ONLINE COUNSELING TO IMPROVE MENTAL HEALTH AMONG MIDWIVES

As one of vital agent in health services, midwives play a central role in promoting well-being of their patients, especially for women and the babies. Unfortunately, the fact that they have poor condition of mental health and well-being can affect their services to patients and also potentially cause their mental health status can be worsen if not handled properly. Based on literature review and prior research in this field, the extension of potential uses of internet has expanded at an astounding rate, that are related to or effected by developing technologies and online counseling has grown as a mental health services in the past 15 or so years.The aim of this research was to evaluate the effectiveness of online counseling to improve mental health used pretest-posttest control group design. Subjects answered the General Health Questionnaire (GHQ-12) and analyzed by t-test SPSS 20. Data analysis showed that there was significant difference between experimental and control group scores. Result proved that online counseling was effective to improve mental health. This finding also provide clearly articulated of online counseling that beginning to coalesce and numerous helpful resources to improving mental health of society.


Introduction
In the world of health, midwives play a significant role for caring of pregnant women. They play crucial role to improve quality of maternity services and support women who have perinatal to postnatal mental problems (Mcneill, et al., 2012). Their excellent service is a way to deliver good mental health for patients. Mental health care is a core and prominent part of the role of all health workers including midwives. Thus, midwives' mental health and well-being is an important thing to make them able to carry out their function as health carrier properly.
Despite of evidence related to the importance of midwives role in public health, in reality they also point out that their work can be obstacles to their own mental health. This condition especially applied for midwives who work in Primary Health Care. In addition, midwives in Primary Health Care are required to complete some administrative tasks beside the first to service patients. As known, their workload automatically increased by some activities exclude doing service to patients, for instance some field activities like home care, immunization, health surveys, and so forth (Sosialita, 2016). The demands to complete all responsibilities which are exhausting can be a significant reason for midwives to feel physically and mentally exhausted.
It is similar to experienced by both contracted and civil servants midwives in Primary Health Care. One of contracted midwives at Simomulyo Primary Health Care revealed that her workload made her stay during all day long and require lots of energy. Her routine task was dealing with patients to service pregnant women as her patients, moreover she still tallied up with other tasks such as administrative task including made report for City Health Office which consists of several parts in one report. All of the reports had deadline that setted by the Head of City Health Office. Those tasks are also augmented by field duties that must be completed in accordance to the deadline. Her fieldwork has to be done according to a predetermined schedule, even at any time if the Chief requested. All of them made she thank that her work as a midwife was overlaid.
"I feel really exhausted. I think that my duties as a midwife in Primary Health Care are too overwhelmed. Many other tasks beside my primary job to deliver services are also given to me. It seems like no day off! I think this is inevitable, yeah I have to do those work in marathon way. I think that midwife who works at Primary Health Care is worse than in other workplaces. As a midwife at Primary Health Care, I have given so many tasks that include direct contact with community around. Too tired. Sometimes it gonna be overwhelmed." Similar thing also expressed by civil servant midwives at Primary Health Care in Surabaya. The unrelenting workload makes their performance less than optimal while do service to patients. They must encounter the demands up to provide excellent service but on the other hand, their performance could not improved because they were not in a good psychological condition. The connection of heavy workload and low performance is one of the aetiology of their physical fatigue, so it causes less performance and poor mental health as consequences.
"... yep sometimes I feel mentally unwell, emm... it is like my mood state is not good and every single thing goes wrong, even though I am a health worker in here. In my mind, that condition happens because the load of my duties is very high. That's it. You know, the demand here are very high. No cessation. Working at Primary Health Care, your tasks can be so excessed. There are too much tasks to be completed in short period of time. It ranging from daily service duties, day care, home visit, to administrative task. It was like we have to work and finish all the tasks to uncertainty time. Every day was deadline. You must ready when the Head Office want you to completed some tasks, then you finished it as soon as possible! So, I think all of those aspects and routine activities has contribution to a poor mental health state." From explanation above, midwives are professionals who deliver services by interact with pregnant women in their crucial phase. When doing their job, midwives require to maintain their mental condition from mental health problems related to their workload and job situation. If their state of mental was poor, so that they could not be chased those demanding task as public health workers.
