Tobacco use among in-school young adolescents in Indonesia: Exploring availability, affordability, and accessibility.

The research on Indonesian adolescents' perception of tobacco control in schools is limited. This study aimed to explore the availability, affordability, and accessibility of tobacco among young adolescents in Yogyakarta Municipality, Indonesia, with a focus on advocating for school teenagers. Focus groups, comprising participants from diverse backgrounds and stakeholders, were conducted in Yogyakarta, Indonesia, to systematically collect varied data. The subsequent analysis employed a robust thematic approach, combining both inductive and deductive processes to ensure a nuanced exploration of emerging patterns and pre-existing frameworks. In addition to focus group data, the study incorporated insights from extensive field observations and research group discussions. The multifaceted approach enhanced the depth of analysis but also facilitated a comprehensive understanding of the complex dynamics. The findings of this study revealed that young adolescents found it extremely easy to purchase cigarettes from local markets. The smoking prevalence among young adolescents was relatively low, with only 10% of the respondents admitting to smoking. Although the Indonesian government has increased surveillance and regulations regarding smoking among young individuals, the actual implementation and effectiveness of these measures remain questionable. The existing anti-smoking approaches in Indonesia have been unsuccessful in curbing smoking among Indonesian school students. The study argues that it is crucial to recognize and value students' perceptions of smoking, as their knowledge of smoking is actively constructed. To address this issue, future anti-smoking education in schools should incorporate interactive sessions rather than solely relying on didactic approaches that highlight the harms of smoking. By engaging students in interactive discussions, they can actively participate in constructing their understanding of the consequences of smoking. Additionally, efforts should be made to enhance the implementation of tobacco control measures within schools and extend the reach of these measures to off-campus environments.

Indonesian COVID-19 lesson: A mixed-methods study on adolescent health status and health services during pandemic.

TOPIC: The COVID-19 pandemic affected adolescents' physical and psychological health. There must be specific services to cater to the needs of adolescents during COVID-19 in Indonesia. Lessons learned from previous pandemics will be beneficial for nurses and other health professionals to prepare services for future pandemics. PURPOSE: This mixed-method study aimed to examine 459 Indonesian adolescents' health, literacy, preventive measures, and preferred health services during the COVID-19 pandemic. This study also examines sociodemographics, respondent characteristics, health information sources, and media choices. RESULTS: A total of 47.5% of adolescents knew about COVID-19, 26.8% experienced physical health changes, and 61.7% considered wearing masks. Adolescent health information came from teachers (26.6%) and the Internet (32.9%). Psychological changes showed 67.8% irritation. Indonesians preferred online counseling (53.8%) and WhatsApp (45.8%) for pandemic health services. COVID-19 literacy did not affect physical or mental health (p > 0.05). CONCLUSIONS: Most adolescents reported mental and physical health changes during COVID-19. Our data suggest that adolescents' strong COVID-19 knowledge did not prevent anxiety and other psychological difficulties. The longitudinal studies could be utilized if pandemic demands social and physical distance. The government, as well as nurses, might utilize WhatsApp-based remote online treatment for health services.

The impact of multimorbidity among adults with cardiovascular diseases on healthcare costs in Indonesia: a multilevel analysis.

