1. Introduction
Refugees are individuals forced to leave their country of origin or habitual residence and are unable to return home safely [
1]. These individuals have a fear of persecution because of their race, religion, nationality, and are unable to avail protection for themselves [
1]. According to the United Nations High Commissioner for Refugees (UNHCR) as of June 2020, estimated there are 26 million refugees globally, many of whom originate from Syria, Venezuela, Afghanistan, South Sudan, and Myanmar [
2]. In Malaysia, there are some 178,990 refugees in 2019, of which the majority are Rohingya refugees from Myanmar (
n = 101,010) [
2]. In the period from 2012 to 2015, many arrived by boat in Thailand after undertaking dangerous journeys across the Andaman Sea and then were smuggled or trafficked into Malaysia [
2]. The Rohingya refugees live throughout Peninsular Malaysia, and are considered illegal or prohibited immigrants [
1,
2]. While in Malaysia, the Rohingya refugees live in overcrowded houses, have minimal access to educational opportunities, employment, healthcare, and social protection or support [
3]. Some Rohingya refugees have lived for decades in Malaysia and established livelihoods or receive remittances from relatives resettled in other countries [
3]. However, they continue to live in precarious economic situations [
3].
While many Rohingya refugees experience physical ill health following injuries or hunger, far more suffer psychological harm [
1]. Therefore, there is a growing concern about the mental health consequences of these vulnerable populations. Previous studies have reported that major depressive disorder (MDD), generalized anxiety disorder (GAD), and post-traumatic stress disorder (PTSD) are the most prevalent mental health disorders (MHDs) affecting refugees worldwide [
4]. Globally, the estimated prevalence of MDD, GAD, and PTSD among refugees was reported at 44%, 40%, and 36% [
4,
5]. The evidence on the prevalence of MHDs among Rohingya refugees specifically is very limited and majority were focused on Rohingya refugees in Bangladesh, whereby the prevalence of MDD, PTSD, and GAD was reported at 89%, 36%, and 14% [
6]. Shaw et al. (2018) reported a much higher prevalence of 98.8% MDD, GAD, and PTSD among refugees in Malaysia. Several studies have identified several risk factors for MHDs among refugees globally such as poor educational levels, unemployment, unmarried, exposure to violence and physical injuries, poor social support, poor religious orientation, and food insecurity [
7,
8,
9]. Aside from a study conducted among Rohingya refugees in Bangladesh that reported being female and older age as significant risk factors for MDD and PTSD [
6], there is still a paucity of studies that have reported on the factors associated with MHDs among Rohingya refugees worldwide. Furthermore, the majority of studies on MHDs among refugees were conducted in high-income countries and non-conflict countries while limited research has been done in first transit areas such as Malaysia and Thailand [
4,
9].
In Malaysia to date, the majority of the studies examining the prevalence and associated factors of MHDs among Rohingya refugees were conducted among adolescents [
9,
10], utilized nondiagnostic based mental health screening instruments [
11,
12], or did not report on the association with perceived social support, religious orientation, food insecurity and MHDs [
11,
12]. There are also unpublished reports conducted by non-governmental organizations (NGOs) [
8]. Therefore, more studies examining the prevalence and associated factors of MHDs among Rohingya refugees in Malaysia are needed as they would highlight the burden of MHDs among this vulnerable population, which otherwise would never surface. Additionally, such studies as this one would provide some understanding regarding the sociodemographic profile and factors (risk and protective) for MHDs among the Rohingya refugees. Furthermore, as Malaysia is a transit country for refugees, most of these refugees are under constant conflict and they require periodic mental health assessment. Unfortunately, they face difficulties accessing basic universal healthcare [
1,
11]. Current programs that look into the health and welfare of these refugees are mainly conducted by UNHCR, Malaysia, and some NGOs [
12]. Therefore, generating more evidence-informed policies for this underprivileged population would require more local based studies.
With the rising number of Rohingya refugees in Malaysia (from 73,900 in 2018 to 101,010 in 2019) [
2], these individuals continue to live in harsh living conditions, and with the lack of healthcare support, it is for sure that many have undetected mental health difficulties. Therefore, this study aimed to determine the prevalence of MDD, GAD, and PTSD among adult Rohingya refugees in Malaysia. Besides, this study also examined factors (such as perceived social support, religious orientation, food insecurity, educational attainment, employment status, duration of displacement, homelessness, exposure to violence, and physical injuries) associated with MDD, GAD, and PTSD.
