Navigating Safety and Health Challenges in Autism Spectrum Disorder Care in Malaysia: A Systematic Literature Review of Caregiver Perspectives and Intervention Outcomes

Navigating Safety and Health Challenges in Autism Spectrum Disorder Care in Malaysia: A Systematic Literature Review of Caregiver Perspectives and Intervention Outcomes | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Systematic Review Navigating Safety and Health Challenges in Autism Spectrum Disorder Care in Malaysia: A Systematic Literature Review of Caregiver Perspectives and Intervention Outcomes Intan Suraya Noor Arzahan, Putri Anis Syahira Mohamad Jamil, Nur Athirah Diyana Mohammad Yusof This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6089146/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Autism Spectrum Disorder (ASD) presents significant challenges globally, and in Malaysia, these challenges are compounded by limited resources and culturally specific obstacles. This systematic literature review (SLR) critically examines empirical studies published between 2019 and 2024 to elucidate the primary safety and health challenges faced by individuals with ASD and their caregivers, as well as the management strategies and interventions employed to address these issues in the Malaysian context. Guided by the PRISMA framework, we searched four major academic databases namely Scopus, Web of Science, ScienceDirect, and Google Scholar and using targeted keywords related to autism safety, caregiver stress, and intervention strategies. After rigorous screening and quality assessment using the Effective Public Health Practice Project (EPHPP) tool, 13 studies were deemed eligible for inclusion. Our review identifies several recurring challenges, including difficulties in managing meltdowns, sensory processing issues, and the risks associated with wandering. These challenges exacerbate caregiver burden, contributing to increased stress, anxiety, and social isolation. Caregivers frequently resort to self-devised strategies such as structured routines, informal support networks, and mindfulness practices. Although various behavioural therapies, community-based programs, and early intervention services show promise in mitigating these challenges, their overall effectiveness is often limited by inconsistent implementation, resource scarcity, and a lack of standardized training for caregivers. The findings underscore the urgent need for contextually tailored support systems and policies that enhance caregiver training and expand accessible, standardized interventions. This review not only highlights the unique safety and health issues within the Malaysian ASD community but also provides a robust foundation for future research and policy development aimed at improving outcomes for both individuals with ASD and their caregivers. Psychology Health Policy Epidemiology Autism Spectrum Disorder Safety Challenges ASD Caregiver Intervention Strategies Malaysia Figures Figure 1 1. Introduction Autism Spectrum Disorder ASD is a neurodevelopmental disorder marked by impaired social interactions, verbal and nonverbal communication deficits, and restricted, repetitive behaviour patterns. On a global scale, the incidence of ASD has been consistently rising. Based on the publication by World Health Organization in November 2023, prevalence of ASD is now around 1 in 100 children. In Malaysia, based on the unpublished data from Ministry of Health in 2005, one in every 625 children has ASD. The increasing occurrence of this condition has drawn attention to the substantial health and safety difficulties experienced by individuals with ASD and those responsible for their care. Providing care for children with ASD involves distinct difficulties that go beyond the usual duties of a caregiver. Caregivers frequently encounter substantial psychological strain, financial hardships, and social seclusion while managing their children with ASD (Tathgur & Kang, 2021 ). Caregivers must employ specialised care practices to manage the symptoms associated with ASD, including difficulties in communication and behavioural challenges. These challenges can result in feelings of burnout and mental health issues for caregivers. In Malaysia, the rising occurrence of ASD reflects worldwide patterns, as there is a growing acknowledgement of the necessity for extensive support networks for individuals with ASD and their caregivers. However, the specific circumstances in Malaysia provide distinct difficulties in addressing the safety and health requirements of individuals with ASD. Like many developing countries, Malaysia encounters substantial deficiencies in delivering services for individuals with ASD (Mohd Rashidi, 2024 ). The absence of specialized services, especially in rural areas, results in numerous families facing difficulties in obtaining essential assistance for their children. Studies have shown that the lack of early intervention centres and specialized schools, primarily concentrated in metropolitan regions, further exacerbates this condition (Ghazali et al., 2021 ; Eng et al., 2024). Consequently, parents frequently undertake extensive journeys to access these services, thereby increasing financial and emotional hardships (Mello et al., 2016 ). Current studies have investigated the safety and health issues faced by individuals with ASD and their caregivers. Still, there is a shortage of comprehensive evaluations that address common safety and health concerns, caregiver management techniques, and intervention available in Malaysia. This SLR aims to fill this knowledge gap by providing a concise and critical analysis of existing studies on safety and health challenges, management and effectiveness of interventions in the Malaysian ASD community conducted in Malaysia. The structure of the paper is as follows: Section 2 highlights the objectives of the SLR. Section 3 outlines the specific procedures utilised in this investigation. Section 4 summarizes the results obtained from the analysis. Section 5 provides an analysis and explanation of the findings. Section 6 discusses the constraints of the study, while Section 7 offers a concise overview and conclusion of the general findings. 2. Objectives This SLR aims to: Identify and analyse the most common safety and health challenges faced in ASD community. Investigate how caregivers perceive and handle these safety and health challenges. Assess the effectiveness of different interventions or strategies in enhancing safety and health outcomes for this population. 3. Methods 3.1 Eligibility Criteria To address the research issues, specific criteria for inclusion and exclusion were devised. These criteria aimed to identify the most common safety and health concerns among ASD community. What is the perception of caregivers regarding these safety and health risks and how do they handle them? Which interventions or methods have demonstrated efficacy in enhancing safety and health outcomes in this population? To maintain the emphasis on original research, only peer-reviewed journal papers with empirical data were chosen, while eliminating review articles, book series, books, book chapters, and conference proceedings. Furthermore, the search was limited to articles written in English to prevent any confusion or difficulties in translation, thereby assuring uniformity in the interpretation of data. The review specifically examined research published between 2019 and 2024 to gather up-to-date information on recent advancements and current practices in ASD safety and health and the caregiver methods. This approach ensured a thorough awareness of the present situation in this field. 3.2 Search strategy This SLR was guided by the PRISMA Statement as illustrated in Fig. 1 , a widely recognised framework in the field of safety and health research. The utilisation of the PRISMA framework facilitated a thorough and systematic exploration of pertinent literature pertaining to safety and health challenges, caregiver management approaches, and intervention therapies within the autistic community. In this study, four primary academic databases were selected for the search: Scopus, WoS, ScienceDirect, and Google Scholar. The search technique incorporated the following keywords: autism safety; autism safety challenges; autism caregiver stress; autism safety challenges; autism interventions; autism safety protocols; autism therapy; autism activity; and autism in Malaysia. These terms were selected to encompass a wide range of research on safety and health in ASD care, with a particular emphasis on locating empirical studies that align with the objectives of this SLR. An illustrative instance involves the utilisation of the subsequent search approach within the Scopus database: (autism OR ASD OR autism spectrum disorder AND caregiver challenges OR caregiver stress OR parents challenges OR parents’ problem OR safety challenges AND intervention strategies OR intervention therapy OR intervention activities AND Malaysia OR Malaysian). Initial searches produced 3,561 articles using the specified keywords. Following eliminating duplicates and applying inclusion and exclusion criteria, a total of 851 articles were selected for further evaluation. The screening method entailed a meticulous analysis of titles and abstracts, identifying 46 papers that fulfilled the specified criteria (Fig. 1 ). Subsequently, these papers underwent a comprehensive evaluation, identifying 13 studies considered highly pertinent to the aims of the SLR. During the following stages, important characteristics were determined from the chosen studies. These variables include the most common safety and health concerns, interventions used by caregivers to manage the situation, and the success of different therapies. This meticulous search technique guaranteed that the SLR thoroughly examined the study issues and yielded useful insights into the safety and health challenges faced by the ASD community. 3.3 Quality Assessment The selected studies in this SLR were evaluated for their quality using the Effective Public Health Practice Project (EPHPP) Quality Assessment Tool for quantitative studies. This tool assesses multiple dimensions of study quality, encompassing factors such as selection bias, study design, confounding variables, blinding, data collection procedures, and attrition rates. The EPHPP tool is supplemented by an elaborate lexicon that guides the evaluation process, guaranteeing uniformity in the assessment of every study. Each study was evaluated based on the previously indicated criteria, leading to an overall grade of high, medium, or low quality. More precisely, studies were classified as high-quality if none of the dimensions were considered weak, moderate quality if one dimension was considered weak, and poor quality if two or more dimensions were considered weak. Subsequently, these scores were combined to evaluate the study's overall quality comprehensively. The quality assessment process was carried out autonomously by all authors participating in the SLR. All conflicts or questions that emerged throughout the assessment were collaboratively addressed and resolved, guaranteeing a consensus on the quality ratings awarded to each study. The stringent quality evaluation method was essential to ensure that the SLR findings were grounded in strong and dependable evidence. This process enhances the validity and reliability of the conclusions reached from the review. 4. Results 4.1 Study selection After conducting a comprehensive examination of the abstracts and complete texts, 13 papers were chosen to be included in this SLR (Abd Latif et al., 2023 ; Abdullah et al., 2022 ; Asahar et al., 2021 ; Chua et al., 2023 ; Kaman et al., 2023 ; Laili et al., 2021 ; Masuri et al., 2023 ; Mohamad Aun et al., 2022 ; Salleh et al., 2024 ; Sidique et al., 2022 ; Wong et al., 2024 ; Yaacob et al., 2021 ; Yalim & Mohamed, 2023 ). The selection of these studies was based on their direct relevance to the primary goals of this review, which include identifying common safety and health issues faced by individuals with ASD, comprehending how caregivers perceive and address these concerns, and assessing the efficacy of interventions or strategies designed to enhance safety and health outcomes for this population. All the chosen research were carried out in Malaysia, guaranteeing a concentrated examination of domestic obstacles and remedies. 4.2 Study characteristics Table 1 presents a thorough overview of the features of the studies that were considered. It focuses on the study participants, the methodologies employed, and the main discoveries pertaining to safety and health issues, caregiver approaches, and the effectiveness of interventions. This specific selection guarantees that the review examines the distinct safety and health difficulties encountered by individuals with ASD and their caregivers in Malaysia. Table 1 Selected journal articles No. Author(s) Year of Study Title Location Study Population Methods Used Key Findings Safety and Health Challenges Management Strategies Effectiveness of interventions 1 (Yalim & Mohamed, 2023 ) 2023 Meltdown in Autism: Challenges and Support Needed for Parents of Children with Autism Peninsular Malaysia Parents of children with ASD Surveys and Interviews Identified the main challenges in managing meltdowns in public spaces, such as lack of public awareness and social stigma, impacting both the child’s safety and caregiver's mental health. Managing meltdowns in public spaces impacts caregivers' safety and mental health. Caregivers implemented structured routines and calming techniques for children, while also seeking social support for themselves. Structured routines and calming techniques effectively reduced the frequency and intensity of meltdowns, improving child safety and caregiver stress levels. 2 (Salleh et al., 2024 ) 2024 Affiliate Stigma, Resilience, and Quality of Life Among Parents of Children with Autism Spectrum Disorder in Two Public Hospitals in Kelantan, Malaysia Kelantan, Malaysia Parents of children with ASD Questionnaires Found that affiliate stigma significantly lowered parental resilience, with stigma being a major factor leading to decreased quality of life among parents. Affiliate stigma leads to reduced resilience and lower quality of life among parents. No specific management strategies were mentioned for caregivers, the focus was on the impact of stigma. No specific interventions were highlighted, the study focused on the impact of stigma rather than intervention outcomes. 3 (Chua et al., 2023 ) 2023 Problem Behaviours and Caregiver Burden Among Children with Autism Spectrum Disorder in Kuching, Sarawak Kuching, Sarawak Caregivers Surveys and Observational Study Showed that hyperactivity and aggression in children with ASD were key factors leading to higher caregiver burden, which in turn exacerbated mental health issues like anxiety and depression among caregivers. Hyperactivity and aggression in children lead to increased caregiver burden and mental health issues. Use behavioural interventions for children, while caregivers engaged in stress-relief practices and sought mental health support. Behavioural interventions like positive reinforcement were moderately effective in reducing challenging behaviours but required consistent application to sustain improvements in child behaviour and caregiver mental health. 