- Open Access
Personal attributes and competencies required by community health workers for a role in integrated mental health care for perinatal depression: voices of primary health care stakeholders from Surabaya, Indonesia
© The Author(s) 2018
- Received: 21 March 2018
- Accepted: 30 July 2018
- Published: 14 August 2018
Non-professional community health workers have been widely reported as possibly having a role in mental health. In Indonesia, their role is currently being introduced in the national health system for perinatal depression. Prior publications have shown that it is generally considered feasible and acceptable by key stakeholders for community health workers to identify and refer women experiencing mental health issues during their perinatal phase to primary care. However, characteristics and competencies required for these workers have not yet been identified.
62 participants from four groups of stakeholders in primary health care in Surabaya were interviewed, including program managers, health workers, community health workers (CHWs), mental health specialists, and pregnant and postpartum women. Semi-structured questions were used to explore participants’ views about characteristics and competencies required by CHWs to identify and refer perinatal depression.
Literacy and social skills were seen as basic characteristics required for CHWs to contribute to perinatal identification, together with willingness to volunteer and time availability. Participants identified females in the age range 30–50 years who have experienced pregnancy as being preferable. To ensure competency, training addressing knowledge about maternal life and depression, and communication skills are regarded as prerequisites for the role.
The results are consistent with WHO guidelines for informal workers working with people with mental disorders in non-specialised settings. The results provide a rationale for the criteria to be met when informal workers are to be involved in primary care mental health area and provide information for the development of training in the identification of perinatal depression.
- Community health workers
- Characteristics and competencies
- Perinatal depression
- Primary health care
- Human resource for mental health
Community health workers (CHWs) play an important role in health care in Indonesia. CHWs provide informal community care and are recruited based on willingness, ability, and availability to run a community-based health service voluntarily. To equip CHWs with skills in health care and ensure capability, they are trained in health-related areas, mainly in maternal and child health , and in other health areas as required. CHWs are also increasingly becoming important in mental health care. For instance, CHWs are currently expected to be part of a national community mental health action team at the primary health care level , and to play a role in identification of depression among pregnant and postpartum women [3, 4]. Despite the lack of national record on perinatal depression, study in Surabaya reported prevalence of perinatal depression was quite high at 22% , calling to involve CHWs for identification of perinatal depression.
Community health workers have a role in mental health care in many developing countries  as an approach to alleviating shortages in the mental health workforce . Depending on local needs, CHWs are trained to contribute to a range of tasks such as detection, diagnosis, treatment, and prevention of mental disorders [7–9]. Studies in India, Pakistan and South Africa have shown that CHWs have effectively filled roles as counsellors and psycho-educators using complex treatment [10–13], including screening and providing interventions to patients with common mental disorders . Intervention studies in Pakistan and South Africa have found that CHWs can be trained to identify and provide intervention for maternal depression [13–15]. CHWs in these studies completed secondary school and were trained in communication skills, psychoeducation on perinatal depression, and intervention technique using stress/anger management  and/or cognitive behaviour therapy . However, very few studies have investigated the personal characteristics and competencies required for CHWs to carry out these tasks [17, 18] despite acknowledgement that knowledge to specific mental health issues and communication skills is important in improving competencies to deliver support.
The WHO defines competence as “…a level of performance demonstrating the effective application of knowledge, skill and management” [19, p. 33]. Competencies reflect three elements: (1) knowledge, understanding and judgment; (2) cognitive, technical and interpersonal skills; and (3) a range of personal attributes and attitudes. This competencies framework suggests three areas of competency for informal CHWs: (1) basic understanding of mental disorders, including understanding symptoms of mental disorders; (2) basic counselling competencies, including listening and communication skills, especially empathic listening; and (3) advocacy. Communication is the most frequently suggested skill for workers dealing with mental health-related issues [16, 18]. The importance of communication skills is demonstrated in the World Health Organization (WHO) Mental Health Gap Action Programme Intervention Guide (mhGAP-IG) on non-specialized health settings, which offers guidelines for mental health actions in developing countries. This document suggests effective communication skills as a general principle of essential care, along with respect and dignity. Description of these skills include preparing an environment that facilitates open communication; being friendly, respectful and non-judgmental; using good verbal communication skills; and being sensitive towards difficult experiences .
