Poor personal protective equipment practices were associated with heat-related symptoms among Asian healthcare workers: a large-scale multi-national questionnaire survey.

BACKGROUND: It is pertinent to understand the perceptions of healthcare workers (HCWs) with their associated personal protective equipment (PPE) usage and heat strain symptoms experienced to effectively combat the negative effects of heat stress during treatment and care activities. METHODS: We evaluated the associated heat stress perceived by HCWs across Asia and validated a questionnaire on perceptions of heat stress, associated PPE usage, and heat strain symptoms experienced. The questionnaire was administered to 3,082 HCWs in six Asian regions. Factor analyses, including Cronbach's alpha, assessed the questionnaire's validity and reliability. Structural equation modelling analysed the effects of knowledge, attitudes and practices, and heat strain symptoms. RESULTS: The questionnaire was found to be reliable in assessing HCWs' knowledge, and attitudes and practices towards heat stress and PPE usage (both Cronbach's alpha = 0.9), but not heat strain symptoms (Cronbach's alpha = 0.6). Despite knowledge of heat stress, HCWs had negative attitudes and practices regarding PPE usage (ß1 = 0.6, p < 0.001). Knowledge (path coefficient = 0.2, p < 0.001), and negative attitudes and practices (path coefficient = 0.2, p < 0.001) of HCWs towards heat stress and PPE usage adversely affected symptoms experienced. CONCLUSIONS: The questionnaire was not reliable in assessing symptoms. HCWs should, nevertheless, still self-assess their symptoms for early detection of heat strain. To effectively attenuate heat strain, understanding HCWs' attitudes and practices towards PPE usage should guide policymakers in implementing targeted heat management strategies.

Cetuximab as first-line treatment for metastatic colorectal cancer (mCRC): a model-based economic evaluation in Indonesia setting.

OBJECTIVES: To assess the cost-effectiveness of cetuximab in combination with chemotherapy fluorouracil, oxaliplatin, and leucovorin (FOLFOX) or fluorouracil, irinotecan and leucovorin (FOLFIRI) compared to standard chemotherapy alone as a first-line treatment for metastatic colorectal cancer (mCRC) with positive KRAS wild type patients in Indonesia. METHODS: A cost-utility analysis applying Markov model was constructed, with a societal perspective. Clinical evidence was derived from published clinical trials. Direct medical costs were gathered from hospital billings. Meanwhile, direct non-medical costs, indirect costs, and utility data were collected by directly interviewing patients. We applied 3% discount rate for both costs and outcomes. Probabilistic sensitivity analysis was performed to explore the model's uncertainty. Additionally, using payer perspective, budget impact analysis was estimated to project the financial impact of treatment coverage. RESULTS: There was no significant difference in life years gained (LYG) between cetuximab plus FOLFOX/FOLFIRI and chemotherapy alone. The incremental QALY was only one month, and the incremental cost-effectiveness ratio (ICER) was approximately IDR 3 billion/QALY for cetuximab plus chemotherapy. Using 1-3 GDP per capita (IDR 215 million or USD 14,350) as the current threshold, the cetuximab plus chemotherapy was not cost-effective. The budget impact analysis resulted that if cetuximab plus chemotherapy remain included in the benefits package under the Indonesian national health insurance (NHI) system, the payer would need more than IDR 1 trillion for five years. CONCLUSIONS: The combination of cetuximab and chemotherapy for mCRC is unlikely cost-effective and has a substantial financial impact on the system.

Does Trastuzumab Offer Good Value for Money for Breast Cancer Patients with Metastasis in Indonesia?

OBJECTIVE: Breast cancer is the most common cancer in Indonesia, with Indonesia's breast cancer mortality rate being the highest among Southeast Asian countries. This study aims to evaluate the cost-effectiveness and budget impacts of adding trastuzumab to chemotherapy versus chemotherapy alone for HER2-positive breast cancer patients in Indonesia. METHODS: We performed a Markov model-based economic evaluation to assess cost-effectiveness, cost-utility, and budget impact. Utility data, direct medical costs, and indirect costs were obtained primarily from interviewing patients. Clinical effectiveness data, on the other hand, were obtained from systematic reviews and real-world data and represented through progression free survival, overall survival, and quality-adjusted life years (QALYs). RESULT: From a healthcare provider's perspective, the total costs for the combined group were USD 14,516, while chemotherapy alone cost USD 7,489. While the cost-effectiveness analysis showed that the combination group had a higher total cost by USD 7,027, PFS was longer in the chemotherapy alone group, with a difference of 2.2 months. The ICER was USD 17,307 for every QALY gained. The total cost of adding trastuzumab over a 5-year period was USD 589 million. CONCLUSION: In conclusion, this economic evaluation suggests that the addition of trastuzumab to standard chemotherapy is not cost-effective in terms of PFS and OS compared with chemotherapy alone.
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Expanding japanese encephalitis vaccination to selected endemic indonesia provinces: A cost-effectiveness analysis.

