Barriers and enablers to access and utilization of mental health care services across Southeast Asia: A preliminary scoping review

While the importance of mental health and its impact on overall health and well‐being has been widely recognized, there continue to be ongoing barriers to accessing mental health services. This is particularly poignant in countries in Southeast Asia (SEA) where there may be further stigma in accessing mental health services. As no reviews have been undertaken on this topic, this review aims to outline the barriers and enablers to access and utilization of mental health care services in SEA. Searches were undertaken in commercially produced and gray literature sources. Two independent reviewers screened the results. The data were then independently extracted, which was then collated and synthesized, using the Health Belief Model (HMB) as a framework. Twelve studies were included in the review. Under the HBM, barriers were grouped into: stigma, poor health literacy, internalized reasons, cultural beliefs, lack of training of health professionals, quality of service, and poor distribution of resources. Enablers included: social support, outreach services, structural stigma, self‐awareness, resources and information, accessibility and affordability, and positive attitudes and beliefs about health professionals. Those accessing mental health care in SEA are confronted by complex barriers and few enablers. Ongoing stigma and a distinct lack of resources pose the greatest challenges, which are even more amplified for those in rural areas and minority groups. A multifaceted strategy that improves the structures, processes, and outcomes of mental health is required within these communities.


| BACKGROUND
Mental health is considered "a state of mental well-being that supports a person in managing stressors within their life and facilitates their ability to participate in their community" (World Health Organization, 2022, p. 8).Globally, the prevalence of mental health conditions remains high, with one in eight people estimated to be living with a mental health condition (World Health Organization, 2022, p. 15).The impact of mental health conditions can be many, both for individual and the community.The World Health Organization (WHO) (2022), p. 15) reports mental health is the leading cause of years lived with disability globally.Apart from the costs to the individual, mental health conditions have an astronomical cost to the global economy, with the World Economic Forum calculating that mental health cost the global economy $2.5 trillion in 2010, with this figure likely to have risen (WHO, 2022, p. 50).Despite the increase in attention and awareness that has been developed globally, barriers still exist to accessing mental health care in almost every region of the world (Velasco et al., 2020).
In countries across Southeast Asia (SEA), national-level mental health legislation and policy development and implementation are still in its infancy, likely due to public perceptions and stigma of mental health, and decreased awareness of mental health conditions (Dessauvagie et al., 2021).The countries included within the SEA include Brunei, Burma (Myanmar), Cambodia, Timor-Leste, Indonesia, Laos, Malaysia, the Philippines, Singapore, Thailand, and Vietnam (Association of Southeast Asian Nations, 2020).One way to address the public's perceptions and stigma of mental health could be through enabling strategies such as supporting legislation, dedicated funding etc.However, within these communities, there is separate legislation for mental health that can safeguard the rights of people with mental health issues (Sharan et al., 2017).Furthermore, the lack of supportive legislation and policy also has an impact on the allocation of resources, with estimates of less than 2% of total health budgets spent on mental health (Maramis et al., 2011).A multitude of reasons have been reported for the limited allocation of the total health budget to mental health, including failure to recognize mental illnesses within the community, low priority of mental health needs, absence of targeted need-based policy assessment, inadequate resources (e.g., low number of psychiatric beds and psychiatrists per 10 000 population), lack of mental health training in the undergraduate curricula, patchy information systems, and failure to optimize available resources (Ito et al., 2012;Sharan et al., 2017).
Community mental health care services can provide accessibility, acceptability, affordability, and scalability of services, including promoting adherence to treatment and positive clinical outcomes (Kohrt et al., 2018).With an estimated 80%-90% of the mental health care budget in SEA countries directed to hospitals, many communities may miss out on the benefits of having locally accessible and affordable mental health care services, which could reduce the financial and social impact of mental health conditions in the region (Maramis et al., 2011).In response to these challenges, some countries in SEA rely on non-governmental organizations, and redesigned systems such as home care and day hospital services to provide screening, assessment, and treatment for individuals seeking mental health care (Ito et al., 2012).
For effective uptake of mental health care services, it is important to identify factors that act as enablers and barriers for people to seek treatment.As there is currently a knowledge gap in the literature, this preliminary scoping review aims to address this gap by providing a summary of the barriers and enablers to the access and utilization of mental health care services within SEA.