BACKGROUND: Cardiovascular diseases (CVDs) are the leading cause of death in Indonesia, accounting for 38% of the total mortality in 2019. Moreover, healthcare spending on CVDs has been at the top of the spending under the National Health Insurance (NHI) implementation. This study analyzed the association between the presence of CVDs with or without other chronic disease comorbidities and healthcare costs among adults (> 30 years old) and if the association differed between NHI members in the subsidized group (poorer) and non-subsidized households group (better-off) in Indonesia. METHODS: This retrospective cohort study analyzed the NHI database from 2016-2018 for individuals with chronic diseases (n = 271,065) ascertained based on ICD-10 codes. The outcome was measured as healthcare costs in USD value for 2018. We employed a three-level multilevel linear regression, with individuals at the first level, households at the second level, and districts at the third level. The outcome of healthcare costs was transformed with an inverse hyperbolic sine to account for observations with zero costs and skewed data. We conducted a cross-level interaction analysis to analyze if the association between individuals with different diagnosis groups and healthcare costs differed between those who lived in subsidized and non-subsidized households. RESULTS: The mean healthcare out- and inpatient costs were higher among patients diagnosed with CVDs and multimorbidity than patients with other diagnosis groups. The predicted mean outpatient costs for patients with CVDs and multimorbidity were more than double compared to those with CVDs but no comorbidity (USD 119.5 vs USD 49.1, respectively for non-subsidized households and USD 79.9 vs USD 36.7, respectively for subsidized households). The NHI household subsidy status modified relationship between group of diagnosis and healthcare costs which indicated a weaker effect in the subsidized household group (ß = -0.24, 95% CI -0.29, -0.19 for outpatient costs in patients with CVDs and multimorbidity). At the household level, higher out- and inpatient costs were associated with the number of household members with multimorbidity. At the district level, higher healthcare costs was associated with the availability of primary healthcare centres. CONCLUSIONS: CVDs and multimorbidity are associated with higher healthcare costs, and the association is stronger in non-subsidized NHI households. Households' subsidy status can be construed as indirect socioeconomic inequality that hampers access to healthcare facilities. Efforts to combat cardiovascular diseases (CVDs) and multimorbidity should consider their distinct impacts on subsidized households. The effort includes affirmative action on non-communicable disease (NCD) management programs that target subsidized households from the early stage of the disease.

The 30 Years of Shifting in The Indonesian Cardiovascular Burden-Analysis of The Global Burden of Disease Study.

IMPORTANCE: Cardiovascular disease (CVD) remains the leading cause of mortality and morbidity. Compared with disease burden rates in 1990, significant reductions in Disability-Adjusted Life Years (DALYs) burden rates for CVD have been recorded. However, general DALYs rates have not changed in Indonesia in the past 30 years. Thus, assessing Indonesian CVD burdens will be an essential first step in determining primary disease interventions. OBJECTIVE: To determine the national and province-level burden of CVD from 1990 to 2019 in Indonesia. DESIGN, SETTING, AND PARTICIPANTS: A retrospective observational study was conducted using data from the Global Burden of Disease (GBD) 2019, provided by the Institute of Health Metrics and Evaluation (IHME), to analyze trends in the burden of CVD, including mortality, morbidity, and prevalence characteristics of 12 underlying CVDs. EXPOSURES: Residence in Indonesia. MAIN OUTCOMES AND MEASURES: Mortality, incidence, prevalence, death, and DALYs of CVD. RESULTS: CVD deaths have doubled from 278 million in 1990 to 651 million in 2019. All CVDs recorded increased death rates, except for rheumatic heart disease (RHD) (- 69%) and congenital heart disease (CHD) (- 37%). Based on underlying diseases, stroke and ischemic heart disease (IHD) are still the leading causes of mortality and morbidity in Indonesia, whereas stroke and peripheral artery disease (PAD) are the most prevalent CVDs. Indonesia has the second worst CVD DALYs rates compared to ASEAN countries after Laos. At provincial levels, the highest CVD DALY rates were recorded in Bangka Belitung, South Kalimantan, and Yogyakarta. In terms of DALYs rate changes, they were recorded in West Nusa Tenggara (24%), South Kalimantan (18%), and Central Java (11%). Regarding sex, only RHD, and PAD burdens were dominated by females. CONCLUSIONS: CVD mortality, morbidity, and prevalence rates increased in Indonesia from 1990 to 2019, especially for stroke and ischemic heart disease. The burden is exceptionally high, even when compared to other Southeast Asian countries and the global downward trend. GBD has many limitations. However, these data could provide policymakers with a broad view of CVD conditions in Indonesia.

Water insecurity is associated with gender-based violence: A mixed-methods study in Indonesia.

Gender Based Violence (GBV) is a global pandemic and water insecurity is increasing in intensity and extent. This study explores the association between these two global health threats. Cross-sectional, quantitative data were collected via surveys (n = 365 adult women) to measure household water insecurity (HWI) and women's experiences of GBV in the last year. Qualitative data were collected from semi-structured interviews (n = 24 men and women), two focus group discussions (n = 25 men and women) and a multi-stakeholder meeting (n = 35 men and women) to explore experiences, attitudes and risk factors associated with HWI and GBV. Multivariate logistic regression analysis showed that women in water insecure households were more than twice as likely to report experiencing GBV in the last year (OR = 2.2, CI: 1.0-4.9, p = 0.051). Examining household water insecurity scores as a continuous variable revealed an increased odds of reporting GBV with each increase in the HWISE score (OR = 1.1, CI: 1.0; 1.1, p < 0.001). Qualitative data indicates that the intersection between HWI, a patriarchal social organization and a caste system produced water-related conflicts between intimate partners, between daughters-in-law and their in-laws, and between masters and enslaved women. These results are presented using an integrated theoretical framework - a Feminist Political Ecology of Health (FPEH) - to illustrate the many ways women encounter and experience multi-dimensional forms of violence across scales in connection to water insecurity. The combination of robust qualitative and quantitative data presented in this study suggests that HWI may be causally related to GBV in this context.