Introduction: A Markov model was used to evaluate the potential health and economic impact of introducing JE vaccine nationally and in selected endemic areas of Indonesia compared to no vaccination from government and societal perspectives over a child's lifetime horizon. Methods: Costs were obtained from hospitalized JE suspected patient billing data from 2014 to 2019 in seven provinces. Local data burden data were derived from the literature. Analysis considered several scenarios, including national and sub-regional introduction in seven provinces via a one-time vaccination campaign in all children 1-15 years old followed by routine immunization among infants (RI), or RI alone without vaccination campaign. Results and discussions: Across scenarios, JE vaccination was projected to range from cost-saving to cost-effective compared to no vaccination at a willingness-to-pay threshold of 0.5x gross domestic product per capita. Including a one-time campaign would avert nearly three times as many JE cases and deaths compared to RI alone while still providing good value for money.

Adding rituximab to chemotherapy for diffuse large B-cell lymphoma patients in Indonesia: a cost utility and budget impact analysis.

BACKGROUND: Rituximab plus cyclophosphamide, doxorubicin, vincristine, and prednisone (R-CHOP) has been used to treat patients with diffuse large B-cell lymphoma (DLBCL) under National Health Insurance (NHI) scheme in Indonesia. This study aims to estimate its cost-effectiveness and budget impact. METHODS: We conducted a cost utility analysis using Markov model over a lifetime horizon, from a societal perspective. Clinical evidence was derived from published clinical trials. Direct medical costs were gathered from hospital data. Direct non-medical costs, indirect costs, and utility data were primarily gathered by interviewing the patients. We applied 3% discount rate for both costs and effect. All monetary data are converted into USD (1 USD = IDR 14,000, 2019). Probabilistic sensitivity analysis was performed. In addition, from a payer perspective, budget impact analysis was estimated using price reduction scenarios. RESULTS: The incremental cost-effectiveness ratio (ICER) of R-CHOP was USD 4674/LYG and 9280/QALY. If we refer to the threshold three times the GDP per capita (USD 11,538), R-CHOP could thus be determined as a cost-effective therapy. Its significant health benefit has contributed to the considerable ICER result. Although the R-CHOP has been considered a cost-effective intervention, the financial consequence of R-CHOP if remain in benefit package under National Health Insurance (NHI) system in Indonesia is considerably substantial, approximately USD 35.00 million with 75% price reduction scenario. CONCLUSIONS: As a favorable treatment for DLBCL, R-CHOP ensures value for money in Indonesia. Budget impact analysis provides results which can be used as further consideration for decision-makers in matters related to benefit packages.

Assessment of the obesogenic environment in primary schools: a multi-site case study in Jakarta.

BACKGROUND: Childhood overweight and obesity have increasingly been recognized as a significant global public health crisis, including in Asia. This study aimed to assess the obesogenic environment in primary schools in Jakarta, Indonesia. METHODS: A qualitative, multi-site, case study design was used to capture different elements of the school environment and policies related to obesity, with a focus on nutrition and physical activity. An adaptation of the Primary School Environmental Assessment tool was used. Six primary schools in Jakarta were purposively selected based on their location, socioeconomic status, and type (public or private). In addition to direct observation at each school, interviews were conducted with the principal, physical education teacher, canteen staff, street food vendors, and students. RESULTS: Among the six schools, two were private and four were public. The most popular foods consumed by students were unhealthy, such as deep-fried foods and sugar-sweetened beverages. Students had easy and constant access to unhealthy foods, whereas only limited variation of healthy foods were available in the school canteen. Some schools also allowed the student to have access to street food vendors. School policies related to healthy eating and physical activities had been implemented, mainly in the form of teaching these topics as part of the school curriculum. However, promotion of healthy eating and physical activities by the schools was still limited. CONCLUSIONS: This study showed the usefulness of the Primary School Environmental Assessment tool in identifying obesogenic factors in urban area of Indonesia. Effective implementation of guidelines to foster good nutritional practices and healthy lifestyles at school should be prioritized to improve the health and nutritional status of the students.

A Life Course Approach to the Prevention of Iron Deficiency Anemia in Indonesia.