| METHODS
A review protocol was developed and published on Open Science Frameworks and can be found at the following link https://osf.io/ky5tb/.

| Search strategy
A scoping search of MEDLINE (1966-2022), PubMed (1996-2022), and the Cochrane Library  was conducted initially to gain an overview of the literature on this topic.This process highlighted commonly used key terms, such as: "South East Asia, barriers, enablers, and mental health services," which were derived from the title, abstract, and subject headings of the retrieved articles.This process assisted in the development of the final search strategy.
Commercially produced databases such as Medline (1966Medline ( -2022)), Embase (1947-2022), Emcare (1995-2022), the Cochrane Library (1993-2022), CINAHL (1937-2022), and PsycINFO (1927-2022) were searched.These databases were chosen as they were identified during the initial scoping search to be prominent databases that provide access to a wide range of peer-reviewed multidisciplinary biomedical literature, including those in the field of public health.
References within the selected articles were reviewed and expanded for further research, to identify relevant articles (pearling).
To avoid publication bias, Google and Google Scholar were also searched for gray literature with the first 10 pages reviewed for relevant studies.There were no limitations on the age, gender, and study type, but humans and the English language were used as limiters

| Study selection
Table 1 provides an overview of inclusion and exclusion criteria.

| Screening
Citations obtained from the search were uploaded to Endnote™.
Following duplicate removal, filtered results were uploaded to Covidence™ where screening and selection of articles were performed.Two independent reviewers (ER and JB) first performed title and abstract screening and then full-text screening.Disagreements by reviewers were moderated by another reviewer (SA).

| Data extraction
A customized data extraction form was developed for this review.All data extraction was completed independently by four authors (SA, RE, EC, and GB).Data from each article were extracted by two reviewers independently to ensure reliability.Reviewer disagreements were resolved through discussion and consensus.

| Data synthesis
A narrative synthesis of the literature was completed due to the nature of the review question, which would be inappropriate for a meta-analysis.Summary tables were used to identify commonly reported barriers and enablers.This review utilized the Health Belief Model (HBM) of health promotion to contextually frame barriers and enablers identified from the literature (Kirscht, 1974).HBM was chosen for two reasons.First, HBM encompasses barriers and enablers through its concepts of perceived barriers and perceived barriers to individuals engaging in health promotion behavior (Rosenstock, 1974).Second, previous literature has used HBM as a framework in assessing barriers and enablers to accessing mental health care (Carpenter, 2010;Jones et al., 2014).The review team was involved in the data synthesis process and supported by the facilitator (SK).

| Search results
Figure 1 outlines the literature selection process.A total of 884 studies (779 from primary sources, 105 from gray sources) were screened by title and abstract.Through the screening process, 60 studies progressed through to full-text review.Full-text analysis led to the inclusion of 12 studies for use in this review, with 48 studies excluded.
The three reasons for exclusion were: wrong outcome (32 studies), wrong study design (eight studies), and wrong population (six studies).

| Description of barriers addressed
Barriers were addressed in all 12 studies (Charlson et al., 2019;Gunasekaran et al., 2022;Hall et al., 2019;Nguyen et Parry et al., 2020;Putri et al., 2021;Subramaniam et al., 2021;Takizawa et al., 2021;Trang et al., 2021;Tristiana et al., 2018;Van et al., 2021;Zay Hta et al., 2021).These barriers could be broadly classified into person-centric (barriers related to the individual and their local context) and system-centric (barriers related to the system and the local jurisdiction) and relate to a mixture of general mental health care and those specific to different mental health conditions.
(2021) additionally explored the increased stigma associated with mental illness for those already belonging to a minority group such as the lesbian, gay, bisexual and transgender (LGBT) community and Vietnamese people with the Human Immunodeficiency Virus (HIV).