Assessment of the role of gut health in childhood stunting in a multisite, longitudinal study in India, Indonesia and Senegal: a UKRI GCRF Action Against Stunting Hub protocol.

INTRODUCTION: Childhood stunting has a complex aetiology, with poor gut health being an important contributor. This study will assess inter-relationships between maternal and infant gut health indices and infant linear growth. Inter-relationships between gut health indices, systemic inflammation and growth hormones in early childhood will also be assessed. METHODS AND ANALYSIS: A longitudinal observational study of cohorts of 600 newborns and their mothers in India, Indonesia and Senegal will be conducted. Women will be recruited during pregnancy and their children followed up to age 24 months. Stool, urine and blood samples will be collected from the women and children for assessments of helminthic and protozoal parasites, bacterial pathogens, faecal microbiota taxa, biomarkers of environmental enteric dysfunction, systemic inflammation and growth hormones. Child anthropometric measurements will be collected at birth and at ages 3, 6, 9, 12, 18 and 24 months. The gut health indices will be integrated with cohort data from other Action Against Stunting Hub (AASH) workstreams for interdisciplinary analyses of childhood stunting and the development of a new typology of stunting. DISCUSSION: This study will advance scientific understanding of the role of gut health in childhood stunting and will contribute to a broader knowledge of the complex aetiology of this condition as part of the interdisciplinary AASH research to reduce the global burden of childhood stunting. ETHICS AND DISSEMINATION: This study has been approved by the relevant Ethics Committees in Senegal, India, and Indonesia and LSHTM. The results will be submitted for publication in peer-reviewed journals.

Ten years of in vitro fertilization in Indonesia: Access to infertility care in a developing country.

OBJECTIVE: This research was conducted to assess access to assisted reproductive technologies (ART) and the current status of the in vitro fertilization (IVF) program that have been implemented in Indonesia over the last 10 years. METHODS: We established a retrospective cohort study and descriptive analysis of the current state of access to infertility care in Indonesia. The data were collected from all IVF centers, clinics, and hospitals in Indonesia from 2011 to 2020, including the number of IVF clinics, total ART cycles, retrieved fresh and frozen embryos, average age of IVF patients, IVF pregnancy rate, and causes of infertility. RESULTS: The number of reported fertility clinics in Indonesia has increased from 14 clinics in 2011 to 41 clinics by 2020. As many as 69 569 ART cycles were conducted over the past 10 years, of which 51 892 cycles used fresh embryos and 17 677 cycles used frozen embryos. The leading cause of consecutive infertility diagnosis was male infertility. Nearly half of the women who underwent IVF procedures (48.9%) were under 35 years old. The pregnancy rate outcome of women who underwent IVF ranged from 24.6% to 37.3%. CONCLUSION: Developments in ART in Indonesia have led to improvements in the ART cycles performed throughout the 10 year period. The identification of key areas that require improvement can provide an opportunity to enhance access to infertility care.

Analysis of Health-Related Quality of Life and Incurred Costs Among Human Immunodeficiency Virus, Tuberculosis, and Tuberculosis/HIV Coinfected Outpatients in Indonesia.