In a recent qualitative study in Indonesia investigating feasibility of mobilizing CHWs to contribute to identification and referral of women with perinatal depression, it was found that not all CHWs currently working in maternal and child health care are perceived capable of carrying out this task . The findings highlighted clear need to define CHWs characteristics and competencies in order to recruit and train CHWs who may contribute to perinatal mental health care. The aim of this qualitative study was to explore the characteristics and competencies required for CHWs to effectively identify and refer women with perinatal depression in Indonesia by examining perceptions of key stakeholders.
Research setting and participants
This article reports on part of a broader study conducted in Surabaya, Indonesia, to investigate feasibility and acceptability of mobilising CHWs for perinatal mental health care. Four stakeholder groups in primary health care (PHC) participated: (1) program managers from the district health office and primary health care services (integrated health service posts) in villages, (2) health workers, i.e. primary care doctors (GPs), nurses, midwives and counsellors in PHC centres, and CHWs from three villages, (3) mental health specialists, and (4) service users, i.e. pregnant and up to 1 year postpartum women. These groups were identified based on PHC system at district level [21, 22].
Program managers were selected from the district health office and three villages. Health workers were recruited from each of the three PHC centres at sub-district level recommended by the health office. Within the catchment area of one of three PHC centres, three villages were randomly selected to recruit community program managers. From each of these villages, two community-based integrated health service posts were identified from which CHWs and service users were recruited. Mental health specialists were recruited from one district hospital. Further details regarding participants are described in Surjaningrum et al. .
Participant views on CHW required competencies were collected through face-to-face semi-structured interviews. Participants were interviewed about their perceptions on attributes and competencies for CHWs involved in identification of perinatal depression, and more specifically about personality, educational background, gender, experience, and other factors suggested by participants. Views on training needs of CHWs were also gathered, including whether they could be trained and content of training required. The first author (ES) carried out interviews in Indonesian with all participants. Interviews were audio-recorded with participant permission and subsequently transcribed.
Interview data (interview transcriptions) were managed using NVivo 11. Data analysis was conducted using framework analysis [23, 24]. Elements of competencies as defined by WHO , were used as a coding framework which covered knowledge, a range of skills (cognitive, technical, and interpersonal), and a range of personal attributes (age, gender, education, and personality). Data analysis was conducted in Indonesian to prevent potential loss of meaning through translation. Transcriptions were translated into English when the analysis process moved to mapping and interpretation. This approach was applied to ensure interpretation was credible by allowing English-speaking collaborators to check and discuss the data.
Ethics and institutional approval
Ethics approval was obtained from the University of Melbourne on May 20th, 2015 (Ethics No. 1543833). Approval to conduct the research in Surabaya was granted by the Department of Health, Surabaya.
Socio-demographic summary of participants
Health workers (n = 12)
Community health workers (n = 12)
Mental health specialists (n = 5)
Program managers (n = 5)
Service users (n = 28)
Total (n = 62)
Level of education
< High school
> High school
Characteristics and competencies
Summary of CHWs' competencies and attributes
Knowledge, skills, attributes
Qualities and specific topics
Knowledge and understanding
Pregnancy: physical and psychological changes during pregnancy
Perinatal depression: symptoms of depression and strategies of detection
Having positive attitude towards the mental health of pregnant women
Being confident towards CHWs’ role for future generation
Skills and personal qualities
Having good communication techniques, i.e. manner of speaking/asking questions and using nonjudgmental and simple language
Being aware to the confidentiality of an issue
Socially active and able to socialize well
Being alert to community needs
Respect for cultural diversity
Open-minded and have problem-solving skills
Mature, patient, and caring to others
Being 30–50 years old is the most preferable; below 30 is less trusted and lack of skills; above 60 is less productive
Level of education
Having basic literacy (reading and writing) is necessary, but having a minimum of high school educational background is more preferred
Female is preferred, but male is acceptable
Self-willingness and are not money-driven, ‘ikhlas’
Have experience in marriage, pregnancy, and working with mothers
Knowledge and understanding
Participants shared their perspectives on the types of knowledge or understandings required by CHWs for identifying perinatal depression. In general, CHWs require basic knowledge about pregnancy, maternal life, child development, perinatal depression, communication techniques, and specific knowledge, such as how to change attitudes, and risk factors.
“People think that pregnancy is a happiness event, however not all people are happy when they are pregnant. …When a CHW meets pregnant women and finds changes, she needs to know [whether a woman needs help]” (Sp 4)
Another important area of knowledge is behavioural signs of mothers and/or their children that indicate depression. Health workers suggested that presentation of depression during pregnancy may be different to that after giving birth. Therefore understanding the signs and symptoms is necessary. CHWs and service users suggested CHWs should understand detection methods, including how to use a screening tool.
