Association of soybean-based food with the prevalence of anaemia among reproductive-aged men and women in rural Central Java, Indonesia.

OBJECTIVE: To assess the association between soybean consumption and anaemic status in Central Java, Indonesia. DESIGN: As part of an overarching sanitation improvement intervention in Central Java, Indonesia, we conducted a cross-sectional study in four rural villages. The study consisted of a 24-h food recall, anthropometric measurements, blood Hb measurement and stool sampling to test for soil-transmitted helminth (STH) infection status. A binary logistic regression model was fitted to test the association between soybean consumption and anaemic status after adjusting for socio-demographic factors, STH infection, dietary diversity and anthropometric status. SETTING: This study took place in four rural villages of Wonosobo regency, Central Java, Indonesia. PARTICIPANTS: Participants were rural villagers aged between 15 and 49 years. RESULTS: A total sample size of 763 was attained, of which 231 were anaemic. The prevalence of anaemia was 30·2 % among men and women of reproductive age, and highest among young males. Consumption of soybean was high (79·8 %). After adjusting for covariates, the protective association between soybean consumption and anaemia was statistically significant (AOR = 0·53, 95 % CI = 0·30, 0·95, P < 0·05). There was a positive association with anaemia among underweight (AOR = 2·75, 95 % CI = 1·13, 6·69, P < 0·05) and those with high diet diversity (AOR = 1·40, 95 % CI = 1·00, 1·97, P < 0·05). CONCLUSIONS: Our results were consistent with studies from other countries finding a protective association between soybean consumption and anaemia. This association appeared stronger for tofu than for tempeh. The prevalence of anaemia in rural Central Java is relatively consistent with nation-wide statistics indicating that interventions targeting anaemia are still largely required.

The double burden of malnutrition and dietary patterns in rural Central Java, Indonesia.

BACKGROUND: Indonesia is undergoing a nutrition transition (NT) comprised of rising rates of overweight/obesity and consumption of high fat food/snacks but is still struck by undernutrition, causing a double burden of malnutrition. Little research pertains to the double burden of malnutrition and its associations with diet in rural Indonesia using primary village level data. METHODS: We conducted a 24-hour food recall and food frequency questionnaire and assessed anthropometric status of rural villagers from four villages in Central Java, Indonesia. Exploratory principal component analysis was used to identify dietary patterns and multi-level modeling was performed to identify variables associated with dietary pattern indicative of the NT. FINDINGS: 1,521 participants were included in analysis. Double burden of malnutrition was prevalent whereby 32.3% of children were stunted, 68.8% of women 35-49 years-old were overweight, and 39% of homes were classified as double burden. The NT was evident in a dietary pattern associated with soft drink, snacks, and animal products. There was small but significant correlation between undernutrition and stunting status among children (r = -0.139, p < 0.01). The NT was associated with young age (B = 1.696, 95% CI = 1.508-1.885) but not with overweight (B = -0.099, 95% CI = -0.184--0.013). INTERPRETATION: Our findings suggest that whilst the typical pattern of the double burden of malnutrition (stunted child/overweight adult) exists in rural Central Java, dietary patterns indicative of the NT are predominant among children, not adults. Overweight among adults may not be necessarily due to a diet indicative of the NT, and nutrition interventions in rural Central Java should focus on educating parents of young children about the health-risks of a diet associated with a NT. FUNDING: Funding was obtained from the UBS-Optimus Foundation and the National Health and Medical Research Council.

Health Risk Assessment for Exposure to Nitrate in Drinking Water in Central Java, Indonesia.

Since 2005, over 30 epidemiological studies have evaluated the association between nitrate in drinking water and adverse health outcomes. Conditions that lead to nitrate pollution in water, such as open defecation, the proximity of septic tanks to water sources, and the use of inorganic fertilizer, are rampant in Indonesia, which has experienced little research evaluating nitrate in drinking water. We conducted a health risk assessment for exposure to nitrate in drinking water and evaluated the nitrate concentration in key water sources in two villages of rural Central Java, Indonesia. The nitrate concentrations in the drinking water ranged from 3.55 mg/L to 26.75 mg/L as NO3-. Daily nitrate intake estimates, calculated at 50% and 95% exposure to the maximum nitrate concentration of the drinking water in both villages, were above the levels associated with birth defects, colorectal cancer, and thyroid conditions observed in other studies. There was a large variation in nitrate concentrations between and within the villages at different water sources. Further research into whether these health outcomes exist in rural Central Java, Indonesia will be required to better understand this risk.

Epidemiology of soil-transmitted helminth infections in Semarang, Central Java, Indonesia.

