Pandemic Pressure: Changes in Hypertensive Management Adherence in Indonesia.

PURPOSE: This study aimed to determine factors associated with changes in adherence to hypertension management (medication adherence and blood pressure control) in respondents with hypertension before and during the COVID-19 pandemic in Bogor City, Indonesia. METHODS: An observational study was conducted using two sources of data (before and during COVID-19 pandemic). Data before the pandemic were derived from the 2019 Cohort Study of Non-communicable Disease Risk Factors. Data during the pandemic were derived from an online survey conducted in September and October 2020. Information from 880 participants were analyzed. The dependent variable was the change in adherence to hypertension management before and during the COVID-19 pandemic. Multivariate analysis was performed using logistic polynomial regression. RESULTS: Respondents who adhered to hypertension management decreased from 82.0% in 2019 to 47.8% in 2020. The likelihood of non-adherence (respondents who did not adhere to hypertension management both before and during the pandemic) increased in respondents below 55 years old, who did not own any healthcare insurance, who were not obese, and who had no other comorbidities. In the partial adherence group (respondents who did not adhere to hypertension management either before or during the pandemic), we found that most respondents adhered before the pandemic but no longer adhered during the COVID-19 pandemic. We found an increased partial adherence in young and highly educated respondents. CONCLUSION: Efforts to improve adherence to hypertension management after the COVID-19 pandemic should target those who were young, highly educated, who did not have any healthcare insurance, and who did not perceive themselves as not having comorbidities.

Suboptimal child healthcare practices and the development of multiple infectious diseases in children aged 24-59 months.

Background: Infections continue to be a major cause of death among children under the age of five worldwide. This study aimed to identify the factors associated with the development of multiple infectious diseases in children aged 24-59 months in Indonesia. Methods: Data from the 2018 Basic Health Research conducted by the Ministry of Health, Republic of Indonesia, were used. Information from 39,948 children aged 24-59 months was analyzed. The outcome variable was the development of multiple infectious diseases, that is, acute respiratory infections, pneumonia, pulmonary tuberculosis, diarrhea, and hepatitis, in the month before the survey. Factors significantly associated with multiple types of infectious diseases were examined using logistic regression. Results: The study found that 76.6% of children aged 24 to 59 months in Indonesia had at least one type of infectious disease. The likelihood of developing multiple types of infectious diseases increased in children whose parents did not practice appropriate handwashing with soap and running water [adjusted odds ratio (aOR) = 1.16, p < 0.001], those who received supplemental food (aOR = 1.38, p < 0.001), those with poor nutritional status (aOR = 1.12, p < 0.001), and those living in urban areas (aOR = 1.07, p = 0.045). Conclusion: Improving caregivers' awareness of adequate child healthcare practices, in addition to nutrition-sensitive and specific interventions to improve children's nutritional status, is required to prevent children from contracting multiple types of infectious diseases.

Determinants of early neonatal mortality: secondary analysis of the 2012 and 2017 Indonesia Demographic and Health Survey.

Background: Most neonatal deaths occur during the first week of life (i.e., early neonatal deaths). In this analysis, we aimed to investigate the determinants of early neonatal deaths in a nationally representative sample of births in Indonesia over the five years before each survey. Methods: Data were obtained from the 2012 and 2017 Indonesia Demographic and Health Survey (IDHS), including information from 58,902 mothers of children aged <5 years of age. The outcome variable was early neonatal death (death of a newborn within the first six days of life). Explanatory variables were categorized into environmental, household, maternal, pregnancy, childbirth, and child characteristics. Multivariate regression methods were employed for analysis. Results: Increased odds of early neonatal deaths were associated with mothers who lacked formal education or had incomplete primary schooling (adjusted odd ratio [OR] = 2.43, 95% confidence interval [CI]: 1.18-5.01), worked outside the house in agricultural (aOR = 5.94, 95% CI: 3.09-11.45) or non-agricultural field (aOR = 2.98, 95% CI: 1.88-4.72), and were required to make a joint decision about health care with their partner or another household member (aOR = 1.79, 95% CI: 1.12-2.84). Increased odds were also observed in smaller-than-average infants, particularly those who received low-quality antenatal care services (aOR = 9.10, 95% CI: 5.04-16.41) and those whose mothers had delivery complications (aOR = 1.72, 95% CI: 1.10-2.68) or who were delivered by cesarean section (aOR = 1.74, 95% CI: 1.07-2.82). Furthermore, male infants showed higher odds than female infants (aOR = 1.85, 95% CI: 1.23-2.76). Conclusions: A multifaceted approach is essential for curtailing early neonatal mortality in Indonesia. Enabling workplace policies, promoting women's empowerment, strengthening the health system, and improving the uptake of high-quality antenatal care services are among the critical steps toward preventing early neonatal deaths in Indonesia.