A specialist suggested that CHWs need to have positive attitudes towards the mental health of pregnant women. This specialist stated that it is important to build a paradigm and understanding that what CHWs are doing is important as an investment in the future generation.
Skills and personal qualities
Participants emphasized the importance of personal qualities and skills. For those who work with mental, neurological and substance use disorders in non-specialized settings, WHO suggests effective communication skills and promoting respect and dignity are general principles . These principles were also reported as necessary skills by study participants from all stakeholder groups.
Knowledge about communication techniques is necessary. Health providers and specialists discussed a need for communication techniques that do not offend mothers, including verbal techniques, such as way of talking, tone, and language used, and non-verbal methods, such as body language, and interview techniques. Mothers recommended that information be provided to CHWs on strategies regarding asking questions that reduce the risk of mothers/women feeling scared or reluctant when gathering information from people less involved in the rest of community (e.g. migrant workers), and when suggesting solutions.
“Those who will to listen, people who can talk smartly, finding opportunities among words. Yes, I think those things” (CHW J4)
Some participants highlighted the importance of people who can maintain confidentiality. In contrast, a communication style that is directive, straightforward, involving a superior tone, and less empathetic, referred to in a local terms as ‘judes’ (salty), is undesirable.
“[the centre] selects CHWs: this person is smart and able to persuade others, is articulate, can provide counselling and broader perspectives. Then that person would be selected to be a CHW and [get trainings]” (CHW NS3)
“CHWs work on several tasks, but for this task I recommend those who are active and have concerns [about issues in the community]” (Nr 3)
Personality and problem-solving skills
“If she [a CHW] has higher education she would have broader experience, is accurate, and can offer solutions because she has learnt more. Those [CHWs] who are less educated but have more experience may also [provide solutions], just like most CHWs in our community” (Pr C1)
“…be patient, able to offer solutions, talk in good manner and soft, because she will talk to people who may have problems…” (Pr E4)
For service providers, it is necessary to have CHWs who are loyal and committed to assist the community under supervision of the PHC centre.
“The [existing] CHWs are already old. I reckon it is better to choose those in their 30s because they are more experienced. If they are below 30, they cannot communicate well and cannot approach well to the community” (CHW M1)
In addition, people in their 30s and 40s were considered to have fewer domestic responsibilities. Most women in Indonesia marry and have children in their 20s and therefore have less domestic tasks in their 30s and 40s.
Service providers had a preference for CHWs in their 50s as they perceived people in this age group are more motivated by personal benefits gained from taking on this role, e.g. gaining knowledge about perinatal mental health that can be transferred to their own family.
People below 30 and above 60 years of age were less preferred to be a CHW involved in the task of depression identification, for reasons that varied among groups of stakeholders. Service users referred to personal feelings that influence age preference. For example, they preferred not to see CHWs below age 30 or of the same age as themselves, because it may generate feelings of shame from sharing psychological experiences and because the relationship would seem “just like talking to one’s own friends”. In agreement with service users, CHWs stated that this age group is less likely to be respected and trusted, and consequently service users may not listen to them. In addition, young people are busy with paid employment and may not be available to take on the role.
“If they are too old, they are reluctant to come to PHC centre, sometimes they also have responsibility such as taking care grandchildren. Therefore, it is better neither too young nor too old…at about 30 to 50 years old. That’s the range” (Cs 3)
“…if we set a specific level of education, we will face problem in finding the CHWs. So we focus on people who are active and able to work together. To be honest, it will be better if we consider education because understanding about depression requires higher knowledge which is identical to higher level of education. However, practically we won’t get them” (Sp 1)
“Usually for CHWs we do not see their education level, because the principle is she will to take the tasks. If we consider their education, then no one may to join” (CPM 3)
“If someone has a bachelor degree but she is not willing to be a CHW, cannot get along with others, talks to others in bad way, then I will not feel comfortable talking to her. So, the more important thing is personal characteristics of the person, not the level of education” (Ppt A5)
Although many participants considered literacy is more important than a certain level of education, most participants recommended people with either a junior or senior high school background as sufficient if a specific level of education were to be required. This level of education is associated with acceptable communication skills, and people with this background are not difficult to find in the community. CHWs with a primary school background are less preferred, as their communication skills are considered poorer.