Soil-transmitted helminth (STH) infections are endemic in Indonesia. However, prevalence data for many parts of the country are incomplete. The aim of this study was to determine human STH prevalence and knowledge and practices relating to STH risk behaviour, to provide a current view of the status of STH infection in rural communities in Central Java. A cross-sectional survey of 16 villages was conducted in Semarang, Central Java in 2015. Demographic and household data together with information about knowledge and practices relating to STH and hygiene were elicited through face-to-face interviews. Stool samples were collected and examined using the flotation method. Children (aged 2-12 years) also had their haemoglobin (Hb) levels, height and weight data collected, and BMI estimated. Data were analysed using univariate logistic regression analysis. A total of 6,466 individuals with a mean age of 33.5 years (range: 2-93) from 2,195 households were interviewed. The overall prevalence of STH was 33.8% with Ascaris lumbricoides (roundworm) the predominant nematode identified (prevalence = 26.0%). Hookworm and Trichuris trichiura (whipworm) were found in 7.9% and 1.8% of participants, respectively. Females were at increased odds of infection with A. lumbricoides (adjusted OR 1.14, 95% CI [1.02-1.29], p = 0.02). Adults in age groups 51-60 and over 60 years had the highest odds of being infected with hookworm (adjusted OR 3.01, 95% CI [1.84-4.91], p<0.001 and adjusted OR 3.79, 95% CI [2.30-6.26], p<0.001, respectively) compared to 6-12 year olds. Farmers also had higher odds of being infected with hookworm (adjusted OR 2.36, 95% CI [1.17-4.76], p = 0.02) compared to other occupation categories. Poverty (OR 2.14, 95% CI [1.77-2.58], p<0.001), overcrowding (OR 1.35, 95% CI [1.27-1.44], p<0.001), goat ownership (OR 1.61, 95% CI [1.10-2.41], p = 0.02) and the presence of dry floor space in the home (OR 0.73, 95% CI [0.58-0.91], p = 0.01) were all household factors significantly associated with an increased odds of infection. Infection with STH was not significantly associated with the gastrointestinal illness (p>0.05), BMI or Hb levels; however, one third of all 2-12 year olds surveyed were found to be anaemic (i.e. Hb concentrations below 110g/l or 115g/l for children under 5 and 5 years or older, respectively), with a greater proportion of school-age children at risk. Knowledge and behaviour related to hygiene and gastrointestinal diseases varied widely and were generally not associated with STH infection. The study revealed that STH infection remains endemic in Central Java despite ongoing deworming programs. Current control efforts would benefit from being re-evaluated to determine a more effective way forward.

Impact of the "BALatrine" Intervention on Soil-Transmitted Helminth Infections in Central Java, Indonesia: A Pilot Study.

Many latrine campaigns in developing countries fail to be sustained because the introduced latrine is not appropriate to local socio-economic, cultural and environmental conditions, and there is an inadequate community health education component. We tested a low-cost, locally designed and constructed all-weather latrine (the "BALatrine"), together with community education promoting appropriate hygiene-related behaviour, to determine whether this integrated intervention effectively controlled soil-transmitted helminth (STH) infections. We undertook a pilot intervention study in two villages in Central Java, Indonesia. The villages were randomly allocated to either control or intervention with the intervention village receiving the BALatrine program and the control village receiving no program. STH-infection status was measured using the faecal flotation diagnostic method, before and eight months after the intervention. Over 8 months, the cumulative incidence of STH infection was significantly lower in the intervention village than in the control village: 13.4% vs. 27.5% (67/244 vs. 38/283, p < 0.001). The intervention was particularly effective among children: cumulative incidence 3.8% (2/53) for the intervention vs. 24.1% (13/54) for the control village (p < 0.001). The integrated BALatrine intervention was associated with a reduced incidence of STH infection. Following on from this pilot study, a large cluster-randomised controlled trial was commenced (ACTRN12613000523707).

Shadow Puppets and Neglected Diseases: Evaluating a Health Promotion Performance in Rural Indonesia.

