Mental Health Literacy in South East Asia in a Cultural Context: A

Systematic Review

Fairuziana

, Marty Mawarpury

, Andriyani E. Lay

, Yeni Fitriani

, Yanti Fitria

Faculty of Psychology, Universitas Indonesia, Depok, Indonesia

Faculty of Medicine, Pyschology Department, Universitas Syiah Kuala, Banda Aceh, Indonesia

Faculty of Training and Education, Universitas Nusa Cendana, Kupang, Indonesia

Faculty of Psychology, UniversitasGadjahMada, Yogyakarta, Indonesia

Psychiatry Medical Unit, Ulin General Hospital, Banjarmasin, Indonesia

yeni.fitriani@mail.ugm.ac.id,yan.fitri.kj@gmail.com

Keywords: Mental Health Literacy, Cultural Context, South East Asia

Abstract: Mental health literacy and positive community attitude toward mental illness significantly

predicted the simultaneous formal help seeking to professional treatment. The diverse setting of

Southeast Asia population mental health literacy with consideration to cultural circumstances are

still understudied. This includes the population’s traditional knowledge, belief, and local

treatments of mental disorders symptoms. This study aims to systematically review available

literature to learn the variety of mental health literacy studies and analyse whether the studies

consider cultural circumstances such as local knowledge and informal help seeking. Studies that

were conducted in South East Asian countries population were systematically reviewed

according to relevant keywords in English and Bahasa Indonesia from selected major electronic

sources. The selected studies focus on the general public, health care workers, and mental health

professionals knowledge; (ii) written in English; Indonesia; (iii) study located the countries of

Southeast Asia; and (iv) focusing on mental health literacy, attitudes, and beliefs about mental

illness and mental, knowledge on mental health, and other related terms. The study result in a

systematic review of 46 articles, which were published between the past 40 years in the period of

1978- 2018. The articles are presented under the themes of 1. ) Mental health literacy among lay

people and healthcare professionals 2.) Attitudes and beliefs toward mental illness and 3.) Help-

seeking approach to mental illness. The findings discovered that while common understanding of

mental disorder is expected to identify the mental health literacy, embedding cultural context

would accommodate the understanding of lay people.

1 INTRODUCTION

The issue of mental health has become a major

concern in both the developed and developing

countries (Ganasen, et al, 2008). According to Steel

et al (2014), the global prevalence of common

mental disorders in 26 high income countries and 37

low and middle income countries indicated that on

average one in five adults experienced a common

mental disorder within the past 12 months. The term

“common” refers to the high prevalent of the

disorder in the community. WHO (2017)

categorizes common mental disorder in two main

categories: depressive disorders and anxiety

disorders.

The prevalence of mental disorder is widely

measured using CIDI (Composite International

Diagnostic Instrument). However, the global

prevalence worldwide shows a wide variety across

regions. One of the factor that affect the reports on

mental health assessment is the ability to recognize

the illness. Steel et al (2009) discovered in Vietnam

that using the international diagnostic accompanied

with a culturally derived diagnostic measure would

improve the overall prevalence compare to using the

CIDI alone.

516

Fairuziana, ., Mawarpury, M., Lay, A., Fitriani, Y. and Fitria, Y.

Mental Health Literacy in South East Asia in a Cultural Context: A Systematic Review.

DOI: 10.5220/0008591505160524

In Proceedings of the 3rd International Conference on Psychology in Health, Educational, Social, and Organizational Settings (ICP-HESOS 2018) - Improving Mental Health and Harmony in

Global Community, pages 516-524

ISBN: 978-989-758-435-0

The expression or idiom to indicate and report

mental disorder across countries may vary and have

influence of cultural factors (Steel, et.al, 2009). For

instance, countries in North East and South East

Asia shows a lower rate of common mental disorder

compared to other region (Steel et al 2009; Steel et

al 2015). It is argued that cultural setting might over

or underestimate the prevalence of mental disorder

(Steel et al, 2014). While symptom of mental

disorder is universal, lay people would have

different ways of expressing the understanding for

the condition. For example, in Sri Lanka, the

vocabulary of “depression” is not common in the

Sinhala ethnic group but are more being used by the

Sri Lankan who respond in English (Amarasuriya,

et.al, 2015). The ability to recognize the problem as

an illness then further relates to the help seeking

behaviour. In addition, the lack of mental health

professionals in the community would then endorse

informal help seeking such as parents and friends.

The ASEAN (Association of South East Asia

Nation) which include 10 countries in South East

Asia, apart from East Timor have generated a task

force on mental health and launched a brief report

regarding the mental health system in the region.