OBJECTIVES: A growing interest in healthcare costs and patients' health-related quality of life (HRQoL) exists in the context of the increasing importance of health technology assessment in countries with high numbers of the HIV and tuberculosis (TB) patient populations, such as Indonesia. This study aimed to analyze the HRQoL and out-of-pocket (OOP) costs of HIV, TB, and TB/HIV coinfected participants in a city in Indonesia with a high prevalence of HIV and TB. METHODS: A cross-sectional survey was conducted in the voluntary counseling and testing and lung clinics of Bekasi City Public Hospital (Indonesia) from January to March 2018. Patients' HRQoL was measured using the EQ-5D-5L questionnaire, whereas OOP costs were extracted from a semistructured questionnaire. RESULTS: Of the 460 eligible participants, 82% resided in the city, 48% of them were married, and their median age was 34 years. Less than half were insured, and more than half had no source of income. The median values of health utilities for participants with HIV, TB, and TB/HIV were perceived as potentially high (1.0, 0.9, and 0.8, respectively). The TB/HIV coinfected outpatients had the highest OOP costs (US$94.5), with the largest contribution coming from direct medical OOP expenditures. Taking loans from family members was adopted as a financial strategy to overcome inadequate household incomes and high treatment costs. CONCLUSION: This study suggests that TB/HIV coinfection potentially lowers HRQoL and increases healthcare costs and the need for economic analysis to underpin cost-effective treatment in such patients.

Costs and scale-up costs of community-based Oral HIV Self-Testing for female sex workers and men who have sex with men in Jakarta and Bali, Indonesia.

BACKGROUND: The proportion of individuals who know their HIV status in Indonesia (66% in 2021) still remains far below the first 95% of UNAIDS 2030 target and were much lower in certain Key Populations (KPs) particularly Female Sex Workers (FSW) and Male having Sex with Male (MSM). Indonesia has implemented Oral HIV Self-testing (oral HIVST) through Community-based screening (HIV CBS) in addition to other testing modalities aimed at hard-to-reach KPs, but the implementation cost is still not analysed. This study provides the cost and scale up cost estimation of HIV CBS in Jakarta and Bali, Indonesia. METHODS: We estimated the societal cost of HIV CBS that was implemented through NGOs. The HIV CBS's total and unit cost were estimated from HIV CBS outcome, health care system cost and client costs. Cost data were presented by input, KPs and areas. Health care system cost inputs were categorized into capital and recurrent cost both in start-up and implementation phases. Client costs were categorized as direct medical, direct non-medical cost and indirect costs. Sensitivity and scenario analyses for scale up were performed. RESULTS: In total, 5350 and 1401 oral HIVST test kits were distributed for HIV CBS in Jakarta and Bali, respectively. Average total client cost for HIV CBS Self testing process ranged from US$1.9 to US$12.2 for 1 day and US$2.02 to US$33.61 for 2 days process. Average total client cost for HIV CBS confirmation test ranged from US$2.83 to US$18.01. From Societal Perspective, the cost per HIVST kit distributed were US$98.59 and US$40.37 for FSW and MSM in Jakarta andUS$35.26 and US$43.31 for FSW and MSM in Bali. CONCLUSIONS: CBS using oral HIVST approach varied widely along with characteristics of HIV CBS volume and cost. HIV CBS was most costly among FSW in Jakarta, attributed to the low HIV CBS volume, high personnel salary cost and client cost. Future approaches to minimize cost and/or maximize testing coverage could include unpaid community led distribution to reach end-users, integrating HIVST into routine clinical services via direct or secondary distribution and using social media network.

Knowledge, attitude, and utilization of traditional medicine within the plural medical system in West Java, Indonesia.

BACKGROUND: The concept of 'medical pluralism' has become more popular among scholars in applied health science and prevalent in societies where one medical system alone cannot adequately meet the health care needs of the entire population. METHODS: The data collection is focused on the knowledge-belief-practice and the utilization of three medical systems in Kabupaten Bandung, West Java, Indonesia. Participants were purposively selected from households with at least one member experienced one of the listed diseases in the questionnaire. The extensive survey using a structured questionnaire has been undertaken to collect data on people's health care utilization behaviour. The dataset is further analyzed using multivariate analysis through non-canonical correlation, with the analytical data provided by Statistical Package for Social Sciences (SPSS). RESULTS: With regards to the total utilization by patients, the traditional medical system presents as the dominant medical system in the research area, accounting for 59.3% (n = 419) of total utilization, followed by the modern medical system (33.0%, n = 233), and transitional medical system (7.7%, n = 54). This study identified that village category, illness, illness duration, occupation, belief in traditional medicine, knowledge of modern medicine, accessibility, cost, proximity to the medical service, and insurance have significant (χ2 = 0.000) relationship with the utilization of medical systems. The results of the multivariate analysis show that the block of the predisposing socio-demographic factors and the block of the predisposing psycho-social factors correlate strongly with the utilization of medical systems. CONCLUSIONS: In general, people in Kabupaten Bandung, West Java, Indonesia seeks treatment from various sources, which in the context of the medical system, consists of the traditional, transitional, and modern medical system; therefore, it adopts the patterns of transcultural health care utilization. In terms of the knowledge, beliefs, and practices of traditional medicine in West Java, the inhabitants of the five research villages were commonly familiar with medicinal plants and speak profoundly about their knowledge of traditional medicine, which in the research area is perceived as accessible, efficacious, affordable and culturally appropriate with Sundanese community.

