Prevalence of adolescent mental disorders in Kenya, Indonesia, and Viet Nam measured by the National Adolescent Mental Health Surveys (NAMHS): a multi-national cross-sectional study.

BACKGROUND: Mental disorders are the leading global cause of health burden among adolescents. However, prevalence data for mental disorders among adolescents in low-income and middle-income countries are scarce with often limited generalisability. This study aimed to generate nationally representative prevalence estimates for mental disorders in adolescents in Kenya, Indonesia, and Viet Nam. METHODS: As part of the National Adolescent Mental Health Surveys (NAMHS), a multinational cross-sectional study, nationally representative household surveys were conducted in Kenya, Indonesia, and Viet Nam between March and December, 2021. Adolescents aged 10-17 years and their primary caregiver were interviewed from households selected randomly according to sampling frames specifically designed to elicit nationally representative results. Six mental disorders (social phobia, generalised anxiety disorder, major depressive disorder, post-traumatic stress disorder, conduct disorder, and attention-deficit hyperactivity disorder) were assessed with the Diagnostic Interview Schedule for Children, Version 5. Suicidal behaviours and self-harm in the past 12 months were also assessed. Prevalence in the past 12 months and past 4 weeks was calculated for each mental disorder and collectively for any mental disorder (ie, of the six mental disorders assessed). Prevalence of suicidal behaviours (ie, ideation, planning, and attempt) and self-harm in the past 12 months was calculated, along with adjusted odds ratios (aORs) to show the association with prevalence of any mental disorder in the past 12 months. Inverse probability weighting was applied to generate national estimates with corresponding 95% CIs. FINDINGS: Final samples consisted of 5155 households (ie, adolescent and primary caregiver pairs) from Kenya, 5664 households from Indonesia, and 5996 households from Viet Nam. In Kenya, 2416 (46·9%) adolescents were male and 2739 (53·1%) were female; in Indonesia, 2803 (49·5%) adolescents were male and 2861 (50·5%) were female; and in Viet Nam, 3151 (52·5%) were male and 2845 (47·4%) were female. Prevalence of any mental disorder in the past 12 months was 12·1% (95% CI 10·9-13·5) in Kenya, 5·5% (4·3-6·9) in Indonesia, and 3·3% (2·7-4·1) in Viet Nam. Prevalence in the past 4 weeks was 9·4% (8·3-10·6) in Kenya, 4·4% (3·4-5·6) in Indonesia, and 2·7% (2·2-3·3) in Viet Nam. The prevalence of suicidal behaviours in the past 12 months was low in all three countries, with suicide ideation ranging from 1·4% in Indonesia (1·0-2·0) and Viet Nam (1·0-1·9) to 4·6% (3·9-5·3) in Kenya, suicide planning ranging from 0·4% in Indonesia (0·3-0·8) and Viet Nam (0·2-0·6) to 2·4% (1·9-2·9) in Kenya, and suicide attempts ranging from 0·2% in Indonesia (0·1-0·4) and Viet Nam (0·1-0·3) to 1·0% (0·7-1·4) in Kenya. The prevalence of self-harm in the past 12 months was also low in all three countries, ranging from 0·9% (0·6-1·3) in Indonesia to 1·2% (0·9-1·7) in Kenya. However, the prevalence of suicidal behaviours and self-harm in the past 12 months was significantly higher among those with any mental disorder in the past 12 months than those without (eg, aORs for suicidal ideation ranged from 7·1 [3·1-15·9] in Indonesia to 14·7 [7·5-28·6] in Viet Nam). INTERPRETATION: NAMHS provides the first national adolescent mental disorders prevalence estimates for Kenya, Indonesia, and Viet Nam. These data can inform mental health and broader health policies in low-income and middle-income countries. FUNDING: The University of Queensland in America (TUQIA) through support from Pivotal Ventures, a Melinda French Gates company.