The multiple factors of suboptimal early feeding practices among infants aged 0-5 months in Indonesia.

Background: Optimal early infant feeding practices are critical to ensure adequate nutrition for infants' growth and development. This study aimed to examine the determinants of suboptimal early feeding practices (i.e., delayed initiation of breastfeeding, prelacteal feeding, and non-exclusive breastfeeding) among infants aged 0-5 months in Indonesia. Methods: We used data collected in the 2012 and 2017 Indonesia Demographic and Health Surveys. Analyses were conducted using information from 3,198 live-born singleton infants aged 0-5 months. The primary outcomes used were: (1) delayed initiation of breastfeeding in the first hour after birth, (2) prelacteal feeding in the first 3 days, and (3) non-exclusive breastfeeding in the last 24 h preceding the survey. Potential predictors analyzed were categorized into the environmental, household, maternal, pregnancy, delivery, and child characteristics. Logistic regression analyses were performed to identify factors significantly associated with each outcome. Results: Approximately 78,6% of infants aged 0-5 months in Indonesia had at least one of the three suboptimal early infant feeding practices. We found a strong association between the three outcome indicators analyzed. The determinants of delayed initiation of breastfeeding included infants from Sumatera region (adjusted odds ratios (aOR) = 2.02, p < 0.001), infants delivered by Cesarean section (aOR = 2.78, p < 0.001), and in non-health facilities (aOR = 1.53, p = 0.003). The determinants of prelacteal feeding in the first 3 days included infants living in urban areas (aOR = 1.32, p = 0.035), the first birth-ranked infants (aOR = 1.32, p = 0.019), and infants who had delayed initiation of breastfeeding in the first hour of life (aOR = 3.90, p < 0.001). The determinants of non-exclusive breastfeeding in the last 24 h included infants whose mothers worked in non-agricultural fields (aOR = 1.52, p < 0.001), infants delivered by Cesarean section (aOR = 1.33, p = 0.044), and the first birth-ranked infants (aOR = 1.28, p = 0.039). Conclusion: There was a high percentage of infants aged 0-5 months who had suboptimal feeding practices in Indonesia. As we found multiple factors associated with suboptimal early feeding practices among infants, integrated approaches, including health promotion and supportive public policy, are required to ensure infants receive adequate nutrition in the early stages of life.

Assessment of factors related to individuals who were never treated during mass drug administration for lymphatic filariasis in Ambon City, Indonesia.

BACKGROUND: One challenge to achieving Lymphatic filariasis (LF) elimination is the persistent coverage-compliance gap during annual mass drug administration (MDA) and the risk of ongoing transmission among never treated individuals. Our analysis examined factors associated with individuals who were never treated during MDA. METHODS: Data were derived from two cross-sectional surveys conducted in Waihaong and Air Salobar Health Center in 2018 and 2019. We analyzed information from 1915 respondents aged 18 years or above. The study outcome was individuals who self-reported never treatment during any round of MDA. All potential predictors were grouped into socio-demographic, health system, therapy and individual factors. Logistic regression analyses were used to examine factors associated with never treatment in any year of MDA. RESULTS: Nearly half (42%) of respondents self-reported they were never treated during any round of MDA. Factors associated with increased odds of never treatment were respondents working in formal sectors (aOR = 1.75, p = 0.040), living in the catchment area of Waihaong Health Center (aOR = 2.33, p = 0.029), and those perceiving the possibility of adverse events after swallowing LF drugs (aOR = 2.86, p<0.001). Respondents reporting difficulty swallowing all the drugs (aOR = 3.12, p<0.001) and having difficulties remembering the time to swallow the drugs (aOR = 1.53, p = 0.049) also had an increased odds of never treatment. The highest odds of never treatment were associated with respondents reporting almost none of their family members took LF drugs (aOR = 3.93, p<0.001). Respondents confident that they knew how to swallow LF drugs had a reduced odds (aOR = 0.26, p<0.001) of never treatment. CONCLUSIONS: Efforts to reassure community members about adverse events, specific instructions on how to take LF drugs, and improving awareness that MDA participation is part of one's contribution to promoting community health are essential drivers for uptake with LF drugs during MDA.