Factors related to quality of life in community-dwelling adults in Sleman Regency, Special Region of Yogyakarta, Indonesia: Results from a cross-sectional study.

BACKGROUND: Quality of life studies in low- and middle-income countries have demonstrated the influence of socioeconomic factors on the quality of life (QoL). However, further studies are required to confirm this association in developing countries with rapidly ageing populations. Using Ferrans et al.'s QoL model, this study aimed to identify the factors associated with the QoL of community-dwelling adults in Indonesia. METHODS: A cross-sectional study among 546 community-dwelling adults aged 50+ years was conducted in Yogyakarta, Indonesia, in 2018. QoL was measured using the Short Form 12 questionnaire, which consists of a summary of physical and mental health. We performed stepwise logistic regression analyses to determine odds ratios (ORs) with 95% confidence intervals (CIs) and examined the association between the QoL (physical and mental health) and demographic characteristics, socioeconomic status, financial management behaviour, multimorbidity status, nutritional status, cognitive impairment status, depression status, and independence. Statistical significance was set at p<0.05. RESULTS: Among the respondents, 15% reported poor physical health, and 9.2% reported poor mental health. Good physical health was significantly associated with the absence of chronic disease (OR 2.39; 95% CI: 1.07-5.33), independence in activities of daily living (OR 3.90; 95% CI 1.57-9.67) and instrumental activities of daily living (OR 4.34; 95% CI 2.28-8.26). Absence of depression was significantly associated with good mental health (OR 2.80; 95% CI 1.3-5.96). CONCLUSION: The QoL of community-dwelling adults in Indonesia is associated with activities of daily living and instrumental activities of daily living, as well as the absence of chronic disease and depression. Efforts should be made to prevent chronic disease and delay functional decline through healthy lifestyles and routine physical and mental health screenings.

Disparity of Neonatal Care Visits by Region in Indonesia: A Secondary Data from Basic Health Research.

BACKGROUND: Neonatal care visit is one of the efforts to reduce the neonatal mortality rate. In Indonesia, few studies have analyzed neonatal care visits by region in the last decade. The purpose of this study was to analyze factors associated with neonatal care visits by region in Indonesia. METHOD: This study was a quantitative study with a cross-sectional design. It used secondary data from Riskedas (Basic Health Research). The total sample size was 64,321 female respondents of childbearing age who had babies aged 29 days to 59 months. The dependent variable was the completeness of neonatal care visits measured through at least one at the first neonatal care visit (KN 1), at least one at the second neonatal care visit (KN 2), and at least one at the third neonatal care visit (KN 3). Data were analysed using a statistical binary logistic regression test. RESULTS: The respondents who had complete neonatal care visits in Indonesia was 47.9%. The region with the highest proportion was Java-Bali at 58.5%, while the region with the lowest proportion was Papua at 23.8%. Variables influencing the completeness of neonatal care visits were delivery attendant, urban residence, secondary and higher education background, parity, delivery at a healthcare facility and compete antenatal care visits. Of these variables, delivery attendant (p < 0.05) was the most significant variable in all regions. CONCLUSION: This study showed that there were significant differences in complete neonatal care visits between regions in particularly between the ones in the west and east part of Indonesia. The government is expected to be able to provide equal distribution of and access to health facilities in rural and eastern Indonesia, especially neonatal services.

Financial Toxicity Experiences of Patients With Cancer in Indonesia: An Interpretive Phenomenological Analysis.

