Conference Proceedings

4th International Conference on Public Health

(ICOPH 2018)

19th – 21st July, 2018

Bangkok, Thailand

Committee of the ICOPH - 2018

The International Institute of Knowledge Management (TIIKM)

Tel: +94(0) 11 3132827

[email protected]
Disclaimer

The responsibility for opinions expressed in articles, studies and other contributions in this
publication rests solely with their authors, and this publication does not constitute an
endorsement by the ICOPH or TIIKM of the opinions so expressed in them.

Official website of the conference

www.publichealthconference.co

Conference Proceedings of the 4th International Conference on Public Health (ICOPH

2018)

Edited by Prof. Dr. Hematram Yadav and Prof. Dr. Rusli Bin Nordin

ISSN 2324 – 6735 online

Copyright @ 2018 TIIKM

All rights are reserved according to the code of intellectual property act of Sri Lanka,
2003

Published by The International Institute of Knowledge Management (TIIKM), No:

531/18, Kotte Road, Pitakotte,10100, Sri Lanka

Tel: +94(0) 11 3098521

Fax: +94(0) 11 2873371

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Hosting Partner:

MAHSA University, Malaysia

Academic Partners:

Faculty of Medical Sciences, University of Sri Jayewardenepura, Sri Lanka

University of Muhammadiyah Malang, Indonesia

Sikkim Manipal University, India

North South University, Bangladesh

Organized By:

The International Institute of Knowledge Management (TIIKM), Sri Lanka

ICOPH 2018 Committee

PROF. DR. HEMATRAM YADAV (Conference Co-Chair, ICOPH 2018)

Department of Community Medicine, MAHSA

University, Malaysia

PROF. DR. RUSLI BIN NORDIN (Conference Co-Chair, ICOPH 2018)

Monash University, Malaysia

PROF. ERNEST MADU (Keynote Speaker, ICOPH 2018)

Chairman and CEO of the Heart Institute of the

Caribbean, Jamaica

PROF. JOHN P. ELDER (Keynote Speaker, ICOPH 2018)

Distinguished Professor and Division Head,

Division of Health Promotion and Behavioral
Science, San Diego State University, USA

DR. CHAIPORN PROMSINGH (Keynote Speaker, ICOPH 2018)

Ministry of Public Health, Thailand

DR. KEITH BUCKLEY (Plenary Speaker, ICOPH 2018)

Director of Physical and Health Education, USA

PROF. DR. PEI LIN LUA (Plenary Speaker, ICOPH 2018)

Universiti Sultan Zainal Abidin (UniSZA),

Malaysia

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PROF. STEVEN L. WEST (Plenary Speaker, ICOPH 2018)

Professor and Chair, Counseling, Educational

Psychology and Research, The University of
Memphis, USA

PROF. DR. FORHAD AKHTAR ZAMAN (Plenary Speaker, ICOPH 2018)

Sikkim Manipal Institute, India

DR. NASRIN BANU LASKAR (Plenary Speaker, ICOPH 2018)

Sikkim Manipal Institute of Medical Sciences,

India

DR. RAGHIB ALI (Plenary Speaker, ICOPH 2018)

Director of the Public Health Research Center at

NYU Abu Dhabi, United Arab Emirates

ASSOC. PROF. M. NASIR UDDIN (Plenary Speaker, ICOPH 2018)

Texas A&M University College of Medicine, USA

DR. J. PAULO MOREIRA (Plenary Speaker, ICOPH 2018)

Princeton Healthcare International (Director for

Europe; Senior Associate for China), USA

DR. JO ANN ANDOY GALVAN (Session Chair, ICOPH 2018)

Taylor’s University, Malaysia

DR. SHIROMI MADUWAGE (Session Chair, ICOPH 2018)

Consultant Community Physician, Sri Lanka

DR. SAIRA MEHNAZ (Session Chair, ICOPH 2018)

Aligarh Muslim University, India

DR. KYU KYU THAN (Session Chair, ICOPH 2018)

Burnet Institute, Australia

DR. SHYAMKUMAR SRIRAM (Session Chair, ICOPH 2018)

University of South Carolina, Columbia, USA

DR. ARIS WIDAYATI (Session Chair, ICOPH 2018)

Universitas Sanata Dharma, Indonesia

DR. FINGANI ANNIE MPHANDE-NYASULU (Session Chair, ICOPH 2018)