4 (Wong et al., 2024 ) 2024 Experiences and Difficulties of Parents in Caring Their Children with Autism Living in Malaysia Peninsular Malaysia Parents of children with ASD Interviews They identified that parents faced difficulties in managing the sensory and communication challenges of their children with ASD, with a lack of support and understanding from healthcare providers being significant gaps. Challenges in managing sensory and communication issues due to lack of support from healthcare providers. Parents used sensory-friendly environments for children and sought counselling services for their mental health. Sensory-friendly environments and consistent communication techniques effectively reduced sensory overload and improved interaction quality, though the impact on overall health outcomes was limited. 5 (Laili et al., 2021 ) 2021 Challenges and Support for Parents of Children with Autism Spectrum Disorder at Work Peninsular Malaysia Working parents of children with ASD Mixed Methods (Interviews & Surveys) It was reported that balancing work and caregiving responsibilities was a major challenge for parents, with stress factors including inflexible work environments and lack of employer support. Stress from balancing work and caregiving responsibilities and lack of employer support exacerbate difficulties. Some parents sought flexible work arrangements, caregiver networks, and stress management strategies. Flexible work arrangements and colleague support were effective in reducing stress, though improvements in work-life balance depended on employer policies. 6 (Kaman et al., 2023 ) 2023 Knowledge Attitudes, and Associated Factors of Caregivers towards Children with Autism Spectrum Disorder in East Coast Peninsular Malaysia East Coast Peninsular Malaysia Caregivers Surveys Highlighted significant gaps in caregivers’ knowledge and attitudes towards ASD, particularly in understanding and managing ASD-related behaviours, which led to ineffective caregiving strategies. No specific safety challenges were highlighted, but gaps in knowledge led to ineffective caregiving strategies. No specific management strategies were highlighted for caregivers, knowledge gaps prevented effective caregiving. No specific interventions were highlighted, focus was on identifying gaps in caregiver knowledge. 7 (Abdullah et al., 2022 ) 2022 The Challenges in Raising Autistic Children: The Voices of Mothers Selangor, Malaysia Mothers of children with ASD Focus Groups Revealed that mothers experienced significant emotional and financial stress, often due to inadequate social support, leading to burnout and reduced quality of caregiving. Emotional and financial stress leads to burnout and reduced quality of caregiving. Mothers relied on informal support networks, sought financial counselling, and engaged in self-care practices. Informal support networks and self-care practices helped to manage stress and prevent burnout, though the long-term effectiveness was variable and dependent on the level of support available. 8 (Sidique et al., 2022 ) 2022 The Current Practices and Challenges of a Community-Based Early Intervention Centre for ASD Children in Malaysia Peninsular Malaysia Caregivers and Educators Case Studies Found inconsistencies in early intervention practices, particularly in accessibility and standardization, which led to disparities in the effectiveness of services provided to children with ASD. Inconsistencies in early intervention services lead to disparities in safety and effectiveness of care. Standardization efforts in early intervention were made, with caregivers receiving training and support. Standardization efforts in early intervention showed promise in improving service effectiveness, though inconsistencies in application limited overall impact. 9 (Asahar et al., 2021 ) 2021 Quality of Life and Child's Autism-Specific Difficulties among Malaysian Main Caregivers: A Cross-Sectional Study Peninsular Malaysia Main caregivers of children with ASD Cross-Sectional Study Identified a strong correlation between the quality of life of caregivers and the severity of ASD-specific difficulties, with caregivers of children with more severe symptoms experiencing greater challenges and lower quality of life. Caregivers of children with severe ASD symptoms face greater challenges, impacting their quality of life. Caregivers participated in support groups and received professional counselling to cope with stress. Support groups and professional counselling were effective in helping caregivers manage stress, particularly for those dealing with severe ASD symptoms in their children. 10 (Masuri et al., 2023 ) 2023 Emotional States and Quality of Life among Parents of Children with Autism Spectrum Disorder (ASD) during COVID-19 in Malaysia Peninsular Malaysia Parents of children with ASD Questionnaires Showed that the emotional states of parents, particularly stress and anxiety, were closely linked to their quality of life during the COVID-19 pandemic, with significant impacts on their mental health. Stress and anxiety during the COVID-19 pandemic lockdown significantly affected parents' mental health. Caregivers practiced mindfulness, used stress management techniques, and sought temporary respite care. Stress management techniques like mindfulness were effective in improving mental health outcomes during the pandemic, though the need for more formalized support was noted. 11 (Abd Latif et al., 2023 ) 2023 Factors Influencing Despair, Self-blame, and Acceptance Among Parents of Children with Autism Spectrum Disorder (ASD): A Malaysian Perspective East Coast Peninsular Malaysia Parents of children with ASD Mixed Methods (Surveys and Interviews) Identified several factors contributing to despair and self-blame among parents, including financial strain, lack of social support, and the severity of the child's ASD.... Community support played a critical role in helping parents achieve greater acceptance and improve their mental health and coping mechanisms. Financial strain, lack of social support, and severity of the child's condition contribute to despair and self-blame among parents. Caregivers engaged in community support groups, practiced acceptance and reframing, and sought professional mental health support. Community support groups and professional mental health services were effective in reducing despair and improving acceptance among parents, though outcomes varied depending on the severity of the child's condition. 12 (Yaacob et al., 2021 ) 2021 Behind the Scenes of Parents Nurturing a Child with Autism: A Qualitative Study in Malaysia Peninsular Malaysia Parents of children with ASD Qualitative Study Documented the unique challenges faced by parents, including navigating the healthcare system, managing daily routines, and dealing with social stigma, which emphasized the need for more comprehensive support. Navigating the healthcare system, managing daily routines, and dealing with social stigma present ongoing challenges. Caregivers sought professional advice, created structured routines, and advocated for the child’s needs while seeking peer support for themselves. Professional advice and structured routines effectively managed daily challenges, but the overall impact on long-term health outcomes was unclear due to the complexity of needs. 13 (Mohamad Aun et al., 2022 ) 2022 Quality of Life Among Mothers of High Functioning Autism Spectrum Disorder (HFASD) Adolescents Selangor & Perak, Malaysia Mothers of adolescents with HFASD Questionnaires Explored the quality of life among mothers of HFASD adolescents, highlighting ongoing challenges such as social isolation and lack of tailored support services despite their children's high functioning. No specific safety challenges were highlighted, but ongoing challenges related to social isolation and lack of tailored support services for mothers. No specific management strategies highlighted; ongoing challenges due to lack of tailored support services. No specific interventions were highlighted, and the focus was on the challenges due to the lack of tailored support services. 4.3 Quality assessment Table 2 provides a concise overview of the quality of the 13 studies that were chosen. The comprehensive evaluation indicates that a substantial percentage of the studies achieved high scores regarding data collection methods (46%) and selection bias (38%). Nevertheless, persistent deficiencies were observed in participant blinding across the investigations, with most studies (85%) being assigned a weak ranking in this category. The evaluation of variables that could affect the results yielded varied outcomes, with 23% of the studies demonstrating a high level of control, 54% showing a moderate level, and 23% displaying a low level. Regarding the study design, 23% of the studies were classified as strong, 69% as moderate, and 8% as weak. The evaluation of withdrawals and dropouts exhibited variation, with 31% of studies being classified as strong, 62% as moderate, and 8% as weak. In total, 23% of the studies were categorised as high quality, 69% as moderate quality, and 8% as low quality. Table 2 Quality assessment results against the effective public health practice project quality assessment tool No. Author(s) Selection Bias Study Design Confounders Blinding Data Collection Withdrawals/Dropouts 1 (Yalim & Mohamed, 2023 ) Strong Moderate Moderate Weak Strong Strong 2 (Salleh et al., 2024 ) Moderate Strong Moderate Weak Strong Moderate 3 (Chua et al., 2023 ) Strong Moderate Strong Weak Moderate Moderate 4 (Wong et al., 2024 ) Moderate Moderate Moderate Weak Strong Moderate 5 (Laili et al., 2021 ) Strong Strong Weak Weak Moderate Moderate 6 (Kaman et al., 2023 ) Weak Weak Weak Weak Moderate Weak 7 (Abdullah et al., 2022 ) Moderate Moderate Strong Weak Strong Moderate 8 (Sidique et al., 2022 ) Strong Moderate Moderate Moderate Strong Strong 9 (Asahar et al., 2021 ) Moderate Moderate Strong Weak Moderate Moderate 10 (Masuri et al., 2023 ) Moderate Strong Moderate Weak Strong Moderate 11 (Abd Latif et al., 2023 ) Strong Moderate Moderate Moderate Moderate Strong 12 (Yaacob et al., 2021 ) Moderate Moderate Strong Weak Strong Moderate 13 (Mohamad Aun et al., 2022 ) Weak Moderate Weak Weak Moderate Weak 4.4 Safety and health challenges in the ASD community in Malaysia The review of the 13 chosen publications revealed several significant safety and health issues faced by individuals with ASD and their caregivers in Malaysia. More than half of the studies have identified considerable difficulties in regulating behaviours associated with ASD, specifically meltdowns, sensory processing problems, and challenging behaviours. These actions frequently led to elevated stress levels and added responsibilities for caregivers. The studies highlighted the urgent requirement for improved support systems and increased public awareness to lessen the burden on caregivers and boost the quality of care for individuals with ASD. Five of the research focused on the emotional and psychological strain faced by caregivers, specifically highlighting elevated levels of stress, anxiety, and depression among parents of children with ASD (Abd Latif et al., 2023 ; Asahar et al., 2021 ; Masuri et al., 2023 ; Salleh et al., 2024 ; Yaacob et al., 2021 ). This research identified insufficient social support and healthcare system shortcomings as significant variables contributing to caregiver distress. Six studies highlighted on the difficulties of accessing suitable services and interventions, particularly in rural or underprivileged locations(Abdullah et al., 2022 ; Laili et al., 2021 ; Masuri et al., 2023 ; Sidique et al., 2022 ; Wong et al., 2024 ; Yaacob et al., 2021 ). This research revealed notable deficiencies in early intervention services. It emphasised the necessity for more easily attainable, cost-effective, and culturally appropriate support systems to enhance assistance for the ASD community. Seven of the studies also examined the efficacy of several behavioural and community-based approaches in enhancing outcomes for individuals with ASD (Abdullah et al., 2022 ; Chua et al., 2023 ; Laili et al., 2021 ; Masuri et al., 2023 ; Sidique et al., 2022 ; Yaacob et al., 2021 ; Yalim & Mohamed, 2023 ). The studies typically concluded that customised interventions, such as well-organized schedules and surroundings designed to accommodate sensory needs, were successful in addressing specific difficulties. Nevertheless, the efficacy of these interventions was frequently compromised by inconsistent execution and a dearth of proficient practitioners, constraining their total influence. In general, the studies repeatedly found that there is a requirement for more extensive and well-coordinated support systems to tackle the complex issues experienced by individuals with ASD and their caregivers. The results indicate that the effectiveness of strategies and interventions is greatly influenced by the presence of resources, public knowledge, and the overall support services infrastructure in the community. 