OBJECTIVES: Financial toxicity (FT) is an important adverse effect of cancer. Recent systematic reviews have shown that FT may lead to treatment nonadherence and impaired health-related quality of life, both of which may adversely influence the survival rates of patients. However, less is known about how patients endure FT, particularly in low- and middle-income countries. The purpose of this study was to explore how patients with cancer experience and cope with FT in Indonesia. METHODS: Semistructured in-depth interviews were conducted to explore the experiences of Indonesian patients with cancer. Qualitative data were analyzed using interpretive phenomenological analysis approach. We purposefully recruited 8 patients undergoing active treatment (aged 27-69 years) who had been diagnosed of cancer over 5 years before and possessed health insurance at the time of diagnosis. RESULTS: We identified 2 main themes: (1) the experienced financial burden, with subthemes underinsurance, out-of-pocket nonhealthcare cancer-related costs, and negative income effect from employment disruption, and (2) the financial coping strategies, with subthemes reallocating household budget, seeking family support, rationalizing treatment decisions, and topping up insurance for family members. CONCLUSIONS: This is the first interpretive phenomenological study on FT in the literature and the first qualitative FT study in Indonesia. Our findings provide insight into the occurrence of FT and coping strategies used by Indonesian patients with cancer. The subjective experiences of patients may be considered to further improve oncology care, support the need for measurement of FT, and provide mitigation programs for patients.

Evaluating the cost-effectiveness of diabetic foot ulcer management by wound care specialists in Indonesia.

Diabetic foot ulcers affect quality of life and economically burden patients and the Indonesian healthcare system. The comparative cost-effectiveness of wound care specialists in private practices (e.g., wound clinics) and wound care nurses in national hospitals remains unknown. Thus, we used a decision tree to compare the cost and healing rates for patients after 12 weeks of wound care. Uncertainty was addressed using one-way and probabilistic sensitivity analyses. Among 89 participants (42 in the national hospital and 47 in the private practice), no significant differences were observed between the two groups in terms of sex, age, education level, smoking status, duration of diabetes, Wagner wound classification, glycated haemoglobin levels, neuropathy status, ankle-brachial index, baseline characteristics, quality of life, DMIST (depth, maceration, inflammation/infection, size, tissue type of the wound bed, type of wound edge, and tunnelling/undermining) score and wound location (p > 0.05). However, significant differences were observed for days from first visit/assessment until complete healing, mean quality of life (p ≤ 0.001) and wound size (p = 0.047). Wound care specialists in private practices had a significantly lower cost of 2,804,423.3 Indonesian rupiah compared to 6,483,493.4 Indonesian rupiah for wound care nurses in national hospitals. The incremental cost-effectiveness ratio was -165,723.9. Therefore, wound care specialists in private practices are more cost-effective for managing diabetic foot ulcers. Probability sensitivity analysis confirmed that 80%-90% of the scenarios were cost-effective. These findings may inform healthcare resource allocation in Indonesia. Additionally, evidence-based cost-effectiveness measures were strengthened in private practices and national hospitals.

Explaining the increase of incidence and mortality from cardiovascular disease in Indonesia: A global burden of disease study analysis (2000-2019).

BACKGROUND: In the last two decades, there has been a discernible shift in the distribution of mortality attributed to cardiovascular disease (CVD) between developing and developed nations; in developed nations, the percentage of deaths caused by CVD decreased from 48% in 1990 to 43% in 2010, while in developing nations, they increased from 18% to 25%. In Indonesia, CVD death has increased substantially and remained elevated in the last ten years. Current behavioral and metabolic risk factors, including hyperglycemia, obesity, dyslipidemia, hypertension, and smoking, enhance the risk of CVD mortality, according to several studies. AIMS: We undertook a study to determine whether the increase in mortality and incidence of CVD can be attributed to changes in the most common metabolic and behavioral risk factors from 2000 to 2019 across 34 Indonesian provinces. MATERIALS AND METHODS: Data from 34 province for CVD incidence and mortality and data on changes in metabolic and behavioural risk factors between 2000 and 2019 in Indonesia were obtained from the Global Burden study (GBD) by The Institute of Health Metrics and Evaluation (IHME). A statistical model was applied to calculate the fatalities attributable to the risk factors change using Population attributable fractions (PAF) and baseline year death numbers. Furthermore, we ran multivariate regressions on Summary Exposure Value of risk factors associated with the increasing mortality, incidence rates in a lag year analysis. R software used to measure heteroscedasticity-consistent standard errors with coeftest and coefci. Covariates were added to adjusted models, including the Socio-demographic Index, Primary health care facilities coverage, and GDP per capita. RESULTS: The age-standardized mortality rate for CVD from 2000 to 2019 in Indonesia, increased from 356.05 to 412.46 deaths per 100,000 population among men and decreased from 357.52 to 354.07 deaths per 100,000 population among women, resulting in an increase of 270.928 per 100,0000 inhabitants of CVD deaths. In the same period, there was an increase in exposure to risk factors such as obesity by +9%, smoking by +1%, dyslipidemia by +1.3%, hyperglycemia by +2%, and hypertension by +1.2%. During this time span, an additional 14,517 men and 17,917 women died from CVD, which was attributable to higher obesity exposure. We apply multivariate regression with province-fixed and year-fixed analysis and find strong correlation between hyperglycemia in women (6; 95%CI 0 to 12, death per 1-point increase in hyperglycemia exposure) with an increasing death rate in ischemic heart disease. We also performed a year lag analysis and discovered a robust association between high low density lipoprotein (LDL) levels in men and women and the growing incidence of ischemic heart disease. The association between a 10-year lag of high LDL and the incidence of ischemic heart disease was five times stronger than that observed for other risk factors, particularly in men (5; 95%CI 2 to 8, incidence per 1-point increase in high LDL exposure). CONCLUSION: Hyperglycemia in women is an important risk factor associated with increasing mortality due to Ischemic Heart Disease (IHD) in Indonesia This study also revealed that the presence of high LDL in both men and women were associated with an increase incidence of IHD that manifested several years subsequent to exposure to the risk factor. Additionally, the highest cardiovascular death portion were attributed to obesity. These findings suggest that policymakers should control high LDL and hyperglycemia 10 years earlier prior to the occurrence of IHD and employ personalized therapy to regulate associated risks.

