Journal Pone 0289943

PLOS ONE
RESEARCH ARTICLE
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
Heni Dwi Windarwati1, Herni Susanti ID2*, Helen Brooks3, Ice Yulia Wardani2, Hasniah4,
Mardha Raya5, Niken Asih Laras Ati ID6, Hasmila Sari7
1 Department of Mental Health Nursing, Faculty of Health Sciences, Universitas Brawijaya, Malang,
a1111111111 Indonesia, 2 Mental Health Nursing Department, Faculty of Nursing Universitas Indonesia, Depok, Indonesia,
a1111111111 3 Mental Health Research Group, Division of Nursing, Midwifery and Social Work, School of Health Sciences,
a1111111111 Faculty of Biology, Medicine, and Health, Manchester Academic Health Science Centre, University of
Manchester, Manchester, United Kingdom, 4 Ministry of Health Polytechnic Aceh, Aceh Besar, Indonesia,
a1111111111
5 Sambang Lihum Psychiatric Hospital, Banjarmasin, Kalimantan Selatan, Indonesia, 6 Faculty of Nursing,
a1111111111 University of Jember, Jember, Indonesia, 7 Mental Health Nursing Department, Faculty of Nursing,
Universitas Syiah Kuala, Aceh Besar, Indonesia
* [email protected]
OPEN ACCESS
Citation: Windarwati HD, Susanti H, Brooks H, Abstract

Wardani IY, Hasniah , Raya M, et al. (2023) Lay
community mental health workers (cadres) in
Indonesian health services: A qualitative Introduction
exploration of the views of people with mental
health problems and their families. PLoS ONE In community-based mental health services, lay workers recruited and trained to support
18(11): e0289943. https://doi.org/10.1371/journal. mental health programs, known as mental health cadres, have an important role in support-
pone.0289943
ing the care of families and people with mental disorders. This study aims to explore the
Editor: Kishor Adhikari, Chitwan Medical College, experiences of people with mental disorders and their families about the role of mental
NEPAL
health cadres in improving mental health and caring for people with mental disorders.
Received: December 17, 2022
Accepted: July 30, 2023 Methods

Published: November 9, 2023 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 diffi-
Peer Review History: PLOS recognizes the
benefits of transparency in the peer review culties (people diagnosed with schizophrenia) and 25 family members who are the primary
process; therefore, we enable the publication of caregivers of people with mental disorders from three provinces in Indonesia: West Java,
all of the content of peer review and author
East Java, and Aceh. Participants were purposively sampled with inclusion and exclusion
responses alongside final, published articles. The
editorial history of this article is available here: criteria used were people with mental disorders and their families who regularly interact with
https://doi.org/10.1371/journal.pone.0289943 mental health cadres. Data were analyzed using inductive thematic analysis through six
Copyright: © 2023 Windarwati et al. This is an stages of coding and theme development.
open access article distributed under the terms of
the Creative Commons Attribution License, which Results
permits unrestricted use, distribution, and
reproduction in any medium, provided the original Several themes were identified. The most significant theme was emotional support provided
author and source are credited. by cadres in terms of reception from cadres about people with mental health problems
PLOS ONE | https://doi.org/10.1371/journal.pone.0289943 November 9, 2023 1 / 21

PLOS ONE Lay community mental health workers and mental disorder
Data Availability Statement: All data supporting (59.1%), tangible support in which cadres help people with mental disorders get treatment
the findings of this study are available within the (52.27%), and cadre roles as duties/mandates (51.36%) was factors that facilitated the suc-
paper.
cess. The finding of this study indicated that cadres were considered to provide a range of
Funding: This work was supported by the different support to people with mental health disorders and their families. In carrying out
Directorate of Research and Community
Engagement University of Indonesia. The funders
their role, there were factors that participants felt increased success in implementing the
had no role in study design, data collection and role of cadres. The cadre-patient/family relationship was influenced by perceived shame,
analysis, decision to publish, or preparation of the trust relationship, and stigma. This research also revealed patient and family expectations
manuscript.
about cadres’ roles.
Competing interests: The authors have declared
that no competing interests exist.
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.
Introduction
Mental health problems are a serious problem and a priority in Indonesia [1]. Severe mental
illness (SMI) is a mental, behavioral, or emotional disorder resulting in functional impairment
and interfering with major life activities [2]. Recent evidence suggests that as many as 6.7% of
households in Indonesia have family members with severe mental illness, where currently,
severe mental illness is the second highest cause of disability in people in Indonesia [3, 4]. In
addition, about 85% of families who have family members with mental disorders have received
treatment at least once to health services, and only 48.9% have received treatment regularly in
the last one month [3]. In Indonesia and in many low- and middle-income countries, the bur-
den of health care on patients with mental disorders is compounded by substantially unmet
mental health care needs and large disparities in mental health care provision [5, 6].
The family as a caregiver began to assume the vital role of care performed for people with
schizophrenia [7]. Family support, acceptance, communication, family hope of recovery for
people with schizophrenia, and assistance carried out when seeking treatment, administering
patient medication, and helping outreach in the community are the roles of the family during
the recovery and rehabilitation process to prevent patient relapse [8, 9]. However, as first-
degree relatives, caregivers experience the burden of care during caregiving for patients with
schizophrenia receiving treatment in hospital and community settings [10, 11]. A recent study
conducted on 136 caregivers showed that caregivers’ personal growth was associated with
good family functioning and adequate professional support in terms of family psychoeduca-
tional intervention positively related to the low burden of care [12, 13]. Effective schizophrenia
treatment integrates specific strategies involving a comprehensive treatment plan and mental
health professionals [7, 14]. Positive aspects and challenges in caregiving for schizophrenia
need adequate support from health professionals and integration into health services.
Integrative collaboration with families and the wider community can improve mental
health services in a therapeutic capacity [15]. Community involvement in mental health ser-
vices is a potential way to overcome the high burden of health care in patients with severe men-
tal disorders [16]. There is a shift from hospital-based mental health services to community-

