Research Articles Open Access Breaking the Chains of AoPasungAo: The Potential Roles of Primary Health Centres and Pharmacists in an Indonesian Setting Sulisetiorini Sulisetiorini1.
Yosi Irawati Wibowo2*.
Bruce Sunderland3.
Adji Prayitno Setiadi4 Master of Pharmacy Program.
Faculty of Pharmacy.
Universitas Surabaya.
Surabaya.
Indonesia Centre for Medicines Information and Pharmaceutical Care (CMIPC).
Faculty of Pharmacy.
Universitas Surabaya.
Surabaya.
Indonesia Medical School.
Faculty of Life Science.
Curtin University.
Perth.
Australia Department of Clinical and Community Pharmacy.
Faculty of Pharmacy.
Universitas Surabaya.
Surabaya.
Indonesia *Corresponding Author: E-mail: yosi_wibowo@staff.
ARTICLE INFO
Manuscript Received: 27 Oct, 2024 Revised: 03 Feb, 2025 Accepted: 22 Feb, 2025 Date of publication: 01 Jul, 2025 Volume: 5 Issue: 2 DOI: 10.
56338/jphp.
KEYWORDS
Health Service.
Pharmacist.
Pasung.
Mental Health Nurse.
Primary Care.
Indonesia
ABSTRACT
Introduction: Healthcare for patients in pasung is often neglected.
Limited data is available on the roles of Primary Health Centres (PHC.
as the main providers of primary care in Indonesia.
This research aims to explore health services provided for patients in pasung at PHCs and to identify the roles of pharmacists.
Methods: This descriptive qualitative research used in-depth interviews with a range of stakeholders .
, patients in pasung .
or the representative family caregivers .
, mental health nurses .
, pharmacists .
] at 5 PHCs in Trenggalek.
Indonesia from May to July 2023.
Inductive thematic analysis was used to address the research questions.
Ethical approval was obtained from the Research Ethics Committee of Universitas Surabaya .
umber 130/KE/V/2.
, and participants provided written informed consent.
Results: Patients in pasung have generally had adequate access to PHCs with no charge for their treatments.
Health services provided for patients in pasung at PHCs were categorised into two main themes: outpatient services .
, medication supply, and homecar.
, and referral to inpatient services.
PharmacistsAo roles have largely related to drug supply, while clinical pharmacy services have been very limited .
, providing drug information when patients obtained their medications at the pharmacy unit.
Conclusion: In conclusion, findings in this study have provided a baseline for future development of mental healthcare for patients in pasung.
Pharmacists have the potential to take up more clinical roles to ensure quality use of medicines among patients in pasung.
Supporting policy and resources should be allocated for PHCs to expand pharmacistAos Publisher: Pusat Pengembangan Teknologi Informasi dan Jurnal Universitas Muhammadiyah Palu Page | 225 Breaking the Chains of AoPasungAo: The Potential Roles of Primary Health Centres and Pharmacists in an Indonesian Setting INTRODUCTION Seclusion and restraint are interventions used to manage people with mental disorders (PWMD) who exhibit aggression and violence in psychiatric settings .
, .
However, this was also practiced in non-psychiatric settings, particularly in a community setting such as a home.
Community confinement methods found in many countries, particularly in low- and middle-income countries where mental health services are under-resourced .
Thousands of confinement cases .
hich is known as pasun.
have been reported in Indonesia .
Pasung uses one or more combinations of different methods, including mechanical restraint .
uch as chain shackle.
and isolation/seclusion for periods of time .
Due to restricted mobility and extremely poor hygiene and diet associated with restraint, many of those subjected to pasung have been found to be undernourished, physically wasting and ill from a range of untreated health conditions, and sometimes deceased .
, .
Although pasung has been officially banned in Indonesia since 1977, its practice has persisted .
The Indonesian Government has claimed that Program Bebas Pasung .
, a program aims for zero case of pasun.
, which was launched in 2010, has successfully reduced rates of pasung as estimated by Human Rights Watch from 18,880 cases in 2010 to 12,220 cases in 2018 .