Application of geospatial information systems (GIS) for assessment of the distribution of periodontal disease in Makassar City, South Sulawesi Province, Indonesia.

Addressing the presence of periodontal disease requires a high level of expertise to detect the disease as well as effective communication to understand patients' problems. Based on basic health data from 2018, the prevalence of this problem in Indonesia is approximately 74%. This study examined the distribution of periodontal conditions in March 2021 in Makassar City, the capital of South Sulawesi Province. To determine the distribution of periodontal disease, a questionnaire was used to find out the severity of this issue. A descriptive observational method, used with a cross-sectional design and a web-based geospatial information system (GIS) application linked to ArcGIS, was conducted. The results showed thatout of the 15 districts in Makassar City, the island district of Sangkarranghad had the highest presence of periodontal disease. Three other districts were classified as also belonging to this low category, while 11 other ones exhibited a medium disease incidence score.

Cost-effectiveness analysis of Japanese Encephalitis (JE) vaccination program in Bali Province, Indonesia.

OBJECTIVE: The incidence of Japanese Encephalitis (JE) in Bali Province remains high, and is one among the highest in Indonesia. The Indonesian Government initiated the JE vaccination campaign followed by a JE vaccine introduction program in Bali Province in 2018. The JE vaccination program then has been fully integrated into the provincial routine immunization program since 2019. We conducted a retrospective economic analysis of JE vaccination program in Bali Province, Indonesia; considering multiple vaccination strategies. METHODS: We conducted a cost-effectiveness analysis using a decision analytic model comparing two vaccination strategies with no vaccination from the societal and government perspectives. These vaccination strategies were: (1) JE vaccination campaign and introduction program, and (2) a routine JE vaccination program. We compared costs and outcomes for three hypothetical cohorts of 100,000 children followed from birth to the age of 10 years, with impacts measured throughout the child's life-time. We measured the economic consequences as costs per case, per death, and per disability-adjusted life year (DALY) averted. RESULTS: A routine JE immunization program was the most cost-effective strategy with a cost per DALYs averted of US$ 212.59 and US$ 94.09 from the government and societal perspectives respectively. In contrast, costs per DALYs averted through the JE vaccination campaign and introduction strategy was US$ 1,473.53 and US$ 1,224.20 from the government and societal perspectives respectively. CONCLUSIONS: Both JE vaccination strategies are cost-effective but they are not cost-saving when compared to no immunization program.

Income Disparity and Healthcare Utilization: Lessons from Indonesia's National Health Insurance Claim Data.

