Vaccine hesitancy and equity: lessons learned from the past and how they affect the COVID-19 countermeasure in Indonesia.

INTRODUCTION: Indonesia has made progress in increasing vaccine coverage, but equitable access remains challenging, especially in remote areas. Despite including vaccines in the National Immunization Program (NIP), coverage has not met WHO and UNICEF targets, with childhood immunization decreasing during the COVID-19 pandemic. COVID-19 vaccination has also experienced hesitancy, slowing efforts to end the pandemic. SCOPE: This article addresses the issue of vaccine hesitancy and its impact on vaccination initiatives amidst the COVID-19 pandemic. This article utilizes the vaccine hesitancy framework to analyze previous outbreaks of vaccine-preventable diseases and their underlying causes, ultimately providing recommendations for addressing the current situation. The analysis considers the differences between the pre-pandemic circumstances and the present and considers the implementation of basic and advanced strategies. KEY FINDINGS AND CONCLUSION: Vaccine hesitancy is a significant challenge in the COVID-19 pandemic, and public health campaigns and community engagement efforts are needed to promote vaccine acceptance and uptake. Efforts to address vaccine hesitancy promote trust in healthcare systems and increase the likelihood of individuals seeking preventive health services. Vaccine hesitancy requires a comprehensive, culturally sensitive approach that considers local contexts and realities. Strategies should be tailored to specific cultural and societal contexts and monitored and evaluated.

CONSUMER EXPECTATION ON SERVICE QUALITY PROVIDE BY PHARMACIST IN SELF MEDICATION PRACTICES AND ITS ASSOCIATED FACTORS IN BANDUNG, INDONESIA.

Self-medication is the use of medicines for therapeutic intent without a clinician's advice or prescription. The National Socioeconomic Survey for Indonesia in 2009 found the percentage of the Indonesians engaging in self-medication is increasing. The objectives of this study were to assess consumers' expectations regarding service quality provide by pharmacist in self-medication practices and determine the factors associated with self-medication in Bandung, Indonesia. We conduct a cross-sectional survey at eight randomly selected community pharmacies during July-November 2012 and purposely sampled 1,200 costumers purchasing medication at those sites. Subjects reported they understood the information about the medicines given by the pharmacist but still wanted more information and time to consult with the pharmacist about their medicines. Factors associated with self-medication were younger age, male gender, greater education and lower income. The intervention is needed to improve appropriate self-medication.

Impact of COVID-19 Pandemic on Routine Childhood Immunization Programs in Indonesia: Taking Rural and Urban Area into Account.

Background: To date, the primary global concern has revolved around addressing the COVID-19 pandemic. However, there is a growing awareness of the pandemic's secondary impacts on critical aspects of healthcare, such as childhood immunization programs. Objective: This study aims to assess the impact of the COVID-19 pandemic on childhood immunization programs in Indonesia, with a specific focus on performance disparities between rural and urban areas. It considers factors like access, utilization, and program workload. Methods: Data were collected from primary health cares (PHCs) in two regions in West Java Province, Indonesia, representing rural and urban areas. A descriptive analysis was conducted to compare vaccination coverage, drop-out rates, and the ratio of vaccinators per dose from 2019 to 2021 in 40 and 22 PHCs for rural and urban areas, respectively. A general linear model was employed to evaluate the differences in these parameters over the three consecutive years. Results: The results indicate fluctuations in vaccine coverage over the three years, with the most significant impact observed in 2020, particularly in rural areas. Statistical analysis revealed a significant difference in routine immunization coverage, drop-out rates, and vaccinator ratios between rural and urban areas from 2019 to 2021 (p<0.05). In 2021, both rural and urban areas displayed significant differences in performance parameters for routine immunization and COVID-19 vaccination (p<0.05), except in terms of coverage for IPV and COVID-19 vaccination. Conclusion: The study highlights a reduction in routine immunization coverage during the pandemic, a concerning issue that increases the risk of vaccine-preventable diseases, particularly in rural areas.

Comprehensive childhood vaccination and its determinants: Insights from the Indonesia Family Life Survey (IFLS).