TIA Bio-Consulting, Malawi

iv
PROF. GIAS U. AHSAN (Session Chair, ICOPH 2018)

North South University, Bangladesh

DR. NATHANAEL SIRILI (Session Chair, ICOPH 2018)

Umeå University, Sweden

DR. MUTALAZIMAH (Session Chair, ICOPH 2018)

Universitas Muhammadiyah Surakarta,

Indonesia

DR. KRISHNADAS V.T. MENON (Session Chair, ICOPH 2018)

Amala Medical College, India

DR. ISLAM AMINUL (Session Chair, ICOPH 2018)

North South University, Bangladesh

DR. MOHAMMAD DELWER HOSSAIN HAWLADER (Session Chair, ICOPH 2018)

North South University, Bangladesh

PROF. HAE-JIN KO (Session Chair, ICOPH 2018)

Kyungpook National University, Korea

DR. SOHIDUL ISLAM (Session Chair, ICOPH 2018)

North South University, Bangladesh

DR. IRFAN NOWROZE NOOR (Session Chair, ICOPH 2018)

National Institute of Preventive and Social

Medicine, Bangladesh

DR. NIZAM UDDIN AHMED (Session Chair, ICOPH 2018)

North South University, Bangladesh

DR. MARY A.-COLEMAN (Session Chair, ICOPH 2018)

University of Ghana, Ghana

PROF. JAKARIYA (Session Chair, ICOPH 2018)

North South University, Bangladesh

ASSOC. PROF. KHADIJA LEENA (Session Chair, ICOPH 2018)

North South University, Bangladesh

DR. MOHAMMAD NASIR UDDIN (Session Chair, ICOPH 2018)

North South University, Bangladesh

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MR. ISANKA. P. GAMAGE (Conference Convener, ICOPH 2018)

The International Institute of Knowledge

Management, Sri Lanka

MR. OSHADEE WITHANAWASAM (Conference Publication Chair, ICOPH 2018)

The International Institute of Knowledge

Management, Sri Lanka

MR. SARANGA MEEPITIYA (Conference Secretariat, ICOPH 2018)

The International Institute of Knowledge

Management, Sri Lanka

Editorial Board-ICOM
Editorial Board - ICOPH 2018
2013

Editors in Chief

Prof. Dr. Hematram Yadav, Department of Community Medicine, MAHSA University, Malaysia

Prof. Dr. Rusli Bin Nordin, Monash University, Malaysia

The Editorial Board is not responsible for the content of any research paper

Scientific Committee - ICOPH 2018

Dr. Narendra Babu, Taylor’s University, Malaysia

Dr. Low Bin Seng, Taylor’s University, Malaysia
Dr. Jo Ann Andoy Galvan, Taylor’s University, Malaysia
Dr Ahmad M. Qureshi., Monash University, Malaysia
Dr. Adeline Chia, Taylor’s University, Malaysia
Prof. Hematram Yadav, MAHSA University, Malaysia
Prof. Dr. Rusli Bin Nordin, Monash University, Malaysia
Prof. Chrishantha Abeysena, University of Kelaniya, Sri Lanka
Assoc. Prof. Haejoo Chung, Korea University, Korea
Dr. Sampatha Goonewardena, University of Sri Jayewardenepura, Sri Lanka
Dr. B. Kumarendran, University of Kelaniya, Sri Lanka
Dr. Munir Qureshi, Monash University Malaysia
Dr. Gul Muhammad Baloch, Taylor’s University, Malaysia
Prof. (Dr) Forhad Akhtar Zaman, Sikkim Manipal University, India