Risk factors for the metabolic syndrome in non-obese older Indonesians.

BACKGROUND AND OBJECTIVES: The problem of metabolic syndrome among non-obese older people is often ignored. This study examines the risk factors for metabolic syndrome in non-obese older people in Indonesia. We analyzed information collected from 3323 non-obese older respondents interviewed in the 2018 Basic Health Research program. METHODS AND STUDY DESIGN: The outcome variable was the metabolic syndrome consisting of three components: high lipid profile, diabetes mellitus, and hypertension. The potential predictors analyzed were socio-demographic and behavioral factors consisting of psychomotor (cigarette smoking + physical activity) and dietary behavior (consumption of fat + fruit/vegetable). Multinomial logistic regression analysis was employed to assess metabolic syndrome risk factors in non-obese older people. RESULTS: We found that the proportion of non-obese older people in Indonesia with metabolic syndrome was 83.8% (95%CI: 82.4-85.2%). The odds of developing 2-3 components of metabolic syndrome increased in respondents from rural areas (aOR=1.26, p=0.033) and those with moderate psychomotor behavior problems (current smoker/ex-smoker with sufficient physical activity) (aOR=1.48, p=0.002). CONCLUSIONS: Health promotion activities are vital to improve awareness and promote healthy behaviors, specifically for those living in rural areas and smoking cigarettes.

The impact of a package of behaviour change interventions on breastfeeding practices in East Java Province, Indonesia.

Suboptimal infant young child feeding practices are frequently reported globally, including in Indonesia. This analysis examined the impact of a package of behaviour change interventions on breastfeeding practices in Malang and Sidoarjo Districts, East Java Province, Indonesia. The BADUTA study (which in the Indonesian Language is an acronym for BAwah DUa TAhun, or children aged less than 2 years) was an impact evaluation using a cluster-randomized controlled trial with two parallel treatment arms. We conducted household surveys in 12 subdistricts from Malang and Sidoarjo. We collected information from 5175 mothers of children aged 0-23 months: 2435 mothers at baseline (February 2015) and 2740 mothers at endline (January to February 2017). This analysis used two indicators for fever and diarrhoea and seven breastfeeding indicators (early initiation of breastfeeding, prelacteal feeding, exclusive breastfeeding under 6 months, predominant breastfeeding, continued breastfeeding, age-appropriate breastfeeding and bottle-feeding). We used multilevel logistic regression analysis to assess the effect of the intervention. After 2 years of implementation of interventions, we observed an increased odds of exclusive breastfeeding under 6 months (adjusted odds ratio [aOR] = 1.85; 95% confidence interval [CI]: 1.35-2.53) and age-appropriate breastfeeding (aOR = 1.39; 95% CI: 1.07-1.79) in the intervention group than in the comparison group, at the endline survey. We found significantly lower odds for prelacteal feeding (aOR = 0.52; 95% CI: 0.41-0.65) in the intervention than in the comparison group. Our findings confirmed the benefits of integrated, multilayer behaviour change interventions to promote breastfeeding practices. Further research is required to develop effective interventions to reduce bottle use and improve other breastfeeding indicators that did not change with the BADUTA intervention.

The relationship of body mass index and mid-upper arm circumference with anemia in non-pregnant women aged 19-49 years in Indonesia: Analysis of 2018 Basic Health Research data.

