Background
In recent years, the care and treatment management of people with mental health problems has become a significant global issue that requires continuous attention (World Health Organization, 2014). This issue has also raised concerns in Indonesia following an increase in the prevalence of mental health cases. The higher incidence of mental disorders in the country highlights the need for policies and attention from the government and society (Rahvy et al., 2020). However, despite efforts to improve the mental health system, Indonesia still needs further progress in this area (Economist Intelligence Unit, 2016). Two major challenges facing the mental health system in Indonesia are a limited number of mental health professionals and an insufficient financial budget for mental health care. These budgetary constraints make it challenging to provide even the most basic standard of mental health care in society (Irmansyah et al., 2009; Pols & Wibisono, 2017).
According to the 2018 Indonesian National Health Survey (Riskesdas), the prevalence of depression among individuals aged over 15 years old was found to be 6.1%, with a staggering 91% of individuals with mental disorders in Indonesia not receiving treatment (Indonesian Ministry of Health, 2018). These findings suggest that mental health services in Indonesia may not be fully accessible to those in need. The Ministry of Health Republic Indonesia conducted this survey on the entire Indonesian population residing in thirty-seven provinces every five years (Indonesian Ministry of Health, 2018).
Overview of Indonesia’s Mental Health System
Health services in Indonesia use a decentralized system whose management is handed over to the respective regional governments. Local governments also have a role in planning and managing the mental health service system. Based on the applicable laws, every province in Indonesia is required to provide at least one mental health hospital (Putri et al., 2021). However, seven provinces have not established mental health hospitals (Suryaputri et al., 2022).
The authors illustrated Indonesia’s mental health referral systems in Figure 1. The referral system is regulated by BPJS Kesehatan (National Health Insurance) system in Indonesia. The referral system starts at primary health care. Patients/caregivers with mental health problems are required to visit primary health care to consult with general practitioners/any health professionals available at sub-district levels. After that, patients/caregivers with mental health problems will receive a referral letter to access psychiatric care at the secondary and tertiary levels. Psychiatric care is available in secondary care and tertiary care. Secondary care levels provide treatment for psychiatric outpatients, and tertiary care levels provide treatment for psychiatric inpatients. BPJS-K covers monthly psychiatric treatment costs for outpatients and two-weeks mental health hospital stays for inpatients.
The availability of mental health services is expected to improve access and minimize treatment gaps. However, previous studies in Indonesia have revealed some challenges to achieving the goal of reducing the mental health treatment gap, such as poor mental health literacy (Brooks et al., 2018), limited availabilities, and ineffective mental health services (Idaiani & Riyadi, 2018; Tasijawa et al., 2021), insufficient numbers of mental healthcare professionals (World Health Organization, 2018), and stigma received by people living with mental illnesses (Hartini et al., 2018). Previous qualitative studies in Indonesia found social challenges, such as health practitioners’ negative attitudes and family communication styles. The previous research suggested the need for the interprofessional collaborative practice among health practitioners as part of a strategy to provide good mental health services (Putri et al., 2021). This paper fills the gap in the literature by exploring a large number of users/outpatients/people living with mental disorders’ perspectives on their access to services.
The objective of our study was to explore participants’ perceptions of barriers and facilitators that affected their access to mental health services in Indonesia. People with mental disorders in this paper are defined as outpatients in psychiatric units at public and private hospitals with depression, bipolar, and anxiety in remission. The study findings can provide information on their struggles to access mental health services in the digital era. It can benefit mental health program implementers in Indonesia, mental health practitioners, students, caregivers, and future researchers. Furthermore, by exploring the barrier and facilitator to accessing mental health services, we can understand how to improve the facilitator/support and reduce/remove the barrier to accessing mental health services.
Theoretical Concepts of Access to Healthcare and Stigma
This paper is situated within the access to health care and stigma concepts. Access to health care means having “the timely use of personal health services to achieve the best health outcomes” (Burke et al., 2010). Barriers are described as factors that prevent/obstruct a given phenomenon. Conversely, facilitators are factors that promote/facilitate/enable a given phenomenon (Pagoto et al., 2007).
Stigma is defined as the negative labeling of a particular group of people. It shapes a negative image of mental disorders and people with mental disorders (Hayward & Bright, 1997). The stigma they received could prevent them from seeking help and treatment for their mental health conditions (Corrigan et al., 2005). Stigma against people with mental disorders is found not only limited to the general population but also among health professionals who work with people with mental disorders (Arboleda-Flórez & Sartorius, 2008; Jorm, 2000).
