Influence of mental health perception and willingness-to-pay towards intention-to-support inclusion of mental health coverage in health insurance schemes: a cross sectional study in Malaysia

INTRODUCTION

The burden of mental disorders continues to increase all around the world with a significant collision on health, major social, human rights, and economic consequences.¹ Mental health disorders include bipolar disorder, dementia, depression and other psychoses.² A steady increase in the prevalence of mental health disorders among adults in Malaysia has been monitored by the national health and morbidity survey.³ 4.2 million out of 14.4 million Malaysian aged 16 and above would suffer from mental illness according to the current prevalence of 29.2%, in which every three in ten adults aged 16 years and above will have some sort of mental health issues in some part of their lives.^3,4

Health insurance is a type of insurance coverage that pays for medical expenses due to an illness.^5,6 The expenses could be the cost of hospitalization, medicine prescription or doctor's consultation fees.^6-8 However, insurance industries do not cover mental health in their insurance plan because there are shortages of mental health practitioners in general and mostly in certain parts of the country.⁹ However, a bigger reason for the exclusion of outpatient mental health coverage in existing health insurance schemes is due to the expensive nature of covering such claims.^10,11

To accommodate the increased expenditure, insurance premiums need to be increased which is deemed non-marketable by insurance providers.^12,13 A common rationalisation used by insurance providers is that there is uneven perception of mental health needs among the public which would deter their willingness to pay for such increased premium.^14,15 Nonetheless, initiatives such as Affordable Care Act in the United States have enhanced their insurance coverage on mental health by showing that some populations have improved perception and welcome the coverage with a higher willingness to pay for the premiums.¹⁶

Such exploration on perception and willingness to pay for mental health coverage in health insurance schemes has not been undertaken in Malaysia so far. Hence, this study is conducted to determine the influence of mental health perception and willingness to pay towards intention to support inclusion of mental health coverage in health insurance schemes with a hypothesis that postulates a direct relationship between the two variables.

METHODS

Study design and sample population

This study was conducted via a cross-sectional survey design among the general public in Malaysia. Sample size was calculated using the Krejcie and Morgan 1970 sampling guide.¹⁷ which deemed a size of 384 respondents as adequate for this study. To account for an acceptable response rate, a target of 800 respondents was decided for this project. An online questionnaire was constructed to be disseminated to target participants for this study. The inclusion criteria were local citizens of Malaysia who gave consent to take part in the study with acceptable literacy in English and aged above 21 years old. Completed questionnaires were scrutinized and incomplete surveys were excluded from the study.

Instrumentation and data collection

There is total of 4 sections in the questionnaire, starting with the demographic profile in section1 followed by section 2 which examines the perception and knowledge towards mental health disorders with total number of 13 questions using a 5 point Likert scale. Section 3 involves the willingness to pay for inclusion of mental health coverage in health insurance plans with a total of 11 similar Likert scale questions. The final section involved Intention-to-support inclusion of mental health coverage in health insurance which was represented by 3 Likert scale questions.

The online study survey was distributed through selected messaging platform and social media as well as state government channels to ensure adequate representation from all over Malaysia. Out of the 800 questionnaires distributed, 414 questionnaires were returned completed, yielding a response rate of 51.8%.

Data analysis

A total of 414 completed questionnaires were analysed using statistical package for the social sciences (SPSS) software 23.0. To obtain descriptive information, exploratory data analysis was done first on both individual variables. To analyse the relationship between mental health perception and willingness to pay towards the inclusion of mental health coverage and intention to support, linear regression was utilized accordingly. A p value less than 0.05 was considered statistically significant.

Ethical consideration

Online consent was obtained from participants prior to participating in this study. Ethics approval for this study was obtained from Perdana University institutional review board.

