A Review of the Relationships among the Key Determinants Affecting the Mental Health Disorders of the People in Greater Mekong Subregion Countries.

BACKGROUND: ASEAN integration aims to transform the GMS into a single market with free flows of products, services, and skilled labor, as well as investment openness, which will ultimately force regional economic growth. Therefore, this integration is likely to bring about a big change to this area in the new era; it can subsequently cause many problems as well, including mental health issues of the people in this region. The characteristic differences among the GMS member countries in terms of trade and investment, so-cial and cultural values, medical information and technology, and the living and working environment have become major problems affecting mental health disorders, which are usually identified as depression, stress, and substance abuse.
METHODS: This review paper is a literature review of the relationship of the determinants affecting GMS mental disorders conducted using the following strategies: 1) collecting data from previous qualitative and quantitative research studies, com-paratively analyzing the literature, articles, published papers, and reports relevant to the existing policies on economic, environmental, and healthcare issues obtained from the GMS; and 2) exchanging information from the institutions involved, including reports and papers regarding the determinants affecting mental health disorders of the people in the GMS, which were used to generate the synthesis of the existing knowledge of the mental health and to provide recommenda-tion programs for the GMS people.
RESULTS: Based on the reviewed literature there are four key factors affecting mental health, especially mental health in GMS populations: 1) the living and work environments; 2) trade and investment; 3) technology and medical information; and 4) social and cultural values. The study found that the increasing number of mental health dis-orders is a big burden for national healthcare spending. Financial issues have become a major key to the wide prevalence of mental disorders in the GMS. Health issues related to mental health disorders are also caused by the environment and other related factors and therefore a stable and a well-balanced environment is an indicator of healthy mental status. In addition, the environment is a way to pursue both physical and mental health because green spaces serve as a mood freshener and can al-leviate anxiety, stress, and depression.
CONCLUSION: Globalization and urbanization should follow sustainable development instructions and concerns about the population's health, especially regarding mental health. These key determinants affect the people's life, especially in terms of mental health thus leading to mental health disorders.

INTRODUCTION

The Greater Mekong Subregion (GMS) is rich with natural resources, cultural diversity, world heritage, and economic 
challenges, which make it one of the most interesting and attractive places for investment [1]. The development of each country in the GMS is currently facing various economic, environmental, and healthcare issues. This study attempted to identify the factors affecting the economic development, environmental problems, and healthcare systems that can lead to mental health disorders in the GMS countries based on summary data obtained from the following studies: 1) The Study of the Determinants Affecting the Health Service System and the Health Status of People in the Greater Mekong Subregion; 2) Environment Management of the Mekong Subregion: A Comparative Study on Urban and Community Environmental Management; 3) The Development of Economic, Society, Environment, and Health under International Cooperation in the Greater Mekong Subregion Countries: A Case Study of the Socialist Republic of Vietnam; a 4) A Study of the Holistic Health Status of the People in the Greater Mekong Subregion countries. ASEAN is an organization in the Southeast Asian region that was founded to provide regional collaboration and support among the member countries in terms of science, culture, technical and economic development, and social welfare and administration [2].

The GMS countries, which are the center of the ASEAN communities bound together by the Mekong River, include the southern part of China, the Lao PDR, Thailand, Myanmar, Cambodia, and Vietnam [3]. The Asian Development Bank has facilitated development in this area for over decades. Economic, social, environmental, political, and public health problems also have emerged and that has affected the local and regional population in the ASEAN member countries because of the ASEAN integration. Effective action plans and economic development are needed to solve to help the affected people in this area, especially the poor. The ASEAN Free Trade Area (AFTA) [4] and the ASEAN Economic Community were also formed to enhance ASEAN economic growth, to open a single market, and to achieve further expansion in international markets [2]. Moreover, these issues have repeatedly occurred in some countries for over decades because the same actions and measures have been employed and have failed to resolve the situation [5]. Previous studies have stated that there are many economic, environmental, and healthcare problems found in the GMS countries [5].

