Exploring Inequalities in the Use, Quality, and Outcome of the Diabetes Management Program of Indonesian National Health Insurance.

Introduction: Access to diabetes management programs is crucial to control the increasing contribution of diabetes to the global burden of disease. However, evidence regarding whether such services are equally accessible for all population groups is still lacking, particularly in the context of low-middle-income countries and under the National Health Insurance (NHI). This study aimed to assess the extent of socioeconomic and geographical inequalities in the use, quality, and outcome of a diabetes management program for beneficiaries of Indonesian NHI. Methods: A total of 628 participants in the NHI diabetes management program in Banyumas District, Indonesia, were included in 2021 in this cross-sectional study. The main variables measured were regular visits to primary care facilities, standard medication, and glycemic control. The rate difference and rate ratio of age-sex standardized prevalence rates, as well as multiple logistic regressions, were used to measure the extent of inequalities. Results: Around 70% of participants regularly visited primary care facilities and received standard medication, but only 35% had good glycemic control. Highly educated participants were more likely to have regular visits compared to low-educated participants (odds ratio [OR] 1.92; 95% confidence interval [95% CI]: 1.04-3.56). Based on employment and type of NHI beneficiaries, a small extent and even reverse inequalities were found although these findings were insignificant statistically. Urban residents were also more likely to have regular visits (OR 6.61; 95% CI: 2.90-15.08), receive standard medication (OR 9.73; 95% CI: 3.66-25.90), and have good glycemic control (OR 3.85; 95% CI: 1.68-8.83) compared to rural residents. Conclusions: Evidence on the extent of socioeconomic inequalities is inconclusive but substantial geographical inequalities in the use, quality, and outcome of diabetes management programs exist among Indonesian NHI beneficiaries. Future implementation policies of the program should consider particularly the geographical characteristics of participants to avoid and reduce inequalities and, hence, the disease burden of diabetes.

Effects of oral Mirtogenol on retinal ganglion cell apoptosis index and intraocular pressure in the Wistar glaucoma model.

The purpose of this research is to determine how Mirtogenol affects intraocular pressure (IOP) and retinal ganglion cells (RGCs) of apoptosis index in Wistar glaucoma models, as well as the relationship between IOP and RGC apoptosis index. Twelve Wistar glaucoma models were divided into two groups for experimental research with a pretest-posttest and posttest-only. The treatment group got oral administration of Mirtogenol 12.3 mg twice a day for 2 weeks, whereas the control group received a placebo in the same way. Apoptotic index and IOP were evaluated both before and after the intervention. A parametric independent t-test was used to determine the difference between groups, and a parametric paired t-test was used to determine the difference within groups. The results showed that the RGC apoptosis index in treatment groups was considerably less when compared to control groups (P < 0.001). In the treatment group, the IOP is decreased compared to the control group (mean difference: -12.67 ± 3.79 vs. 0.69 ± 4.64, respectively, P = 0.002). A significant and solid correlation was found between IOP and RGC apoptosis index (R = 0.884, P < 0.001). Thus, Mirtogenol supplementation is expected to be used to prevent glaucoma progression.

Patients values regarding primary health care: a systematic review of qualitative and quantitative evidence.

BACKGROUND: Accessible and high-quality primary health care (PHC) is fundamental to countries moving towards universal health coverage. In order to improve the quality of patient-centered care provided in PHC, a comprehensive understanding of patients' values is crucial to address any gaps in the health care system. This systematic review aimed to identify patients' values relevant to PHC. METHODS: We searched primary qualitative and quantitative studies about patients' values related to primary care in PubMed and EMBASE (Ovid) from 2009 to 2020. The studies' quality was assessed using Joanna Briggs Institute (JBI) Critical Appraisal Checklist for both quantitative and qualitative studies and Consolidated Criteria for Reporting Qualitative Studies (COREQ) for qualitative studies. A thematic approach was used in the data synthesis. OUTCOME: The database search resulted in 1,817 articles. A total of 68 articles were full-text screened. Data were extracted from nine quantitative and nine qualitative studies that met the inclusion criteria. The participants of the studies were mainly the general population in high-income countries. Four themes emerged from the analysis: patients' values related to privacy and autonomy; values associated with the general practitioners including virtuous characteristics, knowledge and competence; values involving patient-doctor interactions such as shared decision-making and empowerment; and core values related to the primary care system such as continuity, referral, and accessibility. CONCLUSIONS: This review reveals that the doctor's personal characteristics and their interactions with the patients are critical considerations concerning the primary care services from the patients' point of view. The inclusion of these values is essential to improve the quality of primary care.

