support availability). These analyses were carried out separately for prenatal support and postnatal support. All analyses were carried out using SPSS Version 13.0 (SPSS, Chicago, IL). This study has been approved by the Research Ethics Board of Central South University.

RESULTS A total of 666 women were invited to participate in the study and 615 women agreed and completed the prenatal survey. At the 2-week postpartum survey, 24 women withdrew, 25 were lost to follow-up, and 10 had missing information in more than 20% of the variables. A further 41 women were excluded because of recorded major psychiatric disorders and obstetric and/or pregnancy complications, leaving 534 (86.8% of the consented women at 30–32 weeks of gestation) for analysis. Mean age of the women was 28.3 years and w50% had a university education and monthly income of greater than 2,000 Yuan per family member (Table 1). The sociodemographic characteristics of women who participated in the postpartum follow-up and those who did not were similar (Table 1).

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TABLE 1. Socio-demographic characteristics of participants, Changsha, China, 2007 Subjects completed postpartum follow-up (n Z 534) Characteristic Age (yr) 20–24 25–34 35–45 Education University or higher College High school or lower Occupation Public servant, professional Worker, clerk Farmer Others Income (per month per member) >2000 Yuan 1000–2000 Yuan !1000 Yuan Housing Satisfactory Unsatisfactory

Subjects did not complete postpartum follow-up (n Z 91)

(n)

(%)

(n)

(%)

70 424 40

13.10 79.40 7.50

10 74 7

11.00 81.30 7.70

222 130 182

41.60 24.30 34.10

38 24 29

41.80 26.40 31.90

166

31.10

30

33.00

167 122 79

31.30 22.80 14.80

27 21 13

29.70 23.10 14.30

272 138 124

50.90 25.80 23.20

47 24 20

51.60 26.40 22.00

432 102

80.90 19.10

67 24

73.60 26.40

Greater than 70% of the pregnancies were planned and greater than 70% were cesarean deliveries. The mean (SD) of gravidity was 2.16 (1.32) and the mean (SD) number of abortions was 0.92 (1.16) (Table 2). There was no difference in prenatal and postnatal total SSRS scores (Table 3). Differences in prenatal and postnatal scores for subjective support, objective support, and support availability, although small in magnitude, were statistically significant (Table 3). Low prenatal social support was associated with greater risk of PPD, with aOR varying from 2.12 to 3.38 (Table 4). For the three dimensions of social support, objective support had the strongest association and support availability had the weakest association (not significant after adjustment for confounding factors) (Table 4). Low postnatal social support was associated with greater risk for PPD, with aOR varying from 2.06 to 9.64 (Table 5). For the three dimensions of social support, objective support had the strongest association and support availability had the weakest association (not significant after adjustment for confounding factors) (Table 5).

DISCUSSION Our study in a cohort of 534 Chinese women showed that PPD, as measured by the EPDS, occurred in w19% of the parturient women. This rate is similar to rates reported in

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TABLE 2. Perinatal characteristics of participants, Changsha, China, 2007 Participants (n Z 534) Characteristics Planned pregnancy Yes No Gravidity 1 2 >3 Abortion 0 1 >2 Doula Yes No Use of pain relief Yes No Model of delivery Vaginal Cesarean delivery Type of cesarean delivery Emergent Elective Fetal gender Male Female Birth weight (g) 2500–3999 !2499 or >4000 Skin-to-skin Yes No Rooming-in Yes No Breast feeding (any) Yes No

Cases

(%)

396 138

74.20 25.80

212 153 169

39.70 28.70 31.60

231 158 145

43.30 29.60 27.20

220 314

41.20 58.80

452 82

84.60 15.40

119 415

22.30 77.70

149 266

35.90 64.10

295 239

55.20 44.80

465 69

87.10 12.90

463 71

86.70 13.30

467 67

87.50 12.50

506 28

94.80 5.20

previous studies of Chinese postpartum women (6, 26–30). The distribution of demographic characteristics in our study population, such as exceptionally high cesarean delivery rate, is also consistent with the demographic characteristics of Chinese pregnant women reported in recent Chinese literature (6, 31–33). Our study replicates the findings of earlier studies that inadequate social support is a risk factor for developing PPD (12, 14–23). Moreover, our study measured the level of social support during both the prenatal and postnatal periods, suggests that postnatal social support is a more potent predictor of risk for PPD than prenatal support. It is clear from the comparison of results presented in Tables 4 and 5 that the effect of postnatal social support on PPD