However, these did not match with the data from The Indonesian Centre for Health Research where the number of pasung was only slightly decreased from 14.
3% to 14.
0% among PWMD .
It is difficult to accurately estimate the number of pasung cases in Indonesia, since PWMD occurrences are often hidden by their family and not exposed to public view because their illnesses have been perceived by the community and its culture as shameful.
Thus, the actual number of pasung might be higher than predicted .
, .
The continued practice of pasung in Indonesia indicates that there are likely complex issues present in society.
A systematic review, mainly included studies in Indonesia .
=32 out of .
, reported that most of the studies were based on experiences of PWMD in pasung and/or their family .
Some of the studies reported that pasung has been often used for PWMD with severe conditions and aggressive behaviour .
Perceived risk and safety from aggression have been frequently identified as the main reason for pasung.
this has been exacerbated with lack of knowledge and negative stigma about mental disorders .
, 14, 15, .
Support and systems provided for PWMD have been perceived as inadequate, thus causing family members to experience stress and feel powerless as they have to manage the burden alone .
, 16-.
In 2014, the Indonesian Government launched a national health coverage (Jaminan Kesehatan Nasional.
JKN) to provide basic healthcare for the whole population .
The scheme included a referral system with primary healthcare facilities as the gate keeper.
The main public primary healthcare facilities are Puskesmas (Primary Health Centres.
PHC.
, which provides primary healthcare at the district level .
Mental healthcare in Indonesia, however, is not yet a priority.
shortages in personnel as well healthcare facilities have been reported .
There are currently initiatives to provide mental healthcare in PHCs, which number more than ten thousand across Indonesia .
development is only in its initial stages.
Hence, up-to-date data on the current mental healthcare in PHCs is of importance to provide baseline data for a successful Program Bebas Pasung.
Strengthening mental health services in PHCs with a seamless coordination with hospitals, and involving multidisciplinary professionals, would be essential.
Medications are considered as the mainstay of PWMD.
cases of pasung were reported as the result of PWMD failing to continue their medication, thus leading to relapse and aggressive behaviour .
, .
Based on the government standard for pharmacy services at PHCs, pharmacists are responsible for drug management and clinical pharmacy services .
, thus have the potential to contribute to the health of PWMD also in pasung.
This research was conducted in Trenggalek, a municipality in East Java Province.
Indonesia, where since 2015, 166 pasung cases have been reported .
Improved health resources have been reported in Trenggalek PHCs.
2023, all PHCs have a pharmacist staff.
This research aims to explore health services being offered by PHCs to PWMD in pasung as well as to identify the roles of pharmacists.
METHOD
This study used a descriptive qualitative approach .
, which utilised perspectives or experiences of individuals to generate an in-depth understanding on health services being provided for PWMD in pasung in Trenggalek.
This research was conducted in Trenggalek, a municipality in East Java Province.
Indonesia, with an area of 1,261.
40 kmA and a total population of 751,079.
Trenggalek Municipality is divided into 14 districts.
public health Page | 226 J.
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facilities consist of 22 PHCs and one regional public hospital (Rumah Sakit Umum Daerah.
RSUD) .
PHCs are the technical units of the Regional Health Office .
nder the Ministry of Healt.
to provide primary healthcare at the district level.
In each PHC, a mental health nurse is the person in charge for mental healthcare programs .
pecific for PWMD).
in addition, one general practitioner and one pharmacist are available to provide primary care for general For PWMD referred to the regional public hospital, one psychiatrist has been available to provide mental health care since 2016.
Data on PWMD in pasung in Trenggalek at February 2023 included: 3 currently pasung patients, 2 repeated pasung patients, 133 patients with a history of pasung .
uccessfully released since 2.
, 5 hospitalised patients, and 23 patients died .
Sample recruitment This study was conducted from May to July 2023 at five PHCs in Trenggalek.