Economic and Investment in the Greater Mekong Subregion Countries

Considering economic development, Krongkaew explained how the Asian Development Bank (ADB) has made an effort to enhance development in Asia. The initial establishment process of the ASEAN economic zone began in 1992 and continued until 1993. The second step from 1993 to 1996 focused on the feasibility studies in each ASEAN country. The third step from 1996 to 2000 concerned the process of economic recovery in Asia after the global economic crisis [6]. ASEAN integration was intended to improve economic growth by forming the AEC and ASEAN Free Trade Area, but it is still encountering some major problems regarding the economic differences in each member country. However, ASEAN integration will create big changes and challenges in the GMS, but in reality, the movement is advancing rather slowly [7]. In addition, although international support has been provided to the developing countries, the economic growth rate of this area is still low. The World Bank has stated that very few changes or development in the ASEAN countries have been carried out because of political instability and corruption. The democratic countries have had few changes regarding the political and economic aspects, and low standards of democracy have remained the major problem in some ASEAN countries [8]. Political instability, corrupt governance, low standards of democracy, and public ignorance can also worsen the economic growth in this area [9].

ASEAN Economic Community (AEC)

ASEAN was founded around five decades ago and is considered a great economic movement influencing economic growth and challenges in the current years. However, the collaboration among the GMS countries is improving and has shown a positive tendency concerning AEC during ASEAN integration [10]. Based on the AEC Blueprint 2015, which was initiated at the 38th ASEAN Economic Minister Meeting (AEM), all ASEAN countries agreed to conduct a step-by-step AEC operation and take account of characteristic differences, crucial needs, and operational targets and timelines [11]. According to the ASEAN Integration Report (AIR) 2015, Asia’s economic growth was slower than world trade growth. The report also recommended that, in order to enhance economic growth in Asia, it is vital to increase regional production, and trading and investment, especially foreign direct investment or FDI [12]. FDI plays an important role in economic growth enhancement, as Asia’s internal investment is lower than external investment [12]. ASEAN Vision 2020 aims to accomplish economic integration among ASEAN member countries using the current and new policies within a predetermined timeline.

Foreign Direct Investment (FDI)

Investment of the relevant sectors should be carried out in urban areas and in the countryside, together with helpful programs and activities in order to enhance the daily living and economic development of the country [1]. The economic development goals of the AEC are as follows: 1) to keep a balance of sustainable economic improvement and 2) to integrate the regional market into the global economy. In order to reach this goal at the global level, the GMS needs to prepare for international integration and capacity development. Therefore, in order to observe and monitor the progress of the ACE, the ASEAN Secretariat has developed an AEC scorecard, which was revised by the ASEAN Integration Monitoring Office (AIMO). The ASEAN Integration Report 2015 is another monitoring tool that was developed to ensure that AEC operations and progress could reach the goals of AEC 2025 [1]. The AEC should build strong collaboration among the regional members and international sectors in order to meet global standards and to smoothly integrate the ASEAN community into the world economy [2]. Considering the impact of the ASEAN Investment Area (AIA) and Foreign Direct Investment (FDI), the AIA has had little impact regarding the ability and capacity to produce high-quality products. This might affect the transformation timeline and the FDI [13]. The FDI was considered a major element in improving economic and national development [14]. The FDI was the key to enhancing economic growth in ASEAN. The AFTA and AEC might strongly encourage their members to generate regional growth; however, the key success of economic growth was FDI [15]. Therefore, ASEAN has to be well-prepared and strengthen its institutional capacity in terms of governmental law and policy in order to increase and attract more FDI and to satisfy the main economic partners such as the U.S.A., the E.U, Japan, and other potential business partners. It can be inferred that the AFTA is the key to opening FDI opportunity in this region. Lower labor costs and an abundance of raw materials have become attractive factors for investors. Job opportunities, skills, and technology are also beneficial to the stakeholders [13].