Short-Term Effects of a School-Based Comprehensive Sexuality Education Intervention Among Very Young Adolescents in Three Urban Indonesian Settings: A Quasi-Experimental Study.

PURPOSE: To evaluate the effects of a comprehensive sexuality education (CSE) intervention on short-term psychosocial outcomes related to healthy sexuality among very young adolescents in urban Indonesia. METHODS: A quasi-experimental study was conducted between 2018 and 2021 with students aged 10-14 years at 18 schools in Indonesia (Lampung, Denpasar, Semarang). Three schools per site were purposefully selected to receive the SEmangaT duniA RemajA intervention, a two-year, rights-based teacher-led CSE intervention delivered in classrooms (or online after the 2020 COVID-19 outbreak); and matched with three control schools. Surveys were completed by 3,825 students at pre- and posttest (82% retention). The final analytical sample included 1852 intervention and 1483 control students (N = 3,335). Difference-in-difference analysis was conducted to examine the intervention effect on healthy sexuality competencies (knowledge, skills, and attitudes) and personal sexual well-being. RESULTS: Baseline characteristics for intervention and control groups were similar in terms of sex (57% female) and age (mean 12 years). Students receiving SEmangaT duniA RemajA demonstrated significantly greater increase in competencies, including greater pregnancy knowledge, more gender equal attitudes, and communication about sexual and reproductive health and rights, compared to controls. There was no intervention effect on personal sexual well-being, except for self-efficacy to prevent pregnancy. Subgroup analysis indicated more significant effects among females and students in Semarang and Denpasar, than males or students in Lampung. DISCUSSION: While findings demonstrate the potential for CSE programs to improve healthy sexuality competencies in early adolescence, the effect appears to be highly contextualized which may be due to varying levels of implementation quality, especially since the COVID-19 outbreak.

The Impacts of Two Gender-Transformative Interventions on Early Adolescent Gender Norms Perceptions: A Difference-in-Difference Analysis.

PURPOSE: Inequitable gender norms are widespread and can be harmful to the wellbeing of adolescents. This study estimates the effects of two gender-transformative interventions, Semangat Dunia Remaja or Teen Aspirations (SETARA) and Growing Up Great! (GUG!), on gender norms perceptions and attitudes among very young adolescents in poor urban settings in Bandar Lampung, Semarang, Denpasar (Indonesia), and Kinshasa (Democratic Republic of the Congo). METHODS: The study draws from the longitudinal Global Early Adolescent Study, using a quasi-experimental design to evaluate the interventions. Data collection took place between 2017 and 2020. Our analytical samples included 2,159 adolescents in Kinshasa and 3,335 in Indonesia. We conducted a difference-in-difference analysis using generalized estimation equations and generalized linear models, after stratification by site and sex. RESULTS: The interventions shifted a range of gender perceptions, although effects varied by program, city, and sex. SETARA shifted gender-normative perceptions related to traits, roles, and relations, while GUG! effects were more concentrated on attitudes toward chore sharing. SETARA was most effective in Semarang and Denpasar, but not in Bandar Lampung. In addition, both interventions were more consistently effective for girls than boys. DISCUSSION: Gender-transformative interventions can effectively promote gender equality in early adolescence, but effects are program-specific and context-specific. Our findings emphasize the importance of defined theories of change and consistent implementation in gender-transformative intervention.

A latent class approach to understanding patterns of emotional and behavioral problems among early adolescents across four low- and middle-income countries.