based mental health services [17]. The shift in health services increases the integration of men-
tal health services and provides opportunities for the community to obtain sustainable mental
health services [18, 19]. The potential benefits of this transition are improved access to mental
health services, especially for marginalized groups, through connecting and bridging them
with health services and strengthening social supports, and improved mental health care out-
comes [19–21]. The shift from hospital-based mental health services to community-based
health care systems requires elaborate community involvement. The success of community-
based mental health care system is influenced by an interdisciplinary mental health team and a
responsible person for coordinating services between patients and health systems [18, 22], who
is called a lay health worker [23].
Community Health Workers are lay workers recruited from local communities who have
received training and supervision from primary care workers. Their roles include promoting
health programs to increase the coverage of basic health services in the community [24, 25].
They also facilitate access to care and link the community and the health system [26]. The
involvement of Community Health Workers is one way to improve mental health services,
reduce treatment gaps, and increase awareness and mental health [27–30]. Patients with men-
tal disorders need lay health workers to help them with treatment management because the
failure of treatment plans related to patient medication adherence is caused by often forgetting
to take medication or the unavailability of treatment [3]. The study conducted in Ghana
showed that community mental health workers (CMHW) could expand mental health services
by providing counseling services and home visits as part of their duties [31]. Another study on
CMHW in Norway showed that CMHW supports users in the context of life, community par-
ticipation, and service health systems [32].
In Indonesia, lay mental health workers, called mental health cadres, are representatives of
community health centers related to mental health cases in their community. Cadres are
expected to have the knowledge and contribute to the treatment and prevention of mental
health problems in their community [33]. Mental health cadres who have received mental
health training can effectively have the knowledge and ability to implement mental health pro-
grams in the community. Mental health cadres play a role in primary prevention through data
collection, health education, and motivating clients. In the secondary prevention program,
mental health cadres play a role in the early detection and socialization of mental health. Also,
in tertiary prevention, cadres, in collaboration with family, remind and monitor patients to
take their medication regularly [34–36]. Cadres, as community health workers closest to the
community, play a role in assisting patients and their families in controlling the mental health
development of patients [37].
Barriers to mental health services include a lack of awareness of professional health services
[38]. Patients and families, who are the primary caregivers for people with mental disorders
[39, 40], have inadequate knowledge about patients’ mental health conditions. They have poor
awareness about the availability and access to mental health care and misconceptions about
mental health as a problem because of the devil and witchcraft. In addition, as the primary
caregiver, the families are at risk of emotional, physical, medical, financial, and social burdens
[39]. Families experience heavy burdens and low quality of family life while caring for patients
with mental disorders, so they need help to overcome them [41, 42]. These barriers are related
to the role of cadres in assisting patients and families in the community, and the perception of
patients and families who received assistance from mental health cadres has not been
explored.
The role of lay community health workers has been widely studied, but not from the user’s
point of view. Therefore, this study aimed to explore the experience of people with mental dis-
orders and families regarding the roles of mental health cadres in caring for patients with

mental disorders to deeply examine the barriers to community mental health services and how
to increase the role of mental health cadres in implementing and improving mental health ser-
vices in the community.
Materials and methods

Design and context of the study
The study, part of a larger research project titled Exploration of the Role of Mental Health Work-
ers (Cadres) in Community Mental Health Services in Indonesia, explored the experiences of
families and people with mental disorders who received support from mental health cadres
using a descriptive qualitative and the reporting adhered to the Consolidated Criteria for Report-
ing Qualitative research (COREQ). This research has been approved by the Ethics Commission
of the Faculty of Nursing, the University of Indonesia, with an Ethical Eligibility Letter Number
SK-240/UN2.F12.D1.2.1/ETIK 2020. This study followed ethical research principles based on
the Belmont Report [43], which includes the principles of beneficence, justice, and respecting
human dignity. Written consent was obtained from all participants (patients and families).
Participants
The study participants were 25 family members and 19 people with mental health disorders.
They were recruited from three provinces in Indonesia: West Java, East Java, and Aceh, with
details for distribution of focus group discussions in family participants and people with men-
tal disorders presented in Table 1. This study was conducted in these places because Aceh is
one of the provinces in Indonesia with a high prevalence of household members with mental
health problems. In contrast, the other two provinces have a prevalence of mental health prob-
lems below the national average. Therefore, they are pilot projects for implementing the Com-
munity Mental Health Nursing Program in Indonesia. Before conducting the study, the
researcher asked permission from the local government for each site (West Java, East Java, and
Aceh) and coordinated with the Provincial and Regional Health Office. The health office
directed us to the community health center for the research location. First, the community
health center head identified participants according to predetermined inclusion and exclusion
criteria. Then the Head of the community health center, helped by a mental health cadre,
made an appointment for a meeting between the researcher participants, people with mental
disorders, and families.
Most families who participated in this study were female, from 23 years to 67 years. Almost
90% of the participants had nuclear family relationships with the client, while the others were
family relations. The family has cared for the client for around 9.5 years; the longest being 25
years. In addition, the families have interacted with mental health cadres for four years, within
Table 1. Distribution of focus group discussion family and client.

