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Social Determinants and Health Programs to Address Mental Health Issues

Social Determinants and Health Programs to Address Mental Health Issues Among the Urban Poor Community

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Social Determinants and Health Programs to Address Mental Health Issues

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  1. Seminar on “Social Determinants and Health Programs to Address Mental Health Issues Among the Urban Poor Community” Nurul Hidayati binti Saidi Nur Syazmin binti Sies Izanna binti IderisAhmad Zhafir bin Zulkfli @ Zulkifli Basirah Anati binti Basaruddin Nadzirah Mohd Yusof

  2. Urbanisation in Malaysia • Urbanisation? Growth of the urban population  • Following the migration of people from rural to urban areas in search of a better quality of life (employment, education, and better services) • In 2022, 75.5% of Malaysia’s population was estimated to reside in urban areas • Malaysia’s rapid urbanisation has divided society into income groups Department of Statistics Malaysia. (2023, August 8). Household Income Estimates and Incidence of Poverty Report, Malaysia, 2022.  https://www.dosm.gov.my/uploads/release-content/file_20230808213355.pdf

  3. Evolution Of Migration For Urban and Rural • Migration patterns and rates are closely related to the level of urbanization experienced by a country • Major cities in developing countries (Philippines, Indonesia, Vietnam, Thailand, Malaysia)- AGR >2 % • Developed countries (Japan (0.1%-(-0.2%), Australia (1.4%), New Zealand (1.2%) and Singapore (0.8%) have AGR near zero Internal migration  Department of Statistics Malaysia. (2020). Evolution of migration for urban and rural (DOSM/BPPD/4.2020/Series 62). https://www.dosm.gov.my/v1/uploads/files/6_Newsletter/Newsletter%202020/DOSM_BPPD_4-2020_Series-62.pdf

  4. Impact on rapid urbanisation • Significance increase internal migration give rise to difficulties: • In providing adequate services and infrastructure • Employment opportunities • Housing for urban residents Nasib, R., Lukman, K. A., Deligannu, P., Ali, N., Abdul Rahim, N. B., Abdul Rahim, M.M., & Lean Boon Leong, N. (2023). Poverty and depression among theurban poor inMalaysia: A narrative review. Malaysian Journal of Medicine & Health Sciences,19(Supplement 20), 235–240. https://medic.upm.edu.my/upload/dokumen/2024020210593326_2023-0747.pdf

  5. Poverty and Urban Poverty in Malaysia Incidence of absolute poverty • Urban poverty increasingly becoming an important phenomenon in Malaysia due to rapid urbanisation • increase vulnerability of low-income urban residents  • Incidence of absolute poverty in Urban 4.5% (2022)  • World Bank (2005): those whose income falls below the minimum level of basic human needs Department of Statistics Malaysia. (2023, August 8). Household Income Estimates and Incidence of Poverty Report, Malaysia, 2022.https://www.dosm.gov.my/uploads/release-content/file_20230808213355.pdf 8

  6. Urbanization, inequality and poverty • INEQUALITY  • Growing due to rapid urbanization, particularly among low-income and urban poor families • Urban poor and low-income families living in urban squatters and low cost high rise flats (People's Housing Program/ PPR) Nasib, R., Lukman, K. A., Deligannu, P., Ali, N., Abdul Rahim, N. B., Abdul Rahim, M. M., & Lean Boon Leong, N. (2023). Poverty and depression among the urban poor in Malaysia: A narrative review. Malaysian Journal of Medicine & Health Sciences, 19(Supplement 20), 235–240. https://medic.upm.edu.my/upload/dokumen/2024020210593326_2023-0747.pdf