BACKGROUND AND OBJECTIVES: Anemia remains a major public health problem worldwide. This study examined the relationship between anemia and the nutritional status of non-pregnant women aged 19-49 years in Indonesia. METHODS AND STUDY DESIGN: The data were derived from the 2018 Basic Health Research Data of Indonesia. We used information from 11,471 non-pregnant women aged 19-49 years. The dependent variable was anemia (hemoglobin level <12 g/dL). The independent variable was women's nutritional status, a combined indicator of body mass index (BMI) and mid-upper arm circumference (MUAC). Our analysis controlled for women's age, education, physical activity, fruit and vegetable consumption, and the presence of communicable or non-communicable diseases. We performed logistic regression analyses. RESULTS: The prevalence of anemia in non-pregnant women aged 19-49 years was 22.3% (95% confidence interval [CI]: 21.4-23.3). Women with overweight and obesity were less likely to develop anemia than those with a normal BMI, regardless of their MUAC score. The highest odds for developing anemia were observed in underweight women with low MUAC scores (adjusted odds ratio [aOR] = 2.83, 95%CI: 2.19-3.68). Higher odds ratios were also observed in women with insufficient physical activity, despite their sufficient consumption of fruits or vegetables (aOR = 1.87, 95%CI: 1.06-3.28). However, women who had been diagnosed with a non-communicable disease had a reduced likelihood of developing anemia (aOR = 0.75, 95%CI: 0.67-0.83). CONCLUSIONS: Strengthening health promotion activities to improve nutritional status and healthy behaviors, particularly a healthy diet, remains important for women in Indonesia to reduce the prevalence of anemia and improve their overall health status.

Determinants of low breastfeeding self-efficacy amongst mothers of children aged less than six months: results from the BADUTA study in East Java, Indonesia.

BACKGROUND: Despite the increasing rate of exclusive breastfeeding in Indonesia, there is still a need for supportive interventions. The breastfeeding self-efficacy of mothers is a key factor positively associated with optimum breastfeeding practices. Our analysis aims to assess the determinants of low breastfeeding self-efficacy amongst a sample of women with children aged under 6 months in Malang and Sidoarjo Districts, East Java, Indonesia. METHODS: We used information from 1210 mothers of children aged < 6 months recruited in the BADUTA study conducted in 2015-2016 in Malang and Sidoarjo Districts. The outcome variable in this analysis was mothers' self-efficacy for breastfeeding using the 14 statements in the Breastfeeding Self-Efficacy-Short Form. We evaluated 17 potential predictors of breastfeeding self-efficacy, organized into six sub-groups of variables: (1) context/demographic; (2) household factors; (3) maternal characteristics; (4) child characteristics; (5) breastfeeding practices; and (6) antenatal and delivery care. Logistic regression analyses were employed to examine factors associated with mothers' self-efficacy with breastfeeding. RESULTS: More than half of the women in this study had a low level of self-efficacy. One of the factors associated with low breastfeeding self-efficacy found in this study was mothers' problems related to breastfeeding. Mothers who had problems with breastfeeding not related to illness (adjusted odds ratio [aOR] 3.27; 95% CI 2.45, 4.36) or problems related to both illness and non-illness conditions (aOR 3.57; 95% CI 1.37, 9.33) had higher odds of low breastfeeding self-efficacy than those who did not have any problems. Compared to mothers who completed university education, there was a significantly higher odds of low breastfeeding self-efficacy in mothers who completed primary school or lower (aOR 1.88; 95% CI 1.16, 3.05); completed junior high school (aOR 2.27; 95% CI 1.42, 3.63); and completed senior high school (aOR 1.94; 95% CI 1.29, 2.91). Other significant predictors of low breastfeeding self-efficacy were mothers not exposed to any breastfeeding interventions (aOR 1.87; 95% CI 1.09, 3.22); working outside the house (aOR 1.69; 95% CI 1.23, 2.32); not obtaining any advice on breastfeeding (aOR 1.40; 95% CI 1.08, 1.82); with low knowledge of breastfeeding (aOR 1.38; 95% CI 1.03, 1.84); and delivered by Caesarean section (aOR 1.34; 95% CI 1.05, 1.70). CONCLUSIONS: Multipronged breastfeeding education programs and support are required to improve women's self-efficacy with breastfeeding. Improved access to breastfeeding counselors, active support for mothers following cesarean delivery, and increased supporting facilities at workplaces are essential to improve self-efficacy with breastfeeding.

Keeping communities at the centre of efforts to eliminate lymphatic filariasis: learning from the past to reach a future free of lymphatic filariasis.

Since the launch of the Global Programme to Eliminate Lymphatic Filariasis (GPELF) in 2000, more than 910 million people have received preventive chemotherapy for lymphatic filariasis (LF) and many thousands have received care for chronic manifestations of the disease. To achieve this, millions of community drug distributors (CDDs), community members and health personnel have worked together each year to ensure that at-risk communities receive preventive chemotherapy through mass drug administration (MDA). The successes of 20 y of partnership with communities is celebrated, including the application of community-directed treatment, the use of CDDs and integration with other platforms to improve community access to healthcare. Important challenges facing the GPELF moving forward towards 2030 relate to global demographic, financing and programmatic changes. New innovations in research and practice present opportunities to encourage further community partnership to achieve the elimination of LF as a public health problem. We stress the critical need for community ownership in the current Covid-19 pandemic, to counter concerns in relaunching MDA programmes for LF.