The selection of PHCs was based on a consultation with the Chief of Regional Health Office to include PHCs which have PWMD in pasung under their care, i.
: Wl PHC.
Pa PHC.
Ka PHC.
Tu PHC and Rw PHC.
To gain a comprehensive understanding on the health services provided for PWMD in pasung at PHCs, this study recruited a range of stakeholders:
PWMD in pasung or their representative family caregivers.
PWMD in pasung were selected after a consultation with the District Social Welfare Officers (Tenaga Kesejahteraan Sosial Kecamatan.
TKSK - as the person assigned as Aupasung buddyA.
and the mental health nurses .
s the person in charge for mental health services at PHC.
The selection was conducted by considering the maximum variation in the characteristics of PWMD in pasung at PHCs, including: .
pasung status .
, currently pasung, repeated pasung, or history of pasun.
, .
treatment status .
currently on or off pharmacological treatment.
, and .
family history .
, had family members with mental illnesses/pasung or no.
where a total of 14 PWMD also in pasung were included.
While it was impossible to collect data directly from the patients, their family caregivers .
, a family member who was directly involved or responsible for the care of PWMD in pasun.
acted as the representatives .
=12.
as there were two family caregivers with two PWMD with pasun.
Mental health nurses.
One mental health nurse, who has been the person in charge to provide mental healthcare services in the PHC, was selected from each PHC .
Pharmacists.
One pharmacist, who has responsible for pharmacy services, was selected from each PHC .
Data collection Semi-structured interviews were conducted with the family caregivers of PWMD in pasung .
interview guide was used to assist the interviews which explored two key topics: .
access to and health services received, and .
the role of pharmacists.
The interview guide was developed and face-validated with two public health experts, a mental health nurse, and a family caregiver of PWMD in pasung.
Before the interview, the primary investigator (SS) contacted each potential respondent in person with the help of a mental health nurse and/or TKSK.
At that time, the researcher would provide verbal and written information regarding the nature of the study and ask for participation.
if the potential respondent was willing to participate, a written informed consent was obtained and the researcher would make an appointment for an interview.
Interviews were conducted at each respondent's residence using the local language .
Javanes.
the interview took approximately 30-60 minutes and was audio-recorded.
At the end of the interviews, the primary investigator (SS) used a short questionnaire to collect data on the respondents .
amily caregiver.
Ao characteristics, including: gender, age, education, occupation, and relationship with PWMD in as well as to obtain data on the patients in pasung under their care, including: gender, age, marital status, pasung status, working status and family history.
The researchers also identified the patientsAo identification number to trace their medical records at the PHCs and the regional public hospital .
or referral patient.
to obtain information on the diagnosis, treatment, and adherence to treatment.
PatientsAo adherence was assessed by comparing the total number of prescribed drugs and the remaining drugs at the date of observation.
In addition, semi-structured interviews were conducted with PHC mental health nurses .
and pharmacists .
the interviews were assisted with an interview guide to explore two main topics: .
health services provided for PWMD also in pasung, and .
the role of pharmacists.
Before the interview, the primary investigator (SS) provided information regarding the nature of the study and asked for willingness to participate.
if the potential respondents were willing to participate, they were asked to provide a written informed consent.
While mental health nurses and pharmacists providing the interviews refused to be recorded, the primary investigator (SS) included a partner to take Page | 227 Breaking the Chains of AoPasungAo: The Potential Roles of Primary Health Centres and Pharmacists in an Indonesian Setting notes on the interviews.
the interviews lasted approximately 15-30 minutes.
At the end of the interviews, data on the characteristics of the respondents were obtained using a short-questionnaire, including: age, gender, education, length of work and work experience.
Data analysis Audio-recorded data from the interviews were transcribed verbatim by the primary investigator (SS).
Transcripts were reviewed using inductive thematic analysis .
The analysis first involved data familiarization.
significant statements related to health services for PWMD with pasung and roles of pharmacists from the data were then identified and coded.
The process of coding was conducted manually by cutting and pasting between transcript The codes were categorised into a broader conceptual level .
into theme.
