Fatwa Sari Tetra Dewi

'Maintaining balance and harmony': Javanese perceptions of health and cardiovascular disease

Community intervention programmes to reduce cardiovascular disease (CVD) risk factors within urban communities in developing countries are rare. One possible explanation is the difficulty of designing an intervention that corresponds to the local context and culture. Objectives: To understand peoples perceptions of health and CVD, and how people prevent CVD in an urban setting in Yogyakarta, Indonesia. Methods: A qualitative study was performed through focus group discussions and individual research interviews. Participants were selected purposively in terms of socio-economic status (SES), lay people, community leaders and government officers. Data were analysed by using content analysis. Results: Seven categories were identified: (1) heart disease is dangerous, (2) the cause of heart disease, (3) men have no time for health, (4) women are caretakers for health, (5) different information-seeking patterns, (6) the role of community leaders and (7) patterns of lay peoples action. Each category consists of sub-categories according to the SES of participants. The main theme that emerged was one of balance and harmony, indicating the necessity of assuring a balance between ‘good’ and ‘bad’ habits. Conclusions: The basic concepts of balance and harmony, which differ between low and high SES groups, must be understood when tailoring community interventions to reduce CVD risk factors.

Mobilising a disadvantaged community for a cardiovascular intervention: designing PRORIVA in Yogyakarta, Indonesia.

Introduction: Cardiovascular disease (CVD) is a burden for developing countries, yet few CVD intervention studies have been conducted in developing countries such as Indonesia. This paper outlines the process of designing a community intervention programme to reduce CVD risk factors, and discusses experiences with regard to design issues for a small-scale intervention. Design process: The design process for the present community intervention consisted of six stages: 1 a baseline risk factor survey, 2 design of a small-scale intervention by using both baseline survey and qualitative data, 3 implementation of the small-scale intervention, 4 evaluation of the small-scale intervention and design of a broader CVD intervention in the Yogyakarta municipality, 5 implementation of the broader intervention and 6 evaluation of the broader CVD intervention. According to the baseline survey, 60% of the men were smokers, more than 30% of the population had insufficient fruit and vegetable intake and more than 30% of the population were physically inactive, this is why a small-scale population intervention approach was chosen, guided both by the findings in the quantitative and the qualitative study. Experiences: A quasi-experimental study was designed with a control group and pre- and post-testing. In the small-scale intervention, two sub-districts were selected and randomly assigned as intervention and control areas. Within them, six intervention settings (two sub-villages, two schools and two workplaces) and three control settings (a sub-village, a school and a workplace) were selected. Health promotion activities targeting the whole community were implemented in the intervention area. During the evaluation, more activities were performed in the low socioeconomic status sub-village and at the civil workplace.

How is Indonesia coping with its epidemic of chronic noncommunicable diseases? A systematic review with meta-analysis

Background Chronic noncommunicable diseases (NCDs) have emerged as a huge global health problem in low- and middle-income countries. The magnitude of the rise of NCDs is particularly visible in Southeast Asia where limited resources have been used to address this rising epidemic, as in the case of Indonesia. Robust evidence to measure growing NCD-related burdens at national and local levels and to aid national discussion on social determinants of health and intra-country inequalities is needed. The aim of this review is (i) to illustrate the burden of risk factors, morbidity, disability, and mortality related to NCDs; (ii) to identify existing policy and community interventions, including disease prevention and management strategies; and (iii) to investigate how and why an inequitable distribution of this burden can be explained in terms of the social determinants of health. Methods Our review followed the PRISMA guidelines for identifying, screening, and checking the eligibility and quality of relevant literature. We systematically searched electronic databases and gray literature for English- and Indonesian-language studies published between Jan 1, 2000 and October 1, 2015. We synthesized included studies in the form of a narrative synthesis and where possible meta-analyzed their data. Results On the basis of deductive qualitative content analysis, 130 included citations were grouped into seven topic areas: risk factors; morbidity; disability; mortality; disease management; interventions and prevention; and social determinants of health. A quantitative synthesis meta-analyzed a subset of studies related to the risk factors smoking, obesity, and hypertension. Conclusions Our findings echo the urgent need to expand routine risk factor surveillance and outcome monitoring and to integrate these into one national health information system. There is a stringent necessity to reorient and enhance health system responses to offer effective, realistic, and affordable ways to prevent and control NCDs through cost-effective interventions and a more structured approach to the delivery of high-quality primary care and equitable prevention and treatment strategies. Research on social determinants of health and policy-relevant research need to be expanded and strengthened to the extent that a reduction of the total NCD burden and inequalities therein should be treated as related and mutually reinforcing priorities.

A community intervention for behaviour modification: an experience to control cardiovascular diseases in Yogyakarta, Indonesia.