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TABLE 3. Comparison of prenatal and postnatal social support levels, Changsha, China, 2007 Participants (n Z 534) Social support score

Prenatal mean (SD)

Postnatal mean (SD)

Total score Subjective support Objective support Support availability

43.54 (6.24) 23.86 (3.92) 11.28 (3.03) 8.41 (1.82)

43.14 (6.25) 23.54 (3.65) 11.78 (2.66) 7.83 (1.65)

t 1.84 2.44 5.45 9.85

p 0.07 0.02 0.00 0.00

SD Z standard deviation.

is stronger than the effect of prenatal social support. For example, the aOR for depression was 3.38 for women with low prenatal support and 9.64 for women with low postnatal support. We conducted a literature search of MEDLINE (1966–November 2008), using a combination of key words and restricting to humans, female, and English literature. A total of 148 studies with all three key words occurring in the same article simultaneously were identified. Most of these studies were review articles or measured social support descriptively (e.g., ethnicity, religion, socioeconomic status, marital satisfaction, etc.) or looked at the long-term outcomes in the affected mothers and/or their offspring. Only a few studies actually measured social support by formal instruments (17–23), and among them, only three measured social support levels more than once during pregnancy (21–23). Webster et al. (21) measured social support levels (using the Maternity Social Support Scale) in 901 Australian women at their booking-in interview and at 16 weeks postpartum and explored the relationship between the social support level and study outcomes (including PPD). They found that women with low social support in

pregnancy were to be more depressed postnatal (21). However, the authors did not make a comparison of the effects of social supports measured during pregnancy and those measured postnatal. Baker and Taylor (22) made similar observation but again did not compare the effects of social support levels measured prenatally and postnatal. Leung et al. (23) assessed predictors of PPD in 385 Hong Kong Chinese women and found that 56% of the variance in PPD was explained by social support and stress factors and postnatal perceived stress was a major predictor of PPD. These findings are quite consistent with ours, although they measured postnatal perceived stress instead of social support. On the other hand, SSRS scores measured prenatally and postnatal were not significantly different (although the differences of the three subscales were statistically significant, these differences were not important clinically). One explanation for our finding is that PPD is more sensitive to changes in postnatal support than to changes in prenatal support. Our data also showed that social support scores for women who gave birth to a male infant measured postnatal were much higher than those measured prenatally, whereas no fetal gender-associated difference in prenatal social support was observed (data available on request). In a subsequent study, we will further explore whether the genderassociated difference in postnatal social support could explain the higher PPD rate in women who gave birth to a female infant than those who gave birth to a male infant observed in our earlier study (6). We found that among the three dimensions of support, low levels of objective support were most relevant to PPD. This finding is consistent with a previous study by Stuchbery

TABLE 4. Association between prenatal social support and PPD, Changsha, China, 2007

Total score 1st quartile (0–39) 2nd quartile (40–43) 3rd quartile (44–47) 4th quartile (>48) Subjective support 1st quartile (0–20) 2nd quartile (21–23) 3rd quartile (24–26) 4th quartile (>27) Objective support 1st quartile (0–8) 2nd quartile (9–10) 3rd quartile (11–13) 4th quartile (>14) Support availability Lower half (0–7) Higher half (>8)

PPD (n)

PPD (%)

Crude OR (95% CI)

Adjusted OR (95% CI)

37 28 24 14

28.20 24.60 16.20 9.90

2.84 (1.67–4.84) 2.47 (1.40–4.37) 1.63 (0.89–3.00) Reference

3.38 (1.64–6.98) 2.95 (1.40–6.25) 2.12 (0.99–4.56) Reference

24 25 32 22

21.40 22.30 22.10 13.30

1.61 (0.95–2.72) 1.67 (1.00–2.81) 1.66 (1.02–2.70) Reference

1.92 (0.96–3.84) 2.21 (1.10–4.45) 2.16 (1.13–4.13) Reference

33 28 26 16

32.70 22.00 15.20 11.90

2.76 (1.65–4.59) 1.86 (1.07–3.23) 1.28 (0.72–2.29) Reference

3.18 (1.52–6.61) 2.11 (1.03–4.33) 1.59 (0.78–3.27) Reference

41 62

24.30 17.00

1.43 (1.00–2.03) Reference

1.38 (0.85–2.25) Reference

CI Z confidence interval; OR Z odds ratio; PPD Z postpartum depression. Adjusted for maternal age, education, household income, planned pregnancy, the number of abortion, model delivery, Doula, and fetal gender.