Focus Group Name Research Sites Number Or Participatns Method Of Data
Family
FG1 East Java 9 Non Virtual
FG2 Aceh 9 Non Virtual
FG3 Bogor 7 Non Virtual
Client
FG4 East Java 9 Non Virtual
FG5 Aceh 5 Non Virtual
FG6 Bogor 5 Non Virtual
https://doi.org/10.1371/journal.pone.0289943.t001

approximately 3 hours per week. At the same time, all of the people with mental disorders who
participated in this study were diagnosed with schizophrenia. Most people with mental disor-
ders were male and average of 36 years. In this study, 63% of people with mental disorders had
primary school and did not attend school, while the rest were in junior and senior high school.
Almost all participants have been taking the medication regularly in community health cen-
ters. Around 68% of clients had a hospitalization history in psychiatric hospitals. Mental health
cadres have interacted with clients for nine years and regularly meet clients within 1 hour to
25 hours, with an average of around 3 hours per week. The characteristics of family partici-
pants and people with mental disorders in this study are presented in Table 2.
In selecting these participants, a purposive sampling technique was employed to ensure
they met the pre-determined criteria and adhered to the research objectives. Criteria for partic-
ipants in this study were people with mental disorders who lived with their families and did
not have a functional impairment (have been able to work independently) [44]. At the same
time, the criteria for family members of people with mental disorders were parents, siblings,
children, husband/wife, and family relations who are responsible for caring for and meeting
the daily needs of people with mental disorders or who play a role in making decisions for
them [45]. Participants in this study (people with mental disorders and family members) regu-
larly contacted and interacted with mental health cadres in their respective areas of residence.
Inclusion and exclusion criteria for participants were: a) participants are at least 18 years old,
as, at this age, a person is considered an adult and can account for the information conveyed
during the research process, b) able to communicate well using Indonesian or regional lan-
guages (Acehnese/Javanese/Sundanese) which participants and the researchers understand,
and c) physically and mentally healthy at the time of the interview. Before the study, family
members were assessed for their physical examination and psychological status using the Self
Reporting Questionnaire-20 (SRQ-20) [46]. Meanwhile, for people with mental health disor-
ders, a physical assessment and monitoring of symptoms of mental health disorders are carried
out, and stated that the symptoms of mental disorders are controlled. In addition, healthcare
workers carried out physical and mental health examinations at the community health centers
in the participants’ respective areas of residence.
The results of the SRQ-20 analysis on families and people with mental health disorders indi-
cated that all participants did not risk experiencing mental and emotional problems (cut-off
point <6) [3, 47]. Further analysis of the correlation between SRQ-20 and participant charac-
teristics using the Spearman Rank Test showed that SRQ-20 (risk of emotional and mental
health disorders) was significantly related to the estimated time of home visit for cadres in a
week (p-value 0.06). In contrast, age (p-value 0.081), gender (p-value 0.138), and length of
time cadres interact with family and clients (p-value 0.278) did not significantly associate with
the risk of mental-emotional problems.
Therefore, three variables were entered into the Linear Regression analysis to find the vari-
able more related to emotional and mental health problems than the others. After eliminating
the length of time families interact with mental health cadres variables, the results revealed that
the amount of Adjusted Coefficient of Determination (R2 adjusted) from this model, 13.3% of
emotional mental health problems changes were related to the estimated time cadres make
home visits in a week (p-value 0.044; B:-0.297) but not statistically significant with variable age
(p-value 0.070; B:0.265).
Data collection
Data for the study were collected from August 2020 to January 2021 using Focus Group Dis-
cussions (FGD). Focus group discussion is used to gain an in-depth understanding of the

Table 2. Participants characteristics.