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Brig. (Dr) Vijay Mehta, Sikkim Manipal University, India
Dr. Nasrin Banu Laskar, Sikkim Manipal University, India
Dr. B. Kumarendran, University of Kelaniya, Sri Lanka
Dr. Nilanjana Ghosh, North Bengal Medical college, India
Dr. Sapna Shridhar Patil, Taylors University, Malaysia
Dr. Sampatha Goonewardena, University of Sri Jayewardenepura, Sri Lanka
Dr. Haejoo Chung, Korea University, Korea
Asst. Prof. Xuan Chen, Emory University, Georgia
Dr. Hematram Yadav, MAHSA University, Malaysia
Dr. Adeline Chia Yoke Yin, Taylor’s University, Malaysia
Dr. Ahmad Munir Qureshi, Monash University Malaysia, Malaysia
Dr. Jo Ann Andoy Galvan, Taylor’s University, Malaysia
Dr. Narendra Babu Shivanagere Nagojappa, Taylor’s University, Malaysia
Dr. Gul Muhammad Baloch, Taylor’s University, Malaysia
Assoc. Prof. Nithat Sirichotiratana, Mahidol University, Thailand
Dr. Adam Dawria Ibrahim, Shendi University, Sudan
Dr. Farhan Abdul Rauf, Public Health Physician/ Researcher, Consultant - Rehabilitation & Disabilities
Dr. Ahmed Hossain, North South University, Bangladesh
Dr. Sunee Lagampan, Mahidol University, Thailand
Asst. Prof. Dr. Charuwan Tadadej, Mahidol University, Thailand
Prof. Yael Latzer, University of Haifa, Israel
Dr. Saira Mehnaz, Aligarh Muslim University, India
Prof. Dr. G.U. Ahsan, North South University, Bangladesh
Dr. Kulanthayan K.C. Mani, Universiti Putra Malaysia, Malaysia
Dr. Mohammad Nasir Uddin, North South University, Bangladesh
Prof. Md. Jakariya, North South University, Bangladesh
Dr. Gita Sekar Prihanti, University of Muhammadiyah Malang, Indonesia
Dr. Mohammad Delwer Hossain Hawlader, North South University, Bangladesh
Prof. Aminul Islam, North South University, Bangladesh
Dr. Dian Yuliartha Lestari, University of Muhammadiyah Malang, Indonesia
Dr. Meddy Setiawan, University of Muhammadiyah Malang, Indonesia
Dr. Sohidul Islam, North South University, Bangladesh
Prof. Fong, Siu Ming Shirley, The University of Hong Kong, Hong Kong
Assoc. Prof. Khadija Leena, North South University, Bangladesh

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Prof. Anita Abd Rahman, Universiti Putra Malaysia, Malaysia
Assoc. Prof. Nizam Uddin Ahmed, North South University, Bangladesh
Prof. Anita Abd Rahman, Universiti Putra Malaysia, Malaysia
Prof. Sanghamitra Sheel Acharya, Jawaharlal Nehru University, India
Dr. Md. Shahjahan, Daffodil International University, Bangladesh
Dr. Gita Sekar Prihanti, University of Muhammadiyah Malang, Indonesia
Dr. Dian Yuliartha Lestari, University of Muhammadiyah Malang, Indonesia
Dr. Meddy Setiawan, University of Muhammadiyah Malang, Indonesia
Prof. Anita Abd Rahman, Universiti Putra Malaysia, Malaysia
Prof. Siu Ming Shirley Fong, The University of Hong Kong, Hong Kong
Prof. Sanghamitra Sheel Acharya, Jawaharlal Nehru University, India
Dr. Mohammad Delwer Hossain Hawlader, North South University, Bangladesh
Dr. Md. Shahjahan, Daffodil International University, Bangladesh
Prof. Anita Abd Rahman, Universiti Putra Malaysia, Malaysia
Dr. Ahmed Hossain, North South University, Bangladesh
Dr. Kulanthayan K.C. Mani, Universiti Putra Malaysia, Malaysia
Dr. Sunee Lagampan, Mahidol University, Thailand
Asst. Prof. Dr. Charuwan Tadadej, Mahidol University, Thailand
Prof. Yael Latzer, University of Haifa, Israel
Dr. Nizam Uddin Ahmed, North South University, Bangladesh

viii
 MESSAGE FROM THE HOSTING PARTNER ICOPH 2018

Thank you for allowing me to say a few words in this 4th International Conference on Public
Health (ICOPH) 2018. Firstly, I must congratulate TIIKM and its collaborators for organising
this conference and I understand that this conference is focusing on quality of health care.
Quality is a real problem not only in health care but in all sectors of the industry including
Universities. Quality as we know isthe end-point of everything we do and it is setting
standards at all level of the organization and making sure that the standards are met.
Therefore many factors impact on quality. To improve quality of health care, it is not only the
consumers and the providers who need to be addressed but also the availability of resources
that affect quality of care in health care. Therefore in improving quality and safety of the
health care we improve the practice, innovate new ideas, improve assess in health care,
readjust our processes, and improve practice of health care. For us to improve quality we
need to feel a sense of urgency, we need to be tireless and keep up the pressure. From what
we implement not everything works so we need to learn what works, so that we can draw
maps to help others.