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TABLE 5. Association between postnatal social support and PPD, Changsha, China, 2007

Total score 1st quartile (0–38) 2nd quartile (39–43) 3rd quartile (44–46) 4th quartile (>47) Subjective support 1st quartile (0–20) 2nd quartile (21–23) 3rd quartile (24–25) 4th quartile (>26) Objective support 1st quartile (0–9) 2nd quartile (10–11) 3rd quartile (12–13) 4th quartile (>14) Support availability Lower half (0–7) Higher half (>8)

PPD (n)

PPD (%)

Crude OR (95% CI)

Adjusted OR (95% CI)

56 26 12 9

44.10 19.80 11.00 5.40

8.23 (4.89w13.85) 3.70 (1.91w7.20) 2.07 (0.92w4.68) Reference

9.64 (4.09–22.69) 3.69 (1.58–8.59) 2.06(0.81–5.25) Reference

50 28 12 13

45.50 21.50 9.60 7.70

5.91 (3.69–9.48) 2.80 (1.56–5.03) 1.25 (0.59–2.64) Reference

6.25 (2.89–13.52) 2.87 (1.35–6.08) 0.94 (0.39–2.23) Reference

48 27 17 11

44.90 19.30 12.10 7.50

5.95 (3.59–9.87) 2.56 (1.36–4.81) 1.61 (0.79–3.29) Reference

7.03 (3.02–16.35) 2.30 (1.02–5.15) 1.91 (0.83–4.41) Reference

56 47

23.30 16.00

1.46 (1.03–2.06) Reference

1.19 (0.74–1.92) Reference

CI Z confidence interval; OR Z odds ratio; PPD Z postpartum depression. Adjusted for maternal age, education, household income, planned pregnancy, the number of abortion, model delivery, Doula, and fetal gender.

et al. (34). They studied women of Vietnamese, Arabic, and Anglo-Celtic ethnicity. Lack of practical support was associated with depression in Vietnamese women, whereas inadequate emotional support from one’s partner and/or one’s mother was associated with depressive symptoms in Arabic and Anglo-Celtic women (34). This finding suggests that tangible social support, such as assistance with caring for the newborn, may be particularly important for the emotional well-being of postpartum women from Asian cultures. Limitations of our study should be considered in interpreting the study results. We do not know if our cohort women are representative of the total pregnant women population in the participating hospitals during the study period. Thus, we cannot be certain whether there was no selection bias in our sample. We did not measure prenatal depression. As a result, some of the pre-existing depression cases may be misclassified as PPD. Mastery or self-efficacy is an important determinant of depression (35, 36). We did not measure self-efficacy so we cannot analyze its potential impact on the study findings. However, this limitation would impact little on the main objective of this study, namely the different effects of social support levels measured prenatally versus those measured postnatal on the risk of PPD. This is a before and after comparison for the same individual. There will be different mastery or self-efficacy in different individuals, but for the same individual, there will be little change from prenatal to postnatal period (36). In summary, our prospective study in a cohort of Chinese women found that low social support is a risk factor of PPD, with the association being strongest for the postnatal period and for objective social support. These findings may have important implications for perinatal care program

development. For example, social support interventions delivered to women during the immediate postnatal period may be a cost-effective strategy to prevent PPD. These findings may also provide useful information for designing randomized trials to assess the efficacy of social support on PPD. Dr. Xie is an Ontario-University of Ottawa Vision 2010 Postdoctoral Fellow. Dr. Wen is a recipient of the Ontario Women’s Health Council-Institute of Gender and Health of Canadian Institute for Health Research (CIHR) Mid-Career Award. Dr. Walker is a new investigator of CIHR. This study was supported by grants from Hunan Provincial Natural Science Foundation (06JJ4055), Hunan Ministry of Science and Technology (06FJ4103), and Hunan Ministry of Education (06C072) of the People’s Republic of China. We thank the pregnant women and the staff of the participating hospitals in Changsha, China for their support.

