Exploring the potential of civic engagement to strengthen mental health systems in Indonesia (IGNITE): a study protocol

An exploration of the Indonesian lay mental health workers' (cadres) experiences in performing their roles in community mental health services: a qualitative study

BACKGROUND

Volunteers trained to support community mental health programs in Indonesia are known as 'mental health cadres.' These are lay people trained to provide basic support for people with mental illness in their local communities. The role of cadres in community mental health services is to provide health promotion activities and support for people with mental illness, such as home visits and family assistance. Their contribution can potentially address the challenges health services currently face in remote and resource-limited settings. However, little is currently known about implementing this form of the lay workforce and the experiences of mental health cadres in Indonesia in particular. This study aimed to explore the experience of cadres when performing their roles in community mental health services in Indonesia from the cadres' perspective.

METHODS

The study employed a descriptive qualitative design. Purposive sampling was employed to recruit cadres with at least one year of experience handling those diagnosed with schizophrenia across four geographical areas in Java and Sumatra, Indonesia. Data were collected utilising focus groups undertaken between July and November 2020. Due to COVID-19 restrictions, eight focus group sessions for mental health cadres were carried out virtually via Zoom and non-virtual, facilitated by local moderators. Data were analysed using thematic analysis.

RESULTS

The study involved 71 cadres in four regions: Aceh, Jakarta, West Java and East Java. The majority of participants were looking after their families with a minimum of high school-level qualifications. Four themes were interpreted from the data: (1) Motivation for volunteering, (2) The role of cadres in supporting mental health services, (3) Training and support needs in carrying out cadre roles, and (4) Barriers and facilitators to the implementation of cadre roles in local communities.

CONCLUSIONS

Cadres reported a motivation to help people improve their mental health and reduce the stigma associated with mental illness. Cadres also contributed to secondary and primary prevention of mental illness with some limitations. This study's results are relevant to those wishing to understand and optimise the implementation of lay workforces in resource-limited settings.

Lay community mental health workers (cadres) in Indonesian health services: A qualitative exploration of the views of people with mental health problems and their families

INTRODUCTION

In community-based mental health services, lay workers recruited and trained to support mental health programs, known as mental health cadres, have an important role in supporting the care of families and people with mental disorders. This study aims to explore the experiences of people with mental disorders and their families about the role of mental health cadres in improving mental health and caring for people with mental disorders.

METHODS

This study employed a qualitative descriptive design for data gathering. Focus groups were conducted between August 2020 and January 2021 with 19 people with mental health difficulties (people diagnosed with schizophrenia) and 25 family members who are the primary caregivers of people with mental disorders from three provinces in Indonesia: West Java, East Java, and Aceh. Participants were purposively sampled with inclusion and exclusion criteria used were people with mental disorders and their families who regularly interact with mental health cadres. Data were analyzed using inductive thematic analysis through six stages of coding and theme development.

RESULTS

Several themes were identified. The most significant theme was emotional support provided by cadres in terms of reception from cadres about people with mental health problems (59.1%), tangible support in which cadres help people with mental disorders get treatment (52.27%), and cadre roles as duties/mandates (51.36%) was factors that facilitated the success. The finding of this study indicated that cadres were considered to provide a range of different support to people with mental health disorders and their families. In carrying out their role, there were factors that participants felt increased success in implementing the role of cadres. The cadre-patient/family relationship was influenced by perceived shame, trust relationship, and stigma. This research also revealed patient and family expectations about cadres' roles.

CONCLUSIONS

Exploring the experiences of people with mental disorders and their families who received support from cadres could examine the factor that increases success in implementing cadre roles and barriers to mental health services by cadres, which are shame, mistrust, and stigma in the community. Therefore, paying attention to the expectations of people with mental health problems and their families about the cadre's roles in improving mental health services in the community is essential.

Barriers and facilitators to access mental health services among people with mental disorders in Indonesia: A qualitative study

Background

The care and treatment management of people with mental health problems has become a prominent global concern in recent years that requires consistent attention. However, the literature suggests that only a small percentage of individuals with mental health problems in Indonesia receive the necessary mental health care. Therefore, it is crucial to explore this gap.

Objective

This study aimed to explore barriers and facilitators that affect access to mental health services among people with mental health disorders in Indonesia.

Methods

The study employed a qualitative descriptive design and focused on individuals with depression, anxiety, or bipolar disorder. Data were collected through in-depth interviews conducted via WhatsApp chat with 90 participants aged 18-32, who were purposively selected from Sumatra, Java, Kalimantan, and Papua Islands in Indonesia between January and June 2022. Thematic analysis was used to analyze the data.