Iron deficiency anemia (IDA) has a long-term impact on each life stage and remains worldwide a major public health problem. Eleven experts were invited to participate in a virtual meeting to discuss the present situation and the available intervention to prevent iron deficiency anemia in Indonesia. The experts consisted of obstetric gynecologists, pediatricians, nutritionists, midwives, a clinical psychologist, and an education expert. Existing interventions focus attention on preconception and early childhood stages. Considering the inter-generational effects of IDA, we call attention to expanding strategies to all life stages through integrating political, educational, and nutritional interventions. The experts agreed that health education and nutritional intervention should be started since adolescence. Further research to explore the effectiveness of these interventions would be important for many regions in the world. The outcome of this Indonesian consensus is applicable worldwide.

The Road to Healthy Ageing: What Has Indonesia Achieved So Far?

The World Health Organization (WHO) has projected that the world should prepare for an aging society. As the fourth most populous country in the world, the elderly population in Indonesia is also continuously growing. In 2010, the proportion of the elderly group was merely 5%, and it is expected to increase to 11% in 2035. Understanding the current situation of the adult population in Indonesia would be crucial to prepare for the future aging population. This article analyzed the current socio-demographic status, nutrition status, nutrient intake, and health profile of the current Indonesian adult population through a literature review. The key issues to prepare for healthy aging in Indonesia are summarized. Acknowledging the profile of the adult and senior adult population in Indonesia will provide beneficial information for all stakeholders in preparing Indonesia for a better healthy aging population with improved quality of life.

Economic Evaluation of Adding Bevacizumab to Chemotherapy for Metastatic Colorectal Cancer (mCRC) Patients in Indonesia.

OBJECTIVE: Since 2016, bevacizumab has been widely used to treat metastatic colorectal cancer (mCRC) in Indonesia. Nevertheless, the high cost of bevacizumab has raised the question of whether the therapy is considered cost-effective and should be included in the national health insurance system. This study aimed to assess the cost-effectiveness of bevacizumab plus chemotherapy versus chemotherapy alone for the treatment of mCRC patients. METHODS: A Markov model was applied using the perspective of the Indonesian healthcare system to assess cost-effectiveness. The health outcomes were expressed in terms of quality-adjusted life years (QALY) using the validated EuroQoL-5D-5L instrument. Data for medical costs were collected from hospital billings in four hospitals located in three different cities in Indonesia. Meanwhile, data for utility were obtained from interviewing 90 patients who came to the hospital. We compared those mCRC patients who received chemotherapy alone either with FOLFOX or FOLFIRI, versus patients who received the addition of bevacizumab. RESULTS: With the perspective of societal, the incremental cost-effectiveness ratio (ICER) of adding bevacizumab was USD 49,312 per QALY gained using secondary data and USD 28,446 per QALY using real world data. CONCLUSION: Using either a healthcare or societal perspective, the addition of bevacizumab for mCRC treatment was considered not cost-effective.

The implementation of community-based diabetes and hypertension management care program in Indonesia.

Since 2010, Indonesian government has initiated a chronic disease management program, Prolanis (Program Pengendalian Penyakit Kronis) targeted for diabetes and hypertension. The program is continued at the commencement of universal health coverage (UHC) in 2014. "This study aimed to report the utilization and cost of the implementation of Prolanis in Indonesia from 2014 to 2016, or two years since the commencement of Indonesian universal health coverage." Secondary data analysis was performed using publicly available data and data obtained from the national health insurance agency (BPJS); while data on disease prevalence were collected from basic national health survey. There was an increase trend of Prolanis participants, from around 11,000 participants in 2014 to more than 250,000 in 2016. More than 70% of participants were adults living in Java, however, the acceptance rate was very low in other area. Across different activities in Prolanis, physical activity was the most participated ones. In comparison to other regions, regions in Java were the most active area. The total expenditure for Prolanis program in 2016 increased almost triple from the annual cost in 2014. However, the cost per person was actually decreased more than 50%. Within two years of UHC implementation, there were increase covered participants and total costs, but cost per individual was decreased and there was significant difference in of cost between Java and outside Java. Further study and routine monitoring-evaluation process by health authority is needed to assess whether the cost difference would affect the service quality.

Improving Workplace-Based Intervention in Indonesia to Prevent and Control Anemia.

Purpose: The present study determined female workers' experiences and preferences to improve the workplace anemia prevention program in Indonesia by studying their perception of anemia, as well as its risk factors and control. Methods: This qualitative study was conducted using focus group discussions (FGDs) to assess female workers' understanding about anemia and possible improvements for workplace-based intervention in a factory located in East Jakarta, Indonesia. Participants were consisted of 14 FGD groups according to anemia status and potential affecting characteristics, including marital status, ethnicity, religion, and frequency of medical consultations. A semistructured questionnaire was used to determine participants' ideas and experiences of anemia control. Results: A total of 14 FGDs were conducted including 105 female workers who participated in this study. More than half of the participants showed a good understanding of the signs and symptoms of anemia. They expected the company to improve the factory health service by improving accessibility and affordability of food and controlling hazardous substances considered risk factors of anemia in the workplace. Conclusion: Female workers have valuable experience and ideas that should be considered to improve workplace-based anemia intervention. They proposed improvement of workplace-based health services such as improving factory canteen and clinics services and controlling potential anemia risk hazards in the workplace.