Early adolescents (ages 10-14) living in low- and middle-income countries have heightened vulnerability to psychosocial risks, but available evidence from these settings is limited. This study used data from the Global Early Adolescent Study to characterize prototypical patterns of emotional and behavioral problems among 10,437 early adolescents (51% female) living in the Democratic Republic of Congo (DRC), Malawi, Indonesia, and China, and explore the extent to which these patterns varied by country and sex. LCA was used to identify and classify patterns of emotional and behavioral problems separately by country. Within each country, measurement invariance by sex was evaluated. LCA supported a four-class solution in DRC, Malawi, and Indonesia, and a three-class solution in China. Across countries, early adolescents fell into the following subgroups: Well-Adjusted (40-62%), Emotional Problems (14-29%), Behavioral Problems (15-22%; not present in China), and Maladjusted (4-15%). Despite the consistency of these patterns, there were notable contextual differences. Further, tests of measurement invariance indicated that the prevalence and nature of these classes differed by sex. Findings can be used to support the tailoring of interventions targeting psychosocial adjustment, and suggest that such programs may have utility across diverse cross-national settings.

Measuring the Prevalence of Mental Disorders in Adolescents in Kenya, Indonesia, and Vietnam: Study Protocol for the National Adolescent Mental Health Surveys.

PURPOSE: In low- and middle-income countries, there are limited data on mental disorders among adolescents. To address this gap, the National Adolescent Mental Health Surveys (NAMHS) will provide nationally representative prevalence data of mental disorders among adolescents in Kenya, Indonesia, and Vietnam. This paper details the NAMHS study protocol. METHODS: In each country, a multistage stratified cluster sampling design will be used. Participants will be eligible pairs of adolescents aged 10-17 years and their primary caregiver. Adolescents will be assessed for social phobia, generalized anxiety disorder, major depressive disorder, attention-deficit/hyperactivity disorder, conduct disorder, and post-traumatic stress disorder using the Diagnostic Interview Schedule for Children, version 5. Demographics, risk and protective factors, and service use information will also be collected. In the parallel clinical calibration study, diagnoses of major depressive disorder, social phobia, and generalized anxiety disorder made using the Diagnostic Interview Schedule for Children, version 5 will be calibrated against a diagnostic assessment by in-country clinicians in a separate sample. RESULTS: Data collection for the national survey and clinical calibration study will commence in 2021, with dissemination of findings and methodology due to occur in 2022. CONCLUSIONS: Accurately quantifying the prevalence of mental disorders in adolescents is essential for service planning. NAMHS will address this lack of prevalence data, both within the NAMHS countries and within their respective regions, while establishing a gold-standard methodology for data collection on adolescent mental health in low- and middle-income countries. More broadly, NAMHS will encourage capacity building within each country by establishing linkages between researcher, clinician, government, and other networks.

"If it's really excessive, it can enter your heart": A Mixed Methods Investigation of Bullying Among Early Adolescents in Semarang, Indonesia.

Bullying is a major public health concern for Indonesian adolescents, with well-documented links to a range of emotional and behavioral problems. Despite such evidence, few investigations have employed qualitative methods to illuminate youth's own perceptions of bullying and its psychosocial correlates in this context. The current study aimed to address this gap through an exploration of Indonesian adolescents' motivations, perceptions, and beliefs regarding bullying. Building on prior quantitative findings, an explanatory sequential mixed methods approach was used to better understand the myriad ways in which bullying ties into other psychosocial challenges. Qualitative interviews were conducted with a total of 45 adolescents ages 13 to 14 (25 girls and 20 boys) in two junior high schools in Semarang between October and December 2019. Interviews were audio-recorded, transcribed verbatim, and translated into English for analysis. Qualitative data were then coded using an inductive thematic analysis approach. Interviews yielded contextual insights into adolescents' definitions of bullying including the distinction between "normal" and "serious" bullying; related risk behaviors; key drivers; social and emotional consequences; and coping strategies. Across these thematic categories, a number of noteworthy gender differences emerged, highlighting the role that underlying gender norms can play in driving bullying involvement. Further, findings emphasize the need to develop a locally valid definition of bullying which takes into account the ways in which emotional distress may be both a criterion and a consequence of bullying. Findings can be used to inform bullying prevention programs targeting Indonesian youth.

National health insurance contribution to family planning program funding in Indonesia: A fund flow analysis.