'Rama and the Worm' is a shadow puppet production targeting neglected diseases in Central Java. It is an entertainment-based intervention study to promote health by reducing the impact of parasitic diseases such as soil-transmitted helminths (STH). The study uses traditional Javanese shadow puppetry (wayang kulit) as a vehicle in village communities to disseminate health messages and promote behaviour change to prevent diseases caused, primarily, by inadequate sanitation and poor hygiene. The health education messages contained in the play, although using traditional characters and themes, required the creation of a completely new narrative script, using characters and plot lines familiar to the wayang kulit repertoire, but placing them in new situations that relate specifically to health promotion objectives. The intervention was piloted in a village in Central Java, Indonesia using a pre/post design with both qualitative and quantitative analysis. A total of 96 male and female villagers, aged between 7 and 87 years, provided both baseline and follow up data. Participant knowledge and behaviours related to gastrointestinal and helminth-related disease were assessed before and after the intervention through a questionnaire administered by interview. Results revealed statistically significant improvements in both knowledge (48.6% pre-intervention score vs. 62.8% post-intervention score, p < 0.001) and behaviour (77.4% vs. 80.6%, p = 0.004) related to gastrointestinal and helminth disease. Findings of the study indicate the wayang kulit performance is an effective health education tool. The results provide proof of concept with scaling up the next step forward. The wayang kulit production provides a significant additional component for an integrated, comprehensive approach to reduction and elimination of STH infection.

Shadow Puppets and Neglected Diseases (2): A Qualitative Evaluation of a Health Promotion Performance in Rural Indonesia.

Performing arts used as a method of spreading health information dates back to the origins of storytelling. However, interventions in developing, non-Western countries typically utilize Western entertainment forms. This qualitative investigation assesses responses to an intervention designed around traditional Javanese shadow puppetry (wayang kulit). Semi-structured interviews provided in-depth responses from a sample (N = 12) of villagers. Responses analyzed both cross-case and within-case, focused on perceptions of the music and storyline, responses to the intervention, and the perceived appropriateness of wayang kulit for disseminating a health message. Wayang kulit was considered to be interesting and easy to remember, but concerns remained regarding the reliability of information provided through the drama. The fusion of traditional and modern music and story elements were perceived positively. Some participants were inspired to improve their hygiene practices, although the lack of motivation, or belief that they were unable to change was noted. The performance was generally received positively in terms of the nature of the intervention, the fusion of traditional and Western music and story elements, as well as the use of wayang kulit to spread health information. The study provides guidance for modifications to the production, prior to scaling up.

Worm-free children: an integrated approach to reduction of soil-transmitted helminth infections in Central Java.

Among children, infections with soil-transmitted helminths (STH) can cause anemia, impaired growth, and absence from school. Sustainable control of STH infection requires that appropriate latrines be integrated with health-promotion education. We report a pilot study of the effects of a combined latrine-education intervention in Central Java, Indonesia. The participants were 99 children (3-13 years old) in two villages (intervention and control) south of Semarang city. Stool samples were collected from the children and were examined for the presence of helminth eggs. After baseline data were collected, latrines were constructed and health education was given in the intervention village. Then, in both villages, all children who had STH infection at baseline were given 400 mg of albendazole. Eight months later, follow-up stool samples were collected and examined. In both villages, 20% of the children had STH infection at baseline. At follow-up, the incidence of STH infection was much lower in the intervention village than in the control village (4.0% vs. 20.4%; p<0.02). The results of this small pilot study give some confidence that a scaled-up study involving many more children and cluster-randomization of the intervention will be feasible and could provide more conclusive evidence of the intervention's effectiveness.

Health risk assessment for exposure to nitrate in drinking water from village wells in Semarang, Indonesia.

The levels of nitrate in 52 drinking water wells in rural Central Java, Indonesia were evaluated in April 2014, and the results were used for a health risk assessment for the local populations by using probabilistic techniques. The concentrations of nitrate in drinking water had a range of 0.01-84 mg/L, a mean of 20 mg/L and a medium of 14 mg/L. Only two of the 52 samples exceeded the WHO guideline values of 50 mg/L for infant methaemoglobinaemia. The hazard quotient values as evaluated against the WHO guideline value at the 50 and 95 percentile points were HQ50 at 0.42 and HQ95 at 1.2, respectively. These indicated a low risk of infant methaemoglobinaemia for the whole population, but some risk for the sensitive portion of the population. The HQ50 and HQ95 values based on WHO acceptable daily intake dose for adult male and female were 0.35 and 1.0, respectively, indicating a generally a low level of risk. A risk characterisation linking birth defects to nitrate levels in water consumed during the first three months of pregnancy resulted in a HQ50/50 values of 1.5 and a HQ95/5 value of 65. These HQ values indicated an elevated risk for birth defects, in particular for the more sensitive population. A sanitation improvement program in the study area had a positive effect in reducing nitrate levels in wells and the corresponding risk for public health. For example, the birth defect HQ50/50 values for a subset of wells surveyed in both 2014 and 2015 was reduced from 1.1 to 0.71.