Some specialists and service users stated that a tertiary level education would be better for the CHW role, because CHWs with a degree are more open-minded, have better knowledge in general and about depression specifically, and have better problem-solving skills. However, finding people to perform the role of a CHWS with this educational level is not easy and, even if available, they are not always able to communicate and socialize in an appropriate manner with service users.
“I prefer to have women because they have experience being pregnant. If they are men I will be reluctant and hesitate, even with our own husbands sometimes we do not disclose… Men cannot feel what women do, how pregnancy feels like. Men can talk only” (Pr C5)
a CHW has to be ready to social work, has to have KMS [card to go to heaven], ikhlas…” (CHW NS3)
“Certainly those who already have experience in giving birth, being pregnant, having children. Because experience is important, so before helping others she has experienced those situations. At least we can share” (Ppt E4)
“New persons have less experience. It’s better if the existing ones are recruited and then be trained, [because] they already have experience. While the new ones need to be guided” (Ppt A4)
This study investigated characteristics and competencies that CHWs require to participate in integrated mental healthcare for perinatal depression identification, including knowledge, skills and personal qualities, and personal attributes or characteristics. Findings show CHWs require knowledge about pregnancy and maternal life, child development, and perinatal depression. Knowledge about depression is expected to assist CHWs to identify signs and symptoms of depression. It is also suggested to train CHWs to use a screening tool for perinatal depression. The most recommended skills for CHWs in this task are communication and social skills. Other characteristics required for these CHWs are motivation, such as willingness and availability, basic literacy, and women who have experienced pregnancy and are in a certain age range. These findings add information from previous studies and available guidelines about CHWs working in general care and specifically for maternal mental health care. The findings could also become a foundation to develop particular guidelines for recruitment and training of the workforce.
The finding that CHWs require knowledge about pregnancy and maternal life, child development, and perinatal depression is consistent with previous studies where CHWs were provided psycho-education about pregnancy, child development and maternal depression in order to identify and treat mothers with depression [13–15, 18]. Studies on the role of CHWs in mental health care also reported that CHWs were able to identify a certain mental disorder being educated [10, 11, 26, 27], reinforcing the role of specific mental health-related knowledge as competencies required for the role of CHWs in mental health identification. Knowledge regarding perinatal depression and anxiety are within training modules addressing maternal depression, i.e. the Thinking Healthy Program, a manual for management of perinatal depression published by WHO . Consistency with previous studies and international guidelines underscores the knowledge element of competencies for CHWs to carry out perinatal depression identification.
The findings that communication, social, and problem solving skills are expected for the CHW role by most stakeholders have been reported in previous studies [8, 16, 28]. Several studies emphasize communication as a basic skill that is required by CHWs working in the mental health area in diverse contexts. This skill is a core competency for human resources in the mental health area . More specific behaviors reported in this study, such as attentiveness and empathy, listening, and asking questions, are also listed as among behaviors and attitudes within communication skills recommended by mhGAP-IG . In addition, social skills are important due to CHW involvement with the community they serve. These skills were perceived by participants as understanding of social context, being socially active, and/or being aware of community needs. Having these skills means that CHWs have a strong bond with, and social–cultural understanding of, the community. Involvement in the community through social activities is part of ‘previous experience’ required in CHW recruitment , where CHWs should be chosen from and by the community they serve . In this study context, internal recruitment of CHWs in maternal mental health means they should be selected from existing CHWs as their on-going community participation indicates their social skills and sensitivity to, and awareness of, community needs, indicating them asmore appropriate in the role of identifying mental illnesses in the community . For Surabaya, CHWsMCH (CHWs working on maternal and child health whom the study addresses) who are known by pregnant and postpartum mothers are the most suitable ones for depression identification. More specifically is from CHWspregnancy, who are mostly CHWsMCH assigned to regularly monitor the health and pregnancy risk of pregnant and postpartum mothers . Appointing the role to CHWspregnancy means the new task accompanies existing tasks and therefore will not be an extra burden and could increase productivity [32, 33]. However, this possible issue may not the case in this context from the catchment area and work environment point of view . With the catchment area, a CHW in Surabaya covers 50 households , however pregnant mothers made up only about 4%  leaving them to provide services to 2–4 pregnant and postpartum women within walking distance area. Other elements that could be managed is organisation of tasks and supervision. It is reported that mental health assessment for pregnant and postpartum mothers was commonly performed per trimester of pregnancy and at certain time postnatally [35–37] which can be done at a single client visit during regular health status monitoring by CHWspregnancy. Moreover, the availability of a counsellor (psychologist) in every health centre enables an arrangement of supervision from qualified professionals within a monthly refresher program . Considering to use checklist as an aid job which that was raised by health workers in implementing the programme could also overcome this potential issue.
