Differences in knowledge, attitude, and practice regarding hypertension by access to a community-based screening program (POSBINDU): A cross-sectional study from four districts in Indonesia.

BACKGROUND: A high prevalence of hypertension is found in Low- and Middle-income Countries (LMICs) including in Indonesia. However, hypertension awareness, treatment, and control are relativity poor. A community-based program to screen and educate people on non-communicable disease prevention (POSBINDU) was launched by the Indonesian government. However, the association between participation in the POSBINDU program with increasing knowledge, attitude, and practice of hypertension has not been widely assessed. In this study, we compared the knowledge, attitudes, and practices among people who accessed the POSBINDU and those who did not access the POSBINDU program. Subsequently, factors associated with the knowledge, attitudes, and practices among people who accessed the POSBINDU and those who did not access the POSBINDU were explored. METHODS: This was an observational study with a cross-sectional design measuring the knowledge, attitudes, and practices for hypertension control in four districts in Indonesia from October 2019 to January 2020. A total of 1,988 respondents were included in this study. A questionnaire was used to assess the knowledge, attitudes, and practices of hypertension. Simple logistic regression was used to investigate the correlation between the characteristics of respondents and knowledge, attitudes, and practice status. Multiple logistic regression tests were conducted to investigate factors associated with knowledge, attitudes, and practice status. RESULTS: We found that people who accessed POSBINDU had higher odds of having better knowledge (aOR:1.4; 95%CI:1.2-1.8), however, accessed to POSBINDU was associated with lower attitudes (aOR:0.6; 85%CI: 0.5-0.7) and had no association with hypertension-related practice. CONCLUSION: People who accessed POSBINDU have an association with good knowledge, but the association with good attitude and practice was less clear. Therefore, an improvement in the POSBINDU program is needed to increase the attitudes and practices of hypertension.

Effectiveness of community-based diabetes and hypertension prevention and management programmes in Indonesia and Viet Nam: a quasi-experimental study.

INTRODUCTION: Non-communicable diseases (NCDs) have surpassed infectious diseases as the leading global cause of death, with the Southeast Asian region experiencing a significant rise in NCD prevalence over the past decades. Despite the escalating burden, screening for NCDs remains at very low levels, resulting in undetected cases, premature mortality and high public healthcare costs. We investigate whether community-based NCD prevention and management programmes are an effective solution. METHODS: In Indonesia, we compare participants in the community-based NCD screening and management programme Pos Pembinaan Terpadu-Penyakit Tidak Menular with matched non-participants with respect to their uptake of screening activities, health-related behaviour and knowledge and metabolic risk factors. We use statistical matching to redress a possible selection bias (n=1669). In Viet Nam, we compare members of Intergenerational Self-Help Clubs, which were offered similar NCD health services, with members of other community groups, where such services were not offered. We can rely on two waves of data and use a double-difference approach to redress a possible selection bias and to measure the impacts of participation (n=1710). We discuss strengths and weaknesses of the two approaches in Indonesia and Viet Nam. RESULTS: In Indonesia, participants have significantly higher uptake of screening for hypertension and diabetes (+13% from a control mean of 88% (95% CI 9% to 17%); +93% from a control mean of 48% (95% CI 79% to 108%)). In both countries, participants show a higher knowledge about risk factors, symptoms and complications of NCDs (Indonesia: +0.29 SD (0.13-0.45), Viet Nam: +0.17 SD (0.03-0.30)). Yet, the improved knowledge is only partly reflected in improved health behaviour (Viet Nam: fruit consumption +0.33 SD (0.15-0.51), vegetable consumption +0.27 SD (0.04-0.50)), body mass index (BMI) (Viet Nam: BMI -0.07 SD (-0.13 to -0.00)) or metabolic risk factors (Indonesia: systolic blood pressure: -0.13 SD (-0.26 to -0.00)). CONCLUSION: Community-based NCD programmes are well suited to increase screening and to transmit health knowledge. Due to their extensive outreach within the community, they can serve as a valuable complement to the screening services provided at the primary healthcare level. Yet, limited coverage, insufficient resources and a high staff turnover remain a problem. TRIAL REGISTRATION NUMBER: NCT05239572.