Effect of an Integrated Package of Nutrition Behavior Change Interventions on Infant and Young Child Feeding Practices and Child Growth from Birth to 18 Months: Cohort Evaluation of the Baduta Cluster Randomized Controlled Trial in East Java, Indonesia.

The need for a multisectoral approach to tackle stunting has gained attention in recent years. Baduta project aims to address undernutrition among children during their first 1000 days of life using integrated nutrition-specific and nutrition-sensitive interventions. We undertook this cohort study to evaluate the Baduta project's effectiveness on growth among children under 2 years of age in two districts (Sidoarjo and Malang Districts) in East Java. Six subdistricts were randomly selected, in which three were from the intervention areas, and three were from the control areas. We recruited 340 pregnant women per treatment group during the third trimester of pregnancy and followed up until 18 months postpartum. The assessment of breastfeeding and complementary feeding practices used standard infant and young child feeding (IYCF) indicators in a tablet-based application. We measured weight and length at birth and every three-months after that. The enumerators met precision and accuracy criteria following an anthropometry standardization procedure. Among the breastfed children, the percentage of children who achieved the minimum dietary diversity score (DDS) and minimum acceptable diet (MAD) was higher for the intervention group than the comparison group across all age groups. The odd ratios were 3.49 (95% CI: 2.2-5.5) and 2.79 (95% CI: 1.7-4.4) for DDS and 3.49 (95% CI: 2.2-5.5) and 2.74 (95% CI: 1.8-5.2) for MAD in the 9-11 month and 16-18-month age groups, respectively. However, there was no significant improvement in growth or reduction in the prevalence of anemia. The intervention was effective in improving the feeding practices of children although it failed to show significant improvement in linear growth of children at 18 months of age.

Evaluation of a Package of Behaviour Change Interventions (Baduta Program) to Improve Maternal and Child Nutrition in East Java, Indonesia: Protocol for an Impact Study.

BACKGROUND: Over the past decade, the prevalence of stunting has been close to 37% in children aged <5 years in Indonesia. The Baduta program, a multicomponent package of interventions developed by the Global Alliance for Improved Nutrition, aims to improve maternal and infant nutrition in Indonesia. OBJECTIVE: This study aims to assess the impact of the Baduta program, a package of health system strengthening and behavior change interventions, compared with the standard village health services on maternal and child nutrition. METHODS: The impact evaluation uses a cluster randomized controlled trial design with 2 outcome assessments. The first uses cross-sectional surveys of mothers of children aged 0-23 months and pregnant women before and after the interventions. The second is a cohort study of pregnant women followed until their child is 18 months from a subset of clusters. We will also conduct a process evaluation guided by the program impact pathway to assess coverage, fidelity, and acceptance. The study will be conducted in the Malang and Sidoarjo districts of East Java, Indonesia. The unit of randomization is the subdistricts. As random allocation of interventions to only 6 subdistricts is feasible, we will use constrained randomization to ensure balance of baseline covariates. The first intervention will be health system strengthening, including the Baby-Friendly Hospital Initiative, and training on counseling for appropriate infant and young child feeding (IYCF). The second intervention will be nutrition behavior change that includes Emo-Demos; a national television (TV) advertising campaign; local screening TV spots; a free, text message service; and promotion of low-cost water filters and hygiene practices. The primary study outcome is child stunting (low length-for-age), and secondary outcomes include length-for-age Z scores, wasting (low weight-for-length), anemia, child morbidity, IYCF indicators, and maternal and child nutrient intakes. The sample size for each cross-sectional survey is 1400 mothers and their children aged <2 years and 200 pregnant women in each treatment group. The cohort evaluation requires a sample size of 340 mother-infant pairs in each treatment group. We will seek Gatekeeper consent and written informed consent from the participants. The intention-to-treat principle will guide our data analysis, and we will apply Consolidated Standards of Reporting Trials guidelines for clustered randomized trials in the analysis. RESULTS: In February 2015, we conducted a baseline cross-sectional survey on 2435 women with children aged <2 years and 409 pregnant women. In February 2017, we conducted an end-line survey on 2740 mothers with children aged <2 years and 642 pregnant women. The cohort evaluation began in February 2015, with 729 pregnant women, and was completed in December 2016. CONCLUSIONS: The results of the program evaluation will help guide policies to support effective packages of behavior change interventions to prevent child stunting in Indonesia. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR1-10.2196/18521.

