Mental illness affects 450 million people worldwide, leading to mental health-related disability, morbidity and mortality (Tay et al, 2018). In Malaysia, mental health disorders continue to rise, affecting 16.8% of the population according to the latest data (Midin et al, 2018). Furthermore, explorations of mental disorders among Malaysian adults by Midin et al (2018) and Tay et al (2018) revealed that the 2015 National Health and Morbidity Survey (NHMS) demonstrated a threefold increase in incidence over the period 1996 to 2015. The gravity of the challenge of mental health in Malaysia is illustrated by the stark observation that 3 out of 10 Malaysian adults have experienced some form of mental illness. Subsequently, the 2019 NHMS revealed that the prevalence of depression was 2.3%, accounting for half a million Malaysian adults (Institute for Public Health, 2019).
Petkari et al (2018) asserted that individuals living with mental illness encounter a double challenge: first, the effects of the illness on their life and, second, stigmatising attitudes held by society. Additionally, people with mental illness experience a ‘second illness’ due to the social label that is attached to mental illness, which requires additional coping mechanisms (Mestdagh and Hansen, 2014; Morgan et al, 2018). Midin et al (2018) suggested that mental health services in Malaysia are governed by national mental health policies and legislation where advocacy is emphasised. Mental health advocacy is a fundamental component in mental health policies and is a strategy that aims to reduce stigma and discrimination against people with mental health disorders (World Health Organization (WHO), 2019).
Although mental health advocacy is evident in Malaysian mental health policies and legislation, mental illness stigmatisation is still prevalent. Addressing stigmatisation is integral in achieving an equitable quality of life for these individuals. Ibrahim et al (2019) and Rao et al (2009) suggested that stigma is a socially constructed characteristic, where people living with mental illness are considered undesirable by society, leading to their exclusion, discrimination and devaluation. Mental illness stigmatisation contributes to low self-esteem, non-adherence to treatment, increased severity of mental illness symptoms, isolation, and suicide (Ellison et al, 2013; Maunder and White, 2019). Additionally, Clement et al (2013) and Ellison et al (2013) identified that the prevalence of stigmatisation leads to discrimination of those living with mental illness, especially in relation to opportunities associated with housing, employment and resource allocation for mental health services. Rao et al (2009) stated that WHO and the World Psychiatric Association established the interrelation of anguish, disability and poverty with mental illness. The existence of mental illness stigmatisation can result in the absence of help-seeking behaviours, acting as a barrier for effective treatment and rehabilitation (Rao et al, 2009; Sun et al, 2019).
Sun et al (2019) suggested that the risk factors associated with stigmatisation are influenced by the lack of mental health literacy and prior contact with people living with mental illness. Stigma is articulated through social distancing, devaluation or avoidance of people with mental illness (Ellison et al, 2013; Petkari et al, 2018). Rao et al (2009) identified that, despite health professionals being aware of the issues related to stigmatisation, stigmatising attitudes among health professionals persist, raising concerns, as mental health services are the main avenue for people living with mental illness to achieve satisfactory societal integration. Choudhry et al (2016) identified that cultural context is a key factor in determining knowledge, awareness and perceptions, because the interpretation of the illness varies between cultures; for example, many south-east Asians perceive that mental illness is caused by supernatural elements, and that the illness is a consequence of deities' wrath or the denial of deities.
Morgan et al (2018) and Sun et al (2019) suggested ways of mitigating the negative impact of stigmatisation. It is critical to identify those factors contributing to mental illness stigmatisation in order to develop anti-stigma interventions and policies. Furthermore, this reflects the findings of Maunder and White (2019) who reported that the WHO Comprehensive Mental Health Action Plan 2013-2020 (WHO, 2021), first adopted in 2013, specified the importance of reducing stigmatisation because it imposes a significant impact on the wellbeing of people living with mental illness in comparison to the symptoms of the illness itself. Consequently, anti-stigma strategies that are underpinned by stigma research are required (Maunder and White, 2019).
Strategies for stigma prevention and reduction are more often targeted towards health professionals and employers because of their frequent contact and influence with those living with a mental illness (Morgan et al, 2018). However, WHO (2003) previously stated that supporting people living with mental illness involves targeting the general public through mental health promotion and mental health literacy, which are crucial for success. Specifically, Wei et al (2015) concluded that mental health literacy is a useful strategy for recognising mental illness, reducing stigmatisation, and improving help-seeking behaviours. They also proposed that evidence suggests that mental health literacy is a determining factor for improving mental illness stigmatisation at individual, public and institutional levels. Undoubtedly, it is crucial to consider cultural beliefs as part of mental health literacy and understanding those beliefs can provide the foundation for raising awareness of the impact of stigmatisation because cultural beliefs can influence the help-seeking behaviours of those living with mental illness, affecting their recovery (Choudhry et al, 2016).