Environmental Issues in GMS Countries

Better economic performance and population enlargement seems to be a positive tendency of the country’s development, but at the same time, the development progress could in some ways affect the environment [16]. Globalization, socialization, and the countries’ development are increasing rapidly, which can have bad effects on the natural resources. Lack of pollution control, waste management, and proper governance may threaten the environment and the people’s health. Environmental issues are essential and vital to all life forms compared to other issues and they are important issues raised in the ASEAN community [17]. In addition, climate change issues in ASEAN will likely become more serious and threaten human life. People cannot avoid climate change impacts without one-time intervention, prior plans, and preventive solutions [18]. Thailand is currently implementing strict and attentive measures for environmental protection and improvement. Control policy on air pollution management is applied but still needs more collaboration from public and private sectors and other related institutions. Environmental expertise is also required to reduce pollution and to sustain clean air standards [19]. Cambodia has conducted environmental governance and action plans internally under the recommendations of the ADB and World Bank [20]. Although the formation of ASEAN aimed to share regional achievements, it has been difficult to implement environmental intervention because each member country has different levels of ability. ASEAN has no powerful authority to undertake relevant actions and has no other base office except the Jakarta Secretariat [21]. It is also difficult to apply international environmental law in ASEAN. Nowadays environmental laws are mostly emphasized by non-governmental sectors and NGOs. The relevant communities at the regional level and the local population are required to pay more attention to environmental issues [22]. Four major environmental issues affecting the environment at the regional level include: increasing the rate of population growth, lack of development, development processes, and regional readiness [23]. The ADB stated that regional environment intervention, policy making, and problem-solving ability have illustrated good outcomes and good responses to the current environment situation [24]. Therefore, action should be further taken at the regional level before carrying out other interventions or international approaches. Environmental policies have to be well made in order to ensure that the development will not cause environmental problems, destroy ecological systems, and put natural resources in jeopardy [25]. So far the ADB has conducted the following regional environment approaches for the GMS countries: 1) economic cooperation between the GMS members; 2) environmental workgroups; and 3) management policy promotion in the GMS. The GMS collaboration in 1992 aimed to share common visions and commitment to improving the GMS economy and to maintaining environmental stability and sustainable development [20]. The ADB suggested that the GMS should be more attentive to environmental issues and sustainable development. Environmental policy should be strictly and effectively implemented in order to protect the environment during the development process. The GMS Economic Cooperation Program stated that the environment is the main part of sustainable economic development. The fundamental phase of environmental development from 2012 to 2016 was determined with three main purposes: 1) to improve the quality of life and family economy; 2) to adapt well to constant climate change; and 3) to develop sustainable capability [24]. The Mekong River agreements and commitments were initiated in 1995 in order to promote sustainable development, share benefits and utilities in the Mekong basin, enhance policy management, and to maintain the Mekong’s peace and security [20]. However, the environmental issues in this area have become a big concern in regional and global communities. These issues were raised and discussed in order to preserve the world’s natural heritage and to maintain sustainable development, while several countries were focusing on economic development that could cause environmental degradation [22]. Understanding the characteristics of the GMS countries is very important before launching a development program or intervention [20]. It is better to understand the basic values and implementing styles of each country. The ASEAN countries formed an organizational workforce to conduct environmental governance, focusing on environmental management, policy making, and problem-solving [22]. Environmental control strategies and management systems should be mutually carried out at the regional level by each member country. It is vital to make a regional effort regarding environmental management rather than waiting for global actions. Understanding the basic characteristics, weaknesses, and strong points of each ASEAN country can lead to beneficial preparedness [21], and relevant collaboration on environmental management policy between the ASEAN members is crucial for environmental sustainability and stability. Regional environmental governance is also important for sustainable development. A global intervention plan without regional knowledge and understanding should be avoided [22] and ethnicity, political diversity, governance style, challenges and interests, economic differences, and other relevant GMS knowledge should be thoroughly studied before implementing environmental action plans in the GMS [20]. Environmental integration requires collaboration and understanding regarding complicated environmental policies, economic progression, the sociopolitical environment, philosophical orientation, and ethnic differences, and environmental programs should be understood and accepted by the public [26]. Understanding key information makes it easy to interpret the situation and to achieve successful planning and implementation. Multilateral parties, especially international NGOs, should pay more attention to and be concerned about environment issues which could affect the people’s well-being [22]. Effective policy and operations should be applied according to the goals and agreements of ASEAN [19]. The success of the environmental projects in Thailand and Korea resulted from understanding the root of the problems, which clearly pointed to the correct strategic plans and implementation. In addition, human resource development is another key to generating strategic plans and frameworks. This is a good example of how to conduct environmental management at the regional level. ASEAN should address climate change as a serious issue that needs to be discussed and that requires multidisciplinary collaboration in order to find solutions and to determine response plans and disaster preparation [18]. Considering climate change, [27] many countries in ASEAN are facing climate change problems, including the GMS countries such as Lao PDR, Thailand, Cambodia, and Vietnam. It has been recommended that more information be collected to develop and implement climate change response plans with responsibility and accountability at regional and global levels.

