Evaluating treatment of Axis I mental health disorders in Aceh, Indonesia

Abstract

Aims and methodTo share evaluation findings of a new decentralised mental healthcare system addressing Axis I disorders, developed in four subdistricts of Aceh Besar in Indonesia following the 2004 Asian tsunami. Two complementary methodologies were employed: an adequacy survey that assessed whether agreed programme implementation tasks were completed, and an outcome study that utilised patient, caregiver and staff assessment of the programme to determine what changes, if any, resulted from participation in the programme.ResultsThe system is functional in 3 of 4 subdistricts, and 47 of 53 subdistrict clinics (puskesmas) have trained mental healthcare nurses. Both patients and caregivers reported statistically significant differences when ranking patient wellbeing and were able to qualitatively describe specific changes in patient symptomatology and social functioning.Clinical implicationsResults indicate that (a) the creation of a decentralised system with outreach at multiple levels, (b) emphasis on staff capacity building within a wider household-to-hospital continuum of care, and (c) incorporation of community volunteers working with trained medical personnel led to effective treatment options for people with Axis I disorders in a resource-poor setting.

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

“…These initiatives could be particularly valuable in building community resilience and preparedness for natural disasters. For example, following the 2004 Asian Tsunami, trusted community volunteers played a key role in the delivery of much needed mental health services [49].…”

“…Most sources described civic engagement as featuring people with a lived experience of mental health problems (n = 18) or family members/carers (n = 18), however members of the wider local community (n = 15) were also frequently involved. Community members were typically identified as 'trusted individuals' , or community leaders, such as village chiefs, elders, teachers, or religious figures [37,46,49,50]. Civic engagement activity mainly comprised the involvement of service users, carers, or community members in the delivery of services (n = 18), other sources described the involvement of service users, or their families in decision making about care (n = 10), or in the development or adaptation of services (n = 6).…”

“…At an individual level, building trust could be difficult when service users and their families did not want to work with services (C4) due to negative experiences of care, or relationship conflict [44,55]. However, trusting relationships between services, service users and their communities could also lead to increased engagement and service use (O6 [42,44,59]), this was particularly evident where programs trained trusted community members (kader) to work alongside clinicians, allowing them access to communities that might otherwise not be engaged [49,53]. Improved relationships between service users, families and clinicians also meant they could work more collaboratively, increasing the likelihood of person centered care (O5).…”

“…This often required a fundamental shift in current ways of working; a number of sources described how key opportunities for change (C3) opened up space for lived experience to inform the design and delivery of new services. For example, following the tsunami in Indonesia there was an influx of donations and interest from international agencies, which led to the development of a new, decentralised, mental healthcare system, staffed at a village level by community volunteers (kader [49]). There were also accounts of how campaigns and pressure from local NGOs and international agencies, such as the World Health Organisation, were drivers for change (O3 [58,68]).…”

“…A lack of understanding of mental health and the benefits of involvement, awareness of patient's rights and a lack of confidence and knowledge about how to assert these rights was a barrier (C4 [39,44,46,64,69]). A further barrier was the limited infrastructure available to support involvement (C5), such as limited funds, transportation to access remote communities, understaffing, and limited organisational support for involvement from NGOs and statutory services, at both a local and national level [39,47,49,58,59,62,69].…”