Utilization of Mental Health Counseling Services Among Clinic-Attending Refugees and Asylum-Seekers in Malaysia

Background and Purpose: Malaysia is a transitional point for over 175,000 refugees and asylum-seekers registered with the UNHCR. Many refugees face elevated risk for mental health conditions due to conflict-related violence, displacement, exacerbation of pre-existing mental disorders, and issues related with integration into the host community. Despite high levels of psychological distress, utilization of mental health services among refugee and asylum-seekers is often lower than the general population.

Using the Andersen’s Health Service Utilization framework, we examine the relationship between predisposing factors (demographics, social structure, and health beliefs), enabling factors (personal, family and community resources), and need factors (perceived and clinically evaluated needs) on utilization of mental health counseling services among refugees and asylum-seekers in Malaysia.

Methods: Refugees and asylum seekers (n=286) were recruited into the study using time and venue-based random sampling from three health clinics in Klang Valley, Malaysia in 2018. Participants were eligible if they self-identified as a refugee or asylum-seeker and were 18 years and older. Interviewer-administered surveys assessed sociodemographic characteristics, the PC-PTSD screener for PTSD symptomology, and utilization of counseling services.

Multilevel mixed-effects logistic regression was used to assess associations between predisposing factors (gender, age, marital status, education level, years in Malaysia, refugee status, attitude towards mental health counseling), enabling factors (ease of access to healthcare, household income, need for interpreter, health literacy, number of people in household), and need factors (PTSD symptom severity) on utilization of mental health counseling services while accounting for clustering at the clinic level.

Results: Participants were 37 years old (SD=12.6) on average (range: 18-80), and were seeking asylum from Afghanistan (38.1%), Myanmar (38.1%), Somalia (14.3%), or other countries (9.44%). Two-thirds identified as female (66.8%) and 33.2% as male. On average, participants had resided in Malaysia for 4.2 (SD=3.7) years. Most participants had never attended mental health counseling services (71.9%), while 28.1% reported some history of mental health counseling. Approximately one-third (34.3%) met screening criteria for PTSD.

Only a few predisposing, enabling, and need factors were associated with utilization of mental health counseling services. Participants who believed talking to counselors does not help with coping (aOR: 0.03, 95% CI:0.08-0.10), had difficulty accessing their healthcare facility (aOR: 0.09, 95% CI:0.02-0.36), or had higher PTSD symptom score (aOR: 0.63, 95% CI:0.08-0.10) had a lower likelihood of utilizing counseling services. We did not find other predisposing factors (gender, age, marital status, education level, years in Malaysia, refugee status) or enabling factors (household income or size, health literacy) to be associated with counseling utilization.

Conclusions and Implications: Health clinics serving refugees and asylum-seekers may benefit from promoting mental health counseling services among its clientele–in conjunction with understanding the barriers faced when accessing these services–to address the gap in mental health counseling utilization. Access and treatment for mental health conditions is vital to prevent the progression of illness, as untreated mental health conditions can have chronic personal, social, and economic consequences. Future studies should examine how to increase access to care and how to deliver culturally congruent care to improve counseling services.