Aim
It is apparent that mental illness stigmatisation is prevalent in Malaysia. The aim of this review was to explore the stigmatisation of mental illness among the adult population in Malaysia by identifying stigma-influencing factors, the impact of stigmatisation and strategies that can be applied to reduce the stigmatisation of adults with mental illness.
Method
This literature search was initially conducted during the period between February and June 2020 and updated in November 2022, using a systematic strategy following the recommendations of Booth et al (2016) and Aveyard et al (2016).
Search strategy
To adopt a systematic search strategy, the inclusion and exclusion criteria should reflect the overall aim of the review in order to select the relevant material. In view of this, studies that explored social or public stigmatisation of mental illness were included, whereas studies that explored other aspects were excluded. A systematic search of the literature was performed using the electronic databases PsycINFO, CINAHL, PubMed, Scopus, Science Direct, Cochrane, Medline and Web of Science to provide a comprehensive range of literature.
The search strategy used the following key words: mental health, mental illness, mental disorders, stigma, discrimination, prejudice, adult, Malaysia. These search terms were combined to develop a search string: (mental health OR mental illness OR mental disorders) AND (stigma* OR discrim* OR prejudi*) AND adult AND Malaysia*.
The inclusion criteria were adults, primary research articles, empirical studies and peer-reviewed journal articles. The exclusion criteria were children, adolescents, other languages, and review articles. The search was limited to papers written in English and published between 2010 and 2022. To ensure that the relevant information was thoroughly searched and identified, additional searches examining reference lists and author searches were also performed.
Study selection
The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed by using the four-stage flow diagram (Moher et al, 2015). Each article was selected by following each PRISMA stage: identification, screening, eligibility and inclusion. All primary studies detailing stigma and mental illness were included in the review. All selected articles were included in the review regardless of their quality rating; however, their impact was measured accordingly. The articles retrieved were screened by their titles and abstracts to assess if they met the inclusion criteria. Those articles that met the inclusion criteria were accepted for the review. Subsequently, the articles underwent a full-text assessment to assess their eligibility for inclusion.
After initially identifying 146 papers, a total of 13 papers were included in the final review. The included articles were a combination of quantitative and qualitative studies that aimed to explore perceptions of people and examine effectiveness of interventions associated with mental illness stigmatisation in a defined population. Specifically, these studies investigated factors that influence stigmatisation in Malaysia, the impact of stigmatisation and the efficiency of anti-stigma interventions. The studies were conducted in Malaysia, Britain, Hong Kong, and China.
Critical appraisal
The included articles for this review were individually appraised on their methodological quality by using the Critical Appraisal Skills Programme (CASP) checklist (CASP, 2023).
Data analysis
A meta-summary matrix was completed to produce a thematic analysis of the data, drawing upon the approach suggested by Aveyard et al (2016), where ‘a priori themes’ are predominantly based on the emerging objectives of the research generated by the search strategy. This adapted form of thematic analysis (Aveyard et al, 2016) demonstrated the presence of five key themes, discussed below.
Results
A total of 13 papers were included, comprising a mixture of 10 quantitative studies (Swami et al, 2010; Minas et al, 2011; Khan et al, 2011; Loo et al, 2012; Loo and Furnham, 2012; 2013; Razali and Ismail, 2014; Fernandez et al, 2016; Ng et al, 2017; Li et al, 2019) and three qualitative studies (Hanafiah and Van Bortel, 2015; Low et al, 2019; Berry et al, 2020). Considering the distinct dearth of literature on this subject, the recommendations of Booth et al (2016) and Aveyard et al (2016) were followed and included for this review. The main themes identified were stigma influencing factors, socio-demographic factors, stigmatising attitudes, impact of stigmatisation and strategies to reduce stigma.
Stigma influencing factors
Mental illness stigmatisation in Malaysia was influenced by cultural beliefs, limited knowledge regarding mental illness and the lack of education and awareness. Both cultural beliefs and limited knowledge could be associated with the lack of education and awareness (Khan et al, 2011; Loo et al, 2012; Hanafiah and Van Bortel, 2015; Berry et al, 2020).