Results

The barriers to accessing mental health services included: 1) uneasy access to mental healthcare facilities, 2) stigma, lack of social support, and delay in receiving proper treatment, and 3) expensive treatment costs without national health insurance membership. Importantly, the facilitators to access mental health services included: 1) national health insurance membership, 2) support from spouse, family, and closest friends and its association with mental health literacy, and 3) self-help.

Conclusion

The widespread distribution of mental health knowledge is recommended among healthcare providers, including public health practitioners and primary care nurses, to enhance their mental health literacy and competencies while rendering services to individuals with mental disorders. Additionally, efforts should be made to educate and promote awareness among caregivers and communities to reduce the stigma faced by those with mental disorders.

Exploring the perceived challenges and support needs of Indonesian mental health stakeholders: a qualitative study

Background

Despite the large treatment gap in Indonesia, limited studies have attempted to explore both service users’ and providers’ evaluations of the current mental health system holistically. This study aims to explore the perceived challenges and support needs of Indonesian mental health stakeholders.

Methods

This qualitative study collected data from 17 participants from two mental health stakeholders in Yogyakarta (i.e., health professionals and service users) through a semi-structured interview. Thematic analysis was used to analyze the data.

Results

Findings reveal that service providers and users shared equally strong concerns regarding challenges and needs for improving mental health literacy, accessibility to services, and government support. However, a distinct emphasis was made in several areas—with service providers hinting more towards issues with interprofessional collaboration. In contrast, service users emphasized the negative attitude of health professionals and poor accessibility to service information.

Conclusion

The mental health service system is challenged by the lack of accessibility to service information, the limited spread of mental health practitioners, stigma, and lack of mental health literacy among both the public and professionals. A need for improvement in mental health promotion, accessibility, and quality of mental health workers is highlighted to satisfy the needs of both service users and providers.

Civic engagement and mental health system strengthening in Indonesia: a qualitative examination of the views of health professionals and national key stakeholders

BACKGROUND

Mental health services in Indonesia are developing rapidly in response to national and global health policy to support people living with psychosis. This presents a unique opportunity for civic engagement, the active involvement of patients, carers and communities in mental health care, to shape emergent services. In-depth explorations of the views of professionals and other key stakeholders in mental health care on the use of civic engagement in Indonesia are lacking which contributes to a limited understanding of its potential in this regard. The study aimed to explore contemporary professionals' and other key stakeholders' perspectives on the current use of and potential for civic engagement to strengthen mental health systems in Indonesia.

METHODS

Qualitative interviews were undertaken and analysed using thematic analysis underpinned by a critical realist approach. Eighteen multi-disciplinary professionals and lay health workers involved in mental health care in Jakarta and Bogor and 10 national key stakeholders were recruited.

RESULTS

Despite high levels of awareness of and support for civic engagement amongst mental health professionals and policy makers combined with a nascent grass roots movement, analysis revealed unstructured and insufficient mechanisms for civic engagement which resulted in ad-hoc and mostly superficial levels of involvement activity. Civic engagement was thought to require a marked shift in existing practices as well as organisational and societal cultures. Challenging stigma is a key feature of civic engagement and our analysis highlights the relevance of social contact methods which are locally and culturally contextualised in this regard. Our findings point to a need to expand current definitions of civic engagement which focus on indivdiual enablement to ones that also encompass environmental and organisational enablement to optimise the future use of civic engagement in mental health settings.

CONCLUSIONS

Key mental health stakeholders have identified that central aspects of Indonesian culture are well aligned to the ethos of civic engagement which has the potential to facilitate the enactment of recent global health policy. However, full realisation is likely to be impeded by prevailing paternalistic cultures in mental health services and high levels of stigma and discrimination towards those with mental illness in Indonesia without intervention.

Exploring the potential use of patient and public involvement to strengthen Indonesian mental health care for people with psychosis: A qualitative exploration of the views of service users and carers

BACKGROUND

Patient and public involvement (PPI) has the potential to strengthen mental health systems in Indonesia and improve care for people living with psychosis. Current evidence from other parts of the world demonstrates the need to understand the contexts in which PPI is to be enacted to ensure optimal implementation.

OBJECTIVE

To understand service users' and carers' views on the current use and potential applicability of PPI within Indonesian mental health services.

DESIGN

Qualitative study incorporating focus groups analysed using thematic analysis.

SETTING AND PARTICIPANTS

Participants included 22 service users and 21 carers recruited from two study sites in Indonesia (Jakarta and Bogor). All participants had experience of psychosis either as a service user or carer.

RESULTS

Despite the value attributed to PPI in relation to improving services and promoting recovery, current use of such activities in Indonesian mental health services was limited. Participants expressed a desire for greater levels of involvement and more holistic care but felt community organizations were best placed to deliver this because PPI was considered more congruent with the ethos of third-sector organizations. Additional barriers to PPI included stigma and low levels of mental health literacy in both health services and communities.