The background of the ASEAN establishment is

based on some similarities such as geographical

position which lies between two continents and two

oceans, shate the Melayu Austronesia culture, have

the colonialized experience in the past, and have

similar interests in economic, social culture,

security, and politic.

The ASEAN Mental Health Report in 2016

reported that mental health was a challenging issue

in the developing countries. For example there are

two countries which did not have national

information and data about prevalence and mental

illness cases. One country did not have any clinical

psychologist. In addition, limited financial has effect

on health facilities, service and human resources

such as psychiatry and nurse. There were other

similarity in the 10 countries that give effect on the

people’s help-seeking behaviour such as lack of

knowledge, misunderstanding about mental health,

and cultural factor like possession, back magic, and

religion. Emotional factors like fear, shame, and

ignorance were the major barriers to seek help.

Stigma and discrimination are big challenges for

people with mental illness.

In average, less than half of the countries in

South East Asia have a mental health law, including

new laws in many countries that requires an

implementation plan. Some countries never have a

national epidemiology survey on mental health.

These problems are apart from the challenge to

provide a well ratio of human resource and service

in the community towards the need in the

population. A policy brief reported by the ASEAN

Task Force on Mental Health (2013) proposed four

solutions to address mental health issues in 10

countries of ASEAN. One of the strategies

addressed the promotion of depression awareness

and combat stigma using public education

campaigns, which include mental health literacy.

Mental health literacy was introduced by

Anthony Jorm (1997), which is defined as

“Knowledge and beliefs about mental disorders

which aid their recognition, management or

prevention. Mental health literacy includes the

ability to recognize specific disorders; knowing how

to seek mental health information; knowledge of risk

factors and causes, of self-treatments, and of

professional help available; and attitudes that

promote recognition and appropriate help-seeking”.

Jorm’s mental health literacy studies have been

implemented in many parts of the world, in both

western and non-western countries. The knowledge

and belief regarding mental illness is positively

associated to the treatment and help seeking,

whether to professionals, semi-formal or informal

service (Novianty, 2016). The use of English as a

spoken language greatly influence mental health

literacy. Many non-western countries learn that

mental disorder is associated to black spirit and

supernatural which need the help of traditional

healers (Ganasen et al, 2008).

In addition, the lack of research in the field of

mental health is also a challenge for the government

to obtain accurate information and design programs

that fit the needs of mental health (ASEAN, 2016).

The importance of the research role for the

development of mental health programs is also put

forward by Kermode et al (2009). Furnham and

Hamid (2014) argue that the majority of mental

health research pioneered by Jorm et al, conducted

in Western countries that can be reached by

telephone survey. Meanwhile, mental health literacy

in non-western countries is less well known.

The results of research on mental health literacy

conducted in various countries such as Africa

(Aggarwal, et al, 2016 & Atilola, 2016), America

(Altweck, et al., 2016), Canada (Gagnon, Gelinas, &

Friesen, 2015) recommends the importance of

considering cultural factors in mental health literacy

and its relation to help seeking behavior (Kelly &

Wright, 2007). Even Koutoufa & Furnham (2014)

suggests further research on the motivations

underlying one's beliefs and should also examine the

Mental Health Literacy in South East Asia in a Cultural Context: A Systematic Review

517

potential cause-and-effect relationship between

social and psychological conditions and mental

health literacy.

In an ethnographic approach, culture has a role

to determine how society determine the continuum

of normal to abnormal conditions, contribute to

certain cause of mental disorders, provide perception

of health workers in assessing, diagnosing, labelling

disorders and explaining mental illness in their

patients, and influences the way people perceive the

mental illness label that has been given by society

(Burnard, Naiyapatana & Lloyd, 2006). In the

current study, we look at research findings about the

relationship between culture and mental health

literacy in South East Asian countries as well as its

relationship to the behaviour of seeking help.

The current research aims to systematically

review previous research in South East Asia

regarding mental health literacy with two objectives

1.) Learning the variety of mental health literacy

studies 2.)Analysing whether the study considers

cultural circumstances such as local knowledge and

informal help seeking as mental health literacy.

Similarities and differences across literatures will

also be compared to find a pattern in understanding

mental health literacy in the context of South East

Asia region.