Cultural beliefs
Cultural beliefs appeared to be a considerable factor for mental illness stigmatisation as mental illness was conceptualised as spiritual in nature and based on superstition. Berry et al (2020) and Khan et al (2011) explored the beliefs regarding mental illness in Malaysia among the general public where their study participants believed that the causes of mental illness were based on spiritual and superstitious elements. Both studies used semi-structured interviews and validated questionnaires respectively, which added to their internal validity.
Limited knowledge
Limited knowledge regarding mental illness appeared to be a contributing factor towards mental illness stigmatisation in Malaysia. Berry et al (2020) and Loo et al (2012) explored the knowledge of mental illness in Malaysia where Loo et al's (2012) cross-cultural study allowed for comparison of mental illness knowledge from a cultural perspective. Participants from Malaysia acquired the lowest scores in the study compared with participants from Britain and Hong Kong. Both studies identified similar findings using different methodological approaches.
Lack of education and awareness
Lack of mental health education and awareness were considered as primary factors for mental illness stigmatisation in Malaysia. Hanafiah and Van Bortel (2015) explored the perspectives of mental health professionals on mental illness stigmatisation in Malaysia where their study participants recognised the lack of mental health education and awareness as primary causes for stigmatisation. Additionally, the authors approached mental illness stigma from a wider perspective to gain further understanding. However, their findings were limited to urban settings in Malaysia.
Socio-demographic factors
Socio-demographic factors, such as rural and urban living including educational status, were highlighted as considerable factors contributing to mental health stigma. Working in a mental health setting had no positive influence on stigmatising attitudes manifested by healthcare providers. Rural and urban communities demonstrated differences in knowledge and beliefs regarding mental illness that influenced stigmatisation. Swami et al (2010), Minas et al (2011), Loo and Furnham (2012; 2013), Razali and Ismail (2014) and Hanafiah and Van Bortel (2015) investigated the effects of socio-demographic factors, identifying the prevalence of stigmatising attitudes among their participants in Malaysia. Urban participants recognised and categorised mental disorders better in comparison to rural participants. Rural participants believed spiritual and supernatural elements were the causes of mental illness whereas urban participants believed that genetics and lifestyle factors were the causes of mental illness, although some urban groups believed that the causes of mental illness were supernatural. Both rural and urban participants recognised stress and pressure as causes of mental illness.
A quantitative study by Swami et al (2010) provided additional insight pertaining to the treatment of mental illness where rural and urban participants recognised religiosity as a treatment for mental illness, although the participants advocated counselling and lifestyle as better treatments. Additionally, urban living was considered a risk factor for mental illness stigmatisation because urban settings have better healthcare access and resources whereby individuals are required to manage themselves without depending on societal support.
Stigmatising attitudes
Stigmatising attitudes were prevalent among the general public, family members and healthcare providers towards people with mental illness. However, positive attitudes such as willingness to support and expressing compassionate views were also evident among the general public (Berry et al, 2020). Minas et al (2011), Razali and Ismail (2014) and Berry et al (2020) investigated stigmatising attitudes among their participants. Low scores in ‘care’ and ‘support’ elements and high scores in ‘avoidance’, ‘social distancing’ and ‘negative stereotype’ elements were identified in Minas et al's (2011) and Razali and Ismail's (2014) studies; these scores reflected negative attitudes. In contrast, Berry et al's (2020) study explored attitudes among its participants towards individuals living with mental illness where positive attitudes were portrayed.
Impact of stigmatisation
Stigmatisation negatively impacted the psychological, social and emotional wellbeing of people with mental illness. Consequently, the lack of help-seeking behaviours occurred in these individuals, which led to delayed disclosure of their mental health status, thus affecting their recovery. Additionally, the function and productivity of these individuals in wider society were affected. Hanafiah and Van Bortel (2015), Berry et al (2020) and Low et al (2019) explored the perceptions and views among their study participants, who were living with mental illness. These individuals were negatively affected psychologically, which led to reluctance to disclose their mental health status and to take part in help-seeking behaviours due to stigmatisation, which compromised their recovery. They also experienced alienation, disrespect and loneliness and unemployment due to being perceived as a liability to employers. Participants in the study by Low et al (2019) sought societal support and respect to enhance their self-esteem.