Background: Launched in 2014, Indonesia's national health insurance system (JKN) aimed to provide universal health coverage, including contraceptive services, to its population. We aim to evaluate the contribution of JKN to the overall spending for the family planning program in Indonesia. Methods: Data from the Indonesian Demographic Health Survey, Survey on Financial Flows for Family Planning, Indonesia Motion Tracker Matrix, World Population Prospect, and Indonesian ministries' budget accountability reports were entered into the CastCost Contraceptive Projection Tool to define budgetary allocation and spending for the family planning program at the national level in 2019. Results: Indonesia's family planning program in 2019 was financed mostly by the national budget (64.0%) and out-of-pocket payments (34.6%). There were three main ministries responsible for family planning financing: the National Population and Family Planning Board (BKKBN) (35.8%), the Ministry of Finance (26.2%), and the Ministry of Health (2.0%). Overall, JKN contributed less than 0.4% of the funding for family planning services in Indonesia in 2019. The majority of family planning spending was by public facilities (57.3%) as opposed to private facilities (28.6%). Conclusion: JKN's contribution to funding Indonesia's family planning programs in 2019 was low and highlights a huge opportunity to expand these contributions. A coordinated effort should be conducted to identify possible opportunities to realign BKKBN and JKN roles in the family planning programs and lift barriers to accessing family planning services in public and private facilities. This includes a concerted effort to improve integration of private family planning providers into the JKN program.

The Efficacy of Divabirth Vaginal Dilator to Prevent Pelvic Floor Trauma During Labor: A Protocol Study.

Background: Vaginal birth may have a negative impact on nerve structure and function, pelvic floor muscle structure, and function. Reducing the risk of pelvic floor injuries during vaginal birth is one of the most effective ways to prevent labor morbidity in women. There is a lack of tools developed based on this approach, especially in Indonesia. Therefore, we aimed to know the efficacy of a vaginal dilator called Divabirth based on labor outcomes. Methods: This clinical study involved subjects who are randomly grouped in to the control and treatment groups. Subjects in the treatment group are told to utilize vaginal dilator devices for 20 minutes each session, a maximum of two sessions per day, lasting 5 minutes every cycle, from 35 weeks of gestation until delivery. Discussions: The current research contributes valuable information to developing a vaginal dilator intervention program for pregnant women to reduce perineal laceration and improve labor outcomes. It may also help to lower their medical and treatment expenditures. We expect its success to be a step forward in improving reproductive health status. Highlights: Vaginal birth may have negative impact on nerve and pelvic floor muscle structure and functionLack of tool has been developed to reduce the risk of pelvic floor injuries during vaginal birthA study protocol of vaginal dilator usage to know the efficacy based on labor outcomes.

Violence Perpetration in Early Adolescence: A Study of Four Urban Communities Worldwide.

PURPOSE: Violence perpetration is common among adolescents worldwide but existing research largely focuses on boys, older adolescents, and partner violence. Our study sought to identify individual, family, and neighborhood/peer factors associated with violence perpetration in a multinational sample of male and female young adolescents. METHODS: We used cross-sectional data from 5,762 adolescents in four sites in the Global Early Adolescent Study: Flanders, Belgium; Kinshasa, Democratic Republic of the Congo; Shanghai, China; and Semarang, Indonesia. Adolescents resided in high-poverty urban areas and were aged 10 to 14 years. Logistic regression examined pooled and stratified associations between independent variables with peer violence perpetration in the past six months. Factors included media viewing habits, gender norms, victimization, agency/empowerment, adversity, depression, familial relationships, neighborhood cohesion, and peer behaviors. RESULTS: Restricted-model analyses found increased odds of violence perpetration associated with high media consumption, pornography viewing, violence or bullying victimization, having drank alcohol, depressive symptoms, adverse childhood experiences, greater behavioral control, greater decision-making, feeling unsafe in the neighborhood/school, peer alcohol/tobacco use, and witnessing peers start a fight. Decreased odds of violence perpetration were associated with more egalitarian views on two gender norms scales, closer parental relationships, neighbors looking out for one another, and greater availability of adult help. DISCUSSION: Among young adolescents, increased odds of violence perpetration were related to a perceived lack of safety and risky peer behaviors. Parental and neighborhood connections were often associated with decreased perpetration. Further research examining the interplay of such factors among young adolescents is needed to inform effective intervention and policy.