The initial coding was performed by SS, and the transcripts together with the emerging themes were evaluated by the other research team members (AP.
YIW).
if there was disagreement, the themes would be discussed among them to reach a consensus.
Finally, examples of responses were selected to illustrate each theme.
The final themes and quotes were discussed with the respondents as a means of Aomember-checkingAo, thus increasing the credibility of the data .
Data analysis was conducted using the local language AoJavaneseAo .
s the language used during the interview.
the illustrative verbatim quotes and themes were then translated into English.
Characteristics of the respondents were summarised using descriptive statistics.
Data saturation was achieved after 8th interviews with family caregivers.
and 2nd and 3rd interviews with mental health nurses and pharmacists, respectively.
Ethical Approval This study obtained approval from the Research Ethics Committee of Universitas Surabaya .
umber 130/KE/V/2.
, and permission from the Trenggalek Agency of National Unity and Politics (Badan Kesatuan Bangsa dan Politik Kabupaten Trenggalek.
Baskesbangpo.
umber 070/120/406.
030/2023 and 070/176/406.
030/2.
RESULTS
Respondent characteristics Characteristics of the PWMD in pasung and their family caregivers This qualitative study conducted at 5 PHCs in Trenggalek Indonesia, involving 14 PWMD also in pasung who were represented by their family caregivers .
there were two family caregivers with two PWMD in pasun.
Detailed characteristics of PWMD in pasung and their family caregivers can be seen in Table 1.
The family caregivers generally were the parents with varying levels of education from no schooling to high school graduates.
Of the 14 PWMD in pasung, the majority were males .
3%), aged of 30-60 years .
7%), and had an elementary school level .
4%).
all of the patients were not currently working, while the majority had prior employment .
57%).
the ratio of patients currently pasung or repeated pasung versus those with a history of pasung were comparable 1:1.
Most patients were on pharmacological treatments .
/14, 78.
6%), and had good adherence to treatments .
/11, 63.
6%).
In addition, 64.
3% of patients reported to use alternative medicines.
Table 1.
Characteristics of the participated PWMD in pasung and their family caregivers Characteristics PWMD in pasung .
Gender Male Female Age 30-40 years >40-50 years >50-60 years >60 years Education Elementary school graduate n (%) 9 .
Page | 228 J.
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Characteristics Junior high school graduate Senior high school graduate Bachelor degree graduate Marital status Married Widow/widower Single History of employment Yes No, never Pasung status Yes .
urrently in pasung or repeated pasun.
No .
ast history of pasun.
Family history of pasung/mental illness Yes Pharmacological treatment status On medications Off medications Diagnosis .
or those who are on medications, n=.
Schizophrenia Acute psychosis No data Adherence to pharmacological treatments .
hose who are on medications, n=.
Yes Use of alternative medicines Yes Family caregiver .
Gender Male Female Age 30-50 years >50-70 years >70 years Education None Elementary school graduate Junior high school graduate Senior high school graduate Occupation Farmer Self-employment Housewife Relationship with PWMD in pasung Parent Sibling Child Other than direct family .
, nephew or sister/brother in-la.
n (%) 2 .
Page | 229 Breaking the Chains of AoPasungAo: The Potential Roles of Primary Health Centres and Pharmacists in an Indonesian Setting Characteristics of the mental health nurses and pharmacists The mental health nurses who participated in this research were all males, aged from 31 to 54 years, and had been working for 2-28 years.
Meanwhile, the respondent pharmacists were all females with an age of 28-40 years, and had prior employment either in community pharmacy, other PHCs, or hospitals.
Detailed characteristics of the mental health nurses and pharmacists can be seen in Table 2.
Table 2.
Characteristics of participated mental health nurses and pharmacists Characteristics Mental health nurse Gender .
Age Education Year of graduation from nursing education Duration of working at the PHC .
esearch settin.
Prior employment as mental health nurse Pharmacist Gender .
Age Year of graduation from registration program .
Duration of working at the PHC .
esearch settin.