Strategies to reduce stigma
Education, contact with someone with a mental illness and training in psychiatry were strategies that reduced stigmatising attitudes. Additionally, mental health advocacy, policies and legislation, including education and awareness, were fundamental strategies advocated to reduce mental health stigma. Fernandez et al (2016), Ng et al (2017) and Li et al (2019) examined the effectiveness of strategies to reduce stigmatisation of mental illness among their study participants (medical students, nurses and care assistants). These studies found that education and contact significantly improved stigmatising attitudes, especially the combination of both education and contact where contact was either face-to-face or video based. Ng et al's (2017) study illustrated that training in psychiatry among nurses correlated with a reduction of stigmatising attitudes. The study by Hanafiah and Van Bortel (2015) asserted that education and awareness were recognised as significant for societal understanding and acceptance of mental illness.
Discussion
Based upon the evidence collated in this review, the stigmatisation of mental illness observed in Malaysia could possibly be explained by the influence of cultural beliefs where its population believes that the causes of mental illness are spiritual and superstitious. These beliefs, however, are not consistent across the population: people from rural settings in Malaysia recognised spiritual beliefs and superstition as causes for mental illness, whereas people from urban settings recognised biological and lifestyle factors as causes for the illness. However, some rural and urban communities had similar beliefs where they believed spiritual and superstitious elements were linked to the causation of mental illness. These findings were supported by Choudhry et al's meta-synthesis of populations including general adult populations, and populations of students, refugees, service providers and others. Their study also presented varied cultural beliefs such as scientific and supernatural causes for mental illness. Different cultural beliefs between rural and urban settings in Malaysia can be attributed to Vygotsky's (1978) socio-cultural theory, in which people are inclined to agree with the culture of the communities they belong to, which shape their beliefs (Choudhry et al, 2016).
Mental illness stigmatisation among the Malaysian population could be explained by the influence of limited knowledge regarding mental illness. In addition, this knowledge differed from a demographic perspective where people from urban settings had a better understanding of mental illness compared with people from the rural setting. Yeap and Low (2009) found similar results. In addition, educational attainment was found to strongly influence mental health beliefs. Yeap and Low (2009) also identified that lower educational status was related to limited knowledge pertaining to mental health. In view of this, it could be considered that those with lower educational status tend to have limited knowledge of mental illness, which can then influence stigmatising attitudes.
The lack of mental health education and awareness were also identified as influencing factors for stigmatisation. Whereas there was limited evidence on the lack of mental health education and awareness associated with mental health stigmatisation in this review, these areas were not the specific focus of those studies included. A study by Furnham and Swami (2018) identified that education improves mental health literacy because it addresses the knowledge and beliefs regarding mental illness; therefore reducing mental illness stigmatisation. The authors further asserted that it is also important to consider urban and rural variances, culture and educational status as these factors influence mental health literacy while also informing educational interventions.
Attitudes of health professionals
Stigmatising attitudes were not only observed among the general public but also among healthcare providers. It was anticipated that healthcare providers would display positive attitudes. However, Rao et al (2009) identified that stigmatising attitudes were prevalent among healthcare providers. Care delivery to patients with mental illness was found to be reduced as a result of stigmatising attitudes manifested by health professionals. Displaying stigmatising attitudes can infringe ethical principles, affecting the delivery of care and leading to poor recovery outcomes for patients (Aveyard, 2019). It is therefore imperative to improve stigmatising attitudes among healthcare staff to avoid these attitudes interfering in the provision of care required for patient recovery.
The impact of stigmatisation is a significant issue in the maintenance of wellbeing, recovery, and productivity of people with mental illness, because it reduces help-seeking behaviours and delays disclosure. Similar findings were reported by Lasalvia et al (2013) in a study involving 35 countries, including Malaysia, where 79% of participants reported stigmatisation in various aspects of life, especially wellbeing and productivity. Minas et al (2011) and Razali and Ismail (2014) found that the impact from stigmatisation was accentuated by the manifestation of stigmatising attitudes such as avoidance and negative stereotypes from the general public, family members and healthcare providers towards these individuals. Reducing the impact of stigmatisation by improving stigmatising attitudes is integral to the wellbeing and recovery of people living with mental illness.