Correlation between circulating fibrosis biomarkers with left atrial function and left atrial volume index in rheumatic mitral stenosis.

Mitral stenosis is the most common rheumatic heart disease (RHD) disorder worldwide, including in Indonesia. This pathological condition causes left atrial pressure, leading to left atrial fibrosis that affects the structure and function of the left atrial as well as the clinical condition. The aim of this study was to assess the correlation between circulating fibrosis biomarkers with net atrioventricular compliance (Cn) as a parameter of left atrial function, and left atrial volume index (LAVI) as a parameter left atrium structure of changes. A cross-sectional study was conducted at Panti Rahayu Hospital and Permata Bunda Hospital, Purwodadi, Central Java, with a total of 40 RHD patients with severe mitral stenosis. The ELISA was used to measure the levels of carboxy-terminal propeptide of type I procollagen (PICP), matrix metalloproteinase I (MMP-1), tissue inhibitor matrix metalloproteinase 1 (TIMP-1), and transforming growth factor-ß1 (TGF-ß1). The left atrial function was assessed by measuring Cn, and the LAVI parameters were measured to assess left atrium structure/size. The mean levels of circulating fibrosis biomarkers were as follows: PICP 153.96±89.12 ng/mL; MMP-1 1.44±2.12 ng/mL; MMP-1/TIMP-1 ratio 0.38±0.54 and TGF-ß1 2.66±1.96 pg/mL. From the echocardiographic evaluation, the mean Cn was 5.24±1.93 mL/mmHg and the mean LAVI was 152.55±79.36 mL/m2. There were significant correlation between MMP-1 and MMP-1/TIMP-1 ratio with Cn (r=0.345 and r=0.333, respectively; both had p<0.05). PICP and TGF-ß1 biomarkers did not significantly correlate with Cn (p>0.05). Meanwhile, none of the biomarkers had a significant correlation with LAVI (p>0.05). This study highlights that MMP-1 and MMP-1/TIMP-1 ratio are potentially to be used as markers to determine the Cn in RHD patients with severe mitral stenosis. However, further studies with a higher sample size are needed to confirm this finding.

Effect of Dapagliflozin on Patients with Rheumatic Heart Disease Mitral Stenosis.

(1) Background: Mitral stenosis is the most common rheumatic heart disease (RHD). Inflammation and fibrosis are the primary pathophysiology, resulting in left atrial stress and dysfunction. Dapagliflozin is a new heart failure treatment with anti-inflammation and anti-fibrosis effects from previous studies. However, the specific role of dapagliflozin in RHD mitral stenosis is unknown. This study aims to investigate (i) the effect of dapagliflozin on biomarkers of fibrosis, NT-pro BNP levels and left atrial function; (ii) the relationship between the changes in fibrosis biomarkers with left atrial function and NT-pro BNP levels. (2) Methods: An open-label randomized study was conducted on 33 RHD mitral stenosis patients divided into a dapagliflozin group which received 10 mg dapagliflozin and standard therapy, and a control group which only received standard therapy. All patients were examined for levels of PICP, MMP-1/TIMP-1 ratio, TGF-ß1, NT-proBNP, mitral valve mean pressure gradient (MPG), and net atrioventricular compliance (Cn) pre- and post-intervention. (3) Results: This study found a significant increase in PICP and TGF-ß1 and a reduction in the MMP-1/TIMP-1 ratio in the dapagliflozin group and the control group (p < 0.05). In the dapagliflozin group, the levels of NT-pro BNP decreased significantly (p = 0.000), with a delta of decreased NT-pro BNP levels also significantly greater in the dapagliflozin group compared to the control (p = 0.034). There was a significant increase in Cn values in the dapagliflozin group (p = 0.017), whereas there was a decrease in the control group (p = 0.379). Delta of changes in Cn values between the dapagliflozin and control groups also showed a significant value (p = 0.049). The decreased MPG values of the mitral valve were found in both the dapagliflozin and control groups, with the decrease in MPG significantly greater in the dapagliflozin group (p = 0.031). There was no significant correlation between changes in the value of fibrosis biomarkers with Cn and NT-pro BNP (p > 0.05). (4) Conclusions: This study implies that the addition of dapagliflozin to standard therapy for RHD mitral stenosis patients provides benefits, as evidenced by an increase in net atrioventricular compliance and decreases in the MPG value of the mitral valve and NT-pro BNP levels (p < 0.05). This improvement was not directly related to changes in fibrosis biomarkers, as these biomarkers showed ongoing fibrosis even with dapagliflozin administration.