BACKGROUND: Immunization is the most effective intervention for reducing morbidity and mortality rates associated with vaccine-preventable diseases. Despite the Indonesian government's inclusion of several childhood vaccinations in the national immunization program (NIP), the number of unvaccinated or partially vaccinated children remains high. This observational study aimed to determine the completeness of childhood immunization and the factors influencing it in Indonesia. METHODS: Data were extracted from the fifth wave of the Indonesia Family Life Survey (IFLS). The sample (n = 16,236) consists of children residing in 13 provinces, representing over 80% of Indonesia's population. The difference between groups was tested using the chi-square test. Logistic regression was performed to identify the variables associated with the completeness of basic immunization. Immunization is categorized as complete when children have received all the mandatory vaccines recommended by the Ministry of Health. We examined and compared the results using complete case analysis, inverse probability weighting, and multiple imputations. RESULTS: The highest percentages of complete vaccinations were polio, tuberculosis, and DPT. Children who live in Sumatera and Kalimantan were more likely to be fully immunized, with ORs of 0.6 (95%CI 0.48-0.74) and 0.54 (0.37-0.80), respectively. Children who live in urban areas, have mothers who received the tetanus vaccine during pregnancy, have mothers with a higher level of education and health insurance, have fathers aged 41-50, and live with a large number of family members were more likely to be fully immunized (p < 0.05). CONCLUSION: Socioeconomic determinants were strongly correlated with the completeness of childhood vaccination in Indonesia.

Public knowledge, attitudes, and practices during the first wave of COVID-19 in Indonesia.

Background: The COVID-19 pandemic became a global emergency, and it is vital to understand the knowledge, attitudes, and practices of populations regarding this disease to prevent its spread. Objective: The study aimed to investigate the knowledge, attitudes, and practices of the Indonesian public toward COVID-19. Methods: An observational study was conducted in Indonesia between November 2020 and January 2021. The study employed a validated questionnaire with 391 respondents to the survey. A comparative analysis was performed to assess the mean differences in respondents' characteristics in terms of their knowledge, attitude, and practice scores. Furthermore, regression analysis was used to investigate those factors associated with the good practice of health protocols during the COVID-19 pandemic. Results: The findings showed significant differences in the average knowledge scores across gender, geographical location, and educational attainment. Furthermore, significant differences in practices were identified in terms of gender and educational attainment. The findings of the study indicate that the participants demonstrated a significant awareness of COVID-19, as evidenced by their high mean knowledge score of 17.83 ± 1.74 out of a possible total score of 22 points. The results indicate that the respondents exhibited a positive attitude toward COVID-19 prevention measures, as evidenced by an attitude score of 26.95 ± 3.14 out of a possible total score of 30 points. Additionally, the mean score for good practice in health protocols aimed at reducing COVID-19 infection was found to be high (4.23 ± 0.96) at 5 points. This suggests that the study participants had already adopted effective measures to comply with the recommended health guidelines. The results of the regression analysis indicated that gender, level of education, and knowledge were statistically significant predictors for adherence to health protocols during the COVID-19 pandemic (p < 0.05). Conclusion: The aforementioned results offer significant perspectives into the populace's comprehension, disposition, and conduct regarding COVID-19 in Indonesia. These insights could potentially contribute to the formulation of efficacious measures aimed at curtailing transmission of the virus.

Understanding Public Knowledge and Behavior Regarding Antibiotic Use in Indonesia.

Background: Inappropriate use of antibiotics is a prominent factor contributing to the development of antibiotic resistance, which subsequently increases healthcare costs and heightens mortality rates. Objective: This study sought to evaluate the level of knowledge and behavior pertaining to antibiotic usage within the Indonesian population. Methods: This observational study was conducted in Indonesia between December 2019 and June 2020 and employed a validated questionnaire to survey 582 respondents. A comparative analysis was performed to investigate the differences in mean scores across various respondent characteristics, specifically related to their knowledge and practice regarding antibiotic usage. Regression analysis was used to identify the factors influencing the adoption of appropriate behavior in antibiotic utilization. Results: Study participants comprised 68.2% males and 31.8% females. Participants achieved an average score of 4.86 ± 2.40 out of eight points for knowledge and behavior with an average score of 5.29 ± 1.85 out of seven points. Approximately 57.7% and 56.0% of the respondents have knowledge and behavior scores above the average score of the total population, respectively. The findings indicated notable variations in average knowledge scores associated with educational attainment and employment status regarding antibiotic use. Similarly, differences were observed in gender and employment status concerning behavior. Regression analysis highlighted that employment status, trust in physicians, and possessing sound knowledge of antibiotic usage were significant predictors of good behavior in utilizing antibiotics. Some misconceptions were identified, such as using antibiotics to kill viruses and believing antibiotics are effective for any kind of disease. Conclusion: Less than 60% of the respondents have knowledge and behavior scores above the average score of the total population; however, there are some misconceptions regarding antibiotic utilization. This underscores the importance of implementing targeted strategies, such as health education and public health campaigns, to improve the population's understanding of the correct antibiotic use.