I understand that the main purpose in this conference is to discuss and debate all the best
ideas we can muster to improve quality and safety in health care in our work place, because it
is simply not acceptable that millions of people globally are injured, and tens of thousands die
every year, from medical errors that don't need to occur. Globally the public today knows
much more about quality and safety in health care and their expectations are high. The public
is looking for dramatic reductions in medical errors. They expect health information
technologies to help in reducing errors. In many areas of the world mobile technology is
ix
transforming health care. It can help a lone health worker in the most remote and isolated
village to get up to date training and provide high quality care and it can also help connect
health worker to obtain latest information that can save lives. For instance in Liberia during
the Ebola outbreak the Ministry of Health sent critical information to health workers’ through
mobile phones to all parts of the country and similarly the health workers used to send time-
sensitive information to ministry officials and to one another. In future this type technology
will help other countries combating outbreaks and prepare them for future health threats as
well.

I understand that there are over 30 countries being represented in the conference with about
700 abstracts and posters. I wish to congratulate the organizing committee making this
conference happen and I am proud that MAHSA University is part of this endeavor. I
understand that MAHSA University students and staff are actively involved in presenting
papers in the conference. I wish all the participants and staff all the best and I am sure you all
will deliberate and make the best use of the time in this conference

Thank you,

Prof. Tan Sri Datuk Dr. Hj. Mohamed Haniffa bin Hj. Abdullah,
Pro-Chancellor and Executive Chairman,
MAHSA University,
Kuala Lumpur,
Malaysia.

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 MESSAGE FROM THE CONFERENCE CO-CHAIR ICOPH 2018

It gives me great pleasure to welcome all of you to this 4th International Conference on Public
Health (ICOPH 2018) in Bangkok, Thailand. As you all know the theme of this conference is
‘Promoting Quality and Safety in Health Care towards Health Communities’ and this is very
timely as we are facing quality problems in health care globally. Although globally public
health is no longer dominated by infectious diseases but dominated by non-communicable
diseases such as chronic diseases (heart disease, diabetes, cancer, and mental-health
condition), but infectious diseases do still play an important role and pose challenges to
global health security. It is therefore imperative that quality of health care play an important
role in the prevention of these diseases.

Quality healthcare is defined as providing effective and efficient healthcare services

according to the current clinical guidelines and standards, which meets the patient's needs. It
is important and urgent that we implement the principles of quality assurance in all areas of
health care including Public Health. The health care provided must not only be efficient and
effective but it must also be evidence based. Measurement and assessment of quality are
equally important and the two most important methods to assess quality are cost effective and
cost efficient. Although many of the basic tools of quality are available, we seldom apply
these in our work place to assess programmes to see whether they are effective or not. I hope
that this conference will provide you a platform for understanding the concept of quality and
that you will be able to apply these concepts when you return.

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This year we have received more than 700 abstracts for the conference and we are happy of
the tremendous response and support we have received. I am particularly happy that we have
participants who have been regularly attending the last few conference and I would like to
thank them for their support. I am sure that you all will deliberate and discuss some of the
important issues in the next few days and will not only network and take home new ideas but
will also implement some of these ideas when return. Finally let me take this opportunity to
thank all the plenary speakers and members of the organising committee for the excellent
preparations and arrangements for this conference and most importantly you the participants
who have made this conference happen. I would like to thank all the academic partners, all
universities and collaborators particular the Ministry of Health, Thailand for providing the
support for this conference. Hope you will have good time the next few days but don’t forget
to enjoy the beauty of Thailand while you are here.