A Multi-Country Study of Risk and Protective Factors for Emotional and Behavioral Problems Among Early Adolescents.

PURPOSE: Early adolescence (ages 10-14) is a critical period for psychosocial development, but few studies have focused on risk and protective factors for emergent psychosocial challenges among youth living in low- and middle-income countries. This study explored the contribution of social environmental factors to patterns of emotional and behavioral problems among early adolescents across four low- and middle-income countries. METHODS: Participants were drawn from the Global Early Adolescent Study, and included 10,437 early adolescents from six low-resource urban settings in the Democratic Republic of Congo, Malawi, Indonesia, and China. Multivariate latent class regression was used to examine the associations between distinct patterns of emotional and behavioral problems and risk and protective factors across the family, peer, school, and neighborhood levels. RESULTS: Across countries, childhood adversity, peer bullying behaviors, and a perceived lack of school safety were consistently associated with emotional and behavioral problems. With some contextual variability, peer substance use and a perceived lack of neighborhood safety also emerged as significant risk factors. The magnitude of these associations was generally greatest among a subgroup of early adolescents with co-occurring emotional and behavioral problems. DISCUSSION: The overall consistency of findings across countries is suggestive of the generalizability of risk factors in early adolescence and indicates that interventions bolstering psychosocial adjustment among this age group may have applicability in diverse cross-national settings. Given the significance of peer bullying behaviors and school safety, multicomponent school-based interventions may be an especially applicable approach.

What factors shape quality of life for women affected by gynaecological cancer in South, South East and East Asian countries? A critical review.

BACKGROUND: Gynaecological cancers are among the most prevalent cancers worldwide, with profound effects on the lives of women and their families. In this critical review, we explore the impacts of these cancers on quality of life (QOL) of women in Asian countries, and highlight areas for future inquiry. METHODS: A systematic search of the literature was conducted in six electronic databases: Web of Science, Scopus, Global Health (CAB Direct), PsycINFO (Ovid), EBMR (Ovid), and Medline (Ovid). Screening resulted in the inclusion of 53 relevant articles reporting on 48 studies. RESULTS: Most studies were conducted in high and upper-middle income countries in East Asia and used quantitative approaches. Women had predominantly been diagnosed with cervical or ovarian cancer, and most had completed treatment. Four key interrelated domains emerged as most relevant in shaping QOL of women affected by gynaecological cancer: support, including identified needs, sources and forms; mental health, covering psychological distress associated with cancer, risk and protective factors, and coping strategies; sexual function and sexuality, focused on physiological, emotional and relational changes caused by gynaecological cancers and treatments, and the impacts of these on women's identities; and physical health, covering the physical conditions associated with gynaecological cancers and their impacts on women's daily activities. CONCLUSION: QOL of women affected by gynaecological cancer is shaped by their mental and physical health, support, and changes in sexual function and sexuality. The limited number of studies from lower- and middle-income countries in South and Southeast Asia highlights important knowledge gaps requiring future research.

Multiple factors shape the quality of life of women affected by gynaecological cancers in Asian countries as elsewhere. We identified 53 articles reporting on 48 studies, most conducted in high- and upper-middle income East Asian countries, with much less attention to women in lower income countries in South and Southeast Asia. Most studies used quantitative research methods to gain an understanding of the impact on women diagnosed with cervical or ovarian cancer who had completed treatment. Women's quality of life was shaped by their mental and physical health, their support needs, and the changes they experienced in sexual function and sexuality.

Facilitators and barriers for the delivery and uptake of cervical cancer screening in Indonesia: a scoping review.