Methods
Study Design
Qualitative research is crucial in exploring issues that are not well understood, as in the case of this study, as it allows researchers to gain insight into the perspectives of individuals living with mental disorders (Liamputtong, 2019). The researchers adopted a qualitative descriptive research design to explore the issues directly from the participants and in great depth without having to adhere to a particular methodological framework (Sandelowski, 2000). The paper was written in accordance with the consolidated criteria for reporting qualitative research (COREQ) checklist (Tong et al., 2007).
Participants
Study participants were purposively recruited from support groups and online platforms for people with mental health disorders. Participants had to be at least diagnosed with depression, anxiety, or bipolar with aged 18-32. Participants are required to take screening tests using BDI II (Beck Inventory Depression II) to measure their depression level (Beck et al., 1996). The researchers excluded participants who had severe depression levels, participants with psychotic symptoms, those who did not give any response exceeding two weeks after recruitment, and participants who sent a request to refuse an interview. This study had a total of 90 participants with mental disorders from several main islands in Indonesia, namely: Sumatra, Java, Kalimantan, and Papua Islands.
Data Collection
In this study, the researchers used WhatsApp and Google Forms as platforms for data collection (Liamputtong, 2019). All data collection process was conducted from January to June 2022. The study’s participants were young people aged 18-32 who used mobile phones and online apps for daily communication. All of the participants in this study used WhatsApp messenger. This chatting method provides convenience for researchers to eliminate challenges and improve time and cost efficiency when collecting data from multiple sites (Stieger & Göritz, 2006). This online platform method also provides time efficiency in data analysis compared with the traditional approach that uses audio recording and typing all audio records into word sheets (Liamputtong, 2019). In this study, the chatting method also allows the researcher and participants to make an appointment to chat and avoid the awkwardness between the researcher and participants that usually happens in face-to-face in-depth interviews. The use of emojis and stickers in WhatsApp chat also makes the chatting method data collection feel comfortable for both parties.
The researchers gave the participants two choices for sharing their stories/feelings. The first is through WhatsApp chat; this platform usually was chosen by participants who did not have difficulties communicating their stories, feelings, and experiences with people they trust or with new people they perceived they could trust. The second one is through Google Forms. The researchers set all questions with long answers with probing questions. This platform usually was chosen by participants who had difficulties communicating their stories, feelings, and experiences one-on-one.
In-depth interviews through WhatsApp Chat lasted 15-20 minutes, and chat archives were exported and downloaded for analysis. The researchers used the Bahasa Indonesia language for data collection. Following are two main questions the researchers asked participants during WhatsApp chat: 1) Could you please tell me your stories about your experiences accessing mental health services? 2) How do you feel and perceive those conditions/situations? The theoretical concepts of access to healthcare and stigma were used to prepare semi-structured questions.
Data Analysis
Thematic analysis (TA) was applied to the data to determine the significant themes pertinent to the research question. TA is a method for systematically identifying, organizing, and offering insight into patterns of meaning (themes) across a data set (Braun & Clarke, 2012). The data analysis process was done manually. For the first step, the chat archives were exported and downloaded for analysis for in-depth interviews through WhatsApp Chat. In addition, the response sheets were exported and downloaded for analysis for in-depth interviews through Google Forms. In the second step, the transcripts are translated into English for further analysis steps. In the third step, all transcripts were read and reread to find the similarities and patterns between participants’ responses. In the fourth step, Author 1 (LM) was in charge of coding the data and classifying all data into several themes. In the fifth step, the final themes were named and written as a complete summary after a comprehensive discussion with Author 2 (PL) and Author 3 (PV).
Trustworthiness
The trustworthiness was checked with the triangulation method, building rapport, probing, and working with an expert (Liamputtong, 2019). WhatsApp chat with participants was conducted at different times to enhance the data quality. Several techniques were undertaken to improve the trustworthiness of this study. First, building rapport with participants was conducted before the researchers started the in-depth interviews. Building rapport in this study was defined as the researchers were made a good bond/rapport with all participants. The aims of building rapport were: 1) to make participants feel comfortable sharing their feelings, 2) to make them feel comfortable communicating with us, 3) to make the data collection process run well, and 4) to achieve rich data with good quality. Making a good rapport before conducting the in-depth interview has a positive effect. Almost all participants felt comfortable writing their experiences, feelings, and perceptions in a long paragraph. Second, probing was done to help understand the participants’ responses in deeper and more specific meanings. The researchers asked participants to clarify, elaborate, or explain their responses.