5. Discussions 5.1 Prevalent safety and health challenges for individuals with ASD The examination of the 13 chosen papers (Table 1 ) unveiled numerous prominent safety and health issues for ASD community in Malaysia. One common topic explored in nine research was the challenge of effectively handling behaviours associated with ASD, specifically meltdowns, sensory processing difficulties, and challenging behaviours (Abd Latif et al., 2023 ; Abdullah et al., 2022 ; Asahar et al., 2021 ; Chua et al., 2023 ; Laili et al., 2021 ; Masuri et al., 2023 ; Wong et al., 2024 ; Yaacob et al., 2021 ; Yalim & Mohamed, 2023 ). These behaviours provide immediate safety and health hazards to individuals with ASD and pose considerable challenges for their caregivers. The results align with international research that recognises these behaviours as prevalent safety and health issues within the autism community (Zaniboni et al., 2021 ; Zeng et al., 2023 ). An example of a significant safety and health risk in Malaysia is the occurrence of meltdowns in public settings. The dearth of public awareness and comprehension exacerbates these circumstances, resulting in possible injury and heightened caregiver concern. This is consistent with research conducted in other areas, emphasising caregivers' pressure while dealing with public meltdowns. This pressure is typically caused by social stigma and a lack of support from the community (Ashrafun et al., 2024 ; Francis, 2024 ). Nevertheless, this SLR highlight that these issues are exacerbated by cultural considerations, resulting in heightened public scrutiny and increased complexity for caregivers. Five investigations highlighted sensory sensitivities as a significant concern, often resulting in sensory overload (Chua et al., 2023 ; Laili et al., 2021 ; Masuri et al., 2023 ; Wong et al., 2024 ; Yalim & Mohamed, 2023 ) .Experiencing excessive sensory stimulation can lead to challenging reactions or social retreats, making it more challenging to ensure safety and health in both domestic and public environments. The results align with global studies that recognise sensory processing difficulties as a notable element that contributes to safety and health hazards for individuals with ASD (Brown, 2021 ; Camarata et al., 2020 ). Nevertheless, the research conducted in Malaysia emphasised the scarcity of sensory-friendly spaces, which is in stark contrast to countries with more developed infrastructure, resources, and policies that cater to the needs of ASD individuals where such accommodations are becoming more prevalent (Lin et al., 2023 ; Sousa et al., 2024 ).This discrepancy highlights the necessity for increased focus on sensory requirements in Malaysia, specifically in public and educational environments. Wandering around or running away from a safe environment without permission or supervision, which was observed in four of the studies, presents substantial safety and health hazards (Laili et al., 2021 ; Wong et al., 2024 ; Yaacob et al., 2021 ; Yalim & Mohamed, 2023 ), and is a widely recognised concern in the literature (Celia et al., 2020 ; Hodgetts, 2021 ; Meads, 2024 ) where wandering is seen as a significant risk that necessitates the implementation of dedicated safety and health mechanisms. The journal articles in this review has found that the absence of secure surroundings and sufficient supervision are factors that contribute to this risk in Malaysia(Laili et al., 2021 ; Yaacob et al., 2021 ; Yalim & Mohamed, 2023 ). Nevertheless, the situation in Malaysia emphasises the necessity for greater consciousness and measures or resources aimed at preventing ASD individuals from wandering (Mokhtar, 2023 ), especially in rural or disadvantaged regions where caregivers may lack access to specialised instruction or assistance. In general, the assessment underscores the complex nature of safety and health concerns faced by individuals with ASD in Malaysia, emphasising that these issues are closely connected to the daily experiences of caregivers. The assessment highlights safety and health issues that are consistent with global trends, but it also identifies specific challenges that are unique to the setting. These challenges include the heightened public attention during meltdowns and the absence of sensory-friendly environments. To tackle these safety and health concerns, it is necessary to employ a combination of public education, enhanced environmental adjustments, and specific treatments designed to meet the distinct requirements of the ASD population in Malaysia. These findings establish a solid basis for future research and policy formulation to improve safety and health outcomes for individuals with ASD and their caregivers in Malaysia. 5.2 Caregivers’ Management Strategies This SLR reveals a range of intervention utilised by caregivers to manage the safety and health issues linked to the care of individuals with ASD. Although frequently successful, these techniques underscore both the ingenuity of caregivers and the substantial deficiencies in institutional support systems. One prevalent approach seen in seven of the research was implementing organised schedules and employing soothing methods to regulate behaviours such as meltdowns, hostility, and sensory overload (Abd Latif et al., 2023 ; Abdullah et al., 2022 ; Chua et al., 2023 ; Laili et al., 2021 ; Masuri et al., 2023 ; Yaacob et al., 2021 ; Yalim & Mohamed, 2023 ). This approach is in line with previous research, which emphasises the significance of consistency and predictability in decreasing anxiety and behavioural challenges in individuals with ASD (John & Hemalatha, 2024 ; Rizzo et al., 2024 ). Nevertheless, the ASD caregivers frequently create this intervention independently, with minimal input from healthcare experts. In contrast, research conducted in more advanced countries has shown that caregivers usually undergo more structured training in behaviour management approaches (Sun, 2020 ). The dependence on personally devised intervention highlights the urgent requirement for caregiver training programmes in Malaysia that are more easily accessible. Another commonly stated method was utilising informal support networks, such as family and community organisations, as observed in six research studies (Abd Latif et al., 2023 ; Abdullah et al., 2022 ; Laili et al., 2021 ; Masuri et al., 2023 ; Salleh et al., 2024 ; Yalim & Mohamed, 2023 ). Caregivers frequently relied on these networks to seek emotional support, respite care, and guidance in handling daily challenges. This finding aligns with worldwide research that emphasises the significance of social support in reducing caregiver stress and enhancing overall well-being (Li et al., 2023 ). The support networks are typically informal and do not possess the same level of organisation and resources as more formal support systems found in other nations. This highlights a deficiency in the accessibility of official assistance services, which may be resolved by establishing further structured community-based initiatives that offer dependable and continuous support to caregivers. Additionally, ASD caregivers reported engaging in discussions to establish flexible working hours, exploring opportunities to work remotely, or decreasing their work hours to handle their caring responsibilities effectively (Yaacob et al., 2021 ). These findings align with other international studies that acknowledge the significance of workplace flexibility in mitigating caregiver stress and enhancing work-life equilibrium (Bainbridge & Townsend, 2020 ). Nevertheless, from this review, obtaining such agreements can be challenging, especially in work situations that are more traditional or less innovative as in Malaysia (Laili et al., 2021 ; Masuri et al., 2023 ; Salleh et al., 2024 ; Yaacob et al., 2021 ). This poses a substantial obstacle for caregivers who must balance the requirements of their job and caregiving responsibilities without enough institutional assistance. The research also emphasised the significance of self-care habits among caregivers, which were examined in four investigations. Caregivers employed strategies such as practising mindfulness, engaging in physical activity, and seeking respite care to address their own mental and physical well-being effectively (Abd Latif et al., 2023 ; Abdullah et al., 2022 ; Masuri et al., 2023 ; Yalim & Mohamed, 2023 ). These practices align with suggestions from international literature, which emphasise caregivers' need to prioritise their well-being to maintain their caregiving role (Levin & Machado-Gonzalez, 2025 ). However, the efficacy of these measures was frequently constrained by time and financial constraints, since numerous caregivers encountered challenges in continuously upholding self-care routines due to the demanding nature of their duties. In summary, the analysis emphasises that caregivers in Malaysia utilise various approaches to address the challenges associated with caring for individuals with ASD. However, these approaches are typically formulated due to the absence of professional assistance and training. In contrast, caregivers usually have access to a broader range of formalised support services and interventions in contexts with more resources. The results indicate a significant requirement for contextually suitable support structures and training programmes in Malaysia. These would enable caregivers to handle better the safety and health challenges related to ASD. 5.3 Effectiveness of interventions in improving safety and health The studies assessed various interventions, including behavioural therapies, community-based programmes, and early intervention services. The effectiveness of these interventions varied. Four research studies examined behavioural therapies, including applied behaviour analysis (ABA), structured teaching approaches, and sensory integration therapy, to address problematic behaviours and enhance safety and health (Chua et al., 2023 ; Masuri et al., 2023 ; Sidique et al., 2022 ; Yaacob et al., 2021 ). The results typically confirm the efficacy of these therapies, especially in reducing challenging behaviours and addressing sensory sensitivities. Research investigations that utilised Applied Behaviour Analysis (ABA) have shown a significant reduction in instances of self-injury and violence. These findings align with worldwide research highlighting the effectiveness of ABA in addressing severe behavioural problems in individuals with ASD (Sturmey, 2021 ). Nevertheless, in this review, studies emphasised a crucial obstacle where the effectiveness of these interventions relies greatly on the regular implementation and the presence of skilled practitioners, which are frequently scarce in this country. In contrast to more developed nations, where there is a greater abundance of experienced professionals and resources, resulting in better rates of success in intervention outcomes (de Jonge et al., 2024 ). Two studies also examined community-based support programmes to equip caregivers with the necessary skills and resources to handle safety and health problems effectively (Sidique et al., 2022 ; Wong et al., 2024 ). The programmes, which encompassed support groups and workshops, were discovered to be especially advantageous in rural areas where formal services were deficient. The study by Sidique et al. ( 2022 ) demonstrated that the efficacy of these programmes was frequently constrained by disparities in availability and divergent standards of excellence, indicating a necessity for more uniform and easily available community support programmes throughout Malaysia. The findings are supporting Sharma et al. (2022) that emphasized the value of structured support systems. Their study demonstrated that parent-to-parent support groups effectively reduced anxiety and stress among caregivers of children with ASD. This is because, the support groups provided mutual support, psychoeducation, and stress management strategies. Notably, the intervention resulted in statistically significant reductions in parental stress and anxiety, reinforcing the importance of structured community programs. These studies underscore the necessity for a more cohesive approach to caregiver support in Malaysia. While Sidique et al. focused on the geographical disparities in service availability, Sharma et al. provided evidence of how structured and well-implemented programs can enhance caregiver resilience. This emphasizes the need for scalable, culturally relevant, and quality-assured support mechanisms to ensure consistent outcomes across diverse regions. Furthermore, one research investigated using sensory-friendly surroundings and resources, such as sensory rooms and adaptive equipment, to alleviate sensory overload and enhance safety (Wong et al., 2024 ). The effectiveness of these interventions in promoting safety and health for individuals with ASD, particularly in addressing sensory sensitivities that may result in behavioural challenges or self-injurious behaviours, was generally seen. This discovery aligns with global research that supports the implementation of sensory-friendly environments to decrease anxiety and improve the safety and health of individuals with ASD (Anemone, 2024 ; Antosh et al., 2024 ). Nevertheless, the research highlighted that such environments are scarce in Malaysia, especially in public spaces and schools. This indicates a significant gap that must be filled to fully capitalise on these interventions' advantages. In summary, the studies examined in this SLR suggest that there are interventions that can effectively enhance safety and health outcomes for individuals with ASD. However, the effectiveness of these interventions is frequently hindered by external factors such as limited access to services, availability of resources, and inconsistent implementation of programmes. The results highlight the necessity of implementing a more organised strategy for ASD care in Malaysia. This should involve prioritising the expansion of skilled professionals' accessibility, standardising community support programmes, and enhancing the availability of early intervention services, especially in areas that lack sufficient resources. 6. Limitation The review was restricted to studies published in English, potentially excluding relevant literature in other languages, and focused only on papers published between 2019 and 2024, which may overlook earlier foundational studies. Additionally, most of the analyzed studies were of moderate quality, limiting the robustness of the findings. Variations in the implementation and evaluation of interventions across studies further complicate generalization of results. While the focus on the Malaysian context offers important cultural and regional insights, it limits the applicability of findings to other settings with different social, cultural, and healthcare landscapes. Despite these limitations, this review serves as a crucial foundation for future research and policy development to improve safety and health outcomes for individuals with ASD and their caregivers in Malaysia. 7. Conclusion This review highlights critical safety and health concerns for individuals with ASD, including meltdowns, sensory processing difficulties, and challenging behaviours, which pose risks to both individuals with ASD and their caregivers in Malaysia. Caregivers often rely on self-created routines and informal support due to deficiencies in formal systems, while interventions such as behavioural and community-based programs showed promise but are hindered by inconsistent implementation and limited accessibility. The lack of organized instruction and affordable, widely available early interventions further exacerbates these challenges, particularly in rural areas. To improve safety and health outcomes, there is an urgent need for inclusive, culturally tailored, and accessible support systems that address the diverse needs of individuals with ASD and their caregivers. Future efforts should focus on eliminating disparities, ensuring equitable access to resources, and strengthening public awareness and support networks. Declarations Statement on the accessibility of data The article/supplementary material contains the study’s original contributions. Additional questions should be addressed to the corresponding author(s). Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper. Acknowledgement This study was self-funded. References Abd Latif, M. H., Wan Ismail, W. S., Abdul Manaf, M. R., & Abdul Taib, N. I. (2023). Factors Influencing Despair, Self-blame, and Acceptance Among Parents of Children with Autism Spectrum Disorder (ASD): A Malaysian Perspective. Journal of Autism and Developmental Disorders . https://doi.org/10.1007/s10803-023-06155-8 Abdullah, H., Asraf, R. M., Ali, M. A. M., Wahab, N. A., & Baharudin, D. F. (2022). The challenges in raising autistic children: The voices of mothers. International Journal of Evaluation and Research in Education , 11 (1), 78–87. https://doi.org/10.11591/ijere.v11i1.21837 Alenezi, S., Alyahya, A. S., AlKhalifah, S. M., Bakhsh, H. R., Alismail, E. H., Aldhalaan, H., Alwazna, T., Alzrayer, N., AlSuwailem, S. S., Alnemary, F., AlAnsari, A. M. S., Alqulaq, E. I., Alyamani, A., Amer, Y. S., Albawardi, I. M., Albalawi, W. M., Alhassan, M. A., Algazlan, M. S., Alramady, M., & Ad-Dab’bagh, Y. (2022). Saudi Expert Consensus-Based Autism Spectrum Disorder Statement: From Screening to Management. 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Social support and depression of autistic children’s caregivers: The mediating role of caregivers’ self-esteem. Research in Autism Spectrum Disorders , 108 , 102241. https://doi.org/https://doi.org/10.1016/j.rasd.2023.102241 Lin, K., Wang, J., & Wang, C. J. (2023). Current Research in Law & Practice Ensuring Inclusive Education for Children with Autism Spectrum Disorder : Evaluating Legal Frameworks and Implementation Strategies in China This paper delves into the inclusive education system in China to ensure Firstl. Current Research in Law & Practice Journal , 1 (1). Masuri, M. G., Wan Shafie, W. N., Dahlan, A., Sultan Ibrahim, S. A., Tanapalan, C. K., Che Daud, A. Z., Mohd Poot, E. F., Azman, N. A., Nurhidayah, N., & Md Isa, K. A. (2023). Emotional States and Quality of Life Among Parents of Children With Autism Spectrum Disorder (Asd) During Covid-19 in Malaysia. Journal of Health and Translational Medicine , 26 (Special Issue 2), 120–132. https://doi.org/10.22452/jummec.sp2023no2.14 Meads, S. (2024). SensorEase: Designing to Achieve Acceptance of the WanderSearch Location Device . Open Access Te Herenga Waka-Victoria University of Wellington. Mello, M. P., Goldman, S. E., Urbano, R. C., & Hodapp, R. M. (2016). Services for children with autism spectrum disorder: Comparing rural and non-rural communities. Education and Training in Autism and Developmental Disabilities , 51 (4), 355–365. Mohamad Aun, N. S., Zakaria, S. M., Ahmad Badayai, A. R., Idris, I. B., Mohd Daud, T. I., & Mohd Fazree, S. D. (2022). Quality of Life among Mothers of High Functioning Autism Spectrum Disorder (HFASD)Adolescents. International Journal of Environmental Research and Public Health , 19 (11). https://doi.org/10.3390/ijerph19116663 Mohd Rashidi, Q. N. (2024). Call to address disparities in autism care service provision. The Sun . https://thesun.my/malaysia-news/call-to-address-disparities-in-autism-care-service-provision-EA13461454 Mohd Zuki, N. H., & Nik Abdul Rahman, N. S. (2016). Challenges Malaysian teachers face in the inclusion of autistic students in the normal classroom. 2015 4th International Conference on Advanced Computer Science Applications and Technologies (ACSAT) , 4 (2006), 120–130. http://irep.iium.edu.my/52058/ Mokhtar, I. L. (2023). Autism and wandering - safety tips for handling autistic children while outside. Sinar Daily . https://www.sinardaily.my/article/213517/malaysia/national/autism-and-wandering---safety-tips-for-handling-autistic-children-while-outside?utm_source=chatgpt.com Rizzo, A., Sorrenti, L., Commendatore, M., Mautone, A., Caparello, C., Maggio, M. G., Özaslan, A., Karaman, H., Yıldırım, M., & Filippello, P. (2024). Caregivers of Children with Autism Spectrum Disorders: The Role of Guilt Sensitivity and Support. Journal of Clinical Medicine , 13 (14). https://doi.org/10.3390/jcm13144249 Salleh, N. S., Yoong, T. L., Husain, M., Abdullah, K. L., & Cheng, K. Y. (2024). Affiliate Stigma, Resilience and Quality of Life among Parents of Children with Autism Spectrum Disorder in Two Public Hospitals in Kelantan, Malaysia. Malaysian Journal of Medical Sciences , 31 (3), 217–228. https://doi.org/10.21315/mjms2024.31.3.17 Sandbank, M., Bottema-Beutel, K., Crowley Lapoint, S., Feldman, J. I., Barrett, D. J., Caldwell, N., Dunham, K., Crank, J., Albarran, S., & Woynaroski, T. (2023). Autism intervention meta-analysis of early childhood studies (Project AIM): updated systematic review and secondary analysis. Bmj . https://doi.org/10.1136/bmj-2023-076733 Sidique, F. A. A., Khalid, M., Karim, A. H. A., Hamid, S. R. A., Sidek, S. N., Dzulkarnain, A. A. A., & Yusof, H. M. (2022). The Current Practices and Challenges of a Community Based Early Intervention Centre for ASD Children in Malaysia. Journal of Curriculum and Teaching , 11 (8), 97–108. https://doi.org/10.5430/jct.v11n8p97 Sousa, C., Tsvetkova, P., Pérez-Fuster, P., Agius, M., Kostova, S., Bolesta, K., Megda Garcia, F., Nanchen, B., & Tkaczyk, A. H. (2024). Social Inclusion for People with Intellectual Disability and on the Autism Spectrum through Assistive Technologies: Current Needs and Future Priorities. Disability and Rehabilitation. Assistive Technology , 0 (0), 1–13. https://doi.org/10.1080/17483107.2024.2414414 Steinbrenner, J. R., Hume, K., Odom, S. L., Morin, K. L., Nowell, S. W., Tomaszewski, B., Szendrey, S., Mcintyre, N. S., Özkan, Ş. Y., & Savage, M. N. (2020). Evidence-Based Practices for Children, Youth, and Young Adults with Autism. Evidence-Based Practices for Children, Youth, and Young Adults with Autism. , 1–143. Sturmey, P. (2021). Applied Behavior Analysis Treatment of Violence and Aggression in Persons with Neurodevelopmental Disabilities. Applied Behavior Analysis Treatment of Violence and Aggression in Persons with Neurodevelopmental Disabilities . https://doi.org/10.1007/978-3-030-68549-2 Sun, X. (2020). Behavior skills training for family caregivers of people with intellectual or developmental disabilities: a systematic review of literature. International Journal of Developmental Disabilities , 68 (3), 1–27. https://doi.org/10.1080/20473869.2020.1793650 Tathgur, M. K., & Kang, H. K. (2021). Challenges of the Caregivers in Managing a Child with autism Spectrum Disorder — a Qualitative analysis “ D . April . https://doi.org/10.1177/02537176211000769 The Council of Autism Service Providers. (2020). Applied Behavior Analysis for the Treatment of Autism Spectrum Disorder . Wong, F. E., Nurul, A., Mohammad, A. R., Farzana, Y., Nathan, V., Mohammed Shahjahan, K., Shaker Uddin Ahmed, Lubna Shirin, Tania Islam, Tan Sing Ying, Theingi Maung Maung, Tan Yong Chia, Prabal Bhargava, & Nazmul MHM. (2024). Experiences And Difficulties Of Parents In Caring Their Children With Autism Living In Malaysia. Educational Administration: Theory and Practice , 30 (4 SE-Articles), 2569–2574. https://doi.org/10.53555/kuey.v30i4.1895 Yaacob, W. N. W., Yaacob, L. H., Muhamad, R., & Zulkifli, M. M. (2021). Behind the scenes of parents nurturing a child with autism: A qualitative study in Malaysia. International Journal of Environmental Research and Public Health , 18 (16). https://doi.org/10.3390/ijerph18168532 Yalim, T., & Mohamed, S. (2023). Meltdown in Autism: Challenges and Support Needed for Parents of Children with Autism. International Journal of Academic Research in Progressive Education and Development , 12 (1), 784–809. https://doi.org/10.6007/ijarped/v12-i1/16184 Zaniboni, L., Marzi, A., Caniato, M., & Gasparella, A. (2021). Comfortable and safe environments for people with autism: Preliminary analysis of risks and definition of priorities in the design phase. Journal of Physics: Conference Series , 2069 . https://doi.org/10.1088/1742-6596/2069/1/012177 Zeng, S., Xiu, Y., & Tang, S. (2023). A Review of Physical Safety for Individual with Autism Spectrum Disorder. International Journal of Education and Humanities , 6 (3), 71–74. https://doi.org/10.54097/ijeh.v6i3.4184 Additional Declarations The authors declare no competing interests. Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6089146","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Systematic Review","associatedPublications":[],"authors":[{"id":419635308,"identity":"036b9555-07ca-436d-ab70-2eee93a97d72","order_by":0,"name":"Intan Suraya Noor Arzahan","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA50lEQVRIiWNgGAWjYBACNiQ24wMInUBICzOczWxAlBYGJC1sEkRp4ZPuP/i54M/hfP4Zyc+qedu2MfCz5xgw3WzD4zCZw8zSM9sOW864kWZ2m7ftNoNkzxsD5lx8WiSSGaR5Gw4bMNxIgGgxuJFDUAvzb54/hw3kb6R/KwZpsSdCC5s0D9thA6DhZsxgWyQIazGz5m1LNzA886ZYcs652zwSZ54VHM45h1uL/IzEx7d5/lgbyB1P3/jhTdltOf725I2Pc8pwa0EAgQQwxQMiDjCy4VMKA/wHkHl/iNEyCkbBKBgFIwQAAOBeS+jQDXpsAAAAAElFTkSuQmCC","orcid":"https://orcid.org/0000-0002-0966-057X","institution":"Universiti Utara Malaysia","correspondingAuthor":true,"prefix":"","firstName":"Intan","middleName":"Suraya Noor","lastName":"Arzahan","suffix":""},{"id":419635309,"identity":"3c3ed113-a53d-43df-bdfb-443d02530913","order_by":1,"name":"Putri Anis Syahira Mohamad Jamil","email":"","orcid":"","institution":"Universiti Kebangsaan Malaysia","correspondingAuthor":false,"prefix":"","firstName":"Putri","middleName":"Anis Syahira Mohamad","lastName":"Jamil","suffix":""},{"id":419635310,"identity":"9d5884cf-883f-475c-b8c5-673f44ad8691","order_by":2,"name":"Nur Athirah Diyana Mohammad Yusof","email":"","orcid":"","institution":"Universiti Teknologi Malaysia","correspondingAuthor":false,"prefix":"","firstName":"Nur","middleName":"Athirah Diyana Mohammad","lastName":"Yusof","suffix":""}],"badges":[],"createdAt":"2025-02-23 09:09:57","currentVersionCode":1,"declarations":{"humanSubjects":false,"vertebrateSubjects":true,"conflictsOfInterestStatement":false,"humanSubjectEthicalGuidelines":false,"humanSubjectConsent":false,"humanSubjectClinicalTrial":false,"humanSubjectCaseReport":false,"vertebrateSubjectEthicalGuidelines":true},"doi":"10.21203/rs.3.rs-6089146/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6089146/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":77243327,"identity":"faf007af-8f08-4bf3-9ff5-d96d346303ff","added_by":"auto","created_at":"2025-02-26 14:39:03","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":76124,"visible":true,"origin":"","legend":"\u003cp\u003eLiterature search strategy and selection for included studies (n = 13).\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-6089146/v1/b33ccbb73828309bfc9c2931.png"},{"id":77244806,"identity":"2742cab7-9002-4fff-8212-efd06c3bd7dd","added_by":"auto","created_at":"2025-02-26 14:55:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1149955,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6089146/v1/5c975446-77c1-4ea7-8c50-e5bb2b1e6c93.pdf"}],"financialInterests":"The authors declare no competing interests.","formattedTitle":"\u003cp\u003e\u003cstrong\u003eNavigating Safety and Health Challenges in Autism Spectrum Disorder Care in Malaysia: A Systematic Literature Review of Caregiver Perspectives and Intervention Outcomes\u003c/strong\u003e\u003c/p\u003e","fulltext":[{"header":"1. Introduction","content":"\u003cp\u003eAutism Spectrum Disorder ASD is a neurodevelopmental disorder marked by impaired social interactions, verbal and nonverbal communication deficits, and restricted, repetitive behaviour patterns. On a global scale, the incidence of ASD has been consistently rising. Based on the publication by World Health Organization in November 2023, prevalence of ASD is now around 1 in 100 children. In Malaysia, based on the unpublished data from Ministry of Health in 2005, one in every 625 children has ASD. The increasing occurrence of this condition has drawn attention to the substantial health and safety difficulties experienced by individuals with ASD and those responsible for their care. Providing care for children with ASD involves distinct difficulties that go beyond the usual duties of a caregiver. Caregivers frequently encounter substantial psychological strain, financial hardships, and social seclusion while managing their children with ASD (Tathgur \u0026amp; Kang, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Caregivers must employ specialised care practices to manage the symptoms associated with ASD, including difficulties in communication and behavioural challenges. These challenges can result in feelings of burnout and mental health issues for caregivers.\u003c/p\u003e \u003cp\u003eIn Malaysia, the rising occurrence of ASD reflects worldwide patterns, as there is a growing acknowledgement of the necessity for extensive support networks for individuals with ASD and their caregivers. However, the specific circumstances in Malaysia provide distinct difficulties in addressing the safety and health requirements of individuals with ASD. Like many developing countries, Malaysia encounters substantial deficiencies in delivering services for individuals with ASD (Mohd Rashidi, \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). The absence of specialized services, especially in rural areas, results in numerous families facing difficulties in obtaining essential assistance for their children. Studies have shown that the lack of early intervention centres and specialized schools, primarily concentrated in metropolitan regions, further exacerbates this condition (Ghazali et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Eng et al., 2024). Consequently, parents frequently undertake extensive journeys to access these services, thereby increasing financial and emotional hardships (Mello et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2016\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eCurrent studies have investigated the safety and health issues faced by individuals with ASD and their caregivers. Still, there is a shortage of comprehensive evaluations that address common safety and health concerns, caregiver management techniques, and intervention available in Malaysia. This SLR aims to fill this knowledge gap by providing a concise and critical analysis of existing studies on safety and health challenges, management and effectiveness of interventions in the Malaysian ASD community conducted in Malaysia. The structure of the paper is as follows: Section 2 highlights the objectives of the SLR. Section \u003cspan refid=\"Sec3\" class=\"InternalRef\"\u003e3\u003c/span\u003e outlines the specific procedures utilised in this investigation. Section \u003cspan refid=\"Sec7\" class=\"InternalRef\"\u003e4\u003c/span\u003e summarizes the results obtained from the analysis. Section \u003cspan refid=\"Sec12\" class=\"InternalRef\"\u003e5\u003c/span\u003e provides an analysis and explanation of the findings. Section \u003cspan refid=\"Sec16\" class=\"InternalRef\"\u003e6\u003c/span\u003e discusses the constraints of the study, while Section \u003cspan refid=\"Sec17\" class=\"InternalRef\"\u003e7\u003c/span\u003e offers a concise overview and conclusion of the general findings.\u003c/p\u003e"},{"header":"2. Objectives","content":"\u003cp\u003eThis SLR aims to:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eIdentify and analyse the most common safety and health challenges faced in ASD community.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eInvestigate how caregivers perceive and handle these safety and health challenges.\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eAssess the effectiveness of different interventions or strategies in enhancing safety and health outcomes for this population.