  7. Impact of Poverty on Urban Poor's Mental Health in Malaysia • Urbanisation and poverty have always been associated with detrimental effects on the mental health of the urban population • Mental health (WHO): state of wellbeing in which an individual recognizes their abilities to cope with the level of stress in life • Higher prevalence of mental health problems among the urban poor affects their living conditions, surrounding environment, and educational attainment Nasib, R., Lukman, K. A., Deligannu, P., Ali, N., Abdul Rahim, N. B., Abdul Rahim, M. M., & Lean Boon Leong, N. (2023). Poverty and depression among the urban poor in Malaysia: A narrative review. Malaysian Journal of Medicine & Health Sciences, 19(Supplement 20), 235–240. https://medic.upm.edu.my/upload/dokumen/2024020210593326_2023-0747.pdf

  8. Social Determinant of Health of mental health issues among urban poor community • Mental health of urban poor communities profoundly shaped by complex interplay of social, economic and environment (non-medical factors that influence health outcomes).  Nasib, R., Lukman, K. A., Deligannu, P., Ali, N., Abdul Rahim, N. B., Abdul Rahim, M. M., & Lean Boon Leong, N. (2023). Poverty and depression among the urban poor in Malaysia: A narrative review. Malaysian Journal of Medicine & Health Sciences, 19(Supplement 20), 235–240. Allen, J., Balfour, R., Bell, R., & Marmot, M. (2014). Social determinants of mental health. International Review of Psychiatry, 26(4), 392–407. https://doi.org/10.3109/09540261.2014.928270

  9. Mental illness issues among Urban Poor • A stress response pathway may play a role in developing mental health issues such as depression and anxiety in low-income individuals • Depression (1.4 times) and anxiety (1.2 times) are more prevalent in urban than rural populations  • 23.9%-57.8% Urban Poor in Malaysia associated with depression  • Top 5 Asia Pacific's Mental Health issues • Depression  • Anxiety  • Suicidal Behaviour  • Substance abuse disorder  • PTSD  Prevalence of depression 21% Thailand  19.9% Taiwan  19.4% Korea 17.5% Malaysia 16.5% China  Nasib, R., Lukman, K. A., Deligannu, P., Ali, N., Abdul Rahim, N. B., Abdul Rahim, M. M., & Lean Boon Leong, N. (2023). Poverty and depression among the urban poor in Malaysia: A narrative review. Malaysian Journal of Medicine & Health Sciences, 19(Supplement 20), 235–240. https://medic.upm.edu.my/upload/dokumen/2024020210593326_2023-0747.pdf

  10. Nasib, R., Lukman, K. A., Deligannu, P., Ali, N., Abdul Rahim, N. B., Abdul Rahim, M. M., & Lean Boon Leong, N. (2023). Poverty and depression among the urban poor in Malaysia: A narrative review. Malaysian Journal of Medicine & Health Sciences, 19(Supplement 20), 235–240. https://medic.upm.edu.my/upload/dokumen/2024020210593326_2023-0747.pdf

  11. Institute for Public Health. (2020). National Health and Morbidity Survey (NHMS) 2019: Non-communicable diseases, healthcare demand, and health literacy—Infographic booklet. Ministry of Health Malaysia. https://iptk.moh.gov.my/images/technical_report/2020/4_Infographic_Booklet_NHMS_2019_-_English.pdf

  12. Importance of Mental Health Programs • Urban poor not only results on health issues but critical economic and social impact  • Poor mental health significantly impacts individuals in many aspects, including low educational achievement and work productivity, poor community cohesion, high levels of physical ill health, and premature mortality, among other things Nasib, R., Lukman, K. A., Deligannu, P., Ali, N., Abdul Rahim, N. B., Abdul Rahim, M. M., & Lean Boon Leong, N. (2023). Poverty and depression among the urban poor in Malaysia: A narrative review. Malaysian Journal of Medicine & Health Sciences, 19(Supplement 20), 235–240. https://medic.upm.edu.my/upload/dokumen/2024020210593326_2023-0747.pdf