Parents' Knowledge, Attitude, and Practice on Childhood Vaccination During the COVID-19 Pandemic in Indonesia.

BACKGROUND: Vaccination is known to have an enormous impact on improving child health. In Indonesia, the government has included several vaccines in the national immunization program. OBJECTIVE: This study aimed to investigate parents' knowledge, attitude, and practice on childhood immunization during the COVID-19 pandemic in Indonesia. METHODS: A valid and reliable questionnaire was delivered to approximately 276 parents in Jakarta and Bandung, representing the epicenter of the pandemic. This study was conducted from June 2020 to February 2021. The correlations between parents' knowledge, attitudes, and practice with the characteristics of the respondents were investigated. In addition, multiple regression analysis was performed to identify the variables associated with good vaccination practice. RESULTS: The results showed that the mean scores of parents' knowledge, attitude, and practice on childhood vaccinations were 7.22 (± 1.30) out of 9 points, 3.93 (± 0.31) out of 4 points, and 3.59 (± 0.97) out of 5 points, respectively. Respondents graduated from university were more knowledgeable than those graduated from senior high school (p-value <0.05). Employed participants had better scores in knowledge and practice, compared to unemployed participants (p-value <0.05). CONCLUSION: In conclusion, this study found positive correlations between participants' knowledge and attitude, knowledge and practice, and attitude and practice on childhood vaccination during the COVID-19 pandemic in Indonesia.

Cost-Effectiveness Analysis of Chemoradiation and Radiotherapy Treatment for Stage IIB and IIIB Cervical Cancer Patients.

PURPOSE: Cervical cancer is the second most common type of cancer and cause of death from cancer in Indonesia. In 2013, cervical cancer was the most prevalent cancer in Indonesia, with a rate of 0.8 per 1000 women. Based on the National Guidelines for Cervical Cancer Medical Services in Indonesia, the recommended therapy for stages IIB-IIIB cervical cancer is chemoradiation or radiotherapy. This study aimed to evaluate the cost-effectiveness of chemoradiation and radiotherapy for treating stage IIB-IIIB cervical cancer in a national referral hospital in Indonesia. PATIENTS AND METHODS: A cross-sectional study from a healthcare perspective using retrospective patient data was conducted. The included patients had stage IIB-IIIB registered cervical cancer, were in the hospital between January 1, 2015 and December 31, 2017, received chemoradiation or radiotherapy, were ≥18 years old, and had complete clinical data and detailed cost of therapy data. The incremental cost-effectiveness ratio (ICER) were calculated, and a sensitivity analysis was performed. RESULTS: The average treatment cost per patient was $2944 and $3231 for radiotherapy and chemoradiation, respectively. Despite the fact that the treatment effectiveness of chemoradiation (69.1%) was considered to be higher than that of radiotherapy (63.2%), chemoradiation had more potential side effects than radiotherapy. In a comparison with radiotherapy, the ICER of chemoradiation was $48.6 per complete response rate. Additionally, the cost of radiotherapy was the most influential parameter impacting the ICER. CONCLUSION: Chemoradiation was considered to be more costly than radiotherapy. Additionally, the effectiveness of chemoradiation was higher than that of radiotherapy. A cost utility analysis (CUA) is required for further investigation.

Cost-Effectiveness Analysis of Sacubitril/Valsartan Compared to Enalapril for Heart Failure Patients in Indonesia.

OBJECTIVE: Sacubitril/valsartan is a relatively new medication that is more effective than the usual enalapril for heart failure patients with reduced ejection fraction. Therefore, this study aims to determine the cost-effectiveness of sacubitril/valsartan compared to enalapril in Indonesia's healthcare system. METHODS: In this study, a Markov decision-analytic model was developed to estimate the total cost, health outcomes, and cost-effectiveness of sacubitril/valsartan compared to enalapril from Indonesia's healthcare perspective. The input parameters for the cost-effectiveness were predominantly from the PARADIGM-HF trial. Subsequently, the country-specific data were synthesized for medication and hospitalization costs, cardiovascular and non-cardiovascular death, as well as re-hospitalization rate. The incremental cost-effectiveness ratio (ICER) per quality-adjusted life years (QALYs) gained was estimated to determine the cost-effectiveness. Deterministic and probabilistic sensitivity analyses were conducted to assess the impact of parameter uncertainty. RESULTS AND DISCUSSION: In the base case, sacubitril/valsartan was more costly and effective than enalapril with a total cost of IDR 91,783,325,865 (USD 6,487,522) vs IDR 68,101,971,241 (USD 4,813,653) and a total QALYs of 19,680 vs 18,795, resulting in an ICER of IDR 26,742,098 (USD 1890). Based on the willingness to pay threshold GDP per capita in Indonesia, it can be considered cost-effective. The most influential drivers of cost-effectiveness in deterministic sensitivity analysis were risk of mortality outside hospitalization, hospital admission rate, and cost of sacubitril/valsartan. The vast majority of simulation results from probabilistic analysis suggested that sacubitril/valsartan was likely resulted in higher cost and improved QALYs compared with enalapril, indicating the robustness of the model. CONCLUSION: Based on the current price in Indonesia, sacubitril/valsartan can be considered a cost-effective option, although this depends heavily on the willingness to pay threshold. Further studies that incorporate real-world evidence with sacubitril/valsartan are needed to inform the decision-making process.