Prior employment .
ither community pharmacy, other PHC, or hospita.
31-54 years Diploma .
Bachelor degree .
Year of 2002-2018 2-28 years 1 person 5 person 28-40 years Year of 2006-2019 1-12 years 5 person Health services provided to PWMD in pasung Health services provided for PWMD in pasung was no charge and followed a referral system .
nder JKN), with PHCs as the first-point of care.
In addition to a general practitioner and a pharmacist who have provided general care at each PHC, a mental health nurse has been specifically assigned for mental health programs.
The family caregivers reported that the PHCs have been easily accessed .
-3 kilometre.
Based on the interviews.
PHC health services for PWMD in pasung can be categorised into two main themes.
Theme 1: Outpatient services Medication supply The family caregivers of most patients with pasung reported to receive medication supply services from the local PHCs.
Drug management, which was including but not limited to medication supply, at the PHCs was delivered by pharmacists.
The family caregivers of two patients reported to visit the local PHC regularly to obtain the medications, as stated by the family caregiver of P1: "The medicine is from Rw PHC.
(This is don.
regularly every and confirmed by the Rw PHC mental health nurse: "(P1 and P.
have been well .
Their family is actively .
isiting the PHC) to obtain the patientsAo medication.
" However, some patients had their medicines delivered by mental health nurses through home care services, as stated by the family caregiver of P5: "There is Mr.
B .
he mental health nurs.
who delivers the medicine.
" The services have been usually offered for patients who have had no transportation.
When the drugs were not available at the PHC, patients were referred to the regional public hospital, as stated by the Tu PHC mental health nurse: "If the drug stocks are out, the patient would be referred to the regional public Ay and Wl PHC mental health nurse: "The drug - as prescribed by the psychiatrist at the regional hospital is not included .
n the formular.
at the PHC, hence .
he patien.
should go to the hospital.
Ay It should be noted that three patients were not on pharmacological treatments, including: one patient not currently in pasung .
ith controlled symptom.
, and two patients currently in pasung .
ith uncontrolled symptom.
The latter two patients had previously received medications but their family caregivers were reluctant to access further mental health services due to lack of time/resources and/or seeing no satisfying results, as stated by the family caregiver of P8: "Other responsibilities will be neglected if I continuously take care of the patient.
As I also have to Page | 230 J.
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take care of other healthy family members.
I should make a decision .
o stop taking care of the patien.
, particularly since the patient was not getting better.
Ay, or family caregiver of P13: "There has been no improvement in the patient's condition, especially as the mental health clinic and psychiatrist at the regional hospital are still new compared to the mental health facility I accessed before.
The psychiatrist once said that the patient had recovered, yet he had not been well.
Home care services The family caregivers of some patients in pasung reported to receive home care services from mental nurses, as stated by the family caregivers of P6 and P7: "After returning from Kr PHC and Po PHC, up to now, there is a health worker from Ka PHC who gives an injection at home and .
provides oral medication regularly.
" The mental health nurses reported that home care services usually included drug delivery services as well as monitoring the use of drugs or adherence, especially for patients prescribed injections, as stated by the Rw PHC mental health nurse: "The priority .
or providing home car.
is for patients given injections because they are at a high risk for relapse and becoming aggressive.
Some patients in pasung - who were referred to the regional public hospital or were not on medications were not provided any home care services from the PHCs.
Of the three patients who were not on medications, one patient was no longer in pasung and two patients were in pasung .
ith uncontrolled symptom.
Ae the family caregivers of these two patients refused home care services, as stated by the mental health nurse at Tu PHC: "(The home care servic.
was provided for the patient (P.
before, but Ae because the respondent and other family members refused the patientAos treatments, .
he servic.
was no longer being provided.
", and the mental health nurse at Wl PHC:
"Home visits .
or P.
were carried out since there was a report .
f P13 pasung cas.
from residents and the village officer approximately 15 years ago to handle the patient's treatments.