  13. Mapping Existing Mental Health Programs and Services for the Urban Poor in Malaysia • Established policies and programs to improve mental healthcare • Aim to decentralization from institutional care towards community based services  • Advocate comprehensiveness, accessibility abd equity  • The National Mental Health Policy (1998, revised 2012) • Malaysian Mental Health Framework (2002) 

  14. Mental health programs 1st consultation free Follow up- nominal fee (RM5)  Ministry of Health Malaysia. (n.d.). MENTARI Malaysia official portal. https://mentari.moh.gov.my

  15. Malaysian Mental Health Association (MMHA) Subsidized rates (RM50-RM 210/ session)  Psychological Therapy & Support ServicesPhone: +603 2780 6803 (Mon.-Fri. 9am-5pm, except public holidays)Website: www.mmha.org.my

  16. HOPE worldwide Malaysia • Sentul Free Clinic of HOPE worldwide • Penang Free Mobile Clinic • Mental Healthcare Education Program

  17. SCOPURS Malaysia

  18. Befrienders • OutreachBefrienders KL reaches out to the community, particularly to groups at high risk of suicide to provide on-site emotional support, talks, workshop sessions and seminars on • listening skills, • depression and stress, • suicide prevention • mental health awareness.

  19. What Is & What’s The Issues Nadzirah Mohamad Yusof Ahmad Zhafir Zulkifli

  20. Mental Health Programs Despite RM 344.82 million allocated to mental health initiatives in 2020, Malaysia's mental healthcare system faces critical challenges with only 1.27 psychiatrists per 100,000 population—far below the WHO recommendation of 10 per 100,000.

  21. The Multi-Layered System Tertiary Care Secondary Care 4 major psychiatric hospitals (Hospital Bahagia Ulu Kinta, Hospital Permai Johor, Hospital Mesra Bukit Padang, Hospital Sentosa Kuching) serving only 20% of severe cases due to limited 4,000 bed capacity nationwide 58 district hospitals and 25 MENTARI clinics with waiting periods of 2-3 months for initial psychiatric appointments and critical shortage of only 410 registered psychiatrists nationwide Community Support Primary Care Over 30 NGOs including MMHA, Befrienders, and HOPE worldwide operating with limited RM 15 million annual collective funding and reaching only 15% of B40 communities 1,060 Klinik Kesihatan facilities where 72% of GPs report inadequate mental health training and only 19% of clinics offer standard depression screening despite MOH guidelines

  22. The Multi-Layered System • While Malaysia's mental healthcare delivery structure spans multiple levels, these components operate in isolation with no centralized patient record system. • Nearly 65% of patients report confusion navigating referrals between levels, with 38% experiencing treatment discontinuity during transitions. • The lack of standardized communication protocols between tertiary facilities and primary care results in 44% of discharge plans failing to reach community providers. • This creates dangerous gaps in medication management and follow-up care.

  23. Affordability Barriers: Beyond Nominal Fees Direct Medical Costs Consultation fees, medication expenses, therapy sessions Transportation Costs Public transit fares, fuel, parking, potential accommodation Opportunity Costs Lost wages from missed work, childcare arrangements While public mental health services often charge minimal consultation fees, the true cost burden extends far beyond these nominal amounts. For Malaysia's B40 population, these indirect costs can represent a significant portion of monthly income, forcing difficult choices between mental healthcare and other essential needs.

  24. Availability Barrier: Workforce Shortage 1:200,000 Psychiatrist Ratio Psychiatrists per population (WHO recommends 1:10,000) 1:80,000 Psychologist Ratio Clinical psychologists per population 1:6,000 Counselor Ratio Registered counselors per population 70% Urban Concentration Percentage of specialists in major urban centers Malaysia faces a critical shortage of mental health professionals across all specialties. This shortage is compounded by maldistribution, with professionals heavily concentrated in urban areas, leaving rural regions severely underserved.