Health Care-Seeking Behavior of Children With Acute Respiratory Infections Symptoms: Analysis of the 2012 and 2017 Indonesia Demographic and Health Surveys.

Our study examined factors associated with the utilization of health services in children younger than 5 years with acute respiratory infections (ARIs) symptoms in Indonesia. Data were derived from the 2012 and 2017 Indonesia Demographic and Health Survey. Information from 1408 children younger than 5 years showing ARI symptoms in the past 2 weeks before the survey was analyzed using logistic regression analyses. Around 25% of children younger than 5 years with ARI symptoms did not receive medical care. The odds of receiving care increased in mothers from rich households. The odds reduced in children aged 2 or more years; children of mothers not assisted by trained delivery attendants; mothers attending none or <4 antenatal visits; mothers delivering at home, and mothers reporting that permission to visit health services was a problem. Efforts to improve care-seeking behavior are required. Health promotion strategies and interventions to improve access to reach community not regularly exposed to health services are important.

Determinants of the Stunting of Children Under Two Years Old in Indonesia: A Multilevel Analysis of the 2013 Indonesia Basic Health Survey.

Indonesia is ranked fifth among countries with the highest burden of stunting in children under five. This study aims to examine the determinants of stunting in children aged 0-2 years in Indonesia using data derived from the 2013 Indonesia Basic Health Survey. Twenty potential predictors of stunting, categorized into household and housing characteristics; maternal and paternal characteristics; antenatal care services and child characteristics were analyzed. Multilevel analyses were performed to examine the role of cluster/district/provincial differences, as well as individual/household level characteristics and stunting status. Of 24,657 children analyzed, 33.7% (95%CI: 32.8%-34.7%) were stunted. The odds of stunting increased significantly among children living in households with three or more children under five-years-old (aOR = 1.33, 95%CI: 1.03-1.72), households with five to seven household members (aOR =1.11; 95%CI: 1.03-1.20), children whose mothers during pregnancy attended less than four antenatal care services (aOR = 1.22, 95%CI: 1.08-1.39), boys (aOR = 1.33, 95%CI: 1.22-1.45), children aged 12-23 months (aOR = 1.89; 95%CI: 1.54-2.32), and children who weighed <2500 g at birth (aOR = 2.55; 95%CI: 2.05-3.15). The odds also increased significantly with the reduction of household wealth index. Integrated interventions to address environment, an individual level associated with stunting in Indonesia, from the environment- to individual-level factors are important.

Assessing knowledge about lymphatic filariasis and the implementation of mass drug administration amongst drug deliverers in three districts/cities of Indonesia.

BACKGROUND: This research assesses knowledge amongst drug deliverers about the implementation of mass drug administration (MDA) for lymphatic filariasis (LF) in Agam District (West Sumatera Province), the City of Depok (West Java Province) and the City of Batam (Kepulauan Riau Province), Indonesia. METHODS: A cross-sectional survey was conducted from January to March 2015 at these three sites. Respondents were identified using purposive sampling (i.e. cadre, health worker or community representatives). A total of 318 questionnaires were accepted for analysis. Three outcomes were assessed: knowledge about LF; knowledge about MDA implementation; and was informed about MDA coverage. Logistic regression analyses were employed to examine factors associated with these three outcomes. RESULTS: Less than half of respondents were charactersised as having a high level of LF knowledge and less than half a high level of knowledge about MDA. The odds of having a high level of knowledge of LF was significantly lower in Batam City than Agam District, yet higher amongst health workers than cadres. Deliverers living in urban areas reported more feedback on MDA outcomes than in the rural district. Health workers received more feedback than cadres (P < 0.001). Deliverers perceived the difference between coverage (drug receipt) and compliance (drug ingestion) in the community. CONCLUSIONS: There are variations in knowledge about LF and MDA as well as feedback across drug deliverers in MDA across geographical areas. Adaptation of the MDA guidelines, supportive supervision, increasing the availability of supporting materials and directly-observed therapy might be beneficial to improve coverage and compliance in all areas.