No Characteristics Total / Mean Percentage (%) /(Min-Max)
Family
1 Age (years) 44.00 23–67
2 Gender
Male 3 12.00
Female 22 88.00
3 Relationship with Client
Child 4 16.00
Parents 5 20.00
Husband/Wife 2 8.00
Siblings (brother/sister) 12 48.00
Cousin/family relations 2 8.00
4 Length of time family has cared for the client (years) 9.56 1–25
5 Length of time families interact with mental health cadres (years) 4.12 1–18
6 Time estimated of cadre home visit time per week (hours) 3.33 0.25–25
7 SRQ Score
Risk for emotional mental health problems (cut off point � 6) 0 0
Did not have emotional mental health problems (cut off 25 100
point < 6)
Client
1 Age (years) 36,47 25–54
2 Gender
Male 15 78.95
Female 4 21.05
3 Education
Did not attend school 5 26.32
Primary School 7 36.84
Junior High School 4 21.05
Senior High School 3 15.79
4 Medication history at Primary Health Center
Regularly 18 94.74
Not regularly 1 5.26
5 Hospitalization history in psychiatric hospitals
Have 13 68.42
Did not Have 6 31.58
6 Length of time client interaction with mental health cadres 9.84 1–25
(years)
7 Time estimated of cadre home visit time per week (hours) 3.13 0.25–25
8 SRQ Score
Risk for emotional mental health problems (cut off point � 6) 0 0
Did not have emotional mental health problems (cut off 19 100
point < 6)
participants perspectives on the topic in the discussion [48], which was the role of the mental
health cadre in mental health services. Focus group discussion is frequently used when partici-
pants in the study were selected from a group of individuals purposely and aimed to under-
stand social issues in-depth [49]. This was conducted to portray the views of families and
people with mental disorders on mental health cadres who provide in-depth mental health

Box 1. Focus group guideline
1. Opening questions
a What do you think about mental health cadres?

2. Core question
a What do you think about the role of mental health cadres in your area so far?
b What are the things that support and hinder mental health cadres in carrying out
their duties?
c What are your expectations about the role of the mental health cadre in the future?
What do you need to make these expectations come true?
services. The FGD in the family lasted for two hours (in East Java) and one hour (in Aceh and
West Java) used Indonesian and local languages (Javanese, Sundanese, and Acehnese) during
the discussions. On average, FGD in people with mental health disorders lasted for 60–90 min-
utes. The Focus group discussions were complete face-to-face at local community venues facil-
itated by a local moderator with the implementation of a strict COVID-19 health protocol.
Moderators and research participants were involved in face-to-face discussions by applying
physical distancing, wearing masks, and the discussion was held in an open room with decent
air circulation.
Data from the FGD were audio-recorded and field notes to record participants’ non-verbal
responses and conditions that affect the focus group discussion process was also employed. In
addition, a protocol for FGD was used in order to guide the running discussion effectively
(Box 1 shows the focus group guideline). The data obtained in the FGD in the form of audio-
visual recordings were then transcribed using the Indonesian language.
Before commencing the study, we ensured that the selected participants met the established
criteria. The first step of participant selection was screening prospective participants who may
participate in this study. Then, healthcare workers responsible for mental health programs at
community health centers select participants according to the specified criteria. In this process,
we first explained the research objectives and research duration in order the participants are
willing to participate voluntarily or withdraw from the study. For ethical reasons, consent
forms were signed by the participants. For families, the informed consent was signed before
the focus group discussion, while for people with mental disorders, the informed consent was
signed accompanied by their family.
Data analysis
To analyze the data, an inductive thematic analysis was undertaken. Inductive thematic anal-
ysis was carried out through six stages of coding and theme development [50]. We did multi-
ple and repeated readings to obtain familiarisation with the data. The first and second
authors of this study coded the transcripts independently and then held discussions to deter-
mine the final set of codes, in which similar codes would be amalgamated and the duplicated

codes were removed. The final coding framework generated from the discussion process was
organized into sub-themes and main themes that aimed to answer research questions. Other
authors discussed the potential themes generated at this stage to ensure that the themes fully
reflect the data obtained in the research process. The quality criteria for this qualitative
research methodology are based on credibility, confirmability, dependability, and transfer-
ability [51]. Credibility is equivalent to the internal validity of quantitative research, which
shows that research findings are the correct interpretation and have represented the views of
research participants [51–53]. In this study, we ensure the trustworthiness of data analysis
with peer debriefing through collaboration with all researchers, including non-Indonesian
researchers, triangulating data, and providing feedback on data and the resulting themes. All
researchers reviewed and agreed on the themes generated in this study. Confirmability indi-
cates neutrality and the extent to which research findings can be confirmed by other
researchers [52, 54].
We also described the research results in detail, prepared research notes, and used quotes to
present the data to be more transparent. Dependability is consistency and the stability of
research findings over time [51, 52, 54], which is improved by going through regular meetings
with all researchers to avoid bias, assumptions, and data misinterpretation. We provide com-
plete research procedures so that other researchers can follow the same research process.
Transferability refers to the extent to which the results of this study can be transferred to other
settings, contexts, and respondents [52, 54], by providing a comprehensive description of the
research context (participants and the research process). The research team are academics and
mental health professionals, thus enabling an in-depth and comprehensive understanding of
mental health problems. The researcher does not have a personal relationship with the partici-
pants, so there are no assumptions or personal interests, and the results obtained are purely
the opinions of the research participants.
Results
Six themes were interpreted from the data, namely 1) the type of support provided by the
cadre to families and people with mental health disorders, 2) factors that were perceived to
facilitate the success of the implementation of the cadre roles, 3) the roles of shame, 4) trust
relationships with cadres, 5) stigma, and 6) patient and family expectations of the role of cad-
res. The findings are also illustrated in Table 3.
The type of support provided by cadre to families and people with mental
health disorders
The key reported roles of cadres identified by participants were monitoring conditions, pro-
viding information, and treating mental disorders patients. Participants viewed the cadre as a
caring figure who provided care and valued support for people with mental disorders and their
families. Participants described cadres in positive roles and considered cadres providing a
range of different types of support, including emotional, spiritual, informational, tangible sup-
port, social, psychological, and physical support. Emotional support is the action of mental
health cadres in giving attention, care, and affection; spiritual support is the effort of cadres to
encourage spiritual activity, and informational support is the support given in the form of pro-
viding advice and information to improve the health of people with mental disorders. The
forms of emotional, spiritual, and informational support provided by the cadres are illustrated
in the following participant statements:

Table 3. Codes, sub-themes, and themes that emerge when exploring the experiences of families and patients in achieving support from cadres.
Theme Sub Theme Selected code Frequency of Percentage
Occurence Cover
The type of support provided by the cadre Types of Support: Attention 22 50
to families and people with mental health Emotional Support Give love 13 29.54
disorders
Care 18 40.91
Sympathy with people with mental health disorders 11 25
Give support 5 11.36
Reception 26 59.1
Spiritual Support Encouraging spiritual activity 8 18.18
Helping find meaning in life 11 25
Informational Support Teaching people with mental disorders to be better 16 36.37
Giving advice 17 38.64
Cadres inform all mental health activities for people 7 15.91
with mental disorders that are carried out at the
village hall to families
Tangible Support Help get treatment for people with mental health 23 52.27
disorders
Supervise / control the accuracy of taking medication 21 47.73
Helps quickly recognize signs of relapse 7 15.91
Facilitate when people with mental disorders need to 6 13.64
be referred
Providing services to the community 4 9.09
Occupational Support Teaching skills 6 13.64
Helping people with mental disorders Decent work 8 18.18
Teaching art 7 15.91
Sosial Support Invite socialization 8 18.18
Psychological Support Family is happy 10 22.73
Family feeling calm 3 6.82
Physical Support Feel physically fit 9 20.45
The family feels there is a positive activity 4 9.09
Support Time Provided by Support time 13 29.54
Cadres Support duration 3 6.82
Factors that were perceived to facilitate the Internal factors: Friendly 5 11.36
success of the implementation of the cadre Positive Attitude of Mental Attention 14 31.82
roles Health Cadres
Full of love 8 18.18
Commitment Duties/mandate 16 51.36
Responsible 10 22.73
External Factors: Family 7 15.91
Cadre’s Close Relationship Relation 2 4.54
with Patients and Families
Community Leader Support Feeling community leaders are responsible and 4 9.09
monitor activity
Availability of Facilities and Integrated Healthcare Center 5 11.36
Infrastructure for Activities Village meeting hall 2 4.54
The roles of shame Perceived shame Shy 3 6.82
Feel ashamed 4 9.09
Inferior Don’t want meet others 4 9.09
(Continued )

Table 3. (Continued)
Theme Sub Theme Selected code Frequency of Percentage

Occurence Cover
Trust relationships with cadres Rejection Don’t want to meet cadres 2 4.54
Patient sleeping 2 4.54
Don’t want to take medicine, feel no pain 6 13.64
Family Mistrust Family refuses 1 2.27
Closed Family 3 6.82
Stigma Patients in Crisis Feeling incapable 4 9.09
Conflict Offended family 1 2.27
Stigma Labelled negative 4 9.09
Considered useless 2 4.54
Patient and Family Expectations on Cadre Mental Health Cadre’s Commitment in providing service 9 20.45
Roles Ability Communication skills 5 11.36
Sustainability of activities 6 13.64
Partnership 6 13.64
Forms of Cadre Support to Reduce stigma 5 11.36
Families and Patients Provide information 12 27.27
Maintenance assistance 10 22.73
Financial support 6 13.64
Work skills 8 18.18
Home visit 9 20.45
Spiritual support 3 6.82
Mental Health Cadre’s Attention 7 15.91
Attitude Empathy 6 13.64
Communicative 5 11.36
Training Support for Cadre Training for cadre 2 4.54
Advanced training for cadres and families 2 4.54
“The cadres care about my family, always regularly doing home visits. They feel sorry for me
because many of my family members are sick. . .So they (cadres) are also there to comfort me
so that I do not feel sad and my burden is less”
(Family B3—female, 41 years)
“The cadre always looked after me and my family continually monitored whether the medi-
cine was taken regularly. They also like to provide advice so that the patient gets better
quickly”
(Family B3- female, 41 years)
“Cadre who guides us, tells us to recite the Koran, and tells us to pray. . .”
(Patient B1—male, 40 years)
Tangible support is practical and visible support provided by cadres to families and people
with mental health problems. Cadres help patients with mental disorders get treatment, con-
trol the accuracy of taking medication, help families recognize signs of patient relapse, facilitate
when patients need to be referred, and provide services to the community. It is depicted in the
following vignette:

“Cadres usually help us remind whether my family (patient) have been taking medicine. If I
didn’t grab medicine, she would grab medicine for my family, so I do not have to go to Com-
munity health centres”
(Family A2—female, 31 years)
“Cadre regularly visits the house, or if I report signs of recurrence, she (cadre) immediately
responds”
Mental health cadres also encourage people with mental disorders to have jobs, promote
and provide social support. Cadres teach skills, teach art, and help people with mental disor-
ders who are independent and fit to work to have jobs. Cadres taught people with mental dis-
orders skills for making bags, doormats, flower arrangements, making cake boxes, and other
skills such as gymnastics. It is shared by Patient A5 in the discussion:
“Teach skills. . . making. . .bags, making doormats”