| Poor health literacy
Poor health literacy, especially a lack of understanding about mental health, was reported in six studies (Hall et al., 2019;Nguyen et al., 2019;Parry et al., 2020;Putri et al., 2021;Subramaniam et al., 2021;Trang et al., 2021;Zay Hta et al., 2021).Hall et al. (2019) and Zay Hta et al. ( 2021) reported that the lack of available information contributed to the poor knowledge held by the SEA population, while Subramaniam et al. (2021) identified that mental health education was a low priority in schools and workplaces.Three studies (Gunasekaran et al., 2022;Putri et al., 2021;Subramaniam et al., 2021) identified poor health literacy likely leading to further stigma, resulting in ongoing barriers to accessing mental health care.
T A B L E 2 Characteristics of the included studies.(Charlson et al., 2019;Gunasekaran et al., 2022;Hall et al., 2019;Nguyen et al., 2019;Subramaniam et al., 2021;Trang et al., 2021;Tristiana et al., 2018;Zay Hta et al., 2021)  whereby the self-stigma or internal resistance felt by people with mental illnesses limited their ability to access mental healthcare services.

| Cultural beliefs
Cultural beliefs relate to prevailing cultural and religious norms within each jurisdiction about mental health.Cultural beliefs were identified as a barrier to accessing mental health services by five studies (Charlson et al., 2019;Gunasekaran et al., 2022;Hall et al., 2019;Parry et al., 2020;Subramaniam et al., 2021).In three studies (Charlson et al., 2019;Gunasekaran et al., 2022;Parry et al., 2020) it was reported that people tend to visit spiritual healers (Gunasekaran et al., 2022;Parry et al., 2020) or Buddhist monks (Charlson et al., 2019) in preference to mental health professionals.Parry et al. (2020) emphasized the reluctance of people to voice their concerns about mental health when those in authoritative positions did not, leading to improvements in mental health systems, and fewer people accessing mental health care.

| Enablers
Enablers to mental health care access were only reported in five studies (Hall et al., 2019;Nguyen et al., 2019;Subramaniam et al., 2021;Takizawa et al., 2021;Zay Hta et al., 2021).The enablers were centered around personal factors and environmental factors, primarily accessibility and cost.

| Social support
Two studies identified social support as an important enabler.Nguyen An Indonesian study supported these findings with similar subthemes to stigma including personal/patient, public/social, family, employment, and professional/health professional stigma (Subu et al., 2021).A contributing factor to the stigma was poor health literacy.Subramaniam et al. (2021) reported that poor health literacy may result in certain beliefs that people with mental health conditions are violent, lazy, or that their illness may originate from supernatural causes.Addressing the stigma can be a powerful enabler.Nguyen et al. (2019) highlighted that social support was perceived as a facilitator of accessing mental health care for drug users with HIV in Vietnam.This suggests that a person's community and external influences may counteract their stigma and internalized beliefs and influence their ability to feel either empowered or deterred from accessing mental health care (Nguyen et al., 2019).The LGBT community might encounter even more difficulty accessing mental health services due to this "double stigma" effect (Zay Hta et al., 2021).An Australian study by Morgan et al. (2021) explored the current antistigma initiatives and reported that interventions such as education were effective at reducing stigma.Including people with lived experiences as part of the intervention further strengthened the benefits, as did personalized approaches (Reavley & Jorm, 2011).Haque (2010) also highlights the challenges associated with mental health diagnosis and treatment considerations within SEA.For example, common questions used in standardized tests and questionnaires, often developed with Western communities, may lack cultural relevance to the SEA community.Haque (2010) argues for culturally appropriate tests that consider local context and belief systems (such as the role of faith and religion in SEA communities).
Stigma does not occur on its own and is influenced by other barriers, such as poor health literacy and internalized reasons.The research by Gunasekaran et al. (2022) undertaken in Singapore, suggests that internalized stigma can present as self-denial of mental illness.These findings share similarities with Nguyen et al. (2019) who highlighted mental health service stakeholders' perspectives that some patients were confused about their mental health referral, indicating that they have a poor understanding of their condition.Saks (2009) considered that denial of a mental illness can be a coping mechanism where a person attempts to rationalize the uncomfortable truth or merely a symptom of a mental health condition.As selfstigmatization can reduce an individual's engagement in mental health care (Corrigan, 2007), exploring their denial can help them better understand their condition (Saks, 2009).An Australian study by Lyon and Mortimer-Jones (2020) found high power and confidence were associated with low self-stigma, which may mean interventions could focus on improving patients' perceived locus of control.