4. Discussion
The Rohingya of Myanmar are a severely persecuted minority and represent one of the largest groups of stateless people [
6]. Thousands of them reside in refugee camps in South Eastern Bangladesh [
6]. In Malaysia the community has been living invisibly for more than three decades, as they have not gained legal status. The cross-sectional study among adult Rohingya refugees’ ages 18 years and above revealed that the prevalence of MDD in this study was 32.3%. The finding was similar to the prevalence of MDD reported among adult refugees in the United States of America (USA; 32%) and Italy (31%) [
25,
26] but much lower compared to studies among refugees in Malaysia, Australia, and Israel, which reported the prevalence of MDD ranging from 79% to 98% [
5,
27,
28]. Among the studies that reported a similar prevalence of MDD as our study, there were several similarities namely the use of identical instruments to assess for MDD, and the majority of participants were displaced for more than three years [
25,
26]. In contrast, studies reporting a higher prevalence of MDD vary primarily due to differences in methodology, mainly with the instruments used to examine MDD and variation in the participant’s characteristics such as gender and nationalities. Besides, a higher prevalence of MDD was reported in studies that had recruited participants who were in detention [
27]. Hostile conditions in detention centers certainly increase the risk of MDD [
27]. To date, there is limited evidence on the prevalence of MDD among Rohingya refugees [
8]. Riley et al. (2017) reported that the prevalence of MDD among adult Rohingya refugees in Bangladesh was reported at 89%, which is much higher than this study. Aside from methodological variations, it could be possible that unlike Bangladesh, Malaysia is a middle-income country that has a more robust economy and healthcare system; therefore, this might justify a lower prevalence of MDD among Rohingya refugees in our study.
Our study reported the prevalence of GAD at 41.8%, a finding which is consistent with a systematic review that reported an average pool prevalence of GAD among refugees at 40% [
29]. The reasons for this similar finding could be mediated by the fact that the majority of these studies were conducted in middle-income countries. A much higher prevalence of GAD was reported among refugees in Cambodia, USA, and Mexico, which reported a prevalence of GAD at 88%, 77%, and 57% [
28,
30,
31]. These variations could be because, unlike studies conducted among refugees in the USA, Mexico, and Cambodia, the majority of refugees in this study had no exposure to violence. Therefore levels of psychological distress would be much lower [
32]. Additionally, a lack of specificity with regards to the type of GAD assessed could also result in different findings. For example, we reported on GAD, while the studies conducted in Cambodia and the USA reported on unspecified anxiety disorders [
28,
30]. The prevalence of GAD is higher in this study when compared to a study conducted among Rohingya refugees in Bangladesh, which reported a prevalence of GAD at 14% [
6]. Once again the methodological variation (instruments and sample size) might have most probably resulted in these differences.
The prevalence of PTSD in this study was 38.2%, which was similar to the prevalence of PTSD reported among refugees in a systematic review, which reported an average pool prevalence of PTSD at 36% [
29]. Furthermore, studies in Bangladesh, USA, Africa, and Algeria have all reported a similar prevalence of PTSD among the refugee population, ranging from 36% to 38% [
6,
33,
34]. In contrast, studies in the United Kingdom and Australia reports a much higher prevalence of PTSD, at 76% and 70% [
27,
35]. While studies involving refugees in Thailand, Ethiopia, and Uganda all reported a much lower prevalence of PTSD ranging from 11.8% to 20% [
34,
36,
37]. The similarity in findings across studies could be due to the similar type of refugee population assessed, as is the case of this study and that in Bangladesh, which both focused on Rohingya refugees. Then, the degree, duration, and the number of traumatic events may contribute to the variation in PTSD prevalence rates across studies [
37]. At a higher degree, more recent and frequent exposure to traumatic events would result in a higher prevalence of PTSD.
Aside from methodological variations, it is essential to note that variations in the prevalence of mental health disorders across countries could be mediated by several concepts, theories, and models. For example, based on the healthy migrant effect, refugees resettled in countries with better healthcare systems tend to have lower psychological problems [
38]. Better healthcare system results in the more efficient practice of health promotion and prevention activities that would improve the health of refugees. Additionally, based on the migration phase model, refugees residing in transit countries tend to display a higher prevalence of psychological problems compared to those refugees who have been resettled [
39], as evident in this study. Refugees residing in transit countries often lack fundamental human rights and privileges, therefore, predisposing them to repeated or prolonged chronic stress, which in turn increase the risk of developing mental health problems. Furthermore, Rohingya refugees are individuals that were forced to migrate from their country of origin and are subjected to prolonged displacement [
39]. This factor increases the risk of developing mental disorder compared to migrants.