Cost-Effectiveness Analysis of Type 2 Diabetes Mellitus (T2DM) Treatment in Patients with Complications of Kidney and Peripheral Vascular Diseases in Indonesia.

Type 2 diabetes mellitus (T2DM) is a chronic disease with high-cost treatment. This study aimed to analyze the cost-effectiveness of T2DM treatment in hospitalized patients with complications of kidney and peripheral vascular disease (PVD) in Indonesia by focusing on patients of Health Social Security Agency (BPJS Kesehatan). An observational study was applied by collecting data retrospectively from patients' medical record at the biggest public hospital in West Java Province, Indonesia. Two perspectives of payer and healthcare provider were applied to estimate the treatment cost. We considered following inclusion criteria: (i) Hospitalized T2DM patients without complication, with complications of kidney and PVD during 2014-2017; (ii) member of BPJS Kesehatan; (iii) >18 years old patients; and (iv) patients with complete medical record data. The results showed that the majority patients were female (56.72%), 45-64 years old (69.40%), and had a length of stay at 4-10 days (54.48%). The greatest contributions in the total treatment cost were found to be hospital room, medical services and medicines for the treatment of T2DM without complications, with complications of kidney and PVD, respectively. From the perspective of payer, the incremental cost-effectiveness ratios (ICERs) of T2DM treatment with complications of kidney and PVD would be IDR 215,723 and IDR 234,591 per 1 mg/dL blood glucose reduction, respectively. From the perspective of healthcare provider, the ICERs of T2DM treatment with complications of kidney and PVD would be IDR 166,289 and IDR 681,853 per 1 mg/dL blood glucose reduction in both perspectives (1 US$ = IDR 13,451). In a comparison with T2DM without complication, reducing 1 mg/dL blood glucose in T2DM treatment with complication of PVD would require higher cost than in T2DM treatment with complication of kidney from both perspectives.

Cost-Effectiveness of Ferrous Fumarate-Folic Acid and Ferrous Gluconate-Multivitamins in a High Prevalence Area of Iron Deficiency Anemia in Indonesia.

BACKGROUND: Up to now, the combinations of ferrous fumarate-folic acid (FF-FA) and ferrous gluconate-multivitamins (FG-MV) have been implemented by the local government in the province of Papua. Nevertheless, there is no a specific economic evaluation that has been applied to investigate the cost-effectiveness of FF-FA and FG-MV. OBJECTIVE: This study aimed to investigate the cost-effectiveness of FF-FA and FG-MV to be implemented in Teluk Bintuni, as one of the districts with the highest prevalence of iron deficiency anemia in Papua by taking the healthcare perspective into account. METHODS: A prospective observational study was applied by considering two groups of women (15-49 years old) with iron deficiency anemia who received FF-FA and FG-MV from September to November 2018. Applying a purposive sampling method, respondents were selected from 875 targeted women in six sub-districts, who met inclusion criteria. To estimate the total cost, we applied a healthcare perspective that considered direct medical cost only (eg, the procurement cost of iron tablets, cost of Hb test, and cost of healthcare visit). To estimate the effectiveness of intervention, we applied two major parameters, such as Hb level and utility score in quality-adjusted life year (QALY). The cost-effectiveness values were evaluated by using the criteria on the cost-effectiveness of healthcare intervention according to the threshold of gross domestic product (GDP) per capita (cost per QALY gained). RESULTS: From 875 targeted women in six sub-districts who met inclusion criteria, we found approximately 222 women with moderate-severe iron deficiency anemia and 110 women with complete data in the group of FF-FA (n=69) and FG-MV (n-41). The results showed that there were significant differences (p-value <0.05) on the number of respondents, age, oral iron cost, total healthcare cost and utility score in both intervention groups. Comparing the use of FG-MV with FF-FA, we estimated the incremental cost-effectiveness ratios (ICERs) would be $255.77 per controlled patient, $142.09 per patient with Hb increment >2.00 g/dL, $79.93 per patient with Hb increment >1.00 g/dL, and $11.59 per QALY gained. CONCLUSION: The ICER was estimated to be $11.59 per QALY gained, which was highly cost-effective, according to GDP-based cost-effectiveness threshold. In addition, the utility score of women with iron deficiency anemia was considered to be the most influential factor impacting the cost-effectiveness value.