Features Constituting Actionable COVID-19 Dashboards: Descriptive Assessment and Expert Appraisal of 158 Public Web-Based COVID-19 Dashboards.

BACKGROUND: Since the outbreak of COVID-19, the development of dashboards as dynamic, visual tools for communicating COVID-19 data has surged worldwide. Dashboards can inform decision-making and support behavior change. To do so, they must be actionable. The features that constitute an actionable dashboard in the context of the COVID-19 pandemic have not been rigorously assessed. OBJECTIVE: The aim of this study is to explore the characteristics of public web-based COVID-19 dashboards by assessing their purpose and users ("why"), content and data ("what"), and analyses and displays ("how" they communicate COVID-19 data), and ultimately to appraise the common features of highly actionable dashboards. METHODS: We conducted a descriptive assessment and scoring using nominal group technique with an international panel of experts (n=17) on a global sample of COVID-19 dashboards in July 2020. The sequence of steps included multimethod sampling of dashboards; development and piloting of an assessment tool; data extraction and an initial round of actionability scoring; a workshop based on a preliminary analysis of the results; and reconsideration of actionability scores followed by joint determination of common features of highly actionable dashboards. We used descriptive statistics and thematic analysis to explore the findings by research question. RESULTS: A total of 158 dashboards from 53 countries were assessed. Dashboards were predominately developed by government authorities (100/158, 63.0%) and were national (93/158, 58.9%) in scope. We found that only 20 of the 158 dashboards (12.7%) stated both their primary purpose and intended audience. Nearly all dashboards reported epidemiological indicators (155/158, 98.1%), followed by health system management indicators (85/158, 53.8%), whereas indicators on social and economic impact and behavioral insights were the least reported (7/158, 4.4% and 2/158, 1.3%, respectively). Approximately a quarter of the dashboards (39/158, 24.7%) did not report their data sources. The dashboards predominately reported time trends and disaggregated data by two geographic levels and by age and sex. The dashboards used an average of 2.2 types of displays (SD 0.86); these were mostly graphs and maps, followed by tables. To support data interpretation, color-coding was common (93/158, 89.4%), although only one-fifth of the dashboards (31/158, 19.6%) included text explaining the quality and meaning of the data. In total, 20/158 dashboards (12.7%) were appraised as highly actionable, and seven common features were identified between them. Actionable COVID-19 dashboards (1) know their audience and information needs; (2) manage the type, volume, and flow of displayed information; (3) report data sources and methods clearly; (4) link time trends to policy decisions; (5) provide data that are "close to home"; (6) break down the population into relevant subgroups; and (7) use storytelling and visual cues. CONCLUSIONS: COVID-19 dashboards are diverse in the why, what, and how by which they communicate insights on the pandemic and support data-driven decision-making. To leverage their full potential, dashboard developers should consider adopting the seven actionability features identified.

Exploring general practitioners' perceptions about the primary care gatekeeper role in Indonesia.