Poor Knowledge and Nonuse of Long-Acting/Permanent Methods of Contraceptives in Six Districts in Indonesia.

This analysis aimed at examining the association between the level of knowledge about long-acting/permanent methods of contraceptives (LAPM) and nonuse of LAPM among currently married, nonpregnant, and fecund women aged 15 to 49 years intending to limit childbearing. Data were derived from a cross-sectional study in Tuban, Kediri, and Lumajang District (East Java Province) and Lombok Barat, Lombok Timur, and Sumbawa District (Nusa Tenggara Barat Province) in June 2012. Information was obtained from 4323 respondents. Using multivariate logistic regression, we found that women with moderate levels of LAPM knowledge were less likely to use LAPM than women with high levels of knowledge (adjusted odds ratio [aOR] = 2.01, 95% CI = 1.51-2.68). Women with low level of LAPM knowledge were less likely to use LAPM than women with high levels of knowledge (aOR = 4.25, 95% CI = 3.37-5.36). Efforts to strengthen counseling services and increased provider knowledge and counselling skills are important to improve women's knowledge about and use of LAPM.

Increasing the uptake of long-acting and permanent methods of family planning: A qualitative study with village midwives in East Java and Nusa Tenggara Barat Provinces, Indonesia.

OBJECTIVE: this analysis aims to explore midwives' insights into the provision of long-acting and permanent methods of contraception (LAPMs) in the selected areas of East Java and Nusa Tenggara Barat (NTB) Provinces, Indonesia. DESIGN: a qualitative study using in-depth interviews was conducted with 12 village midwives from 12 villages, to explore their perceptions and experiences in delivering family planning services. SETTING: the study was carried out in May-June 2013, as part of the baseline assessment in the Improving Contraceptive Method Mix (ICMM) study. We interviewed 12 village midwives working in 12 villages in six study districts: Tuban, Kediri, and Lumajang Districts in East Java Province; and Lombok Barat, Lombok Timur, and Sumbawa Districts in NTB Province. MEASUREMENT: an interview guideline was used in all interviews. It covered several topics, such as community perceptions of LAPMs, availability of contraception and related equipment, availability of human resources, and midwives' efforts to improve LAPM coverage. All interviews were recorded and transcribed. Content and thematic analyses were carried out by grouping and coding the information based on the identified themes and topics. FINDINGS: according to village midwives interviewed in this study, community-level acceptance of LAPMs has increased over time; however, some still prefer using short-acting methods for a long period. The reasons include lack of awareness about the benefits and side effects of LAPMs, fear of surgical procedures, rumored consequences (for example, that LAPMs would limit women's ability to perform hard physical labor), and religious beliefs. There were several challenges reported by village midwives in delivering LAPM services, such as confusion about midwives' eligibility to provide LAPM services, lack of Contraceptive Technology Update (CTU) and counseling trainings, and shortage of supporting equipment (such as exam tables and IUD and implant insertion kits). There were several strategies implemented by village midwives to improve LAPM use, including strengthening the counseling services, accompanying clients to higher health facilities to obtain LAPM services, and providing services for groups of clients. All village midwives emphasized the importance of strengthening collaboration among stakeholders to increase the uptake of LAPM services. KEY CONCLUSIONS: as midwives are the main family planning providers in Indonesia, efforts to address their challenges is essential. Enabling a supportive policy environment, strengthening promotional activities, increasing the number of training programs designed for village midwives-in addition to enhancing inter-sectoral collaboration-are some recommendations to improve LAPM uptake in study areas.

Improving Coverage and Compliance in Mass Drug Administration for the Elimination of LF in Two 'Endgame' Districts in Indonesia Using Micronarrative Surveys.