2 METHOD

The electronic search database is performed using

PubMed, Google Scholar, ProQuest and Sage. The

literature search is not located within a certain

period to expand the possibility collecting as many

relevant articles to the key search. Articles that have

been obtained during the search process, are from

1976 to 2018. The selected terms of keyword are

used to ensure the entry of articles as much as

possible. Search is done by entering keywords

(attitude), (knowledge), (belief), (culture), (cultural

belief) AND the combination with (mental health

literacy), (mental illness), (mental disorder),

(depression), (anxiety), (schizophrenia) AND

(Southeast Asia) by title and abstract search. The

hand search of the literature was conducted as a

form of citation search study to identify relevant

studies which does not belong to a particular

database.

Based on these primary and secondary

references, the studies included in this paper meet

the following criteria: (i) studies focusing on the

general public, health care workers, and mental

health professionals; (ii) the papers are written in

English; Indonesia; (iii) the focus of this paper is the

countries of Southeast Asia; and (iv) papers focusing

on mental health literacy, attitudes, and beliefs about

mental illness or disorder, knowledge of mental

illness or disorder, relief seeking, beliefs about

seeking treatment, utilization of mental health

services, AND mental illness excluding eating

disorders, substance-related disorders, gambling-

related disorders, learning disabilities, or attention

deficit disorders.

The search criteria yielded 69 articles which

went through screening for no duplicated article by

title and abstract. In addition, article that didnot meet

the inclusion criteria were excluded. At the time of

the screening process, there are 43 articles that meet

the criteria and as many as 26 articleswere excluded,

including titles without abstract. This search method

is not precise and complete yet, as there are

possibilities of not finding articles using a different

term out of the search key both through the database

or by hand.

Figure 1. Flow diagram of systematic review procedure.

ICP-HESOS 2018 - International Conference on Psychology in Health, Educational, Social, and Organizational Settings

518

3 RESULT

This systematic review included 43 articles, which

are published between the past 40 years of 1978-

2018. The studies were conducted amonglay people

and health care professionals in South East Asia.

The present work review category is similar to

Tonsing’s (2017) study which was conducted among

Singaporean population.In that study, a narrative

review approach was conducted to asses 20 articles

under the theme of mental health literacy across the

lay people and health professional participants.

In the present work, most reviewed articles

usevignette study for the data collection and

aresummarized in Appendix B. The 43 articles are

presented under the following subheadings:

1. 23 articles under mental health literacy among

lay people and healthcare professionals

2. 25 articles under attitudes and beliefs toward

mental illness

3. 13 articles under help-seeking approach to

mental illness treatment

Each article is not exclusively under one

heading. Some articles fall under two or three

themes

3.1 Mental Health Literacy among Lay

People and Healthcare

Professionals

This topic is discussed in more than half of the

articles reviewed. The results in Southeast Asian

countries have similar results. From an ethnic point

of view, the rate of Mental Health Literacy (MHL)

differs in comparing the level of MHL in an ethnic

group. For example,the Chineseethnic in the

countryside has lower MHL than ethnic Malaysians.

While in other places mentioned ethnic China-

Singapore has a better MHL than Malaysian and

Indian ethnic.

Factors affecting the MHLto be better in the

community are based on the residential locations

where urban communities have better MHL, higher

education, income and based on religion. MHL

related knowledge is obtained formally and

informally. In terms of time, research from year to

year still shows similarities related to causes and

symptoms of mental disorders. Mental disorders are

still associated with supernatural beliefs and

traditional beliefs.

Many consider mental disorders due to external

factors such as family, occupation, unmarried or

karmic. The symptoms mentioned related to mental

disorders such as lack of hope, physical complaints,

lack of courage, poor mind, defeat, communication

difficulties and abnormal social behaviour, some are

harmful and not.

In terms of individual or groups knowledge,

psychiatrists have the ability to recognize mental

disorders better than others. Traditional healers can

help in recognizing symptoms but are not significant

in their role to reduce or heal symptoms. In terms of

diagnosis, dementia, alcohol abuse and OCD are

better recognized. Depression is better known than

schizophrenia. New schizophrenia is recognized

after years without treatment.

3.2 Attitudes and Beliefs toward

Mental Illness

Some SEA countries have different attitudes toward

mental disorders. For example, urban Chinese

society shows a higher level of knowledge for

depression than rural China. Meanwhile, the urban

and rural Indian urban have a relatively similar

attitude about depression. In another study, the

Chinese Tiansghoa community has a better level of

literacy on depression, followed by Malaysians and

Indians. This fact is associated with education and

income levels. Older age, male gender, lower

education and socioeconomic status are associated

with more negative attitudes toward people with

mental disorders.

The response rate for psychiatrists is higher than

that of the primary healthcare practitioner. The

majority of primary health practitioners and

psychiatrists consider that patients will be

discriminated against, especially schizophrenia and

mania rather than depression. For example, major

health practitioners in Singapore have more negative

views than Singapore psychiatrists about the results

of professional interventions for the three major

psychiatric disorders. These findings have

implications for education and training for primary

health practitioners as well as for the care of

psychiatric patients in primary health environments.