\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e"},{"header":"3. Methods","content":"\u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003e3.1 Eligibility Criteria\u003c/h2\u003e \u003cp\u003eTo address the research issues, specific criteria for inclusion and exclusion were devised. These criteria aimed to identify the most common safety and health concerns among ASD community. What is the perception of caregivers regarding these safety and health risks and how do they handle them? Which interventions or methods have demonstrated efficacy in enhancing safety and health outcomes in this population? To maintain the emphasis on original research, only peer-reviewed journal papers with empirical data were chosen, while eliminating review articles, book series, books, book chapters, and conference proceedings. Furthermore, the search was limited to articles written in English to prevent any confusion or difficulties in translation, thereby assuring uniformity in the interpretation of data. The review specifically examined research published between 2019 and 2024 to gather up-to-date information on recent advancements and current practices in ASD safety and health and the caregiver methods. This approach ensured a thorough awareness of the present situation in this field.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003e3.2 Search strategy\u003c/h2\u003e \u003cp\u003eThis SLR was guided by the PRISMA Statement as illustrated in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, a widely recognised framework in the field of safety and health research. The utilisation of the PRISMA framework facilitated a thorough and systematic exploration of pertinent literature pertaining to safety and health challenges, caregiver management approaches, and intervention therapies within the autistic community. In this study, four primary academic databases were selected for the search: Scopus, WoS, ScienceDirect, and Google Scholar. The search technique incorporated the following keywords: autism safety; autism safety challenges; autism caregiver stress; autism safety challenges; autism interventions; autism safety protocols; autism therapy; autism activity; and autism in Malaysia. These terms were selected to encompass a wide range of research on safety and health in ASD care, with a particular emphasis on locating empirical studies that align with the objectives of this SLR.\u003c/p\u003e \u003cp\u003eAn illustrative instance involves the utilisation of the subsequent search approach within the Scopus database: (autism OR ASD OR autism spectrum disorder AND caregiver challenges OR caregiver stress OR parents challenges OR parents\u0026rsquo; problem OR safety challenges AND intervention strategies OR intervention therapy OR intervention activities AND Malaysia OR Malaysian).\u003c/p\u003e \u003cp\u003eInitial searches produced 3,561 articles using the specified keywords. Following eliminating duplicates and applying inclusion and exclusion criteria, a total of 851 articles were selected for further evaluation. The screening method entailed a meticulous analysis of titles and abstracts, identifying 46 papers that fulfilled the specified criteria (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Subsequently, these papers underwent a comprehensive evaluation, identifying 13 studies considered highly pertinent to the aims of the SLR. During the following stages, important characteristics were determined from the chosen studies. These variables include the most common safety and health concerns, interventions used by caregivers to manage the situation, and the success of different therapies. This meticulous search technique guaranteed that the SLR thoroughly examined the study issues and yielded useful insights into the safety and health challenges faced by the ASD community.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003e3.3 Quality Assessment\u003c/h2\u003e \u003cp\u003eThe selected studies in this SLR were evaluated for their quality using the Effective Public Health Practice Project (EPHPP) Quality Assessment Tool for quantitative studies. This tool assesses multiple dimensions of study quality, encompassing factors such as selection bias, study design, confounding variables, blinding, data collection procedures, and attrition rates. The EPHPP tool is supplemented by an elaborate lexicon that guides the evaluation process, guaranteeing uniformity in the assessment of every study. Each study was evaluated based on the previously indicated criteria, leading to an overall grade of high, medium, or low quality. More precisely, studies were classified as high-quality if none of the dimensions were considered weak, moderate quality if one dimension was considered weak, and poor quality if two or more dimensions were considered weak. Subsequently, these scores were combined to evaluate the study's overall quality comprehensively. The quality assessment process was carried out autonomously by all authors participating in the SLR. All conflicts or questions that emerged throughout the assessment were collaboratively addressed and resolved, guaranteeing a consensus on the quality ratings awarded to each study. The stringent quality evaluation method was essential to ensure that the SLR findings were grounded in strong and dependable evidence. This process enhances the validity and reliability of the conclusions reached from the review.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003c/div\u003e"},{"header":"4. Results","content":"\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003e4.1 Study selection\u003c/h2\u003e \u003cp\u003eAfter conducting a comprehensive examination of the abstracts and complete texts, 13 papers were chosen to be included in this SLR (Abd Latif et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Abdullah et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Asahar et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Chua et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Kaman et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Laili et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Masuri et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Mohamad Aun et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Salleh et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Sidique et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Wong et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Yaacob et al., \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Yalim \u0026amp; Mohamed, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). The selection of these studies was based on their direct relevance to the primary goals of this review, which include identifying common safety and health issues faced by individuals with ASD, comprehending how caregivers perceive and address these concerns, and assessing the efficacy of interventions or strategies designed to enhance safety and health outcomes for this population. All the chosen research were carried out in Malaysia, guaranteeing a concentrated examination of domestic obstacles and remedies.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003e4.2 Study characteristics\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents a thorough overview of the features of the studies that were considered. It focuses on the study participants, the methodologies employed, and the main discoveries pertaining to safety and health issues, caregiver approaches, and the effectiveness of interventions. This specific selection guarantees that the review examines the distinct safety and health difficulties encountered by individuals with ASD and their caregivers in Malaysia.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSelected journal articles\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"11\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAuthor(s)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYear of Study\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eTitle\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eLocation\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eStudy Population\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eMethods Used\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eKey Findings\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c9\"\u003e \u003cp\u003eSafety and Health Challenges\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eManagement Strategies\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c11\"\u003e \u003cp\u003eEffectiveness of interventions\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(Yalim \u0026amp; Mohamed, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2023\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eMeltdown in Autism: Challenges and Support Needed for Parents of Children with Autism\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePeninsular Malaysia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eParents of children with ASD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSurveys and Interviews\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eIdentified the main challenges in managing meltdowns in public spaces, such as lack of public awareness and social stigma, impacting both the child\u0026rsquo;s safety and caregiver's mental health.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eManaging meltdowns in public spaces impacts caregivers' safety and mental health.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eCaregivers implemented structured routines and calming techniques for children, while also seeking social support for themselves.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eStructured routines and calming techniques effectively reduced the frequency and intensity of meltdowns, improving child safety and caregiver stress levels.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(Salleh et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2024\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAffiliate Stigma, Resilience, and Quality of Life Among Parents of Children with Autism Spectrum Disorder in Two Public Hospitals in Kelantan, Malaysia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eKelantan, Malaysia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eParents of children with ASD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eQuestionnaires\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eFound that affiliate stigma significantly lowered parental resilience, with stigma being a major factor leading to decreased quality of life among parents.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eAffiliate stigma leads to reduced resilience and lower quality of life among parents.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eNo specific management strategies were mentioned for caregivers, the focus was on the impact of stigma.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNo specific interventions were highlighted, the study focused on the impact of stigma rather than intervention outcomes.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(Chua et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2023\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eProblem Behaviours and Caregiver Burden Among Children with Autism Spectrum Disorder in Kuching, Sarawak\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eKuching, Sarawak\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCaregivers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSurveys and Observational Study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eShowed that hyperactivity and aggression in children with ASD were key factors leading to higher caregiver burden, which in turn exacerbated mental health issues like anxiety and depression among caregivers.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eHyperactivity and aggression in children lead to increased caregiver burden and mental health issues.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eUse behavioural interventions for children, while caregivers engaged in stress-relief practices and sought mental health support.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eBehavioural interventions like positive reinforcement were moderately effective in reducing challenging behaviours but required consistent application to sustain improvements in child behaviour and caregiver mental health.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(Wong et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2024\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2024\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eExperiences and Difficulties of Parents in Caring Their Children with Autism Living in Malaysia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePeninsular Malaysia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eParents of children with ASD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eInterviews\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eThey identified that parents faced difficulties in managing the sensory and communication challenges of their children with ASD, with a lack of support and understanding from healthcare providers being significant gaps.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eChallenges in managing sensory and communication issues due to lack of support from healthcare providers.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eParents used sensory-friendly environments for children and sought counselling services for their mental health.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eSensory-friendly environments and consistent communication techniques effectively reduced sensory overload and improved interaction quality, though the impact on overall health outcomes was limited.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(Laili et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2021\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eChallenges and Support for Parents of Children with Autism Spectrum Disorder at Work\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePeninsular Malaysia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eWorking parents of children with ASD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eMixed Methods (Interviews \u0026amp; Surveys)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eIt was reported that balancing work and caregiving responsibilities was a major challenge for parents, with stress factors including inflexible work environments and lack of employer support.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eStress from balancing work and caregiving responsibilities and lack of employer support exacerbate difficulties.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eSome parents sought flexible work arrangements, caregiver networks, and stress management strategies.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eFlexible work arrangements and colleague support were effective in reducing stress, though improvements in work-life balance depended on employer policies.