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22. Baker D, Taylor H. The relationship between condition-specific morbidity, social support and material deprivation in pregnancy and early motherhood. ALSPAC Survey Team. Avon Longitudinal Study of Pregnancy and Childhood. Soc Sci Med. 1997;45:1325–1336. 23. Leung SS, Martinson IM, Arthur D. Postpartum depression and related psychosocial variables in Hong Kong Chinese women: findings from a prospective study. Res Nurs Health. 2005;28:27–38. 24. Lee DTS, Yip SK, Chiu HFK, Leung TY, Chan KP, Chau IO, et al. Detecting postnatal depression in Chinese women. Validation of the Chinese version of the Edinburgh Postnatal Depression Scale. Br J Psychiatry. 1998;172:433–437. 25. Cox J, Holden J. Perinatal Psychiatry: Use and Misuse of the Edinburgh Postnatal Depression Scale. London: Gaskell: (Royal College of Psychiatrist); 1994. 26. Cheng RCH, Lai SSL, Sin HFK. A study exploring the risk of postnatal depression and the help-seeking behaviour of postnatal women in Hong Kong. Hong Kong Nursing J. 1994;68:12–17. 27. Pen T, Wang L, Jin Y, Fan X. The evaluation and application of the Edinburgh Postnatal Depression Scale. Chin Mental Health J. 1994;13:18–19. 28. Qing AF, Luo XJ, Yu M. Socio-psychological factors associated with postpartum depression. Health Psychol J. 1998;6:475. 29. Zhang SW. Fetal gender and maternal physical and psychological health. Mat Child Health China. 1995;10:101–102. 30. Zheng SX, Huang T, Zou X. Evaluation of the Edinburgh Postnatal Depression Scale and analysis of the findings. China J Psychiatry. 1996;6:236–237. 31. Chen J, Liu J, Zhang A, Yu L, Zhu X. An analysis of the demographic characteristics of women with cesarean delivery. Mat Child Health China. 2005;20:1116–1117. 32. Chen Q. An analysis of the reasons of increasing cesarean delivery rates in recent years. Suzhou Univ Med Sci J. 2003;23:174–175. 33. Gao X, Pan S, Li S, Ta Q, Song Y, Yuan Z. Passive smoking in pregnant women in Guangzhou. China J Prev Med. 2002;3:224–225. 34. Stuchbery M, Matthey S, Barnett B. Postnatal depression and social supports in Vietnamese, Arabic and Anglo-Celtic mothers. Soc Psychiatry Psychiatr Epidemiol. 1998;33:483–490. 35. Pearlin LI. The sociological study of stress. J Health Soc Behav. 1989;30:241–256. 36. Pearlin LI, Nguyen KB, Schieman S, Milkie MA. The life-course origins of mastery among older people. J Health Soc Behav. 2007;48:164–179.

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APPENDIX: SOCIAL SUPPORT RATING SCALE Instructions: The following questions are asked to describe the support from your family and the society. Please answer them by the best judgment you can make and circle the chosen answer(s). Thanks for your cooperation. 1. How many friends do you consider to be close enough to you that can rely on them for help when you need it? 1. None 2. 1 - 2 3. 3 - 5 4. 6 or more 2. In the last year, you: 1. Stayed away from others and lived alone 2. Moved a lot, and mostly lived with strangers 3. Lived with colleagues, friends, or classmates 4. Lived with your family 3. You and your neighbors 1. Never cared about each other 2. Showed some care when in difficulties 3. Some neighbors cared about you a lot 4. Most of the neighbors cared about you a lot 4. You and your colleagues 1. Never cared about each other 2. Showed some care when in difficulties 3. Some colleagues cared about you a lot. 4. Most of the colleagues cared about you a lot 5. Support and care from family members (put a check mark where applicable) None

Rarely

Some support/care

Strong support/care

Husband or wife Parents Children Sisters or brothers Other family members (e.g., sister-in-law, etc.)

6. In the past, when faced with an emergency, you have received financial or other material support from: 1. None 2. The following (check all that apply):

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a. Husband or wife b. Other family members c. Relatives d. Friends e. Colleagues f. Employer g. Union or government h. Political or religious organizations, society, and nongovernment organization i. Other (please specify) 7. In the past, when faced with an emergency, you have received console and other emotional support from: 1. None 2. The following (check all that apply): a. Husband or wife b. Other family members c. Relatives d. Friends e. Colleagues f. Employer g. Union or government h. Political or religious organization, society, and nongovernment organization i. Other (please specify) 8. When you feel sad or vexed, you. 1. Never talk to anyone 2. Only talk to the closest one or two individuals 3. Will talk to friends if they ask 4. Will talk to friends even if they did not ask 9. When you have difficulties/troubles, you. 1. Rely on yourself and do not accept help from others 2. Rarely ask for help 3. Sometime ask for help 4. Always look for help from family members, relatives, and organizations 10. Your participation in activities organized by political or religious organizations, unions, and student associations, etc., can be described as follows: 1. Never 2. Rarely 3. Frequently 4. Always and playing an active roles in these activities