Mental health contributes less to the behavior of

help seeking. Community attitudes toward mental

illness contributes more significantly to the behavior

of seeking help. Compared with the general

population, mental health professionals have a more

positive attitude toward mental illness. Compared to

nurses, doctors showed a significantly more positive

attitude to 'social restrictions' and 'prejudice and

misunderstanding'. Having a close family or friend

diagnosed with a mental illness is negatively related

to 'social distance' among professionals.

Mental Health Literacy in South East Asia in a Cultural Context: A Systematic Review

519

Stigma against people with mental disorders is

higher in older individuals, men, lower education

and lower incomes. Stigma is lower in individuals

who have experience or have relatives who are

affected by mental disorders. Severe psychotic

disorders (more psychotic) have more stigma in

society.

MHL does not contribute much to the behavior

of seeking medication, while the attitude toward the

illness is the most decisive attempt to seek treatment.

However, the higher the MHL increases the effort to

seek professional treatment.

3.3. Help-seeking Approach to Mental

Illness Treatment

The same problem in almost all countries in SEA,

the number of mental health professionals is still

lacking. Factors that influence the search for

professional treatment are age, gender, ethnicity,

income, personal experience or the nearest person,

and stigma. Among the 13 articles discussing the

approach / behavior of help seeking on the treatment

of illness / mental disorders discovered:

a. Recognize mental disorders and labeling issues

and naming mental disorders. There are still many

lay people unable to recognize the different types of

mental disorders. A negative attitude toward mental

illness that prevents individuals from seeking

professional care, and seeking help, is a common

theme that emerges. Health professionals have

different views on the causes and treatment of

mental disorders. The findings also reveal that

seeking treatment, attitudes and beliefs about mental

illness are associated with mental health literacy. In

ordering, here are some categories of criteria used to

label baa / mental disorder / insane in an individual:

b. Seeking help: traditional healer, simultaneously or

before seeking professional help, The most common

undertaking in dealing with mental disorders is

talking to family. In terms of treatment, there are

some tendencies to believe that mental health

services are only intended for severe psychiatric

disorders such as schizophrenia. The reluctance to

seek professional help is also related to the

perception that the disturbance is not severe enough

to receive assistance. Traditional explanatory models

can provide understanding and integration of the

meaning system of interruptions but are

unsuccessful in alleviating symptoms. The strength

of social support and the trust of patients, friends,

and / or relatives in the treatment of mental illness is

strongly associated with traditional medicine.

Culture is believed to be a major deterrent to

psychiatric care in some countries.

c. Not looking for help. The reason for not seeking

professional treatment is because they do not know

of any health facilities for treatment of mental

disorders, distance to health facilities, beliefs about

other causes that can be treated in other ways, and

financial problems.

4 DISCUSSION

Numerous study of mental health suggested that

characteristic of demographic has affected on

knowledge and mental health literacy. Novianty &

Hadjam, (2017) suggest that there is a direct and

indirect connection between characteristic of

demography and community’s attitude toward

mental health problem and seeking formal help,

potential gender differences in MHL could inform

future intervention (Coles, etc., 2015). Age group

(Marcus &Westra, 2012) and group of racism

(Ypinazar, Margolis, Haswell-Elkins, & Tsey, 2007)

have unique views and needs respect to the

management of mental health problems. Regarding

to socio-economic status, SES is a factor to

recognize psychiatric disorders and treatment

options (Furnham, & Hamid, 2014). SES also has a

consistent relationship with the MHL and has an

inconsistent relationship with help seeking behavior

(Holman, 2015).In this study we also find that most

of research reported demographics factor had affect

toward mental health literacy and level of formal

help-seeking (Yeap& Low, 2009). However, these

factors play different roles on individual and

community group of mental health literacy, hence

influence formal help-seeking. Demographic

characteristic of sample in the studies were

conducted in Indonesia, Malaysia, Singapore, Laos,

Vietnam, Thailand, and Brunei Darussalam covered

various social demographic backgrounds such as

age, gender, education, religion, language, ethnicity,

socioeconomic status, mental disorder patients,

residential location, community, families, students,

religious practitioner and professionals in different

research context.