BACKGROUND: Indonesia's National Health Insurance Program, known as Jaminan Kesehatan Nasional (JKN), has a variety of membership pathways for those wishing to gain access. Claim data from JKN offers a cost-effective way of observing who is accessing healthcare services and what types of services are being used. This study is a novel attempt to measure disparities amongst JKN users in their engagement with services, providing an opportunity to reflect on patterns of use. METHODS: Using claims data collected from JKN users between 2015-2016, we used the Ordinary Least Square estimation model to compare health services utilization among subsidized and non-subsidized users. We focused primarily on the individual use of the hospital for outpatient and inpatient treatment. RESULTS: Analysis reveals that subsidized users access primary healthcare services more frequently than non-subsidized users. Conversely, non-subsidized users access secondary and tertiary health care services more frequently than other users. Subsidized users who utilize secondary and tertiary health care tend to suffer more severe health illnesses than non-subsidized members. CONCLUSIONS: This study concludes that income disparity affects healthcare utilization. Non-subsidized members are more likely than subsidized members to access secondary and tertiary health care services. Our study offers evidence of the potential underutilization of secondary and tertiary healthcare (STHC) by subsidized members, which could lead to inefficiency since subsidized members seeking STHC treatment had severe health conditions, thus needing to be treated longer and requiring higher healthcare expenditures.

Assessment of 28-day survival of patients with sepsis based on vitamin D status: a hospital-based prospective cohort study in Indonesia.

Introduction: sepsis is a potentially life-threatening condition caused by the body´s response to an infection. Recent studies have demonstrated a correlation between low vitamin D status and high mortality in septic patients. This study aims to evaluate the vitamin D status of septic patients at Dr. Sardjito Hospital and describe 28-day survival with very low vitamin D levels (< 8.1 ng/mL). Methods: this prospective cohort study was conducted in the intensive care unit and internal medicine ward at Dr. Sardjito Hospital in septic patients admitted between December 2018 and October 2019. Vitamin D [25(OH)D] was prospectively measured within 24 hours of admission. Data collection used SPSS software for statistical analysis. In addition, the sample size was calculated using the sample size formula used in a comparative survival study intended to find the incidence rate in septic patients. The minimum sample for each group is 23 samples. Results: sepsis-related mortality was higher in patients with low vitamin D. The analysis included 88 septic patients during the study period. The mean age was 56.09 ± 16.82 years and the proportion of males was 46.6%. 26 of 28 patients with vitamin D levels < 8.1 ng/mL died (92.6%), whereas 39 of 60 patients with vitamin D levels ≥ 8.1 ng/mL (65%) died. Multivariate Cox regression analysis showed that vitamin D concentrations < 8.1 ng/mL at admission (p=0.01) and sepsis shock (p=0.02) were associated with increased sepsis mortality. The hazard ratio of 28-day mortality was 1.95 (95% CI 1.15-3.29, p=0.01) for vitamin D levels < 8.1 ng/mL. The average survival was 9 days for patients with vitamin D levels < 8.1 ng/mL (median: 6 days) compared with 14 days for those with vitamin D levels ≥ 8.1 ng/mL (median: 10 days). Conclusion: low serum vitamin D levels (< 8.1ng/mL) at admission were associated with increased 28-day mortality in septic patients.

Incidence of moral hazards among health care providers in the implementation of social health insurance toward universal health coverage: evidence from rural province hospitals in Indonesia.

Objective: To identify the incidence of moral hazards among health care providers and its determinant factors in the implementation of national health insurance in Indonesia. Methods: Data were derived from 360 inpatient medical records from six types C public and private hospitals in an Indonesian rural province. These data were accumulated from inpatient medical records from four major disciplines: medicine, surgery, obstetrics and gynecology, and pediatrics. The dependent variable was provider moral hazards, which included indicators of up-coding, readmission, and unnecessary admission. The independent variables are Physicians' characteristics (age, gender, and specialization), coders' characteristics (age, gender, education level, number of training, and length of service), and patients' characteristics (age, birth weight, length of stay, the discharge status, and the severity of patient's illness). We use logistic regression to investigate the determinants of moral hazard. Results: We found that the incidences of possible unnecessary admissions, up-coding, and readmissions were 17.8%, 11.9%, and 2.8%, respectively. Senior physicians, medical specialists, coders with shorter lengths of service, and patients with longer lengths of stay had a significant relationship with the incidence of moral hazard. Conclusion: Unnecessary admission is the most common form of a provider's moral hazard. The characteristics of physicians and coders significantly contribute to the incidence of moral hazard. Hospitals should implement reward and punishment systems for doctors and coders in order to control moral hazards among the providers.