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Presented at Regional Forum Community Mental Health
in WHOIndonesia , 23-25Oct 2007
By: Dr. Budi Anna Keliat, SKp, MAppSc
Lecturer Faculty of Nursing University of Indonesia,
CMHN Team Leader,
ADB-ETESP Consultant

1. Introduction
The earthquake and tsunami disaster in Nanggroe Aceh Darussalam and Nias has had lasting effects in the absence of effective and adequate community mental health services even prior to the disaster. Even physical problems such as losing property and health problems have affected the emotional status of inhabitants of Aceh, although there has also been some rebuilding of the physical infrastructure. Communities have experienced various mental health problems from mild to severe. Currently, mental health care in Indonesia focuses primarily on mental hospitals, which means, waiting for the patient to be brought to the mental hospital. The program of prevention, promotion, and rehabilitation efforts in the community have been given minimal or less attention, as so often happens in developing countries. However, based on a survey conducted by the Department of Health of Indonesia (SKKRT, (Household Survey) 1995) found that 264 of 1000 family members suffering from mild to severe mental disorders. Meanwhile, who have been hospitalized in mental hospital are those who suffer mainly (but not only) from severe mental disorders and many other persons with mental disorders in the community are not being treated. Based on this fact, there is a clear need to to provide not only mental hospital (hospital based)services but such services need to be accompanied by community mental health services (community based) in order that patients who have never been treated can be cared for immediately.
After the disaster, it was predicted that the number of persons suffering from mental disorder would increase. This is entirely in keeping with the international literature on expected increases of some types of mental health problems. For example in one province in Indonesia most affected by tsunami (Aceh) only has one mental hospital for 4.220.000 population. There are 308 people in the psychiatric hospital. In keeping with international good practice and recommendations from WHO it was regarded as important to take the opportunity of external funding coming into Aceh to develop an integrated system of services for the first time. For that reason, the focus of service development is the public health center (primary health care) in the every district. Human resources in the health centre needed to be trained to provide mental health service in the community.
Three months after the tsunami a programme was developed to train community mental health nurses based at the public health centre (puskesmas). This programme envisaged the development of community mental health nurses at three levels of competency and curriculum development has proceeded on this basis. This curriculum is divided into three phases: Basic Course Community Mental Health Nursing (BC-CMHN), Intermediate Course Community Mental Health Nursing (IC-CMHN), and Advanced Course Community Mental Health Nursing (AC-CMHN).
2. Training of Mental Health Service for Health Providers
The framework of developing the mental health system is based on a comprehensive and integrated model of services. Community mental health nursing has therefore been developed with this framework in mind. Mental health training in Aceh has been progressing in the following areas since the tsunami in December 2004.
a. Training for nurses:
  1. Community mental health nursing (CMHN) for nurses in the public health center
CMHN training is divided into 3 steps:
    1. Community mental health nursing: Basic
The objective of this training is the nurses have ability to take care persons with mental disorders in their home in the community, which focused of caring to the patient and family
    1. Community mental health nursing: Intermediate
The objective of this training is the nurses have the ability to take care psychosocial problems, train the community leaders to be cadre of mental health and develop village alert to mental health (Mental Healthy Village)
    1. Community mental health nursing: Advanced
The objective of this training is the nurses have ability as a leader, advocate, researcher, take care for mentally healthy (mental health promotion), and case manager.
  1. Professional psychiatric nursing practice model for nurses in the mental hospital
The objective of this training is to provide professional nursing service in the hospital based on 4 elements: management approach, compensatory reward, professional relationship and patient care delivery.