However, since 2021, .
he home care servic.
was no longer given due to the strong rejection from the family.
Theme 2: Referral to inpatient services The PHCs can refer patients in pasung for inpatient services at the regional hospital.
The referral was generally made when the patients were first released from pasung, as stated by the family caregiver of P8: "At the hospital, the patient was not chained".
and the family caregiver of P2: Au(The patien.
was immediately hospitalised when he was released from pasung.
" In addition, patients can be referred if their conditions have been severe or aggressive, as stated by the Tu PHC mental health nurse: AoInpatient services are used for aggressive patients Ae being extremely anxious and having a high risk to endanger the surrounding community.
or the Rw PHC mental health nurse: "The referral .
or inpatient car.
was made if the patient is aggressive and anxious, and .
cannot be handled at the PHC.
The role of pharmacists in providing health service for PWMD in pasung All family caregivers indicated that they have not recognised the pharmacist profession, as stated by the family member of P1: "I don't know what or who a pharmacist is.
" On the other hand, all pharmacist respondents stated that they have provided services to patients in pasung, especially in relation with drug management.
Clinical pharmacy services have been limited to provide some drug information when the patients or their family members obtained medications at the pharmacy unit in the PHCs.
Detailed themes and examples of quotes regarding the role of pharmacists can be seen in Table 3.
In parallel, all mental health nurse respondents also perceived the role of pharmacists as being limited to the drug management, as stated by the Tu PHC mental health nurse: "(The pharmacist's role i.
supplying medications for patients with mental disorders.
Page | 231 Breaking the Chains of AoPasungAo: The Potential Roles of Primary Health Centres and Pharmacists in an Indonesian Setting Table 3.
Themes from pharmacistsAo interviews regarding their roles in mental health services for PWMD in pasung Themes Drug management Clinical pharmacy Examples of quotes AuRequesting mental health medications to the Municipality (Health Offic.
, receiving, storing, distributing or supplying of the medications, and documentation.
Ay (Wl PHC Pharmacis.
AuCoordinating with the person in charge for mental health services .
, the mental health nurs.
to manage the stock and procurement of mental health medications.
Ay (Pa PHC Pharmacis.
AuLimited to providing .
ental healt.
Ay (Ka PHC Pharmacis.
AuAprovision of mental health medications, management and documentationAy (Rw PHC Pharmacis.
AuProviding drug information to the patientsAo family caregivers who obtain medications at the PHC.
Ay (Pa PHC Pharmacis.
AuDrug information related to mental health medications.
Ay (Rw PHC Pharmacis.
Since pharmacotherapy is considered as the main stay of mental disorders, pharmacists have a potential role to optimise the use of medications to control symptoms and prevent relapse of PWMD also with pasung.
Several pharmacist respondents expressed their willingness to develop clinical pharmacy services for PWMD also in pasung, as stated by Pa PHC pharmacist: "(W.
are planning to implement home pharmacy care in coordination with the person in charge for mental health services at the PHC .
he realisation will be in 2.
and Tu PHC pharmacist:
"(I am thinking o.
providing counselling to the family caregivers and/or patients with mental illnesses aiming to improve adherence to treatment, as well as preventing drug-related problems by providing clinical pharmacy pharmacists will be required to collaborate with physicians, nurses, other health personnel and the person in charge for mental health care program in optimising drug therapy and preventing drug related problems (DRP).
DISCUSSION
This study provided insights regarding mental health care provided in Indonesian primary care settings.
PWMD also in pasung generally have an adequate access to PHCs .
s the gatekeeper to secondary/tertiary car.
and obtain their medications without any cost.
This finding might indicate improvements in the provision of mental healthcare in Indonesia as some prior studies reported a lack of mental healthcare access and the high cost of medications partially contributing to the practice of pasung in Indonesia .
, .
This improved accessibility might be related to the introduction of JKN in 2014 where a referral system is implemented, and the role of PHCs as the first-point of care is strengthened .
The number of PHCs in Indonesia has continuously increased from 9,731 in 2014 to 10,374 in 2022 (Statistics Indonesia .