Research Team and Reflexivity
The research team comprised one research student (first author LM) and two supervisors. WhatsApp chat data collection was conducted by the first author as the facilitator. Author 2 (PL) and Author 3 (PV) supervised the data collection and analysis process by giving suggestions to ensure good data quality is achieved. Author 1 (LM) is a female public health researcher health. She was a second-year Ph.D. candidate with ten years of qualitative research experience and three years of mixed-method research in some particular settings, such as urban, rural, and remote settings. Author 2 (PL) is a female social sciences researcher in behavioral sciences and medical anthropology. She is a professor with more than twenty years of experience in qualitative and mixed-method research. Author 3 (PV) is a male social sciences researcher in empowerment, patient satisfaction, aging, and biostatistics. He is an assistant professor in social sciences with more than fifteen years of experience in quantitative research and experimental studies. All authors have conducted cross-cultural research and are interested in understanding mental health issues in an underdeveloped nation. These three authors did not have a reciprocal relationship with the study participants. Therefore, it reduced the research bias resulting from peer relations. All authors interpreted the result and were responsible for manuscript writing and evaluation.
Ethical Considerations
Ethics approval was obtained from Chulalongkorn University’s Ethical Committee No. 205.1/64, COA No. 247/2021, before the study began in 2022. At the time of recruitment and interview, respondents provided informed written and verbal consent, which acknowledged their awareness of the study's purpose and potential benefits, their right to withdraw their response, and their right to remain anonymous. Additionally, respondents were informed that they could receive further recommendations if their condition required treatment.
Results
Characteristics of the Participants
There were 90 participants aged 18 to 32 years, both men and women, single and married, in this study. They lived on several islands in Indonesia, such as Sumatra, Java, Kalimantan, and Papua, with various settings in rural, semi-urban, and urban areas. The majority of participants have financial problems and poor relationships with caregivers (Table 1).
| Characteristics | f | % |
|---|---|---|
| Age | ||
| 18-24 years old | 54 | 60.0 |
| 25-32 years old | 36 | 40.0 |
| Sex | ||
| Male | 8 | 8.9 |
| Female | 82 | 91.1 |
| Marital status | ||
| Single | 72 | 80.0 |
| Married | 18 | 20.0 |
| Education level | ||
| < Bachelor’s Degree | 41 | 45.6 |
| ≥ Bachelor’s Degree | 49 | 54.4 |
| Working status | ||
| Unemployment | 51 | 56.7 |
| Employment | 39 | 43.3 |
| Household income | ||
| minimum average in each district varies from 122.10 USD to 312.5 USD | ||
| Low income < 122.10 – 312.5 USD | 58 | 64.4 |
| Middle income ≥ 122.10 – 312.5 USD | 32 | 35.6 |
*USD rate: 21 October 2022, 1 USD = 15,623 IDR
Thematic Findings
From people with mental disorders’ perspectives, this study found some barriers to accessing mental health services in Indonesia, such as geographical barriers, travel costs, stigma and lack of support, and expensive treatment costs. These barriers caused uneasy access to mental healthcare and delay in receiving treatment. On the other hand, this study also found some facilitators in accessing mental health services in Indonesia, such as national health insurance membership, received support, and self-help. The researchers illustrated the overall findings of barriers and facilitators to access mental health services in Indonesia, as shown in Figure 2.
Barriers to Accessing Mental Health Services
The study’s findings revealed some barriers people with mental illnesses face in accessing mental health services in Indonesia. These findings were divided into several themes: 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.
Theme 1. Uneasy access to mental healthcare facilities
Access to available mental health care and clinicians in rural settings may require traveling long distances, making attending treatments more challenging (Graham et al., 2021). It costs more to provide services in rural areas for several reasons (Nicholson, 2008). Consistently to the study findings, some participants residing in rural areas in Indonesia had difficulty accessing mental health facilities due to 1) long-distance travel to mental health care and 2) how much money they had to spend to pay for roundtrip travel costs to the hospital.
“A long-distance journey from my house because it (the psychiatric unit) only exists in large hospitals. The distance was 60 kilometers.” (Informant 7, male, living in a rural setting, unemployed)
“Distance from home that is too far from the hospital. The distance to the hospital is almost 1.5 hours drive. The travel costs have burdened me.” (Informant 9, female, living in a rural setting, unemployed)
In summary, mental health services in rural settings in Indonesia are inaccessible due to the lack of availability of mental health workers and geographical barriers. In addition, the long travel distance is also linked to a financial burden for people with mental disorders in accessing mental health care.