| Poor health literacy
Poor health literacy was an important barrier identified in this review.
A systematic review by Rajah et al. (2019, p. 10)  Individuals with chronic conditions and low health literacy, when compared to people with higher health literacy, tend to be less proactive in health behaviors, refraining from adequate health care, denial of health problems, resulting in poorer health outcomes and less confidence in making lifestyle decisions (Fabbri et al., 2020).Cardiovascular disease, chronic respiratory disease, cancer, and diabetes are closely linked to modifiable risk factors that are associated with poor health literacy (Aaby et al., 2017).This would suggest that poor health literacy is a barrier to not just mental health, but to a range of health issues.Ratnayake and Hyde (2019) suggest that people with higher mental health literacy tend to take part in help-seeking more often than those with low levels of mental health literacy.Heine et al.
(2021) suggest education driven health literacy programs might assist in promoting knowledge, attitudes, and behaviors of knowledge in a range of chronic conditions.Moreover, research suggests education about mental health issues should be a feature of health professional training programs.For example, Trivedi and Dhyani (2007) call for increased exposure to psychiatry within undergraduate medical programs to enable the future workforce to have the knowledge, skills, and competencies to cater to the growing mental health needs of the community.

| Poor distribution of mental health services
An important barrier identified from this review to accessing mental health services was the availability of such services (Parry et al., 2020;Putri et al., 2021).Previous research has highlighted that the lack of access to mental health services was particularly impactful for those who were marginalized and poor (Sharan et al., 2017).An example of limited resources is the availability of only one psychologist and one psychiatrist in Timor Leste (Hall et al., 2019) and 10-15 inpatient mental health beds in Cambodia (Parry et al., 2020).Where services are available, these are centralized in urban areas, resulting in those living in rural areas having limited access (Van et al., 2021).This is problematic as only 43% of people in SEA live in urban areas (Chongsuvivatwong et al., 2011).Similar findings were found in Africa as well (Aguwa et al., 2022).These findings, however, were not universal across all SEA countries.For example, Singapore has an urban dwelling rate of 100%, while Cambodia has a rate as low as 25% (United Nations Population Division, 2018).The high-income economy, combined with the larger urban dwelling population, of Singapore, provides greater access to mental health services compared to other developing countries in SEA.Recent years in the SEA region have seen rapid urbanization of its rural population, leading to a rise in urban density and expansion (Schneider et al., 2015).WHO (2011) suggests rural dwellers often come to urban areas in search of a better life due to the weakening of safety networks and social support.Given the rapid urbanization of many SEA countries, further research is required on the impact of mental health and issues confronting timely access to and availability of services for these migrant communities.Unsustainable urbanization with poor governance and planning, outdated mental health policies, and limited funding may place these communities at greater risk (Schneider et al., 2015;Sharan et al., 2017).

| Enablers
One of the interesting findings from this review was the overlap between some barriers and enablers.Social support was one such factor.Family support could be an enabler in accessing mental health care (Nguyen et al., 2019).This was particularly true for individuals with a family history of schizophrenia, as family support resulted in reduced time to treatment due to better mental health literacy and better identification of the onset of symptoms (Takizawa et al., 2021).

| STRENGTHS AND LIMITATIONS
There are several strengths to this scoping review.Using PRISMA reporting guidelines, this review was underpinned by transparent and rigorous methods in the conduct and reporting of a scoping review.
As the review included both commercially produced and gray literature sources, a range of communities and healthcare stakeholders across SEA were identified from the included studies.These include people with a mental illness, their families and carers, the general adult population, including some minority groups, as well as health care professionals and policymakers.While this does increase the generalizability of the findings, and the included studies reported data from eight of the 13 countries in SEA, there were no studies from Brunei, the Philippines and Myanmar.This highlights the existing knowledge gap about access to mental health services in these communities.Other limitations include language bias, as only studies published in the English language were included in this review.Given the diversity of languages in SEA, studies local to SEA published in native languages may have been excluded.Most populations included in this review were primarily from urban locations, which may mean that access to mental health care may be an even greater issue in regional areas.Additionally, none of these studies mentioned the implications of COVID-19, which has had a significant impact on mental healthcare access elsewhere in the world (Vadivel et al., 2021).