BACKGROUND: In the current healthcare delivery system funded by National Health Insurance (NHI) in Indonesia, the gatekeeper role of primary care services is critical to ensuring equal healthcare access for the population. To be effective, gatekeeping relies on the performance of general practitioners (GPs). However, the perceptions held by Indonesian GPs about their gatekeeper role are not yet well documented. This study describes the self-perceived knowledge, attitudes and performance of Indonesian GPs with respect to the gatekeeper role and explores associated factors. METHODS: We conducted a cross-sectional study of all primary care facilities (N = 75) contracted by the regional NHI office in the Banyumas district. The 73 participating GPs completed a written questionnaire that assessed their knowledge, attitudes and performance in relation to the gatekeeper role. Personal and facility characteristics were analysed in a generalised linear model as possible associating factors, as well as for the association between GPs' knowledge and attitude with performance as gatekeepers. RESULTS: GPs scored relatively high in the domains of knowledge and performance but scored lower in their attitudes towards the gatekeeper role of primary care. In the full-adjusted model, no factors were significantly associated with the knowledge score. Work experience as GPs, private or civil service employment status and rural or urban location of the primary care facility were linked to attitude scores. Full- or part-time employment and type of facility were factors associated with the performance score. Attitude scores were positively associated with performance score. CONCLUSION: GPs in Indonesia are knowledgeable and report that they adequately perform their function as gatekeepers in primary care. However, their attitudes towards the gatekeeper function are less positive. Attitudes and performance with respect to the primary care gatekeeper role are likely influenced more by contextual factors such as location and type of facility than by personal factors. Efforts to address contextual issues could include improvements in practice standards for privately practising physicians and public information campaigns about gatekeeping regulations. Such efforts will be crucial to improving the gatekeeper role of primary care in Indonesia and assuring efficient access to high-quality care for all.

The contribution of service density and proximity to geographical inequalities in health care utilisation in Indonesia: A nation-wide multilevel analysis.

BACKGROUND: Geographical inequalities in access to health care have only recently become a global health issue. Little evidence is available about their determinants. This study investigates the associations of service density and service proximity with health care utilisation in Indonesia and the parts they may play in geographic inequalities in health care use. METHODS: Using data from a nationally representative survey (N = 649 625), we conducted a cross-sectional study and employed multilevel logistic regression to assess whether supply-side factors relating to service density and service proximity affect the variability of outpatient and inpatient care utilisation across 497 Indonesian districts. We used median odds ratios (MORs) to estimate the extent of geographical inequalities. Changes in the MOR values indicated the role played by the supply-side factors in the inequalities. RESULTS: Wide variations in the density and proximity of health care services were observed between districts. Outpatient care utilisation was associated with travel costs (odds ratio (OR) = 0.82, 95% confidence interval (CI) = 0.70-0.97). Inpatient care utilisation was associated with ratios of hospital beds to district population (OR = 1.23, 95% CI = 1.05-1.43) and with travel times (OR = 0.72 95% CI = 0.61-0.86). All in all, service density and proximity provided little explanation for district-level geographic inequalities in either outpatient (MOR = 1.65, 95% CrI = 1.59-1.70 decreasing to 1.61, 95% CrI = 1.56-1.67) or inpatient care utilisation (MOR = 1.63, 95% CrI = 1.55-1.69 decreasing to 1.60 95% CrI = 1.54-1.66). CONCLUSIONS: Supply-side factors play important roles in individual health care utilisation but do not explain geographical inequalities. Variations in other factors, such as the price and responsiveness of services, may also contribute to the inequalities. Further efforts to address geographical inequalities in health care should go beyond the physical presence of health care infrastructures to target issues such as regional variations in the prices and responsiveness of services.

Individual, institutional, and scientific environment factors associated with questionable research practices in the reporting of messages and conclusions in scientific health services research publications.

BACKGROUND: Health Services Research findings (HSR) reported in scientific publications may become part of the decision-making process on healthcare. This study aimed to explore associations between researcher's individual, institutional, and scientific environment factors and the occurrence of questionable research practices (QRPs) in the reporting of messages and conclusions in scientific HSR publications. METHODS: We employed a mixed-methods study design. We identified factors possibly contributing to QRPs in the reporting of messages and conclusions through a literature review, 14 semi-structured interviews with HSR institutional leaders, and 13 focus-groups amongst researchers. A survey corresponding with these factors was developed and shared with 172 authors of 116 scientific HSR publications produced by Dutch research institutes in 2016. We assessed the included publications for the occurrence of QRPs. An exploratory factor analysis was conducted to identify factors within individual, institutional, and environmental domains. Next, we conducted bivariate analyses using simple Poisson regression to explore factors' association with the number of QRPs in the assessed HSR publications. Factors related to QRPs with a p-value < .30 were included in four multivariate models tested through a multiple Poisson regression. RESULTS: In total, 78 (45%) participants completed the survey (51.3% first authors and 48.7% last authors). Twelve factors were included in the multivariate analyses. In all four multivariate models, a higher score of "pressure to create societal impact" (Exp B = 1.28, 95% CI [1.11, 1.47]), was associated with higher number of QRPs. Higher scores on "specific training" (Exp B = 0.85, 95% CI [0.77-0.94]) and "co-author conflict of interest" (Exp B = 0.85, 95% CI [0.75-0.97]) factors were associated with a lower number of QRPs. Stratification between first and last authors indicated different factors were related to the occurrence of QRPs for these groups. CONCLUSION: Experienced pressure to create societal impact is associated with more QRPs in the reporting of messages and conclusions in HSR publications. Specific training in reporting messages and conclusions and awareness of co-author conflict of interests are related to fewer QRPs. Our results should stimulate awareness within the field of HSR internationally on opportunities to better support reporting in scientific HSR publications.