Knowledge, Attitude, and Practice During the COVID-19 Pandemic: A Review.

The World Health Organization declared the novel coronavirus (COVID-19) outbreak a global pandemic on March 11, 2020 due to its rapid spread on a global scale. More than 118,000 cases had been reported in 114 countries, and mortality had reached a total of 4291. Scholars have suggested that the level of panic is correlated with knowledge and attitude among the population. This review presents a summary of knowledge, attitude, and practice during the COVID-19 pandemic among healthcare workers, medical students, and populations in the US, the UK, Italy, Jordan, and China in April 2020. Analysis reveals that the level of the knowledge was positive in general, and optimistic attitudes and good practices are held. Utility of substantial knowledge and positive attitudes and practices hopefully can control the spread of COVID-19.

Perceptions, Knowledge, and Attitude Toward Mental Health Disorders and Their Treatment Among Students in an Indonesian University.

PURPOSE: To identify perception, knowledge, and attitudes toward mental health disorders and their treatment among students in a university in West Java, Indonesia. METHODS: A cross-sectional study which measures perceptions, knowledge, and attitudes of 427 university students using convenience sampling through a 53-item self-administered questionnaire was conducted in January 2020. Either a chi-square test or the Kruskal-Wallis test was employed to analyze the association between student characteristics and variables. Furthermore, Spearman rank correlation coefficient was utilized to evaluate the relationship between variables. RESULTS: A total of 51.29% students had negative perceptions, 50.23% had good knowledge, and 52.46% had positive attitudes toward mental disorders and their treatment. The differences in the experience of visiting a psychologist or psychiatrist were associated with perceptions (P<0.01), knowledge (P<0.01), and attitudes (P<0.01). A positive correlation was observed between perception and attitude (r=0.56; P<0.01) and between knowledge and attitude (r=0.24; P<0.01). The students obtained most information about mental health from social media (92.74%). CONCLUSION: Students demonstrated good knowledge and positive attitude toward mental health disorders. However, some continue to hold negative perceptions regarding approaching someone with a mental disorder, encouraging doubt and fear. Health promotion about mental health disorders and their treatment must be conducted to increase positive perceptions, good knowledge, and positive attitudes of the students. Social media tools can be considered to enhance mental health promotion and prevention of mental health problems.

Medication Profile and Treatment Cost Estimation Among Outpatients with Schizophrenia, Bipolar Disorder, Depression, and Anxiety Disorders in Indonesia.

PURPOSE: The present retrospective study aimed to determine the medication profile and estimate the treatment costs from medical records of new outpatients with schizophrenia, bipolar disorder, depression, and anxiety disorders from a healthcare perspective at a national referral hospital in Indonesia from 2016 to 2018. METHODS: Medical records (including medical and administrative data) of 357 new outpatients with schizophrenia, bipolar disorder, depression, or anxiety disorders were collected from the hospital information system. The records of new outpatients with schizophrenia, bipolar disorder, depression, or anxiety disorders aged >18 years and had only received drugs for treatment were included. The medication profile was descriptively assessed, and estimated costs were calculated based on direct costs from a healthcare perspective. RESULTS: Overall, 173 medical records were further analyzed. The main drugs administered to the new outpatients were atypical and typical antipsychotics for schizophrenia, atypical antipsychotics and mood stabilizers for bipolar disorder, antidepressants and atypical antipsychotics for depression, and antidepressants and benzodiazepines for anxiety disorders. The average annual treatment costs per patient were IDR 3,307,931 (USD 236) for schizophrenia, IDR 17,978,865 (USD 1,284) for bipolar disorder, IDR 1,601,850 (USD 114) for depression, and IDR 1,190,563 (USD 85) for anxiety disorders. CONCLUSION: The most commonly prescribed drugs for schizophrenia were haloperidol and risperidone; for bipolar disorders, sodium divalproex and risperidone; for depression, fluoxetine and sertraline; and for anxiety disorders, sertraline and lorazepam. Considering the high prevalence and estimated treatment costs for mental disorders, special attention is required to prevent an increase in their prevalence in Indonesia.