Medical Information and Health Issues in GMS

Major Healthcare Issues

Southeast Asia is now becoming a global concern regarding healthcare challenges. The multiethnic and cultural diversity and sociopolitical differences there make it difficult to predict the situation in this area. Many health issues are presented in this region, especially in the underdeveloped and developing countries [28]. Population growth, the country’s development, and climate change can cause many healthcare problems. In addition, most of the people in Southeast Asia, especially in the countries along the Mekong River, live in a monsoon area and share a similar environment. The monsoon season is known to spread communicable diseases, and to increase germ growth and disease incubation [28]. Economic disparity has been the major conflict obstructing ASEAN integration, especially in terms of healthcare [29]. Poor countries without an insurance system would be more sensitive to health problems. Other related issues are the free flow of drugs, the inability to control drug use, the development of drug resistance, and the use of prescription drugs [30]. In Cambodia, any store can sell and dispense all kinds of drugs, including antipsychotics and drugs without a prescription from the physician [31]. Health disparities in ASEAN now have led some people to seek better health services in neighboring countries. The patients not only visit other countries for better healthcare, but health professionals such as nurses in the Philippines and Indonesia also emigrate for work purposes. Both legal and illegal immigration to Thailand, Malaysia, and Singapore may have an effect on many health issues and health inequality as well [28]. Home country healthcare services and quality of care dissatisfaction have forced patients to visit or take a medical tour to Thailand or Singapore. It can be inferred that the quality of healthcare in developing countries is still quite low. Health service marketing, challenges, and competitiveness are also a part of the health problems in poor countries since poor patients cannot afford international fees for modern and expensive healthcare service [28]. Primary healthcare is modified, monitored, evaluated, and researched in order to create more choices and benefits for patients and health professionals.

GMS Healthcare

The ASEAN governor should be more attentive, pay more attention to domestic healthcare needs, enhance economic growth, and open the health markets at the same time in order to stabilize healthcare development [29]. Additionally, the governor should put more effort into elevating the current healthcare status by improving health governance. External collaboration is also needed, but the local government should be more active and strengthen its own capacity. The healthcare problems in this region are difficult to manage and control [30], and each member country should contribute to health sustainability, healthcare growth and challenges, health technology development, health management. The patients that cannot afford modern treatment may turn to other alternative services such as traditional medicine, complementary therapy, and a combination of treatments which could lead to the development of other symptoms or diseases [30]. However, qualified healthcare systems, health service improvement, and economic improvement are the key strategic factors for healthcare development. In order to improve healthcare performance, the following components should be addressed: 1) the accessibility to basic healthcare services; 2) the provision of healthcare by the public sector, the private sector, and NGOs; 3) sources of healthcare financing, and 4) the quality of healthcare services. This process requires collaboration between the private and public sectors [29].

Review of the Relationships Among the Key Determinants Affecting Mental Health Disorders in GMS Populations

Based on the reviewed literature there are four key factors affecting mental health, especially mental health in GMS populations: 1) the living and work environments; 2) trade and investment; 3) technology and medical information; and 4) social and cultural values [32].

Living and Work Environment

Among the GMS population, the living and work environment factors are predictive of the well-being and mental health in the three countries: Thailand, Vietnam, and Cambodia [32, 7]. A million GMS people are affected by wildfires, landslides, flash floods, earthquakes, and typhoons each year. Climate changes and natural disasters are a cause of mental health problems [7]. The GMS study on the effects of climate change showed that disasters affected people in terms of both physical and psychological suffering [33]. Lacking adaptive skills, one will face mental health disorders, such as depression, anxiety, and post-traumatic stress disorder (PTSD) [34]. Additionally, the study of the health of men, women, and children in Cambodia, Thailand, and Vietnam illustrated that work restrictions are a crucial indicator of human trafficking. Constrained employees tend to report a higher rate of poor mental health issues, combining PTSD, anxiety, and depression, than non-constrained employees at twice the level. Working as “an unstoppable machine” increases the risk of injury and exhaustion. Many restricted employees indicated a high level of mental health disparities as a long-term effect [35]. Therefore, non-stop working is potentially exacerbated by poor living conditions and unpaid work [35]. As seen in the study by Kiss, Pocoock, and Zimmerman (2015), most of the children and adolescents in the GMS countries presented the severity of depression, anxiety, PTSD, and suicidal behaviors [36].