Geographical inequalities in healthcare utilisation and the contribution of compositional factors: A multilevel analysis of 497 districts in Indonesia.

Substantial inequalities in healthcare utilisation are reported in Indonesia. To develop appropriate health policies and interventions, we need to better understand geographical patterns in inequalities and any contributing factors. This study investigates geographical inequalities in healthcare utilisation across 497 districts in Indonesia and whether compositional factors - wealth, education, health insurance - contribute to such inequalities. Using data from a nationally representative Basic Health Research survey, from 2013 (N = 694,625), we applied multilevel logistic regressions, adjusted for need, to estimate associations of compositional factors with outpatient and inpatient care utilisation and to assess variability at province and district levels. We observed large variation of healthcare utilisation at district level and smaller variations at province level. Cities had higher utilisation rates than rural districts. Compositional factors contributed only modestly to geographical inequalities in healthcare utilisation. The effect of compositional factors on individual healthcare utilisation was stronger in rural areas as compared to cities and other areas with higher population densities. Unexplained district variation was substantial, comparable to that associated with health insurance. In policies to tackle inequalities in healthcare utilisation, addressing geographical factors such as service availability and infrastructures may be as important as improving compositional factors like health insurance.

The accuracy of self-report versus objective assessment for estimating socioeconomic inequalities in disease prevalence in Indonesia.

OBJECTIVES: To estimate socioeconomic inequalities in hypertension and asthma prevalence in Indonesia, to compare estimates based on self-report (SR) to those based on objective assessment (OA), and to assess the role of sensitivity and specificity of SR. METHODS: We used data from the 2014 Indonesia Family Life Survey (n = 34,257). We measured inequalities in hypertension and asthma prevalence in relation to educational level and income, using standardised prevalence rate and the relative index of inequality (RII). Using OA as standard, we calculated the sensitivity and specificity of SR. RESULTS: For hypertension, reversed inequalities were found when estimated by SR instead of OA (RII for education 0.86, 95% CI 0.74-0.99 vs. RII 1.29, 95% CI 1.16-1.44). For asthma, a similar but even larger reversal of inequalities was found. The sensitivity of SR was low overall, and especially for the lowest education or income group. CONCLUSIONS: Results imply that the use of SR may lead to underestimation of socioeconomic inequalities in disease prevalence in a low-income country such as Indonesia. The use of OA is recommended for monitoring inequalities in non-communicable disease prevalence.

Socioeconomic inequalities in the utilisation of hypertension and type 2 diabetes management services in Indonesia.