The wider role of midwives as agent who improve maternal mental health including: a) raising awareness with ensuring that pregnant women and their couples know how to maintain and enhance their psychological well-being, signs of emerging mental health problems and illness, and what to do if these problems occur; b) tackling stigma and discrimination with poor mental health through being confident, open, and knowledgeable in the words of mental care; c) strengthening emotional well-being with providing sensitive and supportive antenatal and postnatal care which can increase parents' emotional well-being and self-efficacy, and reducing anxiety; d) promoting emotional well-being with supporting and enabling women to maintain and enhance their own emotional well-being and reducing their vulnerability to mental illness; e) building trust that help women to feel confident in speaking out if they are unwell; f) securing appropriate care if this is required, then supporting women to access this care; g) supporting family members with fostering emotional and practical support from partners and other family members, and encouraging women to enhance their social networks through antenatal and postnatal activities (Finn & Barak, 2010;Rowan, et al., 2010).
As a result, as public health workers, midwives almost have no time to care their mental health because of heavy workload. For example, many prior studies indicated that midwives who have heavy workload often ignored or delayed their services to patients, misbehaved to patiens, dealt with patients carelessly because of exhausted. Additionally, midwives often lack of awareness while as mental health agent actually they are required to provide excellent service for patients (Finnbogadottir & Dykes, 2010). The truth is, midwives actually have a good opportunity to identify pregnant women who are at risk of or are suffering of perinatal mental illness, therefore, they able to ensure those women and their significant other to get mental health care.
Based on the explanation above, it appears that midwives have important role to mental health and well-being of patients. But, in other hand, their workload has a bad impact on their mental health. Heavy workload leads them to lower mental health and well-being, even it can effect their patients too. Lower mental health have been highlighted as some of the problems of individual in primary community mental health based on the prior research (Sosialita,2019). It would be serious problems when midwives who play a significant role for patients mental health, in otther hand apparently has poor mental health. Therefore, mental health among midwives is important. Related to all, that was a serious discrepancy of the need of mental health and limited access to mental health services among midwives which easy to reach and use. Hence, an intervention that could improve mental health of midwives when they less supportive for mental health is important to be concerned.
Online counseling is a professional therapeutic service through intermediaries of cyberspace media technology to facilitate interaction between counselors and clients (Richards & Vigano, 2013). Online counseling should allow interaction between counselor and client simultaneously at a time, even though no face-to-face. The selection of synchronous counseling services via chat or email as a primary medium is considered more effective than online forums, audio, or webcam (Baker & Ray, 2011). Online counseling method can be used as a counseling tool so that individuals who cannot attend face-to-face counseling can deal with distress, anxiety, and negative feelings through online counseling (Dowling & Rickwood, 2013). From the explanation above, online counseling can be one of the solutions to provide an accessable mental health services for midwives. Online counseling can be used as a mental health service with the aim of improving mental health among midwives.

Method
The type of this research is pretest-posttest control group design. Suject was 10 midwives at Simomulyo Primary Health Care in Surabaya, who met criteria such as: 1) experiencing mental health problems based on screening test used GHQ-12 (General Health Questionnaire); 20 civil servant or contract midwives with minimum 2 years experienced at Simomulyo Primary Health Care; 3) have quality as online client (having access to media technology, feel comfortable to communicate online, able to express thoughts and feelings through writing, and have flexible time to participate in counseling sessions).
GHQ-12 was distributed first to help subject mapping. Questionnaire was collected on the first and last day of the research program. Permission to conduct this research project at Simomulyo Primary Health Care was obtained on April 2017. Research has been conducted for 4 weeks. After intervention was finished and data was collected, analysis used independent sample t-test formula to examine the differences of two groups.