Association between carotid intima media thickness and acute ischemic stroke at an Indonesian tertiary referral hospital.

Objectives: A high prevalence of tobacco smoking contributes to a high incidence of acute ischemic stroke (AIS) in Indonesia. Large-artery atherosclerosis is known to be a significant cause of AIS. The present study was aimed at evaluating the association between AIS and atherosclerosis on the basis of carotid intima-media thickness (CIMT) measurements in a tertiary care hospital in Indonesia. Methods: A total of 79 patients with AIS (case study group) and 79 individuals without AIS (control group) were included. Chi-squared tests and odds ratios were used to compare the groups and determine associations. We also considered factors such as age, body mass index (BMI), sex, type-2 diabetes mellitus (T2DM), hypertension, smoking status, dyslipidemia, socioeconomic status, and educational level in the statistical analyses. A p-value <0.05 was considered statistically significant. Results: Stratification of atherosclerosis into case study and control groups with respect to all study variables indicated a significant relationship (p > 0.05) between atherosclerosis and all variables except low socioeconomic status (p = 0.265) and low educational level (p = 0.180). Regression analysis demonstrated that a BMI ≥25 kg/m2, compared with a normal BMI, was associated with a 2.139-fold higher risk of atherosclerosis. Conclusions: AIS was associated with atherosclerosis, on the basis of CIMT measurements, according to age, BMI, sex, T2DM, hypertension, smoking status, dyslipidemia, socioeconomic status, and education level in the Indonesian population.

Potential and challenges for an integrated management of tuberculosis, diabetes mellitus, and hypertension: A scoping review protocol.

In many low- and middle-income countries (LMICs), the epidemiological transition is characterized by an increased burden of non-communicable diseases (NCDs) and the persistent challenge of infectious diseases. The transmission of tuberculosis, one of the leading infectious diseases, can be halted through active screening of risk groups and early case findings. Studies have reported comorbidities between tuberculosis (TB) and NCDs, which necessitates the development of an integrated disease management model. This scoping review discusses the possibilities and problems of integration in managing TB and NCDs, with a particular emphasis on diabetic mellitus (DM) and hypertension screening and control. We will conduct this review following Arksey and O'Malley's framework for scoping review. We will use key terms related to integrated management, i.e., screening, diagnosis, treatment, and care, of TB, DM, and hypertension in PubMed, Scopus Database, and ScienceDirect for research published from January 2005 to July 2021. This review will also consider grey literature, including unpublished literature and international disease management guidelines on TB, DM, and hypertension from WHO or other health professional organization. We will export the search results to citation manager software (EndNote). We will remove duplicates and apply the inclusion and exclusion criteria to identify the set of papers for the review. After screening the titles and abstract, two authors will independently review the full text of selected studies and extract the data. We will synthesize all selected studies qualitatively and the results will be discussed with the experts. The results will be used as the basis of the development of a guideline for integrated TB, DM, and hypertension management.

Determinants of socioeconomic and rural-urban disparities in stunting: evidence from Indonesia.