RESULTS

A total of 414 respondents were recruited for this study whereby, 243 (58.3%) were male and 171 (41.7%) were female, with the age range of 21-30 as the highest in number. Majority of the respondents were Malays which comprises 49.5%, (205), and the remaining 21.7% (90) were Chinese, 18.2% (75) were Indian and other races comprised of 10.6% (44). Concerning the educational level of the respondents, only 19.8% (82) of respondents’ attained postgraduate qualification and (19.3%) were secondary education while the majority, 44.3% (183) were degree holders. Looking into average monthly income, a vast majority of the respondents were paid below RM 2000 which accounted for 46.9% (194) whereas only 18.8% (78) of the respondents were paid with RM 2001-RM 4000. Most of the respondents 35.3% (146) were taking care of father whereas 15.2% (63) of the respondents were not taking care of any of their parents. Moreover, 62.3% (209) of the respondents were not having pre-existing illness at this moment of time.

Most of the respondents "somewhat disagree" that "most people with mental health problems want to have paid employment. A total of, 56.3%, (n=233) "strongly agree" that "if a friend had a mental health problem, they know what advice to give them to get professional help" while the rest, 43.7%, (n=181) "somewhat agree”. Most respondents, 37.4%, (n=154) "strongly agree" that "medication can be an effective treatment for people with mental health problems and many strongly agree that mental illness is a serious health disorder, 51.0% (n=211) "strongly agree". Majority respondents, 48.8%, (n=198) also "strongly agree" that "people with severe mental health problems can fully recover” and "most people with mental health problems go to a healthcare professional to get help”. As for knowledge, most respondents strongly agree that depression, bipolar disorder, drug addiction and schizophrenia are mental health disorders while interestingly many were unsure that stress was a mental health issue.

As shown in Table 3 60.9% (n=252) responded "definitely yes" that they are willing to pay for mental health coverage as part of the insurance. Nearly three quarters, 71.8% (297) of the participants agreed that they are willing to pay a premium increase of up to 10%. The majority, 59.7% (247) agreed that mental health should be covered as part of the insurance plan. Around half of the respondents, 42.8% (135) agreed to include psychiatric counselling only if there were no additional premiums while vast majority of respondents 71.8% (304) responded that they did not have adequate mental health coverage under their current health insurance plan. Moreover, most of the respondents, 60.9% (252) indicated that they knew of close acquaintances who have been denied coverage of mental health treatment. Lastly, most of the respondents were “confident” that they could pay the increase in the premium on basis of 48.6% (201).

The results of the Pearson correlation analysis revealed that there was a positive correlation between perception towards mental health disorders and the intention-to-support for the inclusion of mental health coverage in health insurance schemes in Malaysia. (r=0.357, p<0.0001). The study also shows that willingness-to-pay is also correlated with intention to support (r=0.345, p<0.0001) (Table 4).

As shown in Table 5, the regression coefficient and determination for perception towards mental health disorder were (ß=0.514, t=5.927, F=34.078, R2=0.312, and p<0.001).

The test results showed there was a significant relationship between perception towards mental health disorders and intention-to-support for the inclusion of mental health coverage in health insurance schemes in Malaysia. Similarly, the regression coefficient and determination for WTP were (ß=0.669, t=8.214, F=43.401, R2=0.401, p<0.001). The test results showed there was a significant relationship between WTP towards the inclusion of mental health coverage in health insurance schemes and ITS.

**less than 0.001

DISCUSSION

The demographic shown in Table 1 above, is similar to the general population in Malaysia. In terms of ethnicity, educational level and average monthly income, the respondents in this study mirror the general characteristics of the Malaysian population.^18,19 This is important as this is a pioneer study looking into both the role of MHP and WTP among Malaysians for inclusion of mental health coverage in health insurance schemes.