BackgroundNon-communicable Disease (NCD) is increasingly burdening developing countries including Indonesia. However only a few intervention studies on NCD control in developing countries are reported. This study aims to report experiences from the development of a community-based pilot intervention to prevent cardiovascular disease (CVD), as initial part of a future extended PRORIVA program (Program to Reduce Cardiovascular Disease Risk Factors in Yogyakarta, Indonesia) in an urban area within Jogjakarta, Indonesia.MethodsThe study is quasi-experimental and based on a mixed design involving both quantitative and qualitative methods. Four communities were selected as intervention areas and one community was selected as a referent area. A community-empowerment approach was utilized to motivate community to develop health promotion activities. Data on knowledge and attitudes with regard to CVD risk factors, smoking, physical inactivity, and fruit and vegetable were collected using the WHO STEPwise questionnaire. 980 people in the intervention areas and 151 people in the referent area participated in the pre-test. In the post-test 883 respondents were re-measured from the intervention areas and 144 respondents from the referent area. The qualitative data were collected using written meeting records (80), facilitator reports (5), free-listing (112) and in-depth interviews (4). Those data were analysed to contribute a deeper understanding of how the population perceived the intervention.ResultsFrequency and participation rates of activities were higher in the low socioeconomic status (SES) communities than in the high SES communities (40 and 13 activities respectively). The proportion of having high knowledge increased significantly from 56% to 70% among men in the intervention communities. The qualitative study shows that respondents thought PRORIVA improved their awareness of CVD and encouraged them to experiment healthier behaviours. PRORIVA was perceived as a useful program and was expected for the continuation. Citizens of low SES communities thought PRORIVA was a “cheerful” program.ConclusionA community-empowerment approach can encourage community participation which in turn may improve the citizen’s knowledge of the danger impact of CVD. Thus, a bottom-up approach may improve citizens’ acceptance of a program, and be a feasible way to prevent and control CVD in urban communities within a low income country.

Designing and collecting data for a longitudinal study : the Sleman Health and Demographic Surveillance System (HDSS).

Background: This paper describes the methodological considerations of developing an urban Health and Demographic Surveillance System (HDSS), in the Sleman District of Yogyakarta, Indonesia. Methods: 1) The Sleman District was selected because it is mostly an urban area. 2) The minimum sample size was calculated to measure infant mortality as the key variable and resulted in a sample of 4942 households. A two-stage cluster sampling procedure with probability proportionate to size was applied; first, 216 Censuses Blocks (CBs) were selected, and second, 25 households in each CB were selected. 3) A baseline survey was started in 2015, and collected data on demographic and economic characteristics and verbal autopsy (VA); the 2nd cycle collected updated demographic data, VA, type of morbidity (communicable and non-communicable diseases, disability and injury) and health access. 4) The data were collected at a home visit through a Computer-Assisted Personal Interview (CAPI) on a tablet device, and the data were transferred to the server through the Internet. 5) The quality control consisted of spot-checks of 5% of interviews to control for adherence to the protocol, re-checks to ensure the validity of the interview, and computer-based data cleaning. 6) A utilization system was designed for policy-makers (government) and researchers. Results: In total, 5147 households participated in the baseline assessment in 2015, and 4996 households participated in the second cycle in 2016 (97.0% response rate). Conclusions: Development of an urban HDSS is possible and is beneficial in providing data complementary to the existing demographic and health information system at local, national and global levels.

The role of Indonesian patients’ health behaviors in delaying the diagnosis of nasopharyngeal carcinoma

BackgroundWith an estimated 13,000 newly diagnosed patients per year, nasopharyngeal carcinoma (NPC) is one of the most common types of cancer in males in Indonesia. Moreover, most patients are diagnosed at an advanced stage of the disease. This study aimed to explore the health behaviors of patients diagnosed with NPC and the possible causes of patient delay in NPC diagnosis.MethodsA qualitative research method was used to gain better insight into patient behaviors. Twelve patients were interviewed using semi-structured interview guidelines. All interviews were recorded, transcribed verbatim and analyzed according to a standard content analysis framework.ResultsMost patients had limited knowledge regarding NPC and its causes. Fifty percent of the patients had a delay of six months from the onset of symptoms to diagnosis. The main reason for this delay was the lack of awareness among the patients, which was influenced by their environment, economic status, family, culture, and religion. The perceived barriers to seeking medical help included direct non-medical costs not covered by health insurance, complex and time-consuming insurance and referral systems, and negative experiences in the past. Health insurance did motivate people to seek medical help.ConclusionThis study provides additional insight into patients’ motivations to delay seeking medical help and can facilitate the design of NPC education programs. To improve awareness of the abovementioned causes for delay, community-based education programs are highly warranted and should focus on the recognition of NPC symptoms and possible solutions to overcome the main barriers at an earlier disease stage.

Evaluasi pelaksanaan peraturan kawasan larangan merokok pada perilaku merokok pegawai pemerintah di Boalemo, Gorontalo

Evaluation of the implementation of the smoking area banning regulations on smoking behavior of government officials in Boalemo, Gorontalo Purpose This study aimed to investigate implementation of regional regulations for banning smoking on employees smoking behavior in a government office in Boalemo. Methods This research used a qualitative approach with a case study design involving 23 subjects. Data collection used systematic observation, regulatory documents, in-depth interviews and focus group discussions. Results Background process of drafting rules were, 1) idea of regent, 2) translation of indicators of clean and health living behavior, 3) Ministry of Health, 4) illness and death data caused by smoking, and 5) impact of smoking. Effectiveness of policy implementation for area smoking ban was largely determined by, 1) input: availability of facilities dedicated to smoking area, effort control, labeling, guidance system and form of communication channel, 2) process: leadership support, stakeholder involvement, social norm, legal regulation regent, monitoring, and evaluation. Rules indirectly provide positive effect for output of small portion of employees in terms of, 1) intention to quit smoking, 2) frequency of smoking in room reduced, and 3) there were some employees who quit smoking. Conclusion Implementation of a policy was determined by: 1) role of leader as indicator of example and role model for subordinates, 2) support and role of all relevant stakeholder, and 3) social norms that encouraged positive behavioral changes in smoking.