Our study found among the Rohingya refugees that being female increased the odds of developing MDD among the Rohingya refugees. Similar results have been reported in studies involving Rohingya refugees in Bangladesh [
6], Syrian refugees in Iraq [
38], Afghan refugees in the Netherlands [
39], and Bosnian refugees in Sweden [
40]. MDD has always been more common among females for various reasons, such as those attributed to genetics, biological changes associated with puberty, cognitive predisposition, sociocultural factors, and feminine roles or stereotypes [
41,
42]. This study also found that refugees that have been physically injured had increased odds of developing MDD. This is an important finding as refugees are a group of individuals who are constantly at risk of being physically injured compared to the general population. This finding is consistent with previous studies done involving Syrian refugees in Iraq [
38], Afghan refugees in the Netherlands [
39], and Vietnamese refugees in Australia [
43]. Several mechanisms can mediate this finding. Physical trauma causes both physical and psychological impairment that may result in a reduction in health-related quality of life, which could increase the chances of MDD [
44]. In contrast to our findings, a study conducted among Rohingya refugees in Bangladesh reported no significant association between physical trauma and MDD [
6]. This discrepancy could be due to methodological variations, namely different instruments used to examine physical injuries, variation in analysis, number of variables controlled for, and sample size.
In this study, participants living in Malaysia for less than a year were more likely to be depressed. This finding implies that newly arrived Rohingya refugees in Malaysia tend to have an increased chance of developing MDD. This is an important finding as any refugee arriving in a new country faces many challenges and obstacles, which is augmented, particularly during their initial arrival period. Previous research points to the potential mental health vulnerability of newly arrived refugees such as in the Sudanese, Iran, Afghan, Indian, and Burmese refugees in Australia [
45,
46,
47,
48]. Newly arriving refugees must learn to navigate an entirely new community, language, and cultural system, while simultaneously coping with the loss of their homeland, family and employment challenges, and difficulties in accessing health and social services [
48,
49]. In our study, the majority of the new arrival refugees were unemployed and unmarried compared to peers with a more extended stay. Therefore, they faced financial uncertainties and poor social support. Lacking necessities, restricted movement, and continued concerns for safety are profound during the early stages [
6]. Moreover, as Malaysia is not a party to the 1951 Refugee Convention and neither a resettlement country [
1]. There is no legislative and administrative framework in place to protect the refugees [
1]. These refugees endure a constant feeling of uncertainty. However, the UNHCR, Malaysia do play an essential role in providing identity documents to these refugees, which would prevent their arrest and detention, including securing their release where necessary [
2]. These factors may result in adjustment issues that could increase the odds of MDD among newly arrived refugees. Dissimilar to our findings, previous studies reported poor mental health outcomes among Cambodian, Vietnamese, African, and Sudanese refugees with a longer duration of displacement [
50,
51,
52,
53]. This variation could be due to differences in the type (nationality) of the refugee population, whereby variation in cultural practices and beliefs across the various refugee populations exist. The differences in cultural practices and beliefs play a pertinent role in the refugees assimilating or adapting to a new setting, culture, and environment.
We also found that refugees with low to moderate perceived social support had increased the odds of MDD. This is an extremely significant finding as refugees, unlike the general population, are deprived of social support due to their underlying circumstances. Similar findings were noted among Sudanese refugees in Australia [
45] and Syrian refugees in Germany and Turkey [
54,
55]. Several reasons justify this finding. As for human beings, social support, be it from immediate or extended families, friends, and social groups, are important elements ensuring good mental health. Poor social support among refugees deprives them of emotional, informational, tangible, and intangible forms of support. The unavailability of any support creates a sense of isolation while in exile, which increases the chances of depression [
45]. Refugees with poor or moderate social support often lack guidance and reliable alliance, which is important for their well-being during their stressful periods [
54]. Based on the stress-mobilizing hypothesis, stress encourages individuals to seek social support, but in the case of refugees when the social support is unavailable, this would result in worsening of their stress, which further predisposes them to develop depression [
56].