  1. Psychiatric intensive care for nurses in the psychiatric intensive care unit in general hospital
The objective of this training is to provide mental health service in psychiatric unit in general hospital
  1. Clinical instructor for nurses act as lecture in school of nursing
The objective of this training is the lecture for mental health nursing course have ability of teaching learning process in the field practice, especially practice in the community, psychiatric unit in general hospital and mental hospital.
b. Training for general practitioner:
  1. General practitioner plus (GP+)
The objective of this training by the Ministry of Health is to give the GP some basic ability to provide early detection and prompt treatment for patients in the health centre. The GP should have the ability to make an appropriate diagnosis if there is a mental disorder as well as prescription, and to decide whether the patient needed referral to mental hospital. This is primary service for mental health problems. This was a 4 day course offered initially before the tsunami in the conflict areas and was supported by WHO a few months following the tsunami. This training has not been implemented in Aceh since 2005 and has been superseded by the modular approach to the joint training of nurses and doctors as part of the ADB funded community mental health nursing programme.
  1. Medical Officer of Mental Health (MOMH)
The objective of this training will be to upgrade the training of GPs to have the ability to provide services at the secondary level health in psychiatric units in general hospitals. MOHM will have the competency to take care of patients suffering from acute conditions (new patient and those who have suffered a relapse), and referral to mental hospital or the nearest public health center. She/he will also provide supervision for GP’s in the public health center. The curriculum and module development of the MOMH programme is being supported by the Asian Development Bank and will be implemented in Aceh for the first time in Indonesia in October 2007.
3. Implementation of Mental Health Nurse Training in Aceh Province,
a. Community Mental Health Nursing
  1. CMHN Basic
The curriculum and the modules were developed by experts in mental health nursing in 2005. The piloting of the basic module and the implementation of the training was undertaken in one district in Aceh initially. This has since been followed by training for 20 districts (10 supported by WHO and 10 supported by ADB). This year, the remaining one district in Aceh will receive training (supported by ETESP Health-ADB), thereby covering the whole province. The training will be followed by 3 month implementation, supervision, monitoring and evaluation. To date 614 nurses have been trained in total at the basic level.
  1. CMHN Intermediate
The curriculum and the modules were developed by expert nurses and trainers who make up the National Forum for Mental Health Nursing . The piloting of the module and the training was funded by WHO in one district which performed well in the implementation of the basic course and was therefore chosen as the pilot site. The training for other districts in 2006 have been supported by HSP USAID for 4 districts and in 2007 have been supported by ADB-ETESP Health for 2 districts one hundred sixty eight (167) nurses were trained at the intermediate level, 2106 community leaders (cadres for mental health) and the level of awareness for mental health disorders raised in 343 villages (community development) named Desa Siaga Sehat Jiwa (village of mental health allertness).
This year, ADB-ETESP Health will continue training in 7 districts following the same standard of 3 phases over a one month period followed by 4 month implementation, supervision, monitoring and evaluation.
To date the community mental health nurses have identified 8016 patients with severe mental health problems, 181 of that in chain.
iii CMHN: Advanced
The curriculum and the module has been developed by the same group of expert nurses as with the basic and intermediate course. For the advanced course in Aceh, it is expected the pilot will be in August 2007 in one district. The participants will be nurses (who have shown the requisite skills and competencies after the BC and IC training). The training will take place in 2 phases over a one month period, and will be followed by 4 month implementation, supervision, monitoring and evaluation. This program is supported by ADB-ETESP Health both in terms of technical assistance and funding.
Additional training of Nurses in Mental Health Care
b. Professional psychiatric nursing practice model
This is aimed at improving the capacity of nurses to care for mental health patients in hospital in a humane and non-restrictive manner. The curriculum and the module for this training was been developed by the expert in mental health nursing before the tsunami and has been operating in one major psychiatric hospital in Java. This was introduced into Banda Aceh mental hospital following the tsunami and WHO funded its implementation in 2 wards to date. On these 2 wards, as a result of the improvement in the care given by nurses and an improvement in the physical environment of the ward, there has been: an increase in patient and family satisfaction; a high bed occupancy rate; and a decrease in the average length of stay.
c. Psychiatric Intensive Care
The curriculum and the module is developing by expert nurses. It is expected the try out will be in 2007 in Psychiatric Intensive Care Unit (PICU) in Jantho general hospital. The participants are from general hospital, which already and plan to develop psychiatric intensive care unit (Banda aceh city, Simeulue, Pidie). This program is being given technical assistance and funding by ADB-ETESP Health.
d. Training for Clinical Instructors in Mental Health
The curriculum and the module is developing by expert nurses. It is expected the try out will be in November 2007 in mental hospital while students are there. The participants are lecturer of mental health nursing from all school of nursing in Aceh.. This program is supported by ADB-ETESP Health.