OBJECTIVES: To describe socioeconomic inequalities in the utilisation of hypertension and type 2 diabetes (T2D) management services in the Indonesian population and to determine whether education level and geographical location contribute to inequalities. METHODS: Cross-sectional study using data from the 2014 Indonesia Family Life Survey (N = 30 762 for hypertension; N = 6758 for T2D). Socioeconomic status was measured by household consumption. The prevalence of hypertension and T2D was determined using internationally standardised clinical measurement, while disease management was defined by participation in screening and current use of medication. The relative index of inequality (RII) was used to estimate inequalities, adjusted to education level and geographical location. RESULTS: For all household consumption quintiles, we observed low rates of screening participation for T2D and low medication use in both hypertension and T2D. We found socioeconomic inequalities in screening participation for hypertension (RII 2.68, 95% CI 2.42-2.96) and T2D (RII 7.30, 95% CI 5.48-9.72) and also for medication use in hypertension (RII 3.09, 95% CI 2.28-4.18) and T2D (RII 2.81, 95% CI 1.09-7.27). Education level contributed to socioeconomic inequalities in screening utilisation for both hypertension and T2D. Geographical location contributed to inequalities in screening utilisation and medication use for T2D. Socioeconomic inequalities in medication use for hypertension and T2D were larger among men than women. CONCLUSIONS: Large socioeconomic inequalities were found in the utilisation of hypertension and T2D management services in Indonesia. Improving affordability, availability and approachability of services is crucial to reduce such inequalities.

INÉGALITÉS SOCIOÉCONOMIQUES DANS L'UTILISATION DES SERVICES DE PRISE EN CHARGE DE L'HYPERTENSION ET DU DIABÈTE DE TYPE 2 EN INDONÉSIE: OBJECTIFS: Décrire les inégalités socioéconomiques dans l'utilisation des services de prise en charge de l'hypertension et du diabète de type 2 (DT2) au sein de la population indonésienne et déterminer si le niveau d'éducation et la localisation géographique contribuent aux inégalités. MÉTHODES: Etude transversale utilisant les données de l'enquête 2014 sur la vie de famille en Indonésie (N = 30.762 pour l'hypertension; N = 6.758 pour le DT2). Le statut socioéconomique a été mesuré par la consommation des ménages. La prévalence de l'hypertension et du DT2 a été déterminée à l'aide de mesures cliniques standardisées à l'échelle internationale, tandis que la prise en charge de la maladie était définie par la participation au dépistage et à l'utilisation courante de médicaments. L'indice relatif d'inégalité (RII) a été utilisé pour estimer les inégalités, ajustées à l'échelle de l'éducation et à la localisation géographique. RÉSULTATS: Pour tous les quintiles de consommation des ménages, nous avons observé de faibles taux de participation au dépistage du DT2 et une faible utilisation de médicaments dans l'hypertension et le DT2. Nous avons constaté des inégalités socioéconomiques dans la participation au dépistage de l'hypertension (RII= 2,68; IC95%: 2,42 à 2,96) et du DT2 (RII= 7,30; IC95%: 5,48 à 9,72), ainsi que de l'utilisation de médicaments pour l'hypertension (IIR= 3,09; IC95%: 2,28 à 4.18) et pour le DT2 (RII= 2,81; IC95%: 1,09-7,27). Le niveau d'éducation a contribué aux inégalités socioéconomiques dans l'utilisation du dépistage pour l'hypertension et le DT2. La localisation géographique a contribué aux inégalités dans l'utilisation du dépistage et de l'utilisation de médicaments pour le DT2. Les inégalités socioéconomiques dans l'utilisation des médicaments contre l'hypertension et le DT2 étaient plus importantes chez les hommes que chez les femmes. CONCLUSIONS: De grandes inégalités socioéconomiques ont été constatées dans l'utilisation des services de prise en charge de l'hypertension et du DT2 en Indonésie. Améliorer l'aspect abordable, la disponibilité et l'accessibilité des services est crucial pour réduire ces inégalités.

Socioeconomic inequalities in healthcare utilisation in Indonesia: a comprehensive survey-based overview.