(Patient A5—male, 35 years)
Families and people with mental disorders also received psychological support and physical
support from mental health cadres, which improves family peace and health. Psychological
support improves psychological well-being, while physical support includes the facilitation of
cadres to support the implementation of people with mental disorders activities.
“I feel happy. There are activities and sports which are carried out at the village hall regularly”
Mental health cadres regularly interacted with participants every day, one to two times a
week, and at least once a month to support families and people with mental disorders. In addi-
tion, participants and cadres frequently have houses adjacent so the cadres can make more vis-
its. The excerpts below illustrate such conditions:
“The cadres service is good. Held at the village hall, every two weeks.”
“Almost every day, she (cadres) comes. After all, our houses are close”
Factors that were perceived to facilitate the success of the implementation

of the cadre roles
The success of cadres in carrying out their duties was perceived by participants to be mediated
by a range of factors (internal and external factors). The positive attitude of mental health cad-
res and commitment of mental health cadres are internal factors perceived by participants that
support the success of cadres in carrying out their duties. Mental health cadres show a friendly,
caring, and loving attitude to patients and families when making visits and carrying out their
duties, thereby increasing family acceptance of the role of cadres. These two vignettes portray
such situations:

“cadres are friendly people, so the family accepts them”

“she feels he has a responsibility to our family”
In addition, participants described cadre commitment as dedication that causes cadres to

do their responsibility. It showed by mental health cadres in the form of obligation and respon-
sibility in providing services is also a major supporter of the successful implementation of the
duties of cadres in the community. In carrying out their duties, cadres make home visits from
one patient’s house to another patient’s house, besides that, mental health cadres also visit the
patient’s family. Patient B1, B3, and Family B4 contend that:
“She (cadres) regularly visit and monitor the condition of my family. I feel that she are respon-
sible for my family, maybe because it is a mandate and duty as a cadre”
“Cadres are always there when we need them”
“Cadre came for guided us to get well soon”
Participants felt close to cadres because cadres were from their communities and viewed
cadres have their own experiences with mental health problems. The close relationship is an
external factor that supports cadres in carrying out their duties properly, for example, mental
health cadres who are still family members or closest relatives. Cadres who are relatives (cous-
ins) or family (wife/husband/close family) of people with mental disorders have better rela-
tionships because they are more open with cadres and usually have more intensive interactions
because they live closer to participants. Patient B1, A4, and Family B9 shared that:
“My wife is a cadre, and I have become calmer and easier to tell something”
“Cadres are my family; I know her; her house was close to me”
“In my opinion, cadres who are still family members are easier, usually easier to close and eas-
ier to open up”
The support of community leaders, as well as the availability of facilities and infrastructure
for the implementation of cadre activities are other external factors that play a role in helping
cadres carry out their duties. Patient A3 and Family A5 stated that:
“There are routine cadre activities at the village hall”


“I see the village head always monitors our activities (cadre and patients/family)”
The roles of shame

While receiving support from mental health cadres, several participants mentioned that they felt
ashamed of the mental health problems they or their families were experiencing. The perceived
shame felt by the patient that caused the patient to feel inferior also made it difficult for the cadres
to carry out their duties because the patient did not want to meet the cadres. It is depicted that:
"I feel shame to meet others. I don’t want to meet them."

“I feel ashamed to be visited by cadres because if cadres visit, it means that there was a men-
tal disorder at my home”
(Familyt B5—female, 23 years)
Trust relationships with cadres

In carrying out their role, participants perceived several obstacles encountered by the cadres in
implementing their duties. Barriers to cadres in carrying out their duties are influenced by two
factors, namely factors from patients and factors from families. When carrying out their duties,
mental health cadres sometimes experience rejection from patients, such as excluding from
meeting with cadres, not wanting to take medicine, or patients not feeling sick, making it diffi-
cult for cadres to carry out their duties properly. Another obstacle that comes from the
patient’s family is the conflict between the family and the family, who does not trust the mental
health cadres. Sometimes, the patient and family do not trust the mental health cadres. This
trust relationship with cadres brings up barriers to cadres carrying out their duties. This trust
relationship easily improved when cadres were family or relatives of the patients. In the FGD,
Family B7 shared that:
“My family didn’t want to meet the cadres and didn’t want to take medicine because they
didn’t feel sick, so when the cadres came, they refused.”
“Cadres are close to us, my family, so I can be more open and more trusting”
Stigma
Participants felt that the support of cadres for patients and families with mental health prob-
lems was related to stigma in the community. Patients’ families sometimes feel offended and
labelled negative by community when cadres make home visits, so the patient’s family is not
open and does not accept advice from cadres. The existence of stigma from the community to
the patient and family causes the patient and their family to feel ashamed and worsens the ser-
vices provided by the cadres. This is because the family feels reluctant to be visited by mental
health cadres. Family B5, B7, and B9 shared in the FGD that:

“Embarrassed because there is a stigma in the community if a cadre is visited, it means that
someone is crazy at home.”
“If a cadre comes to the house, I feel offended”
“I felt offended when the cadres visited, so I just said that if there was no family who was sick
and had recovered”
Patient and family expectations on cadre roles