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(Kaman et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2023\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eKnowledge Attitudes, and Associated Factors of Caregivers towards Children with Autism Spectrum Disorder in East Coast Peninsular Malaysia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEast Coast Peninsular Malaysia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCaregivers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eSurveys\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eHighlighted significant gaps in caregivers\u0026rsquo; knowledge and attitudes towards ASD, particularly in understanding and managing ASD-related behaviours, which led to ineffective caregiving strategies.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eNo specific safety challenges were highlighted, but gaps in knowledge led to ineffective caregiving strategies.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eNo specific management strategies were highlighted for caregivers, knowledge gaps prevented effective caregiving.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNo specific interventions were highlighted, focus was on identifying gaps in caregiver knowledge.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(Abdullah et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2022\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThe Challenges in Raising Autistic Children: The Voices of Mothers\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSelangor, Malaysia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMothers of children with ASD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eFocus Groups\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eRevealed that mothers experienced significant emotional and financial stress, often due to inadequate social support, leading to burnout and reduced quality of caregiving.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eEmotional and financial stress leads to burnout and reduced quality of caregiving.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eMothers relied on informal support networks, sought financial counselling, and engaged in self-care practices.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eInformal support networks and self-care practices helped to manage stress and prevent burnout, though the long-term effectiveness was variable and dependent on the level of support available.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(Sidique et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2022\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eThe Current Practices and Challenges of a Community-Based Early Intervention Centre for ASD Children in Malaysia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePeninsular Malaysia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eCaregivers and Educators\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCase Studies\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eFound inconsistencies in early intervention practices, particularly in accessibility and standardization, which led to disparities in the effectiveness of services provided to children with ASD.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eInconsistencies in early intervention services lead to disparities in safety and effectiveness of care.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eStandardization efforts in early intervention were made, with caregivers receiving training and support.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eStandardization efforts in early intervention showed promise in improving service effectiveness, though inconsistencies in application limited overall impact.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(Asahar et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2021\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eQuality of Life and Child's Autism-Specific Difficulties among Malaysian Main Caregivers: A Cross-Sectional Study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePeninsular Malaysia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMain caregivers of children with ASD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eCross-Sectional Study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eIdentified a strong correlation between the quality of life of caregivers and the severity of ASD-specific difficulties, with caregivers of children with more severe symptoms experiencing greater challenges and lower quality of life.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eCaregivers of children with severe ASD symptoms face greater challenges, impacting their quality of life.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eCaregivers participated in support groups and received professional counselling to cope with stress.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eSupport groups and professional counselling were effective in helping caregivers manage stress, particularly for those dealing with severe ASD symptoms in their children.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(Masuri et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2023\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eEmotional States and Quality of Life among Parents of Children with Autism Spectrum Disorder (ASD) during COVID-19 in Malaysia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePeninsular Malaysia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eParents of children with ASD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eQuestionnaires\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eShowed that the emotional states of parents, particularly stress and anxiety, were closely linked to their quality of life during the COVID-19 pandemic, with significant impacts on their mental health.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eStress and anxiety during the COVID-19 pandemic lockdown significantly affected parents' mental health.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eCaregivers practiced mindfulness, used stress management techniques, and sought temporary respite care.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eStress management techniques like mindfulness were effective in improving mental health outcomes during the pandemic, though the need for more formalized support was noted.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(Abd Latif et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2023\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2023\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eFactors Influencing Despair, Self-blame, and Acceptance Among Parents of Children with Autism Spectrum Disorder (ASD): A Malaysian Perspective\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eEast Coast Peninsular Malaysia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eParents of children with ASD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eMixed Methods (Surveys and Interviews)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eIdentified several factors contributing to despair and self-blame among parents, including financial strain, lack of social support, and the severity of the child's ASD.... Community support played a critical role in helping parents achieve greater acceptance and improve their mental health and coping mechanisms.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eFinancial strain, lack of social support, and severity of the child's condition contribute to despair and self-blame among parents.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eCaregivers engaged in community support groups, practiced acceptance and reframing, and sought professional mental health support.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eCommunity support groups and professional mental health services were effective in reducing despair and improving acceptance among parents, though outcomes varied depending on the severity of the child's condition.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(Yaacob et al., \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2021\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2021\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eBehind the Scenes of Parents Nurturing a Child with Autism: A Qualitative Study in Malaysia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003ePeninsular Malaysia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eParents of children with ASD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eQualitative Study\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eDocumented the unique challenges faced by parents, including navigating the healthcare system, managing daily routines, and dealing with social stigma, which emphasized the need for more comprehensive support.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eNavigating the healthcare system, managing daily routines, and dealing with social stigma present ongoing challenges.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eCaregivers sought professional advice, created structured routines, and advocated for the child\u0026rsquo;s needs while seeking peer support for themselves.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eProfessional advice and structured routines effectively managed daily challenges, but the overall impact on long-term health outcomes was unclear due to the complexity of needs.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(Mohamad Aun et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2022\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e2022\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eQuality of Life Among Mothers of High Functioning Autism Spectrum Disorder (HFASD) Adolescents\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eSelangor \u0026amp; Perak, Malaysia\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eMothers of adolescents with HFASD\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eQuestionnaires\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eExplored the quality of life among mothers of HFASD adolescents, highlighting ongoing challenges such as social isolation and lack of tailored support services despite their children's high functioning.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eNo specific safety challenges were highlighted, but ongoing challenges related to social isolation and lack of tailored support services for mothers.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eNo specific management strategies highlighted; ongoing challenges due to lack of tailored support services.\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003eNo specific interventions were highlighted, and the focus was on the challenges due to the lack of tailored support services.\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003e4.3 Quality assessment\u003c/h2\u003e \u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e provides a concise overview of the quality of the 13 studies that were chosen. The comprehensive evaluation indicates that a substantial percentage of the studies achieved high scores regarding data collection methods (46%) and selection bias (38%). Nevertheless, persistent deficiencies were observed in participant blinding across the investigations, with most studies (85%) being assigned a weak ranking in this category. The evaluation of variables that could affect the results yielded varied outcomes, with 23% of the studies demonstrating a high level of control, 54% showing a moderate level, and 23% displaying a low level. Regarding the study design, 23% of the studies were classified as strong, 69% as moderate, and 8% as weak. The evaluation of withdrawals and dropouts exhibited variation, with 31% of studies being classified as strong, 62% as moderate, and 8% as weak. In total, 23% of the studies were categorised as high quality, 69% as moderate quality, and 8% as low quality.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eQuality assessment results against the effective public health practice project quality assessment tool\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAuthor(s)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSelection Bias\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStudy Design\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003eConfounders\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003eBlinding\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003eData Collection\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c8\"\u003e \u003cp\u003eWithdrawals/Dropouts\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(Yalim \u0026amp; Mohamed, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2023\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStrong\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eWeak\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eStrong\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eStrong\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(Salleh et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2024\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStrong\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eWeak\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eStrong\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(Chua et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2023\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStrong\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStrong\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eWeak\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(Wong et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2024\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eWeak\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eStrong\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(Laili et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2021\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStrong\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStrong\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eWeak\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eWeak\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(Kaman et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2023\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWeak\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWeak\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eWeak\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eWeak\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eWeak\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(Abdullah et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2022\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStrong\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eWeak\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eStrong\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(Sidique