Theme 2. Stigma, lack of social support, and delay in receiving a proper treatment
The stigma against people with mental disorders also poses barriers to mental health service use (Kung, 2004). People with mental disorders are not seeking help because they fear others will react negatively to them (Barney et al., 2006). In this paper, all participants received stigma and negative labels. In addition, some participants received stigma from closest family such as parents, closest friends, neighbors, and health workers at primary health care.
“If I went to the psychiatrist, they would say I am crazy.” (Informant 20, female, living in an urban setting, unemployed)
“No one supports me because they/people perceive those psychiatric medicines are dangerous to consume.” (Informant 31, female, living in an urban setting, unemployed)
“General practitioners in primary health care cannot believe that I am depressed.” (Informant 25, female, living in an urban setting, unemployed)
“Many service providers still do not know about mental health. I was judged as people who was crazy when asking for a referral letter to the first health facility, as well as when treated to a large hospital; the service provider blasphemed and underestimated the depression complaints that I felt.” (Informant 42, living in an urban setting, unemployed)
Some participants experienced several refusals from general practitioners in primary health care to refer them to psychiatric services in hospitals. As a result of the delay in treatment, their symptoms worsened, and suicide attempts or self-harm increased.
“After two times rejected to get referral letters, finally, the general practitioner in primary health care gave me the referral letter after I came again with scars on my hand after self-harm. Should I die first, then they would believe that I am so depressed?” (Informant 47, female, living in an urban setting, unemployed)
“For the first time I went to primary health care, they did not trust me when I said I was depressed. They said that I should bring my parents with me. But how, one reason I got depressed was because of my toxic family. Later, I came with my best friend, and my best friend told them that I was doing self-harm several times. Thank my best friend that I got a referral letter because of her.” (Informant 50, female, living in an urban setting, unemployed)
This study’s finding is consistent with the previous study in Indonesia. It was found that the negative attitude of mental health workers toward patients led patients to delay or stop treatment (Putri et al., 2021). Therefore, general practitioners in primary health care need to respond quickly to the symptoms and give a referral letter to a psychiatrist for those who are needed.
Theme 3. Expensive treatment costs without national health insurance membership
Unmet needs for access to mental health care were greater for the poor, those with low incomes, or without insurance (Wang et al., 2005). Consistently, in Indonesia, patients are required to pay expensive psychiatric treatment costs if they do not have a national health insurance membership (BPJS Kesehatan).
“A hefty cost for me to seek treatment without BPJS (national health insurance).” (Informant 14, male, living in a rural setting, unemployed)
“For now, it seems like the cost because I do not have national health insurance (BPJS Kesehatan), and psychiatrist rates in the city are now quite expensive.” (Informant 19, male, living in an urban setting, unemployed)
“I find it challenging to pay for mental health services costs. I cannot earn money because I am still in college. So, I also often feel tired and want to stop treatment because it is very expensive.” (Informant 22, living in an urban setting, unemployed)
Thus, having national health insurance membership is crucial for people with mental disorders. National health insurance (BPJS Kesehatan) covers all treatment costs and includes various psychiatric medications.
Facilitators to Accessing Mental Health Services
The findings also revealed some facilitators that help people with mental disorders face accessing mental health services in Indonesia. The results were divided into 1) National health insurance membership, 2) Support from a spouse, family, and closest friends and its association with mental health literacy, and 3) Self-help.
Theme 1. National health insurance membership
Mental health remains a challenge for UHC globally. In Indonesia, there are several challenges to mental health services, such as stigma, the limited number of mental health professionals, the need for long-term treatment, and involvement with the health system and national health insurance (Agustina et al., 2019). However, being an active user of national health insurance (BPJS Kesehatan) was one of the factors that were considered very helpful for people with mental disorders to access mental health services. In addition, some participants expressed gratitude because being registered as active users helped them financially because they did not have to pay for their medical expenses.
“I feel lucky I have BPJS Kesehatan (national health insurance), which covers mental health services.” (Informant 70, female, employed)
“Thank God it has been made easier so far as I have BPJS Kesehatan. It is affordable.” (Informant 72, female, employed)
Participants had to go through several referral stages, from primary health care to hospitals with psychiatric units. However, some participants managed to cope with this long process as long as they received free treatment.