INTRODUCTION: Stunting continues to be a prominent health problem in Indonesia. Stunting prevalence is higher in children from poor families or living in rural areas; however, there has been a lack of information on predictors of stunting disparities and stunting risk factors by socioeconomic status (SES) and location of residence (rural or urban). This study aims to examine the factors associated with stunting by SES and rural-urban status, and to assess determinants of stunting disparities by SES and rural-urban status in Indonesia. METHODS: This study analysed data from the Indonesian Family and Life Survey (IFLS) wave 5, conducted in 2014. Data for 3887 children aged 0-59 months, including individual, family and community variables, were analysed. Stratified logistic regression was conducted to assess differences in determinants of stunting by household expenditure (poor or non-poor, representing SES) and rural-urban status. The Oaxaca-Blinder decomposition method was used to assess determinants of stunting disparities by household expenditure and rural-urban status. RESULTS: The analyses showed differences in factors associated with stunting among children in rural versus urban areas, or children in poor versus non-poor households. Mother's short stature and low education level increased the odds of stunting across all groups. However, in children of families with a higher household expenditure, unhealthy snacks were a significant predictor of stunting (adjusted odds ratio (aOR) 1.23, 95% confidence interval (CI) 1.04-1.47). This finding was not found in other groups. Good sanitation significantly reduced stunting in children in families with higher household expenditure and children from urban communities. Nutrition services were significantly associated with stunting in poor children and children from urban areas. The decomposition analyses showed that differences in characteristics explained 55.35% stunting disparity by household expenditure. Meanwhile, rural-urban disparity was mostly explained by differences in responses (56.20%), with low birth weight and unexplained variables as predominant contributors. CONCLUSION: There were slight differences in stunting determinants by household expenditure and rural-urban status in Indonesia. Stunting disparities were attributed to differences in characteristics and responses between the less and more advantaged populations. To improve the effectiveness of stunting reduction programs, specific interventions tailored to address the differences between the more and less advantaged population are needed.

Missed opportunities in hypertension risk factors screening in Indonesia: a mixed-methods evaluation of integrated health post (POSBINDU) implementation.

OBJECTIVES: To assess the implementation and contextual barriers of POSBINDU, a community-based activity focusing on screening of non-communicable diseases (NCDs), mainly hypertension and diabetes, in Indonesia. DESIGN: This was a concurrent mixed-methods study, with a cross-sectional analysis of secondary data and focus group discussions (FGDs) on stakeholder of POSBINDU. SETTING: The study was conducted in seven districts in three provinces in Indonesia, with approximately 50% of the primary healthcare (PHC) were selected as areas for data collection (n PHC=100). PARTICIPANTS: From 475 POSBINDU sites, we collected secondary data from 54 224 participants. For the qualitative approach, 21 FGDs and 2 in-depth interviews were held among a total of 223 informants. PRIMARY OUTCOMES AND MEASURES: Proportion of POSBINDU visitors getting the hypertension screening and risk factors' assessment, and barriers of POSBINDU implementation. RESULTS: Out of the 114 581 POSBINDU visits by 54 224 participants, most (80%) were women and adults over 50 years old (50%) showing a suboptimal coverage of men and younger adults. Approximately 95.1% of visitors got their blood pressure measured during their first visit; 35.3% of whom had elevated blood pressure. Less than 25% of the visitors reported to be interviewed for NCDs risk factors during their first visit, less than 80% had anthropometric measurements and less than 15% had blood cholesterol examinations. We revealed lack of resources and limited time to perform the complexities of activities and reporting as main barrier for effective hypertension screening in Indonesia. CONCLUSIONS: This study showed missed opportunities in hypertension risk factors screening in Indonesia. The barriers include a lack of access and implementation barriers (capability, resources and protocols).

Beyond personal factors: Multilevel determinants of childhood stunting in Indonesia.

BACKGROUND: Stunting is still a major public health problem in low- and middle-income countries, including Indonesia. Previous studies have reported the complexities associated with understanding the determinants of stunting. This study aimed to examine the household-, subdistrict- and province-level determinants of stunting in Indonesia using a multilevel hierarchical mixed effects model. METHODS: We analyzed data for 8045 children taken from the 2007 and 2014 waves of the Indonesian Family and Life Surveys (IFLS). We included individual-, family-/household- and community-level variables in the analyses. A multilevel mixed effects model was employed to take into account the hierarchical structure of the data. Moreover, the model captured the effect of unobserved household-, subdistrict- and province-level characteristics on the probability of children being stunted. RESULTS: Our findings showed that the odds of childhood stunting vary significantly not only by individual child- and household-level characteristics but also by province- and subdistrict-level characteristics. Among the child-level covariates included in our model, dietary habits, neonatal weight, a history of infection, and sex significantly affected the risk of stunting. Household wealth status and parental education are significant household-level covariates associated with a higher risk of stunting. Finally, the risk of stunting is higher for children living in communities without access to water, sanitation and hygiene. CONCLUSIONS: Stunting is associated with not only child-level characteristics but also family- and community-level characteristics. Hence, interventions to reduce stunting should also take into account family and community characteristics to achieve effective outcomes.