In this study, MDD was also found to be significantly associated with food insecurity. This finding suggests that a lack of access and the inability to maintain food supply increases the odds of MDD. It is not surprising as refugees constantly face issues with food availability. Their food availability is closely related to their poor employment status, lack of social support, and their overall status as an underprivileged population. Similar findings have been reported by previous studies conducted among refugees in South Africa, Sri Lanka, and Canada [
57,
58,
59]. Several mechanisms can mediate this finding. For example, a nutritional deficiency that occurs as a result of food deprivation, consumption of cheaper food, which could be lacking in nutritional value, reduction in food intake to provide more food to other household members could all increase the chances of developing MDD [
60]. This is because nutritional deficiencies such as essential fatty acids, folate, and vitamin B12 affect normal brain functioning such as enzymatic activity, cellular and oxidative processes, receptor function, maintenance of neuronal tissue, and synthesis, which have been implicated in the pathogenesis of MDD [
60]. Furthermore, individuals who fail to secure food for themselves or their families would experience psychological distress and insecurity, which would predispose them to develop MDD [
61].
Regarding the factors associated with PTSD, we found that exposure to violence significantly increases the odds of PTSD among Rohingya refugees. Refugees are frequently exposed to violence as a result of torture, rape, murder, genocide, political violence, and war experience [
6]. This is an important finding, as exposure to violence in this already vulnerable population would further predispose them to develop PTSD. Similar results have been replicated in studies involving Syrian refugees in Iraq, Afghan refugees in the Netherlands, and Vietnamese and Bosnian refugees in Australia [
38,
39,
43,
62]. Fundamentally PTSD commonly occurs following exposure to a violent terrifying event, this is because violence disrupts several domains namely personal safety, interpersonal attachments, sense of justice, identity, and existential-meaning, which results in various psychosocial responses within these domains [
63]. Moreover, studies also suggest that exposure to violence causes disturbances in the left hemispheric function, hyperadrenergic activity in the central nervous system (CNS), stimulation of the serotonergic receptors signaling in the CNS, increase in the corticotrophin-releasing factor in the cerebrospinal fluid, and signaling of the dynorphin/κ opioid receptor in the brain, which all may increase the risk of PTSD [
64,
65]. Furthermore, in this study majority of the participants were separated from a family member during the process of migration. The experience of being alone may also result in a traumatic experience that could increase the odds of PTSD.
Our study demonstrated that refugees with food insecurity had increased odds of having PTSD. This is an important finding as in this study the majority of refugees suffer from food insecurity, a finding that might be common to many refugees worldwide. Similar findings have been reported by studies conducted among refugees in Uganda [
37]. Several mechanisms mediate these findings. Food insecurity results in high-stress levels that are generated through the following ways; first insufficient quantity, quality, or diversity of available foods, second feelings of deprivation, or restricted choice about the amount or type of available foods and third having to engage in procurement strategies such as begging, dependence on charity, stealing, or exchanging sex to obtain food [
65]. Furthermore, food insecurity also causes hunger and energy depletion, which affects emotion, cognition, behaviors, and is linked to the recollection of violence and trauma that results in increased chances of PTSD [
65]. Repeated prolonged exposure to food insecurity has been conceptualized as a traumatic experience that could elevate the risk of developing symptoms of PTSD in response [
65,
66,
67].
Our findings have to be interpreted in light of several limitations. First, the use of a self-reported questionnaire could lead to information bias as a result of social desirability bias. We tried to minimize this by ensuring the participants that there were no personal identifiers on the questionnaire as well as that confidentiality was maintained. Second, participants in this study were residing in Selangor, and therefore generalizing the findings to refugees residing in other states in Malaysia must be done with caution. However, as Selangor is the state with the highest number of Rohingya refugees in Malaysia, it makes perfect sense to initiate such a study as a starting point. Third, as this study used a cross-sectional design, we were unable to establish temporal relationships. Finally, the presence of multicollinearity among the independent variables resulted in the removal of some variables from the multivariate analysis, therefore the effects of the removed variables on the outcome could not be observed in this study. Future development of a composite variable to represent the variables with evidence of multicollinearity such as the variable being physically injured and exposed to violence should be attempted to overcome issues of multicollinearity.
To the best of our knowledge, this study is the first study that examines factors namely perceived social support, food security, religious orientation, and its association with MDD, GAD, and PTSD among adult Rohingya refugees in Malaysia. The novelty of this pioneering study adds valuable information on the burden of mental health disorder and estimating the degree of perceived social support, religious orientation, and food insecurity among the Rohingya refugees in Malaysia. Other strengths include the use of MINI, which is based on DSM V criteria, performed through face to face interviews undertaken by trained clinicians, and would, therefore, more likely provide the realistic prevalence of MDD, GAD, and PTSD as compared to using self-administered screening tools that may produce speculative results [
37].