Patients and families hope that mental health cadres can support families in caring for patients
with mental disorders. The ability of mental health cadres is demonstrated by the commitment
of cadres to providing care, sustainability of activities, partnerships with health centers and vil-
lages and the skills of mental health cadres in communicating with families and patients. With
good communication skills, families and patients hope that communication with cadres can
run smoothly and information about mental health can be conveyed properly. In the discus-
sion, Patient B4, Patient C1 and Family C1 voiced that:
“I hope that our activities (with cadres) will run more smoothly.”
“Communication needs to be improved because sometimes things are correct, and things are
not. So hopefully, we can discuss health.”
(Patient C1—male, 33 years)
“More for communication with the health center and village”
(Family C1—female, 62 years)
Another expectation by families and patients towards mental health cadres is the exis-
tence of other forms of support provided by mental health cadres. The form of support in
question is the provision of information, care assistance, financial support and work skills,
home visits, spiritual support, and hopes to reduce the stigma on families and patients with
mental disorders. Although several forms of support have been provided by mental health
cadres, for example, in the form of providing information, care assistance, paper skills sup-
port, home visits, and spiritual support, patients and families hope that this form of support
can be improved for the better with a slightly longer duration. Families perceived that
when cadres have more contact with patients, cadres can see the development of their fami-
lies (people with mental disorders), monitor patient independence, and assess patient signs
and symptoms. Families also perceived that when cadres often visit patients, they can
improve patient recovery. Families and patients also hope that apart from being given
advice, mental health cadres can provide knowledge related to mental health. It is shared
that:
“Cadres can visit so they know how far the progress of our children”

(Family A4—male, 67 years)

“Even though the patient is independent, Cadres still has to visit”
“When visiting the patient’s family, it is hoped that the patient will also be asked their signs
and symptoms.”
“Often see my son at my house to increase his improvement
“Family expectations for Cadre. . . Providing advice and knowledge.”
Stigma causes cadres to experience obstacles in providing services. Families and patients
hope that cadres can provide understanding to families and communities so that families
are more open and do not feel excluded. Families hope cadres can communicate about
stigma and provide counseling to families to reduce stigma in society. Family B2 shared
that:
“Often provides counseling to families. It means working with the village head to be able to
provide counseling to the community regarding the stigma of mental disorders. . .so that
stigma is lost in the community related to mental disorders”
Mental health cadres are expected to have a caring attitude towards their families and
patients and have a sense of empathy. The family hopes that the cadres can have more atten-
tion and a better attitude to patients. In addition, effective communication between cadres
and families and patients’ needs to be further improved. Family C3 and Family C1 contend
that:
“Pay more attention to patients so that they are even better”

“More to communication with cadres”
Families also hope that mental health cadres will receive support from the health system in
the form of training for mental health cadres. With the training of mental health cadres, fami-
lies hope that cadres can carry out their roles better and can provide further training for fami-
lies who care for patients with mental disorders at home.
“So that the mothers in this Community Health Center give more frequent training to Cadres
so that they are better in the community”

Discussion
Cadre support to families and people with mental health disorders
The forms of support provided by cadres to families include emotional support, spiritual sup-
port, and informational support. Cadres can approach families with mental patients because
cadres are in an environment with the same cultural background, using open and friendly
communication strategies [55]. Cadres help families and people with mental disorders by pro-
viding information, referring to Community Health Center, controlling treatment, and other
social assistance [37]. Improving knowledge and insight about schizophrenia through psy-
choeducation promotes social functioning, reduces relapse, and encourages medication treat-
ment adherence in people with schizophrenia [56]. In addition, the care of cadres as social
support can improve the quality of life of patients with mental disorders [57]. Families feel
heard and assisted by cadres in providing care to family members with mental disorders [58].
Families find it helpful when cadres teach patients to worship and train families to accompany
them [55]. Cadres also provide skills training to patients and then distribute the patient’s work
with entrepreneurs or non-governmental organizations [59]. These various efforts are a form
of cadre support so that families and patients with people with mental disorders feel helped.
Families and patients benefit from having mental health cadres in their area of residence.
Supporting factors for cadre success in carrying out tasks

Supporting factors consist of internal factors (friendly, caring, loving attitude to patients and
families) and external factors (closeness of cadres to patients and families, and support from
community leaders). Cadres play a role in connecting health workers with patients and fami-
lies to help the successful resolution of mental health problems in the community [60]. Cadres
show a friendly and empathetic attitude to patients and families when interacting, which
affects the success of the approach [55]. In addition, cadres’ attitude of attention and affection
to patients makes families more cooperative in receiving the information conveyed [61]. The
motivation and sincerity of cadres in doing service can be seen from the efforts to carry out
treatment and home visits so as to increase the success of the community mental health pro-
gram [62]. Health workers provide support in the form of assistance to cadres every time they
carry out tasks such as counseling and treatment for patients with severe mental disorders
[63]. The task of mental health cadres in the community is also assisted by the collaborative
role of community leaders and across sectors to be more effective [64]. Motivation and sincer-
ity from within cadres accompanied by support from other people, both health workers, com-
munity leaders, and cross-sectors, affect the success of solving community mental health
problems.
Factors inhibiting the implementation of cadre duties