Anti-stigma interventions were shown to be effective strategies in reducing stigmatising attitudes. These interventions involved either education or contact with individuals experiencing mental illness, although some of the interventions had a combination of both approaches. Rössler (2016) recommended these approaches, particularly contact, for stigma reduction as being the most effective. A further study by Maunder and White (2019) found that interventions involving contact-based education were effective because participants were educated on the nature and impact of mental illness, including its stigmatisation. This could explain the significant reduction in stigmatising attitudes observed among study participants following contact-based education, demonstrating the effectiveness of a contact and education combination. A contact-based approach can use either video or face-to-face contact, although Maunder and White (2019) suggested that video-based contact is less effective because of the decreased personal contact. However, this review found no significant differences in terms of the effectiveness between both types of contact.
The study conducted by Petkari et al (2018) found that patient contact appeared to be a key component in establishing positive attitudes towards mental illness and that anti-stigma interventions that excluded contact were only effective in the short term. It was not clear whether contact-based interventions in the studies in this review were effective in the long term. Nevertheless, contact with mental health patients could be considered an effective long-term strategy in future anti-stigma interventions.
Mental health policies
Policies and wider advocacy were recognised as central to reducing mental health stigmatisation in Malaysia. Although mental health policies and advocacy in Malaysia exist, they are not fully effective, as reflected by the high prevalence of stigmatisation in the country.
Arguably, these policies lack demographic focus or have not fully addressed the key factors that influence stigmatisation, which have been shown in this review. Additionally, these policies advocated interventions that were not the most effective. For policies and the notion of advocacy to be fully effective, they must tackle mental illness stigmatisation by ensuring that cultural beliefs and limited knowledge regarding mental illness are completely addressed, ideally through face-to face contact-based education. Limited knowledge and cultural beliefs regarding mental illness seem to be key issues in Malaysia and can be correlated with the lack of mental health education and awareness. Furthermore, it is possible that the lack of mental health education and awareness in Malaysia have some influence on mental health literacy in the country. These issues contribute to stigmatising attitudes and therefore will need to be addressed urgently in order to reduce the impact of stigmatisation, which could be achieved through contact-based interventions and robust mental health policies.
Strengths and limitations
The strengths of this review included the transparency of its methodological processes and the use of research approved by ethics committees. The review also adds to the mental health research in relation to stigmatisation across Malaysia and reveals the need for healthcare providers to be more supportive and portray positive attitudes towards people living with mental illness. The limitations of this review were only including articles in the English language and excluding grey and unpublished literature.
Conclusion
Mental illness stigmatisation in Malaysia is influenced by cultural beliefs, limited knowledge regarding mental illness and a lack of mental health education and awareness, which must be addressed by considering socio-demographic factors. Reduction in stigmatising attitudes can be achieved by implementing effective anti-stigma strategies such as contact-based education and robust mental health policies and advocacy. Consequently, this would help to reduce the negative impact of stigmatisation on the lives of those experiencing mental illness. It is vital to target healthcare providers in order to promote optimal care and support, which are necessary for the recovery of patients. Additionally, reducing negative attitudes within the general public would encourage societal support for individuals with mental illness, positively affecting their wellbeing and recovery.
Recommendations to reduce stigmatisation in Malaysia include establishing mental health literacy, strengthening current mental health policies and advocacy, promoting mental health awareness, and encouraging patient contact. Future research is warranted to investigate the impact of stigmatisation on physical wellbeing and interventions that reduce stigmatising attitudes among the general public.
The findings of this review demonstrate that implementation of effective anti-stigma interventions such as contact-based education is an important anti-stigma strategy. This strategy is effective as it addresses the knowledge and beliefs related to mental illness while encouraging patient contact. Additionally, the findings from this review could also inform policymakers in strengthening mental health policies and advocacy by addressing cultural beliefs, inadequate mental health knowledge and those socio-demographic factors that influence stigma. Advocating for effective anti-stigma interventions could lead to a more targeted approach to tackling mental health stigmatisation in Malaysia.
KEY POINTS
- Cultural beliefs, limited knowledge of mental illness and mental health, and lack of mental health education negatively influence stigmatisation of people with mental illness
- Stigmatisation significantly affects the wellbeing and function of people living with mental illness
- Interventions such as contact-based education effectively reduce stigmatising attitudes manifested by healthcare providers
- Establishing mental health literacy, encouraging patient contact, promoting mental health awareness and strengthening mental health policies could reduce mental illness stigmatisation and its impact in Malaysia
CPD reflective questions
- How often do you undertake assessment of stigmatisation experienced by people living with mental health conditions in your clinical practice and what do you feel would help to develop your confidence in doing this?
- Can you identify barriers and enablers that impact on the stigmatisation of patients living with a mental illness?
- What important aspects of the stigmatisation of mental health can you learn from this review?