MENTAL HEALTH OF PRIMARY CARE ATTENDEES IN KOTA KINABALU, SABAH Dr Ahmad Faris Bin Abdullah https://orcid.org/0000-0001-8373-2802 Student no 316831 A thesis submitted in total fulfilment of the requirements of the degree of Doctor of Philosophy March 2018 Global and Cultural Mental Health Unit, Centre for Mental Health Melbourne School of Population and Global Health The University of Melbourne i ABSTRACT This PhD thesis aims to investigate the mental health problems, care and service among the government clinics in Sabah, Malaysia, focusing on one of the most densely populated districts of Kota Kinabalu. Background behind undertaking of this project was based on existing epidemiological facts and studies from Sabah and peninsular Malaysia is presented. The lack of adequate mental health services, mental health research, poverty, immigration and other specific issues that are discussed in the literature review. This is a cross-sectional, general health clinic-based study among primary care attendees in the Kota Kinabalu district of Sabah. Aim: The study was designed to determine the prevalence of common mental disorders among primary care attendees in Kota Kinabalu and to identify the associated factors. It also determined the treatment gap, disability and perceived need for psychiatric treatment and care and mental health service utilization among primary care attendees with probable common mental disorder. Method: Simple random sampling method was used to select patients at three government general outpatient clinics. A total of four hundred and eighty-one patients were invited to participate. Four hundred and thirty agreed and fifty-one patients (10.6%) refused. Respondents were further interviewed by trained interviewers using a standard proforma to obtain socio-demographic data and clinical profile, Patient Health Questionnaire (PHQ), Work and Social Adjustment Scale (WSAS), General Practitioner User Perceived Need Questionnaire and Mental Health Service Utilization Questionnaire. ii Results: The prevalence of common mental disorders among primary care attendees were 52.1%, with 224 out of 430 respondents having a probable common mental disorder. This was higher than the previous two studies done in West Malaysia, where the prevalence of mental disorder in the primary care setting was found to be 24.7% and 26.7% respectively. Ninety-five respondents (22.1%) had more than one psychiatric diagnosis. Using univariate analysis: young age, female, monthly income less than RM1000 (1AUD=RM2.97), unemployment, student, secondary/tertiary education and recent stressors were all significantly associated with common mental disorder (PHQ positive). Using a logistic regression method, five factors were significantly predictive of common mental disorders. These were young age (18-29 years of age), female gender, higher education, income less than RM1000 and history of being physically or sexually victimized. Two hundred and nineteen (97.8%) out of two hundred and twenty-four respondents with common mental disorder had some form of disability. One hundred and sixty- three (72.8%) were slightly disabled, thirty-seven respondents (16.5%) were moderately disabled and nineteen (8.5%) were severely disabled. There was a significant and consistent positive association between the moderate disability and co-morbid common mental disorder in nearly all items of disability. The severely disabled group was shown to have a positive association with co- morbidity in two of five items of disability. These were private leisure activities and family relationship. Two hundred and five, out of two hundred and twenty-four respondents with a common mental disorder were not receiving any treatment. This was a treatment gap of 91.5%. Twenty-four respondents sought help from a traditional healer, twelve went to other professional mental health services and only three were seen by psychiatrist. Only four patients had been admitted to a psychiatric ward. The most sought out mental health services in this population were counselling (49.1%) and mental health information (41.1%). The least common mental health service provided was for medication (20.5%). The most common reason given for not accessing mental health services or treatment was “I preferred to manage myself the problem”. iii Conclusions: The project has identified high prevalence of mental common mental disorders, a wide treatment gap and a high level of perceived unmet need in primary care clinics around Kota Kinabalu. Based on the results recommendations are made for mental health service improvements in the clinics, which serve a multi-cultural society. iv DECLARATION This is to certify that i) the thesis comprises only my original work towards the Doctor of Philosophy, except where indicated in the preface; ii) due acknowledgement has been made in the text to all other material used; iii) the thesis is fewer than 100,000 words in length, exclusive of tables, maps, bibliographies and appendices Signature Ahmad Faris bin Abdullah Matrics no: 31681 v ACKNOWLEDGEMENTS I would like to extend my gratitude to my supervisors, Professor Harry Minas and Professor Graham Meadows for their invaluable guidance, inspiration, assistance and coaching. Harry has shown so much care and promptly advised and responded to my questions. Both of my supervisors have given valuable support by providing scientific grounding and constructive feedback. I wish to thank all the Directors and Heads of Department at the Sabah State Health Department and Ministry of Health for approving the use of government facilities for the study. My gratitude also to my two deans who I served while working on this project, Prof Datuk Dr D Kamaruddin D Mudin and Prof Dr Zainal Ariffin bin Mustapha My special thanks to friends and colleagues who supported and understood my situation during the work: Urban, Dilip, Wendy, Sandi, Chrystalle, Encik Awang, Zul, Supian and Jen. This study also may not be completed if not for the support that I received from my beloved friend and local supervisor, the late Professor Dr Kumaraswamy Narasappa. vi DEDICATION I feel compelled to write this thesis as a moral duty to tell the story of how mental health issues are dealt in this part of the world. Although we are sophisticated and modern in our infrastructures and technology, we remain backward in humanity and mental health. I need to rise above my own difficulties, shortcomings and remind myself of the higher purpose of this beginning. I dedicate this thesis to my late grandfather Haji Zainuddin bin Mahmud who morally instilled within me a love for knowledge. To my beloved parents Mr Abdullah Abu Hassan and Rahimah Zainuddin who brought me up with virtues and inspired me to be the professional I have become. To my teachers who inspired me Prof Dr Ramli Hassan, Prof Dr Osman Ali and Datuk Dr Abdul Aziz. Finally, my loving wife and my children who had to put with my absence and long hours in finishing this project. vii CONTENTS ABSTRACT ....................................................................................................................................... II DECLARATION ................................................................................................................................ V ACKNOWLEDGEMENTS ........................................................................................................... VI DEDICATION ................................................................................................................................. VII CONTENTS .................................................................................................................................. VIII TABLE OF TABLES AND FIGURES ................................................................................... XIII CHAPTER 1. INTRODUCTION ................................................................................................... 1 SECTION 1.1. INTRODUCTION TO SABAH ........................................................................................... 3 Current Socioeconomic Status & Urban-Rural Poverty ................................................................ 4 History ................................................................................................................................................................ 5 Immigrants and indigenous groups ...................................................................................................... 5 SECTION 1.2. THE MENTAL HEALTH SYSTEM IN SABAH ...................................................................... 6 Organization of mental health services .............................................................................................. 7 Mental health outpatient facilities ........................................................................................................ 8 Day treatment facilities .............................................................................................................................. 9 Mental health in primary care ................................................................................................................ 9 Human resources ........................................................................................................................................ 10 Financing and utilization of mental health services .................................................................. 11 SECTION 1.3. PERSONAL REFLECTION ..................................................................................................