BACKGROUND: Cervical cancer (CC) is the second most common female cancer. In Indonesia, national CC screening coverage is low at 12%, highlighting the need to investigate facilitators and barriers to screening. OBJECTIVE: This review synthesises research on facilitators and barriers to the delivery and uptake of CC screening; analyses them in terms of supply- and demand-side factors and their interconnectedness; and proposes recommendations for further research. METHODS: Medline Ovid, CINAHL, Global Health, Neliti, SINTA and Google Scholar were searched, applying a search string with keywords relevant to screening, CC and Indonesia. In total 34 records were included, all were publications on CC screening in Indonesia (2000-2020) in English or Indonesian. Records were analysed to identify findings relevant to the categories of barriers and facilitators, supply-and demand-side factors. RESULTS: Demand-side facilitators identified included:  husband, family or social/peer support (14 studies); information availability, knowledge and awareness (12 studies); positive attitudes and strong perception of screening benefit and the seriousness of CC (12 studies); higher education and socioeconomic status (11 studies); having health insurance; and short distance to screening services (4 studies). Evidence on supply-side was limited. Supply-side facilitators included counselling and support (6 studies), and ease of access (6 studies). Demand-side barriers identified focused on: lack of knowledge/awareness and lack of confidence in screening (14 studies); fear, fatalism and shame (10 studies); time and transportation constraints (8 studies); and lack of husband approval and support (6 studies). Supply-side barriers included: lack of skilled screening providers (3 studies); lack of advocacy and health promotion (3 studies); resource constraints (3 studies); and lack of supervision and support for health care providers (3 studies). CONCLUSIONS: Facilitators and barriers were mirrored in the supply- and demand-side findings. The geographical scope and population diversity of existing research is limited and further supply-side research is urgently needed.

Sexual wellbeing in early adolescence: a cross-sectional assessment among girls and boys in urban Indonesia.

BACKGROUND: Early adolescence (ages 10-14) is a critical period of physical, cognitive, social and emotional development, which affect sexual and reproductive health and rights (SRHR). Yet, little is known about positive or healthy aspects of sexuality development during this period of life, especially in South East Asia where sexual norms remain restrictive. The objective of this study is to assess the prevalence and correlates of sexual wellbeing among early adolescent girls and boys ages 10-14 years in Indonesia. METHODS: Data for this cross-sectional study were collected as part of the Global Early Adolescent Study via a school-based survey in three Indonesian urban sites in 2018 (N = 4309). We assessed the prevalence of multiple indicators of sexual wellbeing (e.g. SRHR knowledge and communication, gender attitudes, body satisfaction, self-efficacy, freedom from violence) and tested for differences by sex using Chi-square, Student t-test, and Wilcoxon rank-sum test. Multivariable logistic regression models were used to assess the adjusted odds ratio of selected indicators in relation to sociodemographic factors, romantic relationship status, and sexual activities. RESULTS: The mean age of students was 12 years (53% girls); 90% had started puberty. SRHR knowledge and communication was low overall, but higher among boys than girls. Boys were more likely than girls to report high body satisfaction, less feelings of guilt in relation to sexuality, but also to have experienced physical peer violence. In contrast, girls were more likely to hold gender equal attitudes, greater perceived self-efficacy to say 'no', and to report being bullied by boys. In multivariable models, romantic relationship experiences, perceived voice (boys and girls) and decision-making (girls) were associated with three or more indicators of sexual wellbeing. CONCLUSIONS: While young adolescents in Indonesia score high on some aspects of sexual wellbeing, misconceptions, feelings of guilt and uncertainties related to sexuality are common, with clear gender differences. These findings confirm the need for comprehensive sexuality education that begins early in adolescence.

Progress towards reducing sociodemographic disparities in breastfeeding outcomes in Indonesia: a trend analysis from 2002 to 2017.