et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2022\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStrong\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eStrong\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eStrong\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(Asahar et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2021\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStrong\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eWeak\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(Masuri et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2023\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eStrong\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eWeak\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eStrong\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(Abd Latif et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2023\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eStrong\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eStrong\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(Yaacob et al., \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2021\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eStrong\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eWeak\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eStrong\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e(Mohamad Aun et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2022\u003c/span\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eWeak\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eWeak\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003eWeak\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003eModerate\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eWeak\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003e4.4 Safety and health challenges in the ASD community in Malaysia\u003c/h2\u003e \u003cp\u003eThe review of the 13 chosen publications revealed several significant safety and health issues faced by individuals with ASD and their caregivers in Malaysia. More than half of the studies have identified considerable difficulties in regulating behaviours associated with ASD, specifically meltdowns, sensory processing problems, and challenging behaviours. These actions frequently led to elevated stress levels and added responsibilities for caregivers. The studies highlighted the urgent requirement for improved support systems and increased public awareness to lessen the burden on caregivers and boost the quality of care for individuals with ASD.\u003c/p\u003e \u003cp\u003eFive of the research focused on the emotional and psychological strain faced by caregivers, specifically highlighting elevated levels of stress, anxiety, and depression among parents of children with ASD (Abd Latif et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Asahar et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Masuri et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Salleh et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Yaacob et al., \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). This research identified insufficient social support and healthcare system shortcomings as significant variables contributing to caregiver distress. Six studies highlighted on the difficulties of accessing suitable services and interventions, particularly in rural or underprivileged locations(Abdullah et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Laili et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Masuri et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Sidique et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Wong et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Yaacob et al., \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). This research revealed notable deficiencies in early intervention services. It emphasised the necessity for more easily attainable, cost-effective, and culturally appropriate support systems to enhance assistance for the ASD community.\u003c/p\u003e \u003cp\u003eSeven of the studies also examined the efficacy of several behavioural and community-based approaches in enhancing outcomes for individuals with ASD (Abdullah et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Chua et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Laili et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Masuri et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Sidique et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Yaacob et al., \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Yalim \u0026amp; Mohamed, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). The studies typically concluded that customised interventions, such as well-organized schedules and surroundings designed to accommodate sensory needs, were successful in addressing specific difficulties. Nevertheless, the efficacy of these interventions was frequently compromised by inconsistent execution and a dearth of proficient practitioners, constraining their total influence. In general, the studies repeatedly found that there is a requirement for more extensive and well-coordinated support systems to tackle the complex issues experienced by individuals with ASD and their caregivers. The results indicate that the effectiveness of strategies and interventions is greatly influenced by the presence of resources, public knowledge, and the overall support services infrastructure in the community.\u003c/p\u003e \u003c/div\u003e"},{"header":"5. Discussions","content":"\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003e5.1 Prevalent safety and health challenges for individuals with ASD\u003c/h2\u003e \u003cp\u003eThe examination of the 13 chosen papers (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e) unveiled numerous prominent safety and health issues for ASD community in Malaysia. One common topic explored in nine research was the challenge of effectively handling behaviours associated with ASD, specifically meltdowns, sensory processing difficulties, and challenging behaviours (Abd Latif et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Abdullah et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Asahar et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Chua et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Laili et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Masuri et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Wong et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Yaacob et al., \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Yalim \u0026amp; Mohamed, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). These behaviours provide immediate safety and health hazards to individuals with ASD and pose considerable challenges for their caregivers. The results align with international research that recognises these behaviours as prevalent safety and health issues within the autism community (Zaniboni et al., \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Zeng et al., \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). An example of a significant safety and health risk in Malaysia is the occurrence of meltdowns in public settings. The dearth of public awareness and comprehension exacerbates these circumstances, resulting in possible injury and heightened caregiver concern. This is consistent with research conducted in other areas, emphasising caregivers' pressure while dealing with public meltdowns. This pressure is typically caused by social stigma and a lack of support from the community (Ashrafun et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Francis, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Nevertheless, this SLR highlight that these issues are exacerbated by cultural considerations, resulting in heightened public scrutiny and increased complexity for caregivers.\u003c/p\u003e \u003cp\u003eFive investigations highlighted sensory sensitivities as a significant concern, often resulting in sensory overload (Chua et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Laili et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Masuri et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Wong et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Yalim \u0026amp; Mohamed, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) .Experiencing excessive sensory stimulation can lead to challenging reactions or social retreats, making it more challenging to ensure safety and health in both domestic and public environments. The results align with global studies that recognise sensory processing difficulties as a notable element that contributes to safety and health hazards for individuals with ASD (Brown, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Camarata et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Nevertheless, the research conducted in Malaysia emphasised the scarcity of sensory-friendly spaces, which is in stark contrast to countries with more developed infrastructure, resources, and policies that cater to the needs of ASD individuals where such accommodations are becoming more prevalent (Lin et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Sousa et al., \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).This discrepancy highlights the necessity for increased focus on sensory requirements in Malaysia, specifically in public and educational environments.\u003c/p\u003e \u003cp\u003eWandering around or running away from a safe environment without permission or supervision, which was observed in four of the studies, presents substantial safety and health hazards (Laili et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Wong et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Yaacob et al., \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Yalim \u0026amp; Mohamed, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), and is a widely recognised concern in the literature (Celia et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Hodgetts, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Meads, \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) where wandering is seen as a significant risk that necessitates the implementation of dedicated safety and health mechanisms. The journal articles in this review has found that the absence of secure surroundings and sufficient supervision are factors that contribute to this risk in Malaysia(Laili et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Yaacob et al., \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Yalim \u0026amp; Mohamed, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Nevertheless, the situation in Malaysia emphasises the necessity for greater consciousness and measures or resources aimed at preventing ASD individuals from wandering (Mokhtar, \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2023\u003c/span\u003e), especially in rural or disadvantaged regions where caregivers may lack access to specialised instruction or assistance.\u003c/p\u003e \u003cp\u003eIn general, the assessment underscores the complex nature of safety and health concerns faced by individuals with ASD in Malaysia, emphasising that these issues are closely connected to the daily experiences of caregivers. The assessment highlights safety and health issues that are consistent with global trends, but it also identifies specific challenges that are unique to the setting. These challenges include the heightened public attention during meltdowns and the absence of sensory-friendly environments. To tackle these safety and health concerns, it is necessary to employ a combination of public education, enhanced environmental adjustments, and specific treatments designed to meet the distinct requirements of the ASD population in Malaysia. These findings establish a solid basis for future research and policy formulation to improve safety and health outcomes for individuals with ASD and their caregivers in Malaysia.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec14\" class=\"Section2\"\u003e \u003ch2\u003e5.2 Caregivers\u0026rsquo; Management Strategies\u003c/h2\u003e \u003cp\u003eThis SLR reveals a range of intervention utilised by caregivers to manage the safety and health issues linked to the care of individuals with ASD. Although frequently successful, these techniques underscore both the ingenuity of caregivers and the substantial deficiencies in institutional support systems. One prevalent approach seen in seven of the research was implementing organised schedules and employing soothing methods to regulate behaviours such as meltdowns, hostility, and sensory overload (Abd Latif et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Abdullah et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Chua et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Laili et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Masuri et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Yaacob et al., \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Yalim \u0026amp; Mohamed, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). This approach is in line with previous research, which emphasises the significance of consistency and predictability in decreasing anxiety and behavioural challenges in individuals with ASD (John \u0026amp; Hemalatha, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Rizzo et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Nevertheless, the ASD caregivers frequently create this intervention independently, with minimal input from healthcare experts. In contrast, research conducted in more advanced countries has shown that caregivers usually undergo more structured training in behaviour management approaches (Sun, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). The dependence on personally devised intervention highlights the urgent requirement for caregiver training programmes in Malaysia that are more easily accessible.\u003c/p\u003e \u003cp\u003eAnother commonly stated method was utilising informal support networks, such as family and community organisations, as observed in six research studies (Abd Latif et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Abdullah et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Laili et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Masuri et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Salleh et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Yalim \u0026amp; Mohamed, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Caregivers frequently relied on these networks to seek emotional support, respite care, and guidance in handling daily challenges. This finding aligns with worldwide research that emphasises the significance of social support in reducing caregiver stress and enhancing overall well-being (Li et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). The support networks are typically informal and do not possess the same level of organisation and resources as more formal support systems found in other nations. This highlights a deficiency in the accessibility of official assistance services, which may be resolved by establishing further structured community-based initiatives that offer dependable and continuous support to caregivers. Additionally, ASD caregivers reported engaging in discussions to establish flexible working hours, exploring opportunities to work remotely, or decreasing their work hours to handle their caring responsibilities effectively (Yaacob et al., \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). These findings align with other international studies that acknowledge the significance of workplace flexibility in mitigating caregiver stress and enhancing work-life equilibrium (Bainbridge \u0026amp; Townsend, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Nevertheless, from this review, obtaining such agreements can be challenging, especially in work situations that are more traditional or less innovative as in Malaysia (Laili et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Masuri et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Salleh et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Yaacob et al., \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). This poses a substantial obstacle for caregivers who must balance the requirements of their job and caregiving responsibilities without enough institutional assistance.