  25. Availability Barrier: Limited Service Range Medication-Focused Treatment Psychotherapy Gaps Overreliance on pharmacological interventions due to time constraints and resource limitations Limited availability of evidence-based therapies like CBT, DBT, and family therapy Community-Based Care Specialized Services Limited home visits, community rehabilitation, and supportive housing options Insufficient services for children, elderly, and specific conditions like eating disorders

  26. Availability Barrier: Gaps for Specific Needs Current mental health services frequently fail to address the unique needs of specific vulnerable populations. The urban poor face compounding stressors of financial instability, poor housing conditions, and limited social support, yet specialized interventions addressing these social determinants remain scarce. Similarly, caregivers of individuals with mental illness or disabilities experience significant psychological burden but find few support services designed specifically for their needs. Specialized programs for refugees, people with disabilities, and other marginalized groups remain underdeveloped.

  27. Overarching Challenge: Social Stigma Stereotypes & Misconceptions Widespread beliefs that mental illness indicates weakness or danger Discrimination & Judgment Fear of being labeled "crazy" or facing social rejection Avoidance of Help-Seeking Reluctance to acknowledge problems or approach mental health services

  28. Overarching Challenge: Self-Stigma Internalized Shame Individuals absorb negative societal attitudes, developing feelings of inadequacy and embarrassment about their mental health struggles. This internalized shame often becomes more debilitating than the mental health condition itself. Self-Imposed Isolation Anticipating rejection, many withdraw from social connections preemptively, further worsening their mental health through increased isolation. This withdrawal removes potential support systems that could aid recovery. Treatment Resistance Self-stigma leads to reluctance in acknowledging problems and skepticism toward treatment effectiveness. Many convince themselves they should be able to "snap out of it" without professional intervention.

  29. Overarching Challenge: Cultural & Religious Interpretations Traditional Belief Impact on Help-Seeking Attribution to spiritual causes (e.g., "jin" possession) Preference for traditional healers over medical professionals View of mental illness as punishment Increased shame and secrecy Belief in character weakness as cause Emphasis on willpower over treatment Family reputation concerns Concealment of mental health issues Religious interpretations of suffering Reliance solely on prayer/religious practices Cultural and religious interpretations of mental health symptoms significantly influence help-seeking behaviors. While traditional and religious approaches can provide important comfort and meaning, they sometimes delay access to evidence-based treatments when used exclusively.

  30. Systemic Gap: Insufficient Budget Allocation • Despite the growing burden of mental health conditions, budget allocations remain disproportionately low. Mental health services receive approximately 2% of the total healthcare budget, far below the WHO recommendation of at least 5%. This underfunding manifests in inadequate facilities, staff shortages, and limited service availability.

  31. Systemic Gap: Primary Care Integration Challenges Resource Constraints Training Limitations Primary care clinics often lack adequate time, screening tools, and referral pathways to effectively address mental health concerns alongside physical health. Policy Development Many primary care providers receive insufficient mental health training, leading to low confidence in diagnosing and managing mental health conditions. Malaysia has established policies for mental health integration into primary care, but implementation varies widely across different regions and facilities.

  32. Systemic Gap: Healthcare Worker Wellbeing Key Contributing Factors • Excessive workloads and insufficient staffing • Limited professional development opportunities • Inadequate supervision and emotional support • Administrative burdens reducing patient care time • Limited recognition of mental healthcare as specialized work • Stigma preventing healthcare workers from seeking help Healthcare providers themselves face significant mental health challenges, including burnout, compassion fatigue, and secondary traumatic stress. These issues directly impact the quality of patient care and contribute to high turnover rates in mental health professions.