BACKGROUND: Improving breastfeeding practice is important for reducing child health inequalities and achieving several Sustainable Development Goals. Indonesia has enacted legislation to promote optimal breastfeeding practices in recent years. We examined breastfeeding practices among Indonesian women from 2002 to 2017, comparing trends within and across sociodemographic subgroups. METHODS: Data from four waves of the Indonesia Demographic and Health Surveys were used to estimate changes in breastfeeding practices among women from selected sociodemographic groups over time. We examined three breastfeeding outcomes: (1) early initiation of breastfeeding; (2) exclusive breastfeeding; and (3) continued breastfeeding at 1 year. Multivariate logistic regression was used to assess changes in time trends of each outcome across population groups. RESULTS: The proportion of women reporting early initiation of breastfeeding and exclusive breastfeeding increased significantly between 2002 to 2017 (p < 0.05), with larger increases among women who: were from higher wealth quintiles; worked in professional sectors; and lived in Java and Bali. However, 42.7% of women reported not undertaking early initiation of breastfeeding, and 48.9% of women reported not undertaking exclusive breastfeeding in 2017. Women who were employees had lower exclusive breastfeeding prevalence, compared to unemployed or self-employed women. Women in Java and Bali had higher increase in early initiation of breastfeeding and exclusive breastfeeding compared to women in Sumatra. We did not find statistically significant decline in continued breastfeeding at 1 year over time for the overall population, except among women who: were from the second poorest wealth quintile; lived in rural areas; did not have a health facility birth; and lived in Kalimantan and Sulawesi (p < 0.05). CONCLUSIONS: There were considerable improvements in breastfeeding practices in Indonesia during a period of sustained policy reform to regulate breastfeeding and community support of breastfeeding, but these were not distributed uniformly across socioeconomic, occupation and geographic subgroups. Concerted efforts are needed to further reduce inequities in breastfeeding practice through both targeted and population-based strategies.

Impact of Indonesia's national health insurance scheme on inequality in access to maternal health services: A propensity score matched analysis.

BACKGROUND: Reducing inequality in maternal, neonatal and infant mortality are key targets in the Sustainable Development Goals. This study is the first to evaluate the impact of Indonesia's national health insurance scheme, Jaminan Kesehatan Nasional (JKN), on access to maternal health services by sociodemographic status. METHODS: Using data from the 2017 Indonesia Demographic and Health Survey (IDHS) on women with live births in 2016-2017, we conducted propensity score matching (PSM) analysis to evaluate the association of JKN enrollment on the following maternal health care utilisation outcomes: (1) at least four antenatal care (ANC4+) visits; (2) ANC4+ visits and received essential components of ANC; (3) skilled birth attendance; (4) facility-based delivery; (5) post-natal care (PNC); and (6) PNC with skilled provider. Analyses were conducted at the national level and by economic subgroup and region of residence. Additionally, we investigated the potential negative impact of JKN on access to maternal health services among the uninsured population by looking at trends over time using data from the 2012 and 2017 IDHS. RESULTS: Of the 5429 women who had recently given birth, 61% were insured by JKN in 2017. After matching treated and untreated women on key sociodemographic characteristics, enrollment in JKN was associated with a higher prevalence of receiving ANC4+ visits (7.4%, 95% confidence interval (CI) = 4.8-9.39); ANC4+ visits and received essential components of ANC (5.6%, 95% CI = 3.3-7.9); skilled birth attendance (3.0%, 95% CI = 1.5-4.5; facility-based delivery (10.2%, 95% CI = 7.5-12.7); PNC (4.0%, 95% CI = 2.2-5.7); PNC with skilled provider (4.5%, 95% CI = 2.6-6.5). Effect sizes were larger among the poor and those living in less-developed areas, such as Eastern Indonesia and Sulawesi, except for at least ANC4+ and received clinical components. CONCLUSIONS: Expansion of health insurance coverage was associated with reductions in sociodemographic inequalities in access to maternal health services in Indonesia. However, large differences in utilisation persist across regions and by economic subgroup. Accelerating progress toward universal health coverage may reduce health inequalities in other low and middle-income countries.