\u003c/p\u003e \u003cp\u003eThe research also emphasised the significance of self-care habits among caregivers, which were examined in four investigations. Caregivers employed strategies such as practising mindfulness, engaging in physical activity, and seeking respite care to address their own mental and physical well-being effectively (Abd Latif et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Abdullah et al., \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Masuri et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Yalim \u0026amp; Mohamed, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). These practices align with suggestions from international literature, which emphasise caregivers' need to prioritise their well-being to maintain their caregiving role (Levin \u0026amp; Machado-Gonzalez, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). However, the efficacy of these measures was frequently constrained by time and financial constraints, since numerous caregivers encountered challenges in continuously upholding self-care routines due to the demanding nature of their duties. In summary, the analysis emphasises that caregivers in Malaysia utilise various approaches to address the challenges associated with caring for individuals with ASD. However, these approaches are typically formulated due to the absence of professional assistance and training. In contrast, caregivers usually have access to a broader range of formalised support services and interventions in contexts with more resources. The results indicate a significant requirement for contextually suitable support structures and training programmes in Malaysia. These would enable caregivers to handle better the safety and health challenges related to ASD.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec15\" class=\"Section2\"\u003e \u003ch2\u003e5.3 Effectiveness of interventions in improving safety and health\u003c/h2\u003e \u003cp\u003eThe studies assessed various interventions, including behavioural therapies, community-based programmes, and early intervention services. The effectiveness of these interventions varied. Four research studies examined behavioural therapies, including applied behaviour analysis (ABA), structured teaching approaches, and sensory integration therapy, to address problematic behaviours and enhance safety and health (Chua et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Masuri et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Sidique et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Yaacob et al., \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). The results typically confirm the efficacy of these therapies, especially in reducing challenging behaviours and addressing sensory sensitivities. Research investigations that utilised Applied Behaviour Analysis (ABA) have shown a significant reduction in instances of self-injury and violence. These findings align with worldwide research highlighting the effectiveness of ABA in addressing severe behavioural problems in individuals with ASD (Sturmey, \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). Nevertheless, in this review, studies emphasised a crucial obstacle where the effectiveness of these interventions relies greatly on the regular implementation and the presence of skilled practitioners, which are frequently scarce in this country. In contrast to more developed nations, where there is a greater abundance of experienced professionals and resources, resulting in better rates of success in intervention outcomes (de Jonge et al., \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eTwo studies also examined community-based support programmes to equip caregivers with the necessary skills and resources to handle safety and health problems effectively (Sidique et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Wong et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). The programmes, which encompassed support groups and workshops, were discovered to be especially advantageous in rural areas where formal services were deficient. The study by Sidique et al. (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) demonstrated that the efficacy of these programmes was frequently constrained by disparities in availability and divergent standards of excellence, indicating a necessity for more uniform and easily available community support programmes throughout Malaysia. The findings are supporting Sharma et al. (2022) that emphasized the value of structured support systems. Their study demonstrated that parent-to-parent support groups effectively reduced anxiety and stress among caregivers of children with ASD. This is because, the support groups provided mutual support, psychoeducation, and stress management strategies. Notably, the intervention resulted in statistically significant reductions in parental stress and anxiety, reinforcing the importance of structured community programs. These studies underscore the necessity for a more cohesive approach to caregiver support in Malaysia. While Sidique et al. focused on the geographical disparities in service availability, Sharma et al. provided evidence of how structured and well-implemented programs can enhance caregiver resilience. This emphasizes the need for scalable, culturally relevant, and quality-assured support mechanisms to ensure consistent outcomes across diverse regions.\u003c/p\u003e \u003cp\u003eFurthermore, one research investigated using sensory-friendly surroundings and resources, such as sensory rooms and adaptive equipment, to alleviate sensory overload and enhance safety (Wong et al., \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). The effectiveness of these interventions in promoting safety and health for individuals with ASD, particularly in addressing sensory sensitivities that may result in behavioural challenges or self-injurious behaviours, was generally seen. This discovery aligns with global research that supports the implementation of sensory-friendly environments to decrease anxiety and improve the safety and health of individuals with ASD (Anemone, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Antosh et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Nevertheless, the research highlighted that such environments are scarce in Malaysia, especially in public spaces and schools. This indicates a significant gap that must be filled to fully capitalise on these interventions' advantages. In summary, the studies examined in this SLR suggest that there are interventions that can effectively enhance safety and health outcomes for individuals with ASD. However, the effectiveness of these interventions is frequently hindered by external factors such as limited access to services, availability of resources, and inconsistent implementation of programmes. The results highlight the necessity of implementing a more organised strategy for ASD care in Malaysia. This should involve prioritising the expansion of skilled professionals' accessibility, standardising community support programmes, and enhancing the availability of early intervention services, especially in areas that lack sufficient resources.\u003c/p\u003e \u003c/div\u003e"},{"header":"6. Limitation","content":"\u003cp\u003eThe review was restricted to studies published in English, potentially excluding relevant literature in other languages, and focused only on papers published between 2019 and 2024, which may overlook earlier foundational studies. Additionally, most of the analyzed studies were of moderate quality, limiting the robustness of the findings. Variations in the implementation and evaluation of interventions across studies further complicate generalization of results. While the focus on the Malaysian context offers important cultural and regional insights, it limits the applicability of findings to other settings with different social, cultural, and healthcare landscapes. Despite these limitations, this review serves as a crucial foundation for future research and policy development to improve safety and health outcomes for individuals with ASD and their caregivers in Malaysia.\u003c/p\u003e"},{"header":"7. Conclusion","content":"\u003cp\u003eThis review highlights critical safety and health concerns for individuals with ASD, including meltdowns, sensory processing difficulties, and challenging behaviours, which pose risks to both individuals with ASD and their caregivers in Malaysia. Caregivers often rely on self-created routines and informal support due to deficiencies in formal systems, while interventions such as behavioural and community-based programs showed promise but are hindered by inconsistent implementation and limited accessibility. The lack of organized instruction and affordable, widely available early interventions further exacerbates these challenges, particularly in rural areas. To improve safety and health outcomes, there is an urgent need for inclusive, culturally tailored, and accessible support systems that address the diverse needs of individuals with ASD and their caregivers. Future efforts should focus on eliminating disparities, ensuring equitable access to resources, and strengthening public awareness and support networks.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eStatement on the accessibility of data\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe article/supplementary material contains the study\u0026rsquo;s original contributions. Additional questions should be addressed to the corresponding author(s).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of Competing Interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgement\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was self-funded.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eAbd Latif, M. H., Wan Ismail, W. S., Abdul Manaf, M. R., \u0026amp; Abdul Taib, N. I. (2023). Factors Influencing Despair, Self-blame, and Acceptance Among Parents of Children with Autism Spectrum Disorder (ASD): A Malaysian Perspective. \u003cem\u003eJournal of Autism and Developmental Disorders\u003c/em\u003e. https://doi.org/10.1007/s10803-023-06155-8\u003c/li\u003e\n\u003cli\u003eAbdullah, H., Asraf, R. 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A Review of Physical Safety for Individual with Autism Spectrum Disorder. \u003cem\u003eInternational Journal of Education and Humanities\u003c/em\u003e, \u003cem\u003e6\u003c/em\u003e(3), 71\u0026ndash;74. https://doi.org/10.54097/ijeh.v6i3.4184\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"Universiti Utara Malaysia","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Autism Spectrum Disorder, Safety Challenges, ASD Caregiver, Intervention Strategies, Malaysia","lastPublishedDoi":"10.21203/rs.3.rs-6089146/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6089146/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eAutism Spectrum Disorder (ASD) presents significant challenges globally, and in Malaysia, these challenges are compounded by limited resources and culturally specific obstacles. This systematic literature review (SLR) critically examines empirical studies published between 2019 and 2024 to elucidate the primary safety and health challenges faced by individuals with ASD and their caregivers, as well as the management strategies and interventions employed to address these issues in the Malaysian context. Guided by the PRISMA framework, we searched four major academic databases namely Scopus, Web of Science, ScienceDirect, and Google Scholar and using targeted keywords related to autism safety, caregiver stress, and intervention strategies. After rigorous screening and quality assessment using the Effective Public Health Practice Project (EPHPP) tool, 13 studies were deemed eligible for inclusion. Our review identifies several recurring challenges, including difficulties in managing meltdowns, sensory processing issues, and the risks associated with wandering. These challenges exacerbate caregiver burden, contributing to increased stress, anxiety, and social isolation. Caregivers frequently resort to self-devised strategies such as structured routines, informal support networks, and mindfulness practices. Although various behavioural therapies, community-based programs, and early intervention services show promise in mitigating these challenges, their overall effectiveness is often limited by inconsistent implementation, resource scarcity, and a lack of standardized training for caregivers. The findings underscore the urgent need for contextually tailored support systems and policies that enhance caregiver training and expand accessible, standardized interventions. This review not only highlights the unique safety and health issues within the Malaysian ASD community but also provides a robust foundation for future research and policy development aimed at improving outcomes for both individuals with ASD and their caregivers.\u003c/p\u003e\n\u003cp\u003e\u003cbr\u003e\u003c/p\u003e","manuscriptTitle":"Navigating Safety and Health Challenges in Autism Spectrum Disorder Care in Malaysia: A Systematic Literature Review of Caregiver Perspectives and Intervention Outcomes","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-02-26 14:38:58","doi":"10.21203/rs.3.rs-6089146/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"de4cc1de-fbb6-4caf-893b-1cfe9c5ae411","owner":[],"postedDate":"February 26th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[{"id":44738296,"name":"Psychology"},{"id":44738297,"name":"Health Policy"},{"id":44738298,"name":"Epidemiology"}],"tags":[],"updatedAt":"2025-02-26T14:38:58+00:00","versionOfRecord":[],"versionCreatedAt":"2025-02-26 14:38:58","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6089146","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6089146","identity":"rs-6089146","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}