  33. Interconnectedness of Barriers Initial Barrier A person experiencing mental health symptoms lives in a rural area with limited service availability (availability barrier) Compounding Effect They must travel long distances to reach appropriate services, incurring significant transportation costs (accessibility → affordability barrier) Cascading Impact Long travel time means taking a full day off work, resulting in lost wages (affordability worsens) Stigma Overlay Concerns about being seen at a mental health facility add psychological burden (stigma compounds all other barriers)

  34. Key Takeaways System Structure Malaysia has developed a multi-layered mental health system but suffers from fragmentation and coordination challenges between service levels The 3 A's Accessibility, affordability, and availability barriers create significant obstacles to effective mental healthcare, particularly for vulnerable populations Pervasive Stigma Social stigma, self-stigma, and cultural interpretations of mental health create powerful deterrents to help-seeking behavior Systemic Issues Insufficient funding, implementation gaps in primary care integration, and healthcare worker burnout undermine service delivery

  35. What Next ? Nurul Hidayati Saidi Basirah Anati

  36. High-Impact Recommendations

  37. 1) Strengthen Community-based Mental Health Service (CBMHS) trained laypersons or community health workers deliver basic mental health support Delivered close to where people live (e.g: clinics, schools, homes) Often embedded within primary health care and social support systems Address clinical, social, and cultural aspect of mental health Engage families, community members, and peers in care and recovery Model of care that provides mental health support and treatment within the community, rather than relying primarily on centralized/ institutionalized care

  38. Why does CBMHS matter? CBMHS are designed to decentralize mental health care  making it more accessible, affordable, and acceptable, especially for underserved populations like the urban poor CBMHS bring services closer to where people live  integrating mental health into primary care, community centers, and homes

  39. Study by Kirkbride et al. (2024):

  40. The article by Hoeft et al., 2018 reinforces that CBMHS thrives on structured task-sharing, community involvement, and adaptability • These are the principles essential for serving urban poor populations

  41. Beatrice Adedayo et al., 2023: • 40 studies from 12 countries • Most interventions reported reduced depression and anxiety and improved quality of life, resilience, and social functioning. • Interventions were delivered by: • Health/social care professionals • Trained lay workers • Peer volunteers or community facilitators Key findings: Community-based interventions can be effective and culturally adaptable for older adults in LMICs no one-size-fits-all model

  42. 2) Effective Mental Health Integration into Primary Care Why does this matter? ensures that mental health is: • Accessible to all • Treated early before escalation • Managed holistically with physical health • Less stigmatized due to normalized settings

  43. Malaysia's National Mental Health Strategic Plan (2020–2025) supports primary-level MH integration WHO’s mhGAP campaign promotes early care-seeking in primary care. Great Britain: Improving Access to Psychological Therapies (IAPT) trains non-specialists in CBT for mild/moderate depression eMentalHealth Norway links electronic records of MH and primary care. 🇲🇾 PHQ-9 used in Klinik Kesihatan for early detection of depression. Malaysia's National Mental Health Strategic Plan (2020–2025) supports primary-level MH integration

  44. MENTARI Program • initiated by the Ministry of Health Malaysia (MOH) to improve outreach and re-integration of people with mental health problems • at least one MENTARI in each state, and they are managed by the Department of Psychiatry and Mental Health in the nearest hospital • treatment team: led by a psychiatrist and team members include medical officers, occupational therapists, nurses, and medical social workers.  Volunteers provide assistance in non-clinical activities (Mentari Malaysia Official Portal, n.d.)

  45. Gaps in the MENTARI Program

  46. Potential innovation for improvement: Key findings from the article: • Describe integrated care models in primary care that improve mental health outcomes • Factors That Enable Successful Implementation Collaborative Care Model (USA & Netherlands) • IMPACT Model (USA): Co-located mental health staff and care managers in primary care proven to improve depression outcomes in elderly and minority populations. • ProMPT Trial (Germany): Use of healthcare assistants to monitor depressive patients via phone. Resulted in improved adherence and symptom reduction.

  47. 3) Health in All Policies (HiAP) Approach (Intersectoral Action / Health in All Policies, 2025) • a way of making decisions that always takes health into account by all other sectors • intersectoral collaboration ensures that health and equity are central to policy development across various sectors

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