Core health-components, contextual factors and program elements of community-based interventions in Southeast Asia - a realist synthesis regarding hypertension and diabetes.

BACKGROUND: In Southeast Asia, diabetes and hypertension are on the rise and have become major causes of death. Community-based interventions can achieve the required behavioural change for better prevention. The aims of this review are 1) to assess the core health-components of community-based interventions and 2) to assess which contextual factors and program elements affect their impact in Southeast Asia. METHODS: A realist review was conducted, combining empirical evidence with theoretical understanding. Documents published between 2009 and 2019 were systematically searched in PubMed/Medline, Web of Science, Cochrane Library, Google Scholar and PsycINFO and local databases. Documents were included if they reported on community-based interventions aimed at hypertension and/or diabetes in Southeast Asian context; and had a health-related outcome; and/or described contextual factors and/or program elements. RESULTS: We retrieved 67 scientific documents and 12 grey literature documents. We identified twelve core health-components: community health workers, family support, educational activities, comprehensive programs, physical exercise, telehealth, peer support, empowerment, activities to achieve self-efficacy, lifestyle advice, activities aimed at establishing trust, and storytelling. In addition, we found ten contextual factors and program elements that may affect the impact: implementation problems, organized in groups, cultural sensitivity, synergy, access, family health/worker support, gender, involvement of stakeholders, and referral and education services when giving lifestyle advice. CONCLUSIONS: We identified a considerable number of core health-components, contextual influences and program elements of community-based interventions to improve diabetes and hypertension prevention. The main innovative outcomes were, that telehealth can substitute primary healthcare in rural areas, storytelling is a useful context-adaptable component, and comprehensive interventions can improve health-related outcomes. This extends the understanding of promising core health-components, including which elements and in what Southeast Asian context.

Improving knowledge, acceptance, and utilization of female condoms among sex workers through a peer education: a mixed methods study in Surakarta Municipality, Central Java Province, Indonesia.

Female sex workers (FSW) are high-risk for HIV infection. The authors conducted a quasi-experimental study by providing peer education on 110 FSWs, and routine HIV education on 120 controls, in Surakarta Indonesia. An additional qualitative study was performed to explain the contextual factors contributing to the effectiveness of peer education. The difference in difference approach showed that peer education improved knowledge, acceptance, and utilization of female condom. The improvements were related to the clients' perceptions, access, and available interactive communication with the peer educator. The peer education program should be enhanced to support the prevention of HIV/AIDS.

Lack of an Exposure Response and Interaction With HLA-DPß1 and DRß1 Polymorphisms in the Development of Beryllium Toxicity in a High Beryllium Exposure Cohort.

OBJECTIVE: To evaluate interaction of HLA-DPß1 and DRß1 polymorphisms with metrics of beryllium exposure, in the development of beryllium sensitization (BeS) and chronic beryllium disease (CBD). METHODS: A matched case-control study of 61 CBD, 41 BeS, and 259 controls from two beryllium-processing facilities. RESULTS: BES and CBD were significantly associated with presence of DPßE69. Dose response of exposure was not observed for the development of BES and CBD with/without adjustment for DPßE69 (P > 0.05). The DRßE71 polymorphism was more common in BeS than CBD after adjusting for exposure and maybe a protective factor (aOR 0.4, 95% CI 0.2 to 0.9) against the progression of BeS to CBD. CONCLUSION: No exposure-response association was found, which may reflect that the workers in this high exposure cohort were above a threshold level where an exposure-response could be observed.