Trade and Investment

When the GMS countries became more open in trade and investment from other countries, poverty was reduced among these countries. On the other hand, the service sectors have been growing more than the agricultural and manufacturing sectors when compared with the past [33]. Thus, this change has created labor migration, human trafficking, and sexual abuse. Human trafficking and child abuse are a consequence of this change [33].

In the study by Kiss, Pocock, and Zimmerman (2015) among 387 children and adolescents, various types of mental health problems were reported, for instance, 12% of attempted suicide and self-harm behaviors, 56% of depression, 33% of anxiety disorder, 26% of PTSD, and 20% of abuse at home. Physical violence due to trafficking of persons was found to be 41% and 19% among boys and girls, respectively. Additionally, sexual abuse was presented in 23% of the girls and in 1% of the boys [36]. Likewise, 43.2% of female entertainment workers (FEWs) experienced high levels of psychological distress. This population is one of the high-risk groups with poor health outcomes, including attempted suicide, substance use, and risky sexual behaviors [37].

Technology and Medical Information

Notably, the prevalence of depression, anxiety disorders, and suicidal ideation Ga increased among patients admitted to the primary care unit. However, mental health disorders are difficult to identify and manage by family nurse practitioners [38]. Medical administration in primary care settings becomes a health issue since the risk factor of severe depression and suicidal ideation originates from the current use of antidepressant medication [38]. Consequently, untreated mental health disorders are strongly associated with high rates of the use of psychoactive drugs and suicidal attempts [39].

Social and Cultural Values

The factors contributing to mental health disorders are significantly correlated with social inequalities, whereby high social inequalities bring about extreme mental health risks. Not only do low-income and disadvantaged populations suffer from nonequivalence, but communities also receive the impact of societal disproportion. Therefore, deep-rooted poverty, social inequality, and community discrimination have been seen to cause mental health disparities among the vulnerable groups, especially in the GMS populations [40].

Purposes of study

To identify the key determinants affecting the mental health disorders of people in the GMS

To review the relationships among the key determinants affecting the mental health disorders of the GMS people

METHODOLOGY

This review paper is a literature review of the relationship of the determinants affecting GMS mental disorders conducted using the following strategies: 1) collecting data from previous qualitative and quantitative research studies, comparatively analyzing the literature, articles, published papers, and reports relevant to the existing policies on economic, environmental, and healthcare issues obtained from the GMS; and 2) exchanging information from the institutions involved, including reports and papers regarding the determinants affecting mental health disorders of the people in the GMS, which were used to generate a synthesis of the existing knowledge of the mental health and to provide recommendations programs for the GMS people.

DISCUSSION

The GMS’s economy is increasingly growing, although there are economic disparities in this area. The passive response of the AFTA, which does not match the purposes of ASEAN, is still an unsolvable issue; and this may cause the more issues [4]. The trading business in the AEC may cause an unstable national economy, as many modern and high technology products are imported to this region while few local products are exported to other countries. This imbalance of imports and exports can cause trouble and badly affect the national economy [34, 35]. The trading of substandard products can also cause problems for other countries; for example, if low-quality food products are exported, they may have an impact on global population health in terms of food safety and security. Some GMS countries are known for their low labor costs, thus attracting FDI, but this actually has a negative effect on one’s own country [36]. A great amount of labor from Myanmar, Lao, and Cambodia legally and illegally migrates to Thailand every year, which reveals that there are economic problems in their home country [13]. The ADB has carried out many development programs and has put a lot of effort into the AEC, so a good outcome is expected; however, not much progress has been shown in some countries. Further, democratic and bureaucratic malpractice, including corruption and public ignorance, can worsen the economic growth rate. The main obstacles to development include: 1) severely-impoverished natural resources; 2) a large number of poor people, which can cause environmental problems; and 3) the progress of development has not met sustainable environmental demands and has not changed the economic status of the population [23]. Regional development implementation cannot be achieved without the understanding of the differences and difficulties in ASEAN in terms of the economic, environment, and healthcare situation [41]. The environment has become the top issue in the world in terms of sustainable development. Constant climate changes, a broken-down ecosystem, and natural disasters require all related sectors to pay more attention to the problems and focus on the environment. Environmental management policies and projects need to be established and implemented in a more practical way. Poverty alleviation, sustainable development, and environmental safety plans and intervention can contribute to national economic improvement [23]. Investment is another problem in ASEAN that needs to be discussed. Foreign direct investment is basically needed for ASEAN’s economic improvement because the AEC and AFTA have aimed to build a single market, with free flow of goods and services and internal trade in this area also attracting FDI. The economic diversity and disparity of ASEAN have an effect on healthcare systems and also cause health problems, which leads to healthcare conflicts in vulnerable countries [42].