Sampling method used convenience type to recruit midwives of Primary Health Care. Information about this research was sent to Simomulyo Pimary Health Care on 3 weeks before the inttervention program began. Twenty midwives who completed questionnaire were female. Further demographic or personal data were collected from midwives who be this research partisipants. Online counseling in this research was conducted every 7 -9 pm for a week.
Online counseling sessions were conducted in 2 hours twice per weeks. Implementation of online counseling was adjusted to agreement between group members and counselors related to the execution time. Counselors in this research were psychologists or psychology personnels at Primary Health Care who being trained to facilitate counseling sessions. In addition, midwives as reserach subjects in this research, can do face-to-face sessions in accordance with agreement. Thus, online counseling in this research used combination of synchonous and asynchronous method.
Data from questionnaire were coded and entered into Statistical Package for Social Science (SPSS) by the researcher to analysis data. The aim of data analysis was to compare responses between experimental and control group. However, owing to inadequate statistical power in the sample to detect differences between the groups, this was not possible. The aim was, therefore, revised to generally explore mental health of midwives at Public Health Care.
Result of intervention can be seen by conducting a different test on experimental group and control group, then compared the gan score on GHQ-12 scale. If data distribution showed normal and homogeneous, then data analysis technique used parametric statistical method with tindependent technique (two sample t-test). Result of statistical test can be used to calculate the effect-size of the intervention, so that could determined the effectiveness of online counseling seen by changes of dependent variable value before and after  Basically, online counseling in this research was made up as a refinement of limitations and weakness of online counseling in many previous studies. The weakness of online counseling in many studies are related to the research samples that was relatively small and participants that had not been very specific. Considering these condition, so this research was conducted after researcher made a problem mapping which include mental health problems of subjects. Therefore, in order to overcome those limitations, so this research was conducted on midwives who work at Primary Health Care in Surabaya.

Results and discussion
Total of 20 primary health care midwives completed the GHQ-12 questionnaire. The findings are presented under two headings of screening and identification of mental health problems. It showed that almost of all midwives experienced some stressful events related to their job in Primary Health Care. This state influenced their mental health condition. Heavy workload that is correlated to psychological distress symptoms, for instance sleep difficulty, feel underpressured, feel unable to overcome some daily problems, feel unhappy, lost confidence, feel useless to contribute something important, and so forth. The description of subject characteristics of this research participant as follows : The data showed that subject of this research consisted to 100% female. The average age of experimental group is 28.7 years old and the control group is 29.1 years old. The psychological problems are: (1) in the experimental group: family problems 30%, partner relationship problems 20%, social relationship problems 30%, work problems 10%, and anxiety about the future 10%.
The use of scale in this study is to compare whether the score after intervention is lower or higher than before intervention. Thus, it can be seen the effectiveness of intervention which is in this study was online counseling. After that, the normality and homogenity test is needed towards data use SPSS 20 for Windows. The result of the intervention can be seen by conducted a different test on the experimental and control group. Based on the table 2, it can be concluded that the data distribution in both experimental and control groups was normal because the significance value was 0,503 (0,503>0,05).  on table 3, it can be concluded that the significance value of the gain score of metal health was 0,149>0,05 then H0 was accepted, so data variant between experimental and control groups was homogeneous.
These are the statistical analysis of pre-test and post-test data on GHQ-12 scale and gain score between the experimental and control groups. The effect size showed 2,68 that is categorized tend to effective. Iit means that online counseling was effective enough to improve mental health in experimental group who have psychological problems. From the 20 midwives who involved in this study, 10 midwives who entered the control group got online counseling sessions. Online counseling was carried out by WhatsApp group at 7-9 pm every Saturday for a month. In conducted online counseling, group members can do face-to-face counseling with counselor. Counselor provided time sessions for group members to arrange agreement of both.
Fron the result of this study, findings related to etiology of their poor mental health were caused by work demands, personal problems, or other problems that were exacerbated by tasks in daily work. Evenmore, uncontrollable workload also cause social dysfunctions such as difficult to concentrate on some activities or jobs, do not have significant role in daily life, unable to make a decision, feel not enjoy to do daily activities, feel unable to bear some problems, and do not feel happy enough (Jones, et al., 2010).