Findings of this study about CHW attributes/characteristics are consistent with characteristics required for CHWs in general, and in the mental health area. However, attributes such as gender, age, education and experience are very much associated with women’s health. Findings on the preference for female CHWs to carry out this role is very specific in the context of maternal depression as a women’s health issues. This is also evident in early development of the role of CHWs in maternal and child health where women were most preferred [30, 38]. The same argument also applies to the requirement for CHWs to have had experience in pregnancy, mainly by service users, as also highlighted in studies about CHWs working in different health areas . On the other hand, characteristics such as willingness, ability, and availability are widely reported as general criteria in recruiting CHWs . Indonesian guidelines about integrated health service posts, which CHWs work within, requires these three elements as basic criteria in selecting CHWs .
All CHW required competencies build the trustworthiness of CHWs in carrying out a role in maternal mental health. Knowledge about mental health of mothers and brief intervention or problem solving skills enhances ability of CHWs to identify women with depression and take necessary action, such as referral to relevant services. This action requires motivation or willingness to help others . To do so, being aware of others’ feelings and building trust with service users, health services, and the community are necessary and may be associated with maturity that is related to age and level of education. This argument suggests the need for a higher level of education rather than basic literacy, with a previous report .
There is a need for further exploration about the level of knowledge that can be transferred to CHWs, the depth of communication skills that CHWs can attain through training, and training methods that fit with their capability. CHWs are a good source of information in development of a training curriculum, as they have good understanding of cultural and interpersonal relations with the community, including acceptable communication and manners in approaching users.
Participants of the study were stakeholders of primary health care centres with limited networks at the village level. Management of the recruitment of CHWs is held by the Family Welfare Movement at the village level, whereas policy about management of recruitment and deployment is determined by the Family Welfare Movement at the district level. Therefore, perceptions from this organisation at district level are required to build better conclusions. In addition, the “recently established category” of CHWspregnancy were not invited to participate by the researcher since its existence was only recognised during the research process. Inclusion of their views would contribute to a better understanding of their role and responsibilities in future maternal mental health care and would provide better understanding about the characteristics and competencies required. The small sample size within health care system in the study area is a weakness, yet the number is big enough for a qualitative study. The use of unstandardized interview tool is among methodological limitation. Moreover, the district health system of the study site is very specific within the decentralized governance system, therefore generalizability of the findings to national context is poor.
This study provides detailed information about competencies required by CHWs carrying out perinatal depression identification and referral. Many studies examining the role for CHWs in the mental health area have not been based on community voices, despite a common agreement that CHWs are selected from and based on criteria set by the community they serve. This study fills this gap in knowledge and provides a rationale for the criteria for CHW recruitment  in the specific context of maternal mental health care in Surabaya, Indonesia. Study findings show consistency with criteria being used in selecting CHWs in many studies, and with guidelines on recruiting CHWs in general and CHWs in mental health specifically. Elements such as knowledge and skills are also consistent with those stated in international guidelines for informal workers working in mental health published by WHO. Thus, generalisation of these findings to management of CHWs carrying out the role for perinatal depression identification in other contexts may be possible.
ES conceived of the study, participated in its design and coordination, carried out the interviews and drafted the manuscript. RK, HM, and AJ guided ES in the conception and design of the study and supervised her work. RK also provided guidance on analysis and interpretation of the material. All authors read and approved the final manuscript.
We would like to thank to all participants whom we interviewed for this study, particularly the CHWs-manager who distributed letters of invitation to potential participants; Ms. Putri Maharani and Erwin Erianto for helping with communication, transportation, and permit documents. Our deepest gratitude goes to all.
The authors declare that they have no competing interests.
Availability of data and materials
The datasets used and/or analysed during the current study are available from the corresponding author on request.
Consent for publication
The authors declare that the content of the manuscript has not been published, or submitted for publication elsewhere.
Ethics approval and consent to participate
Ethical approval for the study was obtained from the University of Melbourne in the document No. 1543833. A research permit was released by Health Office of Surabaya. Informed consent was obtained from all participants prior to data collection.
This study is part of the doctoral degree project conducted by the first author under supervision of the co-authors, based in Australia. There is no external funding to support the research.
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