The range of age sample is the lowest 15 years

and highest 65 years old. Tze-Ping et al (2008)

indicated that a large proportion of adults with

mental disorders do not seek help. While the

younger sample which have good knowledge of

mental health were more willing to seek help (Yeap

& Low, 2009). Gender factors influence perception

ICP-HESOS 2018 - International Conference on Psychology in Health, Educational, Social, and Organizational Settings

520

and awareness of pain. In general, women tend to be

more aware of symptoms than men who tend to be

unaware of health problems and are more likely to

delay seeking help. Education level is related to

good MHL in some mental disorder. The level of

education affects access to good mental health

information and can receive relevant information

from good education.

Ethnic differences is significantly a factor

associated with MHL against some disorders such as

how mental health is described and labelled, for

example Indians can identify depression and

dementia and more Malays can recognize dementia.

Ethnicity also affects one's belief in the cause of

mental illness. Hong Kong ethnic Chinese are more

likely to believe that social factors cause mental

illness than genetic factors. The Japanese use fewer

psychiatric labels when compared to Australians

(Chong SA, et al, 2016).

According to the socioeconomic status, there are

differences in helps seeking behaviour to

professionals. The low-SES families seeks more

formal help than high-SES families. Families with

lower middle-class socioeconomic status that have

family members with mental disorders tend to refer

to professional help seekers than families with

above-average incomes that tend to cover up in

shame (Novianty & Hadjam, 2017).

Language and religion play a major role

especially in the therapeutic process. The language

differences of the therapist and the patient affect the

expression, idiom, and meaning. Religious

differences will affect the perspective and beliefs of

individuals about mental disorders. Religion is the

lifeline of the individual, which is then adopted as

the ideology and philosophy of the state

(Kumaraswamy, 2007).

According to the findings, most countries in

South East Asia were find available to provide

studies about mental health literacy, except the

Philippines and East Timor. Most studies elaborated

the mental health literacy and attitude. While fewer

studies emphasized in the help seeking behaviour, it

has been covered in the first two categories. The

categories are somewhat overlapped because each

article would usually explain two categories in one

article, for instance, mental health literacy and help

seeking or attitude and help seeking. Thus, the

category does not exclusively determine the

differences of one article to another.

Given the respondent’s participation, most of the

participants are distinctly grouped according to their

living place such as urban and rural, or education

major such as medical and non-medical, and age

group. Students’ literacy are moderate.

The studies show that the understanding of

mental illness are associated with the level of

income. Rural participants tend to have less income

and lower education attainment which consequently

gives less information about mental health. Thus,

people living in rural area associate the causation of

mental health problems to God’s destiny and

supernatural causation. However, none of the urban

or rural citizen use supernatural labels to identity the

problem.Ethnicity are related to the understanding of

mental health cases, but the predictors are still

associated to income levels and education

attainment.

Most mental health literacy vignettes requires the

participants to correctly answer the case with a

psychotic label instead of lay people’s label such as

emotional distress. On the other hand, the use of

English as the main spoken language does affect the

participant’s knowledge to recognize the mental

health cases in a medical term.

Rural participants would endorse for religious

treatment compare to the urban’s who prefer to

modify their lifestyle, visiting a psychologist, or

psychiatrist. Recognizing culture as part of the

understanding of mental health was discovered in

several studies. In Thailand, there is a mixture of

modern and traditional treatment for mental illness

which appear to be available in rural areas compare

to the capital in Bangkok. In Javanese culture, the

spiritual connection become a coping mechanism

and screening tool to identify depression disorder.

The idiom of “discouragement” is expressed a

demotivated feeling. In the Laotian society, folk

diagnosis are categorized with some social label

called “baa label”. Social explanation were also

found in Indonesia and Malaysia. It is argued that

mental health problems have similar symptoms

around the world, however the expression are

different according to the value and belief system in

the society.

Religion also holds an important role to define

mental health literacy. Lay people in countries such

as Brunei Darussalam and Malaysia believe that

mental disorder is a consequence for not obeying the

Islamic commands. Buddhist is also one of the

religion in many parts of South East Asia, which

holds value to recognize the mental health state of a

person.

Mental Health Literacy in South East Asia in a Cultural Context: A Systematic Review

521

5 CONCLUSION

The present study in South East Asia Region have

covered most of the studies available related to

mental health literacy. Lay beliefs about

schizophrenia may serve different functions for

different ethno-cultural groups, which has an

influence on help-seeking behaviour. The folk

diagnosis of mental disorders is made not based on

the strength of one criterion, but several. While a

common understanding of mental disorder is

expected to identify the mental health literacy,

adding cultural context would accommodate the

understanding of lay people. Studies in mental

health literacy should integrate anthropology and

sociology as valuable perspective to a better

understanding of the community’s literacy on mental

health.

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