The role of decision-making pattern on the use of long-acting and permanent contraceptive methods among married women in Indonesia.

Objectives: This study aimed to analyse the association between the decision-making pattern and the use of long-acting and permanent methods of contraception (LAPMs) among married and cohabiting women in Indonesia, by controlling for variables at the individual and community or regional level, and geographical area (province).Methods: A cross-sectional survey was conducted using secondary data from Performance Monitoring and Accountability 2020 (PMA2020) which involved 4724 married or cohabitating women aged 15-49 years. Data were analysed using bivariate and multivariate analysis. Multilevel logistic regression was performed to investigate the determinants by taking geographical area into account.Results: The majority of women (63.8%) had made their own decision on current contraceptive use, 30.1% had made a joint decision with their partner or health care provider, and 6.1% had not been involved in the decision-making process. Multilevel analysis showed that the decision-making pattern and individual level factors were significantly associated with LAPM use, and variables at community or regional level were not significant predictors. Compared with women who had made their own decision on contraceptive use, LAPM use was 2.3 times higher in women who had made a joint decision with their partner or health care provider (odds ratio [OR] 2.3; 95% confidence interval [CI] 2.0, 2.7; p < .001) and more than three times higher in women not involved in the decision-making process (OR 3.1; 95% CI 2.3, 4.1; p < .001).Conclusion: Coercion potentially occurs in the contraceptive decision-making process. Our findings suggest that LAPM use may be increased by encouraging joint contraceptive decision making. Increasing women's participation in the decision-making process is an integral part of respecting women's reproductive autonomy.

A Qualitative Study of Parental Knowledge and Perceptions of Human Papillomavirus and Cervical Cancer Prevention in Rural Central Java, Indonesia: Understanding Community Readiness for Prevention Interventions.

Background: Cervical cancer (CC) is a leading cause of cancer deaths among Indonesian women. Pilot prevention programs, including human papillomavirus (HPV) vaccination for young adolescent girls, and cervical screening for women, have been implemented. However, many communities are yet to receive these interventions, nor targeted education regarding CC prevention. This study explored community readiness and acceptance of HPV vaccination and CC screening, as well as knowledge and perceptions of HPV and CC, to determine facilitators and barriers to upscaling CC prevention in rural Central Java. Methods: Qualitative data collection in October 2015 consisted of four focus group discussions with married women and men, and 22 semi-structured interviews with married women. All 57 participants, 39 women and 15 men, lived in Purworejo Regency in rural Central Java. Results: Most participants had no knowledge of HPV or the causal link between HPV and CC. However, most participants were supportive of vaccinating their children against HPV. Most participants had heard of cervical cancer, although understandings of symptoms and causes were very poor. Less than half of the women interviewed had undergone CC screening. Multiple barriers to screening were reported, including: a dislike of pelvic exams; embarrassment at being screened by a male doctor; anxiety over the cost; fearing a positive result; and being asymptomatic and thus not perceiving the need for screening. Conclusions: Extensive community education about HPV and CC, targeting women and men, adolescents, health workers and teachers, is crucial to support the introduction of the HPV Demonstration Program and the upscaling of CC screening. Low incomes among rural families underline the need for the HPV vaccine to be provided free within the National Immunization Program, and for CC screening to be free at primary health clinics.

Measuring agency as a dimension of empowerment among young adolescents globally; findings from the Global Early Adolescent Study.

•Agency, a domain of empowerment, is a measurable construct amongst early adolescents age 10-14.•Three sub-scales - Voice, Freedom of Movement, and Behavioral Control and Decision-making - comprise the measurement of agency.•Differences in the Freedom of Movement sub-scale show a growing equity gap between boys and girls across multiple countries.•Users of the scales must consider context when adapting the items to account for differences in culture and environment.