The patterns of self-reported maternal complications in Indonesia: are there rural-urban differences?

INTRODUCTION: Specific and targeted intervention is needed to reduce the relatively high maternal mortality and morbidity in Indonesia. The apparent rural-urban disparities might require different intervention strategies. Therefore, this study aims to assess patterns and sociodemographic determinants of self-reported maternal morbidity in rural and urban areas. METHODS: Data from the Indonesian Demographic and Health Survey 2012 were analyzed. In this cross-sectional survey, maternal morbidity status and sociodemographic factors were obtained through questionnaire-based interviews. Women who completed the maternal morbidity questionnaire were included in the analyses (n=12 679). Descriptive statistics were used to assess differences in proportion; mixed-effects regression was used to evaluate the association between sociodemographic factors and maternal morbidity. RESULTS: Approximately 53.3% of women reported experiencing pregnancy and/or labor complications, with a lower proportion in rural areas (51.3%) than in urban areas (55.1%). The patterns of pregnancy morbidities were similar for rural and urban women. The highest proportion of pregnancy morbidity was classified as 'other', followed by 'bleeding'. There were slight differences in the type of labor morbidities. Compared to urban women, women in rural areas had a higher prevalence of bleeding and infection, but a significantly lower prevalence of pregnancy rupture of membrane. Nulliparity was a dominant factor for self-reported maternal morbidity. Younger urban, but not rural, women represented a higher proportion of maternal morbidity. In urban areas, women with social disadvantage represented a higher proportion of morbidity. However, in rural areas, a higher prevalence of maternal morbidity was seen in women of higher socioeconomic status. These rural-urban disparities might be partially caused by differences in knowledge of maternal morbidities and sociodemographic status between rural and urban women. CONCLUSIONS: This study found similar patterns of pregnancy morbidity, but slight differences in labor morbidity patterns. Specific interventions for major maternal complications within rural or urban areas are important. There were also differences in the proportion of self-reported maternal complications by sociodemographic factors, which might be caused by differences in reporting. Intervention to improve knowledge and awareness of maternal complication is needed, specifically for socially disadvantaged women and women living in rural areas.

Expanding the scope beyond mortality: burden and missed opportunities in maternal morbidity in Indonesia.

BACKGROUND: Indonesia still faces challenges in maternal health. Specifically, the lack of information on community-level maternal morbidity. The relatively high maternal healthcare non-utilization in Indonesia intensifies this problem. OBJECTIVE: To describe the burden of community-level maternal morbidity in Indonesia. Additionally, to evaluate the extent and determinants of missed opportunities in women with maternal morbidity. METHODS: We used three cross-sectional surveys (Indonesian Demographic and Health Survey, IDHS 2002, 2007 and 2012). Crude and adjusted proportions of maternal morbidity burden were estimated from 43,782 women. We analyzed missed opportunities in women who experienced maternal morbidity during their last birth (n = 19,556). Multilevel mixed-effects logistic regressions were used to evaluate the determinants of non-utilization in IDHS 2012 (n = 6762). RESULTS: There were significant increases in the crude and adjusted proportion of maternal morbidity from IDHS 2002 to IDHS 2012 (p < 0.05). In 2012, the crude proportion of maternal morbidity was 53.7%, with adjusted predicted probability of 51.4%. More than 90% of these morbidities happened during labor. There were significant decreases in non-utilization of maternal healthcare among women with morbidity. In 2012, 20.0% of these women did not receive World Health Organization (WHO) standard antenatal care. In addition, 7.1% did not have a skilled provider at birth, and 25.0% delivered outside of health facilities. Higher proportions of non-utilization happened in women who were younger, multiparous, of low socioeconomic status (SES), and living in less-developed areas. In multilevel analyses, missed opportunities in healthcare utilization were strongly related to low SES and low-resource areas in Indonesia. CONCLUSION: The prevalence of maternal morbidity in Indonesia is relatively high, especially during labor. This condition is amplified by the concerning missed opportunities in maternal healthcare. Efforts are needed to identify risk factors for maternal morbidity, as well as increasing healthcare coverage for the vulnerable population.