, and it has been targeted to achieve 1 PHC per district.
This present study reported that the majority of PWMD in pasung have a PHC close to their residences .
-3 k.
, but some patients have been referred to the hospital .
hich is furthe.
as their medications were unavailable at the PHCs.
Further evaluation on the drug use for PWMD in PHCs would be required to provide feedback for the current drug formulary .
, considering to include regular medications for PWMD also in pasun.
and to maintain the stocks.
Additionally.
PHCs in this study reported to provide medication delivery service for patients in pasung if they or their caregivers were unable to visit the PHCs.
This practice, however, should be formalised with the development of a standard operating procedure (SOP) which provides a clear step-by-step instruction to ensure medication supply for PWMD in pasung.
the SOP also needs to define responsibilities of each personnel involved in the service.
While this service is currently delivered by a mental health nurse .
s part of home care service.
, the involvement of a pharmacist warrants consideration.
Based on the pharmacy practice standards in PHCs .
, a pharmacist is responsible for the quality of drug management and use in PHCs.
To ensure medication supply for PWMD in pasung, pharmacists in PHCs should initially obtain a complete list of PWMD also in pasung treated under their PHCs.
The pharmacist would be required to monitor whether these patients visit the PHCs to obtain their medications on schedule.
if not, the pharmacist in coordination with the mental health nurse can arrange for a delivery While for PWMD in pasung who has referred to the hospital, the PHC pharmacist should work closely with the hospital pharmacist to ensure that the patients obtain their medications in timely manner.
Establishing comprehensive documentation as well as a supporting information technology would be of importance to maintain continuity of care between PHCs and hospitals.
Evidence has shown that PWMD often require a long-term Page | 232 J.
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pharmacological treatment, and hence, adherence to treatment plays a key role to achieve adequate symptom control and prevent relapses .
, .
Regardless of improved access to medications via PHCs, this study indicated that there were some patients in pasung who currently are not on medications .
espite of their uncontrolled symptom.
, as their family caregivers refused to access health facilities due to lack of time/resources to take care of the patient and/or seing no satisfying progress with the treatment.
In parallel, previous Indonesian studies have shown the difficulty in managing the burden for caring patients in pasung among family caregivers, thus the patientsAo treatment are often neglected .
, 16, .
This situation is even more complex as prior research indicated that most family caregivers of PWMD have poor knowledge of mental disorders .
, 18, .
Hence, they might not be aware that PWMD often requires long-term treatment to control the symptoms, and even demand to see results in a short time.
if satisfying results are not seen, they might feel lack of motivation, thus leading to discontinuation of treatment for PWMD and prolonged the practice of pasung.
In addition to the family issues, communities play an essential role in supporting the recovery of PWMD with pasung.
Social stigma and discrimination of the affected person and their family often cause them to be isolated and seek the help of spiritual/traditional healers rather than medical treatment .
, 34, .
Multifactorial approaches involving the family, the community and the local health facility .
articularly PHCs as the front line of mental health service.
would be of importance to create a secure environment and provide adequate support to overcome the use of pasung.
Health education of family members and community should be considered to create awareness and to develop positive and empathetic attitudes towards patients with pasung .
, by clarifying misconceptions of mental illnesses, importance of medication adherence, training for home-based car.
Hence, optimising the role of PHCs in mental health services .
eyond supplying medication.
warrants further considerations, e.
, by providing proper mental health education.
Further, this study indicated that pharmacistsAo roles in mental health services at PHCs have been mainly related to drug management .
, planning, procurement, distribution or supplying medications at the pharmacy uni.
Clinical pharmacy services have been conducted in a very limited fashion, and thus, their role in this area has not yet been recognised by other health professionals .
, mental health nurse.
as well as by the patient or carer.
pharmacotherapy is considered the mainstay of PWMD .
, .
, pharmacists have the potential roles in optimising the use of medications among PWMD also in pasung.
Although this study has not evaluated the quality use of medications among PWMD in pasung .
rescription revie.