As the result of this research, midwives at Primary Health Care experienced lack of mental health because of their daily role. That condition can be reduced and eliminated by online counseling. Online counseling being good and effective tool to bring mental health progressiveness for midwives. Flexibility in online counseling process was allegedly as one of the most important factor that contribute for successful counseling (Dowling & Rickwood, 2013). Additionally, interaction between clients and counselor as important as group dynamics between members created mutual supportive relationship.
Negative symptoms was decreasing although not significant. Score of experimental group was greater than the control one, but the differences of variable scores showed not significant. Regardless, subject feel quite helped to release tension so that they could be relax. Result of this research showed that online counseling was able to improve mental health of midwives but the result was not significant. This could be happened because of the limitation of this research.
Midwives who are being subjects in this research are coming from Primary Health Care where a huge of workshift and additional tasks were given in a vary way. This condition led to the differences of active participation between one group member to another. Subject also could be differ on absorbed the benefit of online counseling in every single session, depend on the level of active participation of each group member.
Beside that, uncontrolled heavy workload also cause the loss or lack of focus in followed a session series of counseling. Regardless all of the limitations, at least there was a finding of decline of negative symptoms such as stress and social dysfunctions after a month of online counseling process. This is what made online counseling could improve mental health of midwives as subject of this research. In fact, the effectiveness of online counseling was greatly determined by factor of client trust. Research by Sosialita (2019) revealed that attitude towards counseling process was an important and significant for the success of group counseling process.
In the case of midwives, online counseling could be used as therapeutic tool to deal with their distree, anxiety, and other negative feeling. It helps midwives to recover and return to improve well-being after problems that they had experienced, so they can be reach fully-functioning in everyday life. In line with this findings, research by Baker and Ray (2011) also revealed that online counseling has become the preferred therapeutic method for professionals because it offers easy access, convenience, flexibility, anonymity, and other aspects that are not obtained by face-to-face counseling.
In this research, the willingness of midwives to follow each counseling session seriously becomes the main factor of effectiveness online counseling. Other than that, thoughts by midwives about counselor and counseling processes were also positive, thereby it could affect their commitmen as well. This made online counseling that they got were useful for them. Furthermore, in this online counseling, intervention delivered through synchronous services via chat or email as a primary medium and also face-to-face so that counseling session should allow positive interaction simultaneously at a time. This was same with prior researches that showed online counselin through chat or email is considered more effective than online forums, audio, or webcam, moreover with face-to-face method, so it would be more effective (Richards & Vigano, 2013;Dowling & Rickwood, 2013;Baker & Ray, 2011).

Conclusions
Online counseling is one of the interventions that can improve mental health by means of decreased the negative symptoms. This intervention suggested that it can be given to improve mental health of midwives, so that their services are excellence. Based on the comparison of this finding research to prior researches, so it can be concluded that online counseling is one of methods which providing easy access for mental health services. But, for further research, it necessary of online counseling so this intervention become an effective tool for improving mental health amog midwives.
This research also revealed that online counseling has proven to be effective in addressing psychological problems among midwives, especially problems related to family, relationship, social, and vocational matters as like what midwives in this research were experienced. Moreover, effectiveness of online counseling in this research was also could be understood from the cost and time flexibility for its users, particularly for midwives who having vary tasks to do.
Affordability of cost, time flexibility, and characteristics of online counseling that makes counseling processes easy enables midwives to follow each session wiithout difficulties. Intervention by online medium is also provided easy access so that midwives feel comfortable for using technology tools. Therefore, dynamic process of online counseling allows subjects (midwives) to have control for responding, whereas they could be free to respond and express their feelings without being judged. Unfortunately, this research also have number of weakness, such as limitation of subject research, so that future researches must be expanded related to subject size. Beside that, online counselors or facilitators should be professional whom have been trained formally to deliver online counseling.