OBJECTIVE: Monitoring inequality in healthcare utilisation is essential to reduce persistent inequalities in health in lower-middle income countries. This study aimed to assess socioeconomic inequalities in the utilisation of primary care, secondary care and preventive care in Indonesia. METHODS: A cross-sectional study was conducted using data from the 2014 Indonesia Family Life Survey with a total of 42 083 adult participants. Socioeconomic status (SES) was measured by educational level and income. Healthcare utilisation was measured in: (1) primary care, (2) outpatient in secondary care, (3) inpatient care and (4) cardiovascular-related preventive care. The magnitude of inequalities was measured using the relative index of inequality (RII). RESULTS: Small educational inequalities were found for primary care utilisation (RII 1.13, 95% CI 1.01 to 1.26). Larger educational inequalities were found for outpatient secondary care (RII 10.35, 95% CI 8.11 to 13.22) and inpatient care (RII 2.78, 95% CI 2.32 to 3.32). The largest educational inequalities were found for preventive care, particularly regarding blood glucose tests (RII 30.31, 95% CI 26.13 to 35.15) and electrocardiography tests (RII 30.90, 95% CI 24.97 to 38.23). Compared with educational inequalities, income inequalities were larger for primary care (RII 1.68, 95% CI 1.52 to 1.85) and inpatient care (RII 3.11, 95% CI 2.63 to 3.66), but not for outpatient secondary care and preventive care. CONCLUSIONS: Socioeconomic inequalities in healthcare utilisation in Indonesia are particularly large in secondary and preventive care. Therefore, it is recommended to prioritise policies focused on improving timely, geographical and financial access to secondary and preventive care for lower SES groups.

The evolution of income-related inequalities in healthcare utilisation in Indonesia, 1993-2014.

OBJECTIVE: While the major policy changes in the Indonesian healthcare system over the last 25 years have been well documented, less is known about the accompanying changes in inequalities in healthcare utilisation during this period. Our study aimed to describe the trends in income-related inequalities in healthcare utilisation in Indonesia during the period 1993-2014. METHODS: A repeated cross-sectional study was conducted using data from the Indonesian Family Life Surveys from 1993, 2000, 2007, and 2014. We measured outpatient and inpatient healthcare utilisation in public and private provider as well as the overall utilisation. Standardised prevalence rate and relative index of inequality (RII) were used to measure the extent of inequalities in healthcare utilisation by income level (income-related inequalities). RESULTS: Relatively large income-related inequalities were observed in the utilisation of private outpatient care and public and private inpatient care in 1993. Income-related inequalities in public and private outpatient care utilisation decreased between 1993 and 2007 but increased in 2014. Income-related inequalities in public and private inpatient care utilisation continued to decrease between 1993 and 2014. The largest decrease was observed in private inpatient care utilisation. CONCLUSION: Income-related inequalities in all types of healthcare utilisation decreased until 2007. This trend continued until 2014 only for public and private inpatient care utilisation. This phenomenon may be explained by the changes to the healthcare system (e.g. expansion of the government health insurance programme and health sector decentralisation), which coincided with the changes in inequalities in healthcare utilisation in Indonesia.

Occurrence and nature of questionable research practices in the reporting of messages and conclusions in international scientific Health Services Research publications: a structured assessment of publications authored by researchers in the Netherlands.

OBJECTIVES: Explore the occurrence and nature of questionable research practices (QRPs) in the reporting of messages and conclusions in international scientific Health Services Research (HSR) publications authored by researchers from HSR institutions in the Netherlands. DESIGN: In a joint effort to assure the overall quality of HSR publications in the Netherlands, 13 HSR institutions in the Netherlands participated in this study. Together with these institutions, we constructed and validated an assessment instrument covering 35 possible QRPs in the reporting of messages and conclusions. Two reviewers independently assessed a random sample of 116 HSR articles authored by researchers from these institutions published in international peer-reviewed scientific journals in 2016. SETTING: Netherlands, 2016. SAMPLE: 116 international peer-reviewed HSR publications. MAIN OUTCOME MEASURES: Median number of QRPs per publication, the percentage of publications with observed QRP frequencies, occurrence of specific QRPs and difference in total number of QRPs by methodological approach, type of research and study design. RESULTS: We identified a median of six QRPs per publication out of 35 possible QRPs. QRPs occurred most frequently in the reporting of implications for practice, recommendations for practice, contradictory evidence, study limitations and conclusions based on the results and in the context of the literature. We identified no differences in total number of QRPs in papers based on different methodological approach, type of research or study design. CONCLUSIONS: Given the applied nature of HSR, both the severity of the identified QRPs, and the recommendations for policy and practice in HSR publications warrant discussion. We recommend that the HSR field further define and establish its own scientific norms in publication practices to improve scientific reporting and strengthen the impact of HSR. The results of our study can serve as an empirical basis for continuous critical reflection on the reporting of messages and conclusions.