| CONCLUSION
Using HBM as an overarching framework, findings from this review indicate that those accessing mental health care in SEA are confronted by complex barriers and few enablers.Ongoing stigma and a distinct lack of resources pose the greatest challenges, which are even more amplified for those in rural areas and minority groups.These findings highlight the need for a multifaceted strategy that can influence social determinants of mental health through legislative support, dedicated human, financial, and healthcare resources, educational imperatives that promote improved communication and training, integrated and coordinated models of care, and a partnership approach between stakeholders (patients, carers, health care professionals, funders, etc).Such approaches that consider these factors are likely to promote access to and sustained engagement with mental health care within these communities.
et al. (2019)  addressed social support from family through verbal and financial support, as well as accompanying patients to appointments.Takizawa et al. (2021) outlined that a family history of mental illness may assist with health literacy by enabling family members to recognize symptoms more readily.3.5.6 | Outreach servicesHall et al. (2019) reported outreach services provided by health workers traveling to inaccessible areas to provide care to those living in decentralized rural areas.The study outlined that while these services helped reduce the impact of barriers such as income, accessibility, and transport, they were challenging to implement due to cost and weather.Zay Hta et al. (2021) also supported accessibility and affordability as key enablers.3.5.7 | Self-awarenessZay Hta et al. (2021) identified self-awareness as an enabler, especially in the context of individuals in the LGBT community with mental health issues.Self-awareness involves the awareness of needing a coping mechanism to manage their health, as well as acknowledging professional help as a valid form of support.4| DISCUSSIONThe purpose of this review was to explore the current body of literature on barriers and enablers for accessing mental health care in SEA.As the countries in this region share similarities in culture, ethnicity, and beliefs, the goal of this review was to identify common barriers and enablers to mental health care, resulting in actionable plans in the future.The findings from this review indicate that those accessing mental health care in SEA are confronted by complex barriers and few enablers.Using the HBM as the overarching framework, this review has mapped barriers like stigma, poor health literacy, internalized factors, and poor distribution of mental health services, while the only correlated enablers were social support, outreach services, and self-awareness.The findings from this review provide important implications for structures (system redesign, resource allocation, and educational imperatives), processes (clinical practice changes and modes of care), and outcomes (adequate data collection and measurement) for mental health care in SEA.4.1 |The multifaceted nature of stigma and its impact on accessing mental health care Stigma as a barrier can manifest across a diversity of a person's experiences and actions.BothGunasekaran et al. (2022) andSubramaniam et al. (2021) divided stigma into sub-themes, which were structured differently with similarities in their messages.Both studies highlighted that stigma could arise from within oneself-encompassing negative thoughts and stereotypes, from others-fear of discrimination from family, community, and professionals, and from a systemic causefunding, health professionals, improper care.
Choudhry et al. (2021) supported these findings by highlighting that mental health literacy and acknowledging the seriousness of mental health issues were important enabler to accessing mental health care.A Dutch study also identified that while talking to family acted as a facilitator, due to increased understanding and support, participants also preferred speaking to professionals due to a more objective viewpoint and family sometimes being the cause of mental illness(Leijdesdorff et al., 2021).Badu et al. (2018) used self-help groups to increase family acceptance of people with mental illness, resulting in greater familial support.Anderson et al. (2015) proposed that community engagement and planning interventions might have added value as well.A systematic review byMaddock et al. (2021) identified that the most promising evidence for psychological and social interventions for mental health issues and disorders in SEA came from the evaluation of lay (peers and non-professionals) delivered interventions.Findings fromMaddock et al. (2021) suggest that by promoting lay-delivered interventions, resource and financial barriers may be overcome.However, for this to be sustained,Rathod et al. (2017) call for a multifaceted approach which also strengthens legislation, dedicated resource allocation, integrated and coordinated models of care, improved communication and training, and a partnership approach that involves patients, carers, and the wider community.
Inclusion and exclusion criteria.
Internalized reasons, in this context, refer to one's motivation.This considers why the individual desires, commits, or sets goals to engage, or not engage, in behavior and may incorporate their perspective on societal norms.Seven studies Tristiana et al. (2018),)uyen et al., 2019) not seeking mental health care.Denying one's mental illness was reported in two studies(Charlson et al., 2019;Nguyen et al., 2019)while a lack of understanding of mental health was explored bySubramaniam et al. (2021).Hall et al. (2019)andGunasekaran et al. (2022)highlighted decreased self-efficacy and sense of personhood that people with mental illnesses encountered.Similar findings were also reported by Zay Hta et al. (2021),Gunasekaran et al. (2022)andTristiana et al. (2018),