BACKGROUND: As the Global Programme to Eliminate Lymphatic Filariasis (LF) approaches its 2020 goal, an increasing number of districts will enter the endgame phase where drug coverage rates from mass drug administration (MDA) are used to assess whether MDA can be stopped. As reported, the gap between reported and actual drug coverage in some contexts has overestimated the true rates, thus causing premature administration of transmission assessment surveys (TAS) that detect ongoing LF transmission. In these cases, districts must continue with additional rounds of MDA. Two districts in Indonesia (Agam District, Depok City) fit this criteria-one had not met the pre-TAS criteria and the other, had not passed the TAS criteria. In both cases, the district health teams needed insight into their drug delivery programs in order to improve drug coverage in the subsequent MDA rounds. METHODOLOGY/PRINCIPAL FINDINGS: To inform the subsequent MDA round, a micronarrative survey tool was developed to capture community members' experience with MDA and the social realm where drug delivery and compliance occur. A baseline survey was implemented after the 2013 MDA in endemic communities in both districts using the EPI sampling criteria (n = 806). Compliance in the last MDA was associated with perceived importance of the LF drugs for health (p<0.001); perceived safety of the LF drugs (p<0.001) and knowing someone in the household has complied (p<0.001). Results indicated that specialized messages were needed to reach women and younger men. Both districts used these recommendations to implement changes to their MDA without additional financial support. An endline survey was performed after the 2014 MDA using the same sampling criteria (n = 811). Reported compliance in the last MDA improved in both districts from 57% to 77% (p<0.05). Those who reported having ever taken the LF drug rose from 79% to 90% (p<0.001) in both sites. CONCLUSIONS/SIGNIFICANCE: Micronarrative surveys were shown to be a valid and effective tool to detect operational issues within MDA programs. District health staff felt ownership of the results, implementing feasible changes to their programs that resulted in significant improvements to coverage and compliance in the subsequent MDA. This kind of implementation research using a micronarrative survey tool could benefit underperforming MDA programs as well as other disease control programs where a deeper understanding is needed to improve healthcare delivery.

Healthcare-seeking behaviors for acute respiratory illness in two communities of Java, Indonesia: a cross-sectional survey.

Understanding healthcare-seeking patterns for respiratory illness can help improve estimations of disease burden and inform public health interventions to control acute respiratory disease in Indonesia. The objectives of this study were to describe healthcare-seeking behaviors for respiratory illnesses in one rural and one urban community in Western Java, and to explore the factors that affect care seeking. From February 8, 2012 to March 1, 2012, a survey was conducted in 2520 households in the East Jakarta and Bogor districts to identify reported recent respiratory illnesses, as well as all hospitalizations from the previous 12-month period. We found that 4% (10% of those less than 5years) of people had respiratory disease resulting in a visit to a healthcare provider in the past 2weeks; these episodes were most commonly treated at government (33%) or private (44%) clinics. Forty-five people (0.4% of those surveyed) had respiratory hospitalizations in the past year, and just over half of these (24/45, 53%) occurred at a public hospital. Public health programs targeting respiratory disease in this region should account for care at private hospitals and clinics, as well as illnesses that are treated at home, in order to capture the true burden of illness in these communities.

Factors associated with not using antenatal iron/folic acid supplements in Indonesia: the 2002/2003 and 2007 Indonesia Demographic and Health Survey.

BACKGROUND: This analysis examined factors associated with non-use of antenatal iron/folic acid supplements in Indonesia. METHODS: Data from the 2002/2003 and 2007 Indonesia Demographic and Health Surveys (IDHS) were used, providing survival information for 26,591 most recent deliveries over the five-year period prior to each survey. The main outcome variable was non-use of iron/folic acid supplements. Using logistic regression, we examined the role of external environment, predisposing, enabling, need factors, and previous utilization of other maternal care services in non-use of antenatal iron/folic acid supplements. RESULTS: Mothers from outer Java- Bali Region and rural areas (OR=1.73, 95% CI: 1.48-2.03) had increased odds for not using antenatal iron/folic acid supplements. The likelihood for not using the supplements increased with the reduction of household wealth index and parental education. The odds increased amongst mothers with low autonomy on her own health care (OR=1.24, 95% CI: 1.04-1.49), high birth-rank infants, mothers with low knowledge of obstetric complications and low exposure to mass media. Enabling factors associated with increased odds for non-use of iron/folic acid supplements included mothers reporting money to pay health services (OR=1.28, 95% CI: 1.13- 1.44) and distance to health services (OR=1.20, 95% CI: 1.02-1.40) were major problems. Our study demonstrated the importance of antenatal care as a distribution channel of the supplements. CONCLUSIONS: Increasing community awareness, coverage and access to health services along with strengthening counselling sessions during antenatal care and community participation in health programs are necessary to improve the uptake of iron/folic acid supplements, to increase infant survival in Indonesia.