However, due to successful advocacy concerning the programmed by the Ministry of Health an additional 63 nurses have now been trained as national trainers for the programmed from other provinces in Indonesia.
4. Successes of the Community Mental Health Nurse Training Program
a. External evaluation from UTS Sydney Australia.
The community mental health nursing programme was externally evaluated in February/March 2007 funded by ADB-ETESP Health. The major finding are: The curriculum is very comprehensive and was said to be:
1) Highly appropriate for the nursing interventions that are required
2) Suitable for the mental health needs of the target population, with a focus on interventions for patients with psychosocial problem and psychotic disorders
3) Detailed to provide nurses clear guidelines for intervention
4) Descriptive and well explained
5) Based on a lifespan view with attention to all ages and stages, from children to the elderly
The advantages of this CMHN program are as follows:
1) Enhancement of community awareness about mental health problem and improvement in their ability to take care the patients
2) Improvement in the community willingness to bring the patients to the CMHN nurse, as well as enhance the CMHN nurses motivation and satisfaction to pursue CMHN program.
3) A greater percentage of patients receive regular medication and supervision in some areas
4) Provide an opportunity for family to discuss problems in coping with clients and to receive support.
5) Prevention of immediate admission to psychiatric hospital for those clients who are visited
b. Research
Two researches conducted by postgraduate nursing student from faculty of nursing University of Indonesian, supported by ADB-ETESP Health, one in Pidie and the other one in Bireuen
1) Reseach in Pidie: Factors releted to performance of community mental health nurses in Pidie
There are five factors have significant relationship with nurse’s performance: background education (diploma3 nursing), the process of recruitment, the process of training, the support of supervisor, and the process of supervision.
2) Research in Bireuen: The relationship between community mental health care with the level of independency of patient with mental disorder in Bireueen.
There are four aspect of patient’s independency: activity daily living, social skill, problem solving and compliant of medication. The findings are 57 % patient self care of activity daily living, 53 % self care of social skill, 40.8 % self care of problem solving and 60.9 % compliant of medication.
The nurses caring related to the level of independency are home visit (nursing care to the patient and family during home visit) by nurses, home visit by cadre, group activity therapy and rehabilitation activities.
c. External Evaluation from Columbia University
waiting from Matina
5. Challenges faced in Implementation
The problems have been identified during the program implementation are:
  1. An inadequate referral system largely due to the absence secondary services and prior to the CMHN programme very limited mental health services in the community
  2. Problems in access to the Public Health Center owing to geographic conditions and transportation limitations,
  3. Limited range of medication,
  4. Inadequate recording-reporting/monitoring-evaluation in some districts where the facilitators are not strong
  5. Inadequate allocation of funds for mental health because mental health program is not mandatory program.
  6. An irregular supply of medication in some areas because of inadequate logistical planning.
  7. Creating networks of care with local non-governmental organizations who provide psychosocial care. Religious leaders, women leaders are also important.
  8. Maintaining advocacy to ensure in the future budgets are allocated for community mental health nursing activities. This has to be done not only at the district level but with the local parliament as well given the decentralized nature of the government system.
  9. To work towards community mental health nursing becoming one of the compulsory programmes at the primary care level. There are currently 6 compulsory programmes at the primary care level, but this excludes mental health.
Key words: Community mental health nurses, public health center, basic course community mental health nursing, intermediate course community mental health nursing, village of mental health alertness,Cader
Presented by: Dr. Budi Anna Keliat, SKp, MAppSc

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