Mental health cadres experience rejection from patients, such as patients not wanting to meet
mental health cadres, feeling embarrassed, not wanting to take medicine, not feeling sick, and
family conflicts that make it difficult for cadres to carry out their duties. Patients sometimes
refuse the presence of mental health cadres because they feel that cadres are not health workers
who can provide assistance [65]. Stigma still high in society towards mental disorders makes
families and patients hide their pain and not feel sick [66]. The stigma of mental illness in the
community and health services hampers the quality of mental health services [67]. Conflicts in
the family, such as relationships between family members or work problems, can have a nega-
tive impact on mental health and health-seeking behavior [68]. Caring for family members
with mental health disorders is challenging for caregivers and causes varying degrees of care

burden requiring routine psychological family intervention [10, 13]. For example, the care-
giver burden was higher in community settings (28.28%) and in caregivers of individuals with
psychosis (35.88%) [11]. Another inhibiting factor is the attitude of patients who refuse treat-
ment. The patient refuses to take medication because he has already undergone treatment and
has not recovered or does not feel sick, so other collaborative efforts are needed in approaching
the patient and family [69]. The thing that hinders the success of the cadre’s duties is the
patient and the family in responding to the treatment process for mental disorders.
Patients and family expectations on cadre roles

Patients and families hope that communication with mental health cadres can run smoothly
and information about mental health can be conveyed properly. Patients and families also
hope to receive support or attention from cadres, reduce community stigma, and cadres
receive training. Training could grow cadres’ confidence and their relationships with others;
this can support the effective treatment of schizophrenia, which requires integrating psychoso-
cial intervention strategies and optimal medication use [14, 70]. The role of cadres in conduct-
ing counseling, assisting in monitoring, and implementing therapy is very beneficial for
patients and families so that families hope that the relationship between cadres and patients is
maintained [71]. Adequate professional support from cadres is positively related to good fam-
ily functioning, so it has a positive impact on reducing subjective and objective burdens of care
[12]. Also, families need social support from cadres as people who are closer and help commu-
nicate with professional health workers [72]. Family involvement and social support, such as
cadres in treating mental disorders, influence the patient’s confidence to recover [73]. The
main hope felt by patients and their families is the reduction of stigma in society because
stigma affects the family’s attitude in receiving a diagnosis and also efforts to seek health care
for patients with mental disorders [66]. Patients and families hope to continue to receive posi-
tive support from cadres and health workers, reducing societal stigma so that patients can be
independent and productive.
Conclusions
Families and patients with mental disorders feel the cadres’ commitment and good attitude in
helping families monitor conditions, provide information, and treat patients with mental dis-
orders. Data from patients and families show expectations for cadres to improve their ability
to communicate and deliver care, commitments related to the continuity of activities, and
partnerships with Community Health Center and cadres inhibiting factors in carrying out
their duties. First, in the form of refusal, the patient does not want to take medicine and violent
behavior. The family factor refuses to be visited because they feel ashamed due to the stigma
related to mental disorders from the community. This study contributes to achieving the
Global Goals of the 2030 Agenda for Sustainable Development, which was ensuring healthy
lives and promoting well-being for all at all ages through the role of mental health cadres in
supporting the care of patients with mental disorders and their families, thereby increasing
family well-being and bridging mental health services for people with mental disorders. To
optimize the role of cadres in society, a more structured training program is needed to
improve the capabilities of cadres. In addition, programs that target the improvement of com-
munity literacy related to mental disorders are needed.
Acknowledgments
The authors would like to express their gratitude to all who contributed to this research.

Author Contributions
Conceptualization: Heni Dwi Windarwati, Herni Susanti.
Data curation: Ice Yulia Wardani, Hasniah, Mardha Raya.
Formal analysis: Ice Yulia Wardani, Hasniah, Mardha Raya.
Methodology: Heni Dwi Windarwati, Herni Susanti.
Validation: Helen Brooks.
Writing – original draft: Niken Asih Laras Ati, Hasmila Sari.
Writing – review & editing: Heni Dwi Windarwati, Herni Susanti, Helen Brooks, Niken Asih
Laras Ati, Hasmila Sari.
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PLOS ONE

Lay community mental health workers

Citation: Windarwati HD, Susanti H, Brooks H, Abstract

Accepted: July 30, 2023 Methods

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Materials and methods

Table 1. Distribution of focus group discussion family and client.

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Table 2. Participants characteristics.

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Box 1. Focus group guideline

a What do you think about mental health cadres?

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Theme Sub Theme Selected code Frequency of Percentage

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“Teach skills. . . making. . .bags, making doormats”

Factors that were perceived to facilitate the success of the implementation

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“cadres are friendly people, so the family accepts them”

In addition, participants described cadre commitment as dedication that causes cadres to

“There are routine cadre activities at the village hall”

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The roles of shame

"I feel shame to meet others. I don’t want to meet them."

Trust relationships with cadres

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Patient and family expectations on cadre roles

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(Family A4—male, 67 years)

“Pay more attention to patients so that they are even better”

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Supporting factors for cadre success in carrying out tasks

Factors inhibiting the implementation of cadre duties

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Patients and family expectations on cadre roles

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