People will live longer if they have decreased financial difficulties and can afford high-quality health services. This indicates that the key factors in achieving better healthcare are poverty alleviation and economic elevation [43, 44]. There are many poverty and economic problems in the ASEAN countries. The healthcare system is essential in both developing and developed countries. Medical integration and collaboration in ASEAN is a good sign of economic development; however, poor people in developing countries cannot afford expensive healthcare services like the medical tours to Thailand and Singapore [28]. Most of the countries in the GMS countries are facing financial difficulty, which leads to healthcare issues [35]. The social inequalities that exist contribute to the development of mental health disorders [40]. Many studies have revealed a strong relationship among mental health, mental disorder, economic status, and financial issues [37, 36, 41]. Previous studies have reported that the most common mental health disorders in Asian countries are severe depression, suicide, substance abuse, violence, and antisocial behavior [45, 43]. The literature also states that there is a shortage of healthcare personnel, hospitals, and mental disorder facilities and supplies [46, 47]. In fact, the increasing number of mental health disorders is a big burden for national healthcare spending [43]. Financial issues have become a major key to the wide prevalence of mental disorders in the GMS [43, 44, 51]. Health issues related to mental health disorders are also caused by the environment and other related factors [48], and therefore a stable and a well-balanced environment is an indicator of healthy mental status [49]. In addition, the environment is a way to pursue both physical and mental health because green spaces serve as a mood freshener and can alleviate anxiety, stress, and depression [50].

CONCLUSION

The economic, environmental, and healthcare problems in the GMS area should be solved through policy development, follow-up planning, strategic implementation, and collaboration among all related sectors [7]. The participation of NGOs and local communities in community development to maintain environmental sustainability is crucial. Strong correlations among economic development and environmental and healthcare improvement indicate that economic growth should be enhanced in a sustainable way without a break-down of the environment; therefore, environmental divergence can subsequently cause many health problems. In order to improve the GMS’s current economic, environmental, and healthcare status, appropriate planning and interventions are needed. ASEAN should pay more attention to its members’ role in the AEC, AFTA, and other ASEAN integrations and ensure that they have an opportunity to improve their economic status [2]. In addition, the ASEAN countries have to be well-prepared for international investment, such as FDI and global trade investment [13]. However, environmental management is a special part of economic development and globalization, so it is essential to ensure that the ecology and environment are secure. Globalization and urbanization should follow sustainable development instructions and concerns about the population’s health, especially regarding mental health [23]. These key determinants affect the people’s life, especially in terms of mental health thus leading to mental health disorders.

Limitation and recommendations

Limitations

The scope of this literature review focused on five main countries: Thailand, Lao PDR, Myanmar, Cambodia, and Vietnam. There was a lack of data from stakeholders, which are considered important sources.

The study suggests elevating the economy of the people in the region by retaining ASEAN’s integration vision and promises, a green environment, and safe urbanization. Developing policies that promote sustainable development may prevent serious health issues due to climate change.

Further recommendations are to provide social support programs to improve the quality of care, treatment, facilities, and services, especially in terms of hospitals and healthcare personnel responsible for patients with mental health disorders [51].

The ADB’s vision should be maintained and implemented, especially in terms of implementing rules and regulations that promote the people’s well-being and enhance the population’s quality of life and health [1].

For Research Investigators

Future research is strongly recommended in order to understand more about the GMS people and their characteristics; especially more data should be obtained from all stakeholders in the GMS.

Consent for Publication

Not applicable.