Theme 2. Support from a spouse, family, and closest friends and its association with mental health literacy
Most young people feel more comfortable talking and sharing with close friends or family members when they are having problems, including mental health problems (Offer et al., 1991). In this study, some participants received positive support from their spouses, family, and best friends. This positive support gave people with mental disorders a sense of feeling safe, comfortable, and motivated to undergo psychiatric treatment. A sense of feeling safe was perceived by participants’ positive support that made them feel safe and comfortable in communicating their mental conditions and struggles to the closest people. Feeling safe was also perceived as they would not receive any gaslighting or stigma and are not labeled as “Weirdos” and embarrassed. A sense of security was also perceived as the participant’s closest acceptance of the survivor’s mental condition, so they had the motivation to undergo treatment in a mental health service.
“I received support from my husband and children. It is enough for me.” (Informant 44, female, living in an urban setting, employed)
“I have a very supportive environment, from my husband, family, the husband’s family, and my closest friends.” (Informant 63, female, living in an urban setting, unemployed)
In this paper, support is one of the facilitators that bridge people with mental disorders to accessing mental health services. In addition, support is also considered an essential factor in reducing the treatment gap and stigma.
Theme 3. Self-help
Self-help is one of the empowering treatments. Self-help can also be considered one of the best factors in terms of efficacy for treating mild to moderate depression (Lovell et al., 2008; Morgan & Jorm, 2009). In this paper, some participants still regularly accessed mental health services even though they were stigmatized. Self-help is an internal factor that manifests as motivation to access public health services. Therefore, it was considered more important than external factors that prevent them from accessing mental health services.
“I do not care about stigma either. The point is that I want to be stable and heal anyway.” (Informant 16, female, living in an urban setting, unemployed)
“I do not care if I got stigmatized negatively because of consultation with a psychiatrist. I do not care because who feels the benefits of receiving treatment is myself.” (Informant 27, female, living in an urban setting, unemployed)
This phenomenon could be described as a motivation that enhances and strengthens people with mental disorders to help themselves even though they receive stigma and negative labels.
Discussion
This study found that financial hardship was the most crucial barrier for people with mental disorders to access mental health services. Therefore, national health insurance (BPJS Kesehatan) was identified as one of the factors considered very helpful for people with mental disorders to access mental health services. These findings align with previous studies that suggested health insurance as one factor that can help to reduce treatment expenses (Berchick et al., 2019). Thus, having health insurance is associated with access to mental health services (Wang et al., 2005). However, many Indonesians are unaware of BPJS-K’s tiered referral system (Handayani et al., 2018), highlighting the need for collaboration between local government and health sectors to disseminate information and promote the benefits of having national health insurance.
This study further revealed that most participants experienced stigma and discrimination, but a self-help attitude was deemed more important than external factors such as stigma and discrimination. These findings are consistent with a previous study on positive motivators for seeking mental health treatment, such as hope, desires for a better life, and personal resolve (Pieters & Heilemann, 2010).
Individuals with good mental health literacy can recognize mental disorder symptoms and problems, seek help and information, and appreciate the importance of addressing mental health concerns. Conversely, individuals with inadequate mental health literacy tend not to comprehend the significance of mental health, which can also stigmatize those with mental disorders (Hurley et al., 2020; Tambling et al., 2021).
The study identified a knowledge gap among primary healthcare workers regarding the appropriate timing for referring patients to psychiatric units. Additionally, not all primary healthcare workers have the necessary understanding and skills to treat individuals with mental disorders in a humane and empathetic manner. Therefore, training in Mental Health Gap Action Programme (mhGAP) (World Health Organization, 2008) is necessary for primary healthcare workers to address this knowledge gap and improve their competencies in providing mental health services.
This study comprehensively explored the barriers and facilitators to accessing mental health services in Indonesia, with participants from multiple regions. Future research could focus on understanding societal perceptions of mental disorders and the underlying reasons for persisting stigma. Furthermore, developing appropriate mental health education programs based on local context could be beneficial. Finally, it is essential to note that this study did not examine the perspectives of elderly individuals with mental disorders who may not use smartphones or the viewpoints of caregivers.
Conclusion
This study highlights that there is still much work to be done to improve access to mental health services. Providing mental health education in schools, communities and through television broadcasts can help reduce stigma and increase mental health literacy. To address financial barriers, the public should be informed of the benefits of having national health insurance membership. Furthermore, this study provides insight into the perspectives of service users regarding the difficulties they face in accessing mental health services. This serves as a reminder for healthcare workers, including general practitioners, mental health nurses, public health practitioners, and psychiatrists, to approach their work with compassion and strive for better mental health outcomes. Mental health training is also essential for those working in mental health service delivery. The study recommends widespread dissemination of mental health knowledge to primary healthcare workers, such as public health practitioners and nurses, to enhance their mental health literacy and competencies in providing services to individuals with mental disorders.