MHP

The results from this study demonstrate that most Malaysians have favorable perception and knowledge towards mental health disorders. Most agreed that bipolar disorder, schizophrenia, anxiety, addiction and depression are serious health concerns which is similar to previous studies.^20,21 However, many felt stress was not a mental health concern and this is probably due to the trivializing attitudes toward stress.²² Stress is one of the most common condition individuals come across daily. So much so, that many do not perceive it as a medical concern.²³ This assumption should be changed because stress is the first indicator of both mental health and metabolic complications.²⁴ The study also showed that many respondents felt that individuals with mental health should not seek paid employment. A similar pattern of results were obtained in a previous study where there are some employees with mental disorders who complained about various work-related stigma and opposition from colleagues about their employment.²⁵ A past study noticed, employment discrimination is one way of shunning people with mental disorders from key areas of life.^26,27 Employment enables in-society participation and allow people with mental disorder to purposefully engage in the broader community.²⁷ Supportive employment plans can be an aid for individuals with mental disorders and help believe themselves that they are primed for community integration.²⁸ Human perceptions on mental health disorders influences one’s work opportunity and it is important these perceptions are informed by facts and not stigma.²⁹

This study also showed that MHPs is a significant predictor of intention to support inclusion of mental health coverage in health insurance schemes. Perception and attitudes are important aspect of behavioural practice. Those with positive perception of mental health are likely to be concerned about future mental health expenses and supportive of mental health coverage. Inversely, those with negative perception or low knowledge on mental health are more likely to avoid any forum or discourse on mental health coverage which inadvertent would become a barrier to their sup-port of mental health coverage inclusion in health insurance schemes in Malaysia.³⁰ In Malaysia, private healthcare is considered a more sensible option for mental health care due to confidentiality and privacy concerns. However, without insurance, patients may choose to lessen treatment or even opt out of it due to tremendous cost.³¹ The Malaysia psychiatric association (MPA) has ensured for mental health treatment to be included in health insurance premiums.³² Our results show that high emphasis on improving perception and knowledge is pertinent to public adoption and acceptance of mental health coverage in health insurance schemes.

WTP

The majority of the respondents were willing to pay a certain additional amount for mental health coverage in their health insurance schemes. 90% of the respondents were willing to pay between 10%-25% increase in the premium for this particular coverage. A study from Arif has shown that individuals with high educational levels (such as the respondents in this study) are very likely to have higher WTP due to the realization that high cost of medical care cannot be managed by individual income.³³ The higher level of education backs in the understanding of how much to pay for mental health insurance. This study also showed that many respondents were comfortable if psychiatric counselling for mental health problems was included in the basic health plan without any additional premiums. This is because insured individuals who have low incomes may encounter significant financial barriers that make it a burden for them to pay for high additional premium.³⁴ A 10-25% increase was deemed acceptable for many respondents.

Out study also showed that WTP is a strong predictor for intention to support mental health coverage in health insurance schemes. The rationale for this could be attributed to suggestion given by a study done in Iran, which shows that respondents with higher WTP are more likely to be health conscious and concerned on having adequate coverage of themselves.^35,36 Therefore, those individuals who are more willing to pay for health insurance are also more likely to expect more coverage in their insurance schemes. Couple with the affordability agreed above, this study provide an initial insight into consumer interest in purchasing mental health coverage in their insurance schemes. Malaysian insurance providers should adopt strategies seen in European countries for mental health coverage and develop similar schemes in accordance with Malaysian affordability.³⁷ Insurance companies should have a predetermined premium loading for mental health coverage that also considers not only treatment of mental illness but also inclusive of other interventions such as psychosocial rehabilitation, psychotherapy, and counselling which are likely to go on for months.³⁸

CONCLUSION

In conclusion, this study has shown individual MHPs and WTP play a major role in determining support for inclusion of mental health coverage in health insurance schemes. This study provides a clear insight for policy makers to develop recommendations that improve knowledge and perceptions of mental health disorders to ensure equitable access to health care.^39,40

The study also provides an insight into consumer affordability for mental health coverage that could encourage insurance companies to consider including mental health care in their insurance schemes.

Funding: No funding sources

Conflict of interest: None declared

Ethical approval: The study was approved by the Institutional Ethics Committee

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