Developing a workplace lactation promotion model in Indonesia using Delphi technique.

BACKGROUND: Working mothers have a higher risk to terminate breastfeeding earlier than stay-at-home mothers. Researchers reported that support from the workplace by creating lactation facilities and develop supportive programs are necessary to increase the success of exclusive breastfeeding. The aim was to achieve expert consensus on developing a workplace-based lactation promotion model. METHODS: A three-round online survey using Delphi approach was conducted to reach consensus on to the development of a lactation program at a workplace. RESULTS: Twenty-two experts from Indonesian health authority, community medicine, child health and obstetrics were invited to join the Delphi study; 15 (68.2%) enrolled in the first round. The response rate in the second and third round was 80.0% (12/15) and 86.7% (13/15), respectively. The first round categorized the workplace-based promotion model into seven dimensions, i.e. policy and regulation, facility, education material, target participants, promotion approach, human resources, and time. In the final round, "maternity leave of 3-6 months" (median (Q1;Q3):2 (1, 4)) and "employees have the right to breast-pumping every 3 hours" (median (Q1;Q3):3 (2, 4)) ranked as the two most important indicators regarding policy and regulation. A dedicated lactation room (median (Q1;Q3):1 (1)) is the highest ranked indicator regarding facility dimension. Regarding education materials, benefits of breast milk for babies ranked as the highest indicator while for the education and delivering methods dimensions, social media and interactive counseling were two highest ranked indicators. The top management in the company and lactation counselor are the two highest-ranked indicators in human resources dimension. CONCLUSION: In the view of experts, involvement of a dedicated policy maker in the company, a workplace-based lactation counselor, regular promotion with interactive education and dedicated facilities are necessary to develop an effective workplace-based lactation promotion model.

Challenges and Supports of Breastfeeding at Workplace in Indonesia.

Due to increased number of women workers in Indonesia in the last decade, numbers of women living as a worker and a housewife have increased. This also increases the potential risk of breastfeeding discontinuation. Three months of maternal leave policy and inadequate lactation promotion support in workplace have been identified as factors that hinder lactating practices. The World Health Organization recommendation of 6 months of exclusive breastfeeding and joined regulation of three Indonesia ministers (Ministry of Health, Ministry of Labour, and Ministry of Women Empower) have failed to improve the exclusive breastfeeding rate among female workers in Indonesia due to the lack of a standardized guideline on lactation promotion at workplace. In addition, very limited or no studies have been conducted to evaluate the impact of workplace-based lactation intervention programs on exclusive breastfeeding rate among female workers. This is because the relationship of lactation with working performance and productivity could not motivate employer to invest in workplace-based lactation promotion facility or program.

Economic evaluation of policy options for dialysis in end-stage renal disease patients under the universal health coverage in Indonesia.

OBJECTIVES: This study aims to assess the value for money and budget impact of offering hemodialysis (HD) as a first-line treatment, or the HD-first policy, and the peritoneal dialysis (PD) first policy compared to a supportive care option in patients with end-stage renal disease (ESRD) in Indonesia. METHODS: A Markov model-based economic evaluation was performed using local and international data to quantify the potential costs and health-related outcomes in terms of life years (LYs) and quality-adjusted life years (QALYs). Three policy options were compared, i.e., the PD-first policy, HD-first policy, and supportive care. RESULTS: The PD-first policy for ESRD patients resulted in 5.93 life years, equal to the HD-first policy, with a slightly higher QALY gained (4.40 vs 4.34). The total lifetime cost for a patient under the PD-first policy is around 700 million IDR, which is lower than the cost under the HD-first policy, i.e. 735 million IDR per patient. Compared to supportive care, the incremental cost-effectiveness ratio of the PD-first policy is 193 million IDR per QALY, while the HD-first policy resulted in 207 million IDR per QALY. Budget impact analysis indicated that the required budget for the PD-first policy is 43 trillion IDR for 53% coverage and 75 trillion IDR for 100% coverage in five years, which is less than the HD-first policy, i.e. 88 trillion IDR and 166 trillion IDR. CONCLUSIONS: The PD-first policy was found to be more cost-effective compared to the HD-first policy. Budget impact analysis provided evidence on the enormous financial burden for the country if the current practice, where HD dominates PD, continues for the next five years.