DISCUSSION AND CONCLUSION

Participants felt that there was potential value in the use of PPI within Indonesian mental health services with careful consideration of individual contexts. Future aspirations of involvement enactment should ensure a central design and delivery role for third-sector organizations. Facilitators to global collaborative research in the context of the current study are also discussed.

Implementing civic engagement within mental health services in South East Asia: a systematic review and realist synthesis of current evidence

INTRODUCTION

Civic engagement (CE) has the potential to transform mental health services and could be particularly important for low and middle-income countries (LMICs), which are rapidly developing to respond to the burden of poor mental health. Research from high income countries has found many challenges associated with the meaningful implementation of CE in practice, but this has been underexplored in LIMCS and in South East Asia (SEA) in particular.

METHODS

We completed a realist synthesis and systematic review of peer reviewed publications and grey literature to identify the context and actions which promote successful implementation of CE approaches in SEA. We used a theory-driven approach-realist synthesis-to analyse data and develop context-mechanism-outcome configurations that can be used to explain how civic engagement approaches operate in South East Asian contexts. We worked closely with patient and public representatives to guide the review from the outset.

RESULTS

Fifty-seven published and unpublished articles were included, 24 were evaluations of CE, including two Randomized Controlled Trials. The majority of CE interventions featured uptake or adaptation of Western models of care. We identified important cultural differences in the enactment of civic engagement in SEA contexts and four mechanisms which, alongside their contextual barriers and facilitators, can be used to explain how civic engagement produces a range of outcomes for people experiencing mental health problems, their families and communities. Our review illustrates how CE interventions can be successfully implemented in SEA, however Western models should be adapted to fit with local cultures and values to promote successful implementation. Barriers to implementation included distrust of services/outside agencies, stigma, paternalistic cultures, limited resource and infrastructure.

CONCLUSION

Our findings provide guidance for the implementation of CE approaches within SEA contexts and identify areas for further research. Due to the collectivist nature of many SEA cultures, and the impact of shared traumas on community mental health, CE might best be implemented at community level, with a focus on relational decision making.Registration This review is registered on PROSPERO: CRD42018087841.

Evaluating the acceptability of a co-produced and co-delivered mental health public engagement festival: Mental Health Matters, Jakarta, Indonesia

BACKGROUND

Public engagement events are an important early strategy in developing a meaningful research agenda, which is more impactful and beneficial to the population. Evidence indicates the potential of such activities to promote mental health literacy. However, this has not yet been explored in Indonesia.

AIM

This paper describes a mental health public engagement festival carried out in Indonesia in November 2018 and uses evaluation data to consider the acceptability and use of such activities in Indonesia in the future.

METHOD

Evaluation data was collected from 324 of the 737 people who attended a six-day mental health festival comprising 18 events including public lectures, film screenings, arts activities, exercise classes and panel discussions. Attendees were asked to evaluate the festival in terms of its quality, benefits and areas for improvement. Descriptive statistics were used to analyse the evaluation data. 87 service users, carers, academics and professionals also engaged in a research prioritisation exercise to collaboratively determine mental health research priorities for Indonesia.

RESULTS

Participants evaluated the festival extremely positively with a significant majority (92%) rating the quality of the festival as good or excellent. Attendees reported an increase in their understanding of mental health issues and identified intended behaviour change including an increased propensity for future engagement with mental health research. Key strengths of the festival included the central role of patients, carers and the local community in the design and delivery of the festival which promoted emotional engagement and development of shared understanding and the use of international experts which in attendees' opinion further enhanced the credibility of festival activities.

CONCLUSION

This manuscript indicates that a co-produced mental health public engagement festival is a potentially acceptable way to increase awareness of mental health in Indonesian populations. Future festivals should be larger in scope and target men, older people and the general public to maximise benefit and incorporate rigorous evaluation of effectiveness.

Early psychosis in Indonesia: reflections on illness and treatment

This paper provides an overview of more than 22 years of research conducted in the central Javanese province of Yogyakarta, Indonesia, by teams of researchers associated with Gadjah Mada University and Harvard University, led by the authors of this essay. This work is placed in the context of the very limited literature on early psychosis and mental health services in Indonesia. It provides an overview of mental health services in Indonesia and of this team's research trajectory, then addresses four key domains: the cultural phenomenology of early experiences of psychotic illness; patterns of onset, with a particular focus on extremely rapid onset psychoses; patterns of care-seeking for first episode illness; and mental health services and patterns of utilization. It then discusses the importance of rapid onset psychosis for research on early psychosis, and the question of whether collinearity of rapidity of onset and rapidity of care-seeking raises questions about the long-standing finding that a short duration of untreated psychosis leads to better outcomes. It concludes by discussing difficulties of prioritizing early intervention models in settings with very low mental health resources.