, it has indicated that non-adherence patients have been likely to have uncontrolled symptoms compared to adherence patients .
/3 patients versus 3/8 patients, respectivel.
Hence.
PHC pharmacists can play an active role in improving patient adherence as well as to monitor the effectiveness and adverse effects of the treatment.
Further, pharmacists can provide prescription review services to ensure quality use of medications and to prevent drug-related problems (DRP.
International studies have reported the potential of pharmacist-led medication review services for community-based mental healthcare patients .
Moreover, a metaanalysis of pharmaceutical care interventions, such as medication review, has positive outcomes on the mental health domain of the SF-36 quality of life instrument .
In addition.
PHC pharmacists may be well-placed to provide drug information or counselling to PWMD or their carers while obtaining medications at pharmacy units.
Providing high quality information will improve patientsAo capability in shared decision making, in which patients and health professionals make health decisions together (Chong et al.
Evidence has shown that pharmacistsAo engagement in a shared decision-making process has been shown to promote and support psychotropic medication adherence .
Supporting policy, funding, training and resources, however, should be considered when pharmacists at PHCs are expected to take on a broader role in clinical pharmacy services for PWMD.
This study has some limitations which warrant acknowledgement.
As qualitative data are a product of views, experiences and perceptions of respondents it can be biased if respondents do not share their true responses .
However, mental health services at PHCs are generally in the early stage of establishment, and thus, this study has an exploratory nature .
, no right or wrong answer.
hence, response bias was expected to be minimal.
While this study included a small sample size, it included a range of patients/carers, mental health nurses, and pharmacists.
of which are the main stakeholders in mental health care services at PHCs.
Within the scope of the study, data saturation was achieved.
The use of multiple data sources .
, triangulatio.
should improve the credibility of the findings .
In addition, this study was conducted at only five PHCs in Trenggalek.
however, it should be noted that, with the implementation of JKN in 2014, the Indonesian health system and the conditions of PHCs should be Page | 233 Breaking the Chains of AoPasungAo: The Potential Roles of Primary Health Centres and Pharmacists in an Indonesian Setting more standardised.
Future research should address these limitations to further refine understanding to enhance mental health care in primary settings.
CONCLUSION
PHCs have been involved in providing care for patients in pasung in a limited fashion .
, mainly medications supply with limited homecare service.
, thus a more standardised and patient-oriented care should be Pharmacists have the potential to take on broader roles by providing clinical pharmacy services .
prescription review, monitoring, drug information and counsellin.
To take on these roles, supporting policy and resources should be allocated for PHCs and pharmacists.
Further research involving other stakeholders at PHCs and hospitals would be required to establish a continuity of mental healthcare with clear roles among health professionals in the team as well as between health facilities (PHCs and hospital.
AUTHORAoS CONTRIBUTION STATEMENT Sulisetiorini: Formal analysis.
Investigation.
Methodology.
Writing Ae original draft.
Yosi Irawati Wibowo:
Data curation.
Methodology.
Writing Ae original draft.
Bruce Sunderland: Conceptualization.
Writing - review & Adji Prayitno Setiadi: Conceptualization.
Supervision.
Writing - review & editing.
CONFLICTS OF INTEREST
The authors declare no conflict of interest.
DECLARATION OF GENERATIVE AI AND AI-ASSISTED TECHNOLOGIES IN THE WRITING
PROCESS
The authors declare that they have not used any type of generative AI for the writing this manuscript.
SOURCE OF FUNDING STATEMENTS
This research did not receive any specific grant from funding agencies in the public, commercial, or not-forprofit sectors.
ACKNOWLEDGMENTS
We sincerely thank all respondents who took part in the study as well as the staff from Trenggalek Health Office and the related PHCs for all the support and technical assistance while conducting the data collection.
ACKNOWLEDGMENTS
The authors have no additional acknowledgments to disclose.
This study was completed solely with the contributions of the authors without external assistance.
BIBLIOGRAPHY