Thank you and regards,

Prof. Dr. Hematram Yadav,

Co-Chairman Organising Committee,
Department of Community Medicine,
MAHSA University,
Kuala Lumpur,
Malaysia.

xii
 MESSAGE FROM THE CONFERENCE CO-CHAIR ICOPH 2018

Welcome to the 4th International Conference on Public Health (ICOPH 2018) with the theme:
Promoting Quality and Safety in Health Care towards Healthy Communities. On behalf
of the Organizing Committee, Prof. Hematram Yadav and I would like to warmly welcome
you to Bangkok, Thailand with the Thai’s customary welcoming address of Sawasdee! We
would like to thank everyone for making your time and effort to attend this international
conference. In particular, to the event organizer, TIIKM (The International Institute of
Knowledge Management), under the abled stewardship of Mr Isanka P. Gamage, co-founder
and managing director, and his elite group of highly talented, motivated, and dedicated young
entrepreneurs; scientific committee members who have voluntarily supported the arduous
task of reviewing abstracts for the conference; hosting partner (MAHSA University);
academic partners (Faculty of Medical Sciences, University of Sri Jayewardenepura, Sri
Lanka; University of Muhammadiyah Malang, Indonesia; Sikkim Manipal University, India;
North South University, Bangladesh); strategic partners [The 16th World Congress of the
European Association for Palliative Care (EAPC 2019); International Conference on
Community Nursing and Public Health 2018]; Tour & Accommodation Partner
(GLOBEENJOY); Event partner (Blue Arc); and ALL keynote and plenary speakers,
sessions chairs, delegates and accompanying persons, including virtual presenters. Thank you
all for supporting ICOPH 2018!

The quality and safety of healthcare is one of the most important factors in health and it has
become one of the global health priorities to ensure healthy lives and promote well-being for

xiii
all. This global commitment is contained in the Third Sustainable Development Goal of the
World Health Organization (SDG3: Ensure healthy lives and promote well-being for all at all
ages). Quality improvement is meant for enhancing safety, effectiveness, and efficiency of
health care which can be achieved through various quality methods. The quality of healthcare
is applicable for all levels of health care including health education system and advanced
technologies. ICOPH 2018 creates a great platform to discuss current landscape and next
steps for improving quality of health care. The conference will bring together leading
academicians, medical students, clinicians, public health professionals, health care specialists,
health care workers, health economists, researchers, scientists, health workers, policy makers,
social workers and other related professionals. ICOPH 2018 is a global gathering with
renowned speakers, presentations, panel discussions, round table discussions, and valuable
networking opportunities.

The organizers have prepared an impressive list of 16 conference tracks, publication and
conference chair workshop, round table discussion, students’ session and gathering, and
exhibition, as well as opportunities to publish selected full papers in high quality
international, peer-reviewed journals. Four award categories have been created to honour the
best presentations: best presentation award, best student presentation award, sessions’ best
award, and best poster presentation award. Two eminent keynote speakers will deliver state-
of-the art lecture on the following: Dengue infections and Childhood Obesity: Battling
Epidemics that know no Boundaries (Prof. John P. Elder, Distinguished Professor and
Division Head, Division of Health Promotion and Behavioral Science, San Diego State
University, United States), and Reducing the Global Burden of Cardiovascular Disease: A
Model for Sustainable Cardiac Care Development in Developing Countries (Prof. Ernest
Madu, Founder of the Heart Institute of the Caribbean ), and a special guest speaker from
Thailand, Dr. Chaiporn Promsingh, Medical Officer on Health Promotion, Advisory Level,
Office of Senior Advisor Committee, Department of Health, Ministry of Public Health,
Thailand. Eight plenary speakers have agreed to share their experiences in this conference:
Prof. Dr. Forhad Akhtar Zaman ( Global Burden of Tuberculosis & Drug Resistant TB ),
Dr. Nasrin Banu Laskar (Clean India Mission ), Dr. Raghib Ali (Cardiovascular Disease),
Dr. Keith Buckley (Evaluating the Right to Affordable Healthcare), Prof. Dr. Pei Lin Lua
(Community Health Education Empowerment Via e-Health Innovations), Prof. Steven L.
West (Routine Dental Exams of Persons with Disabilities in the U.S.), Assoc. Prof. M. Nasir
xiv
Uddin (Molecular pathogenesis of preeclampsia and its potential therapeutics) and Dr. J.
Paulo Moreira (Financing Health and Wellness Tourism Projects: Success Factors).

The conference will be an excellent opportunity to network and discuss current issues in
public health across the globe, with the scope aligned towards the understanding and
realization of the World Health Organization’s Third Sustainable Development Goal (SDG3).
Following from ICOPH 2017 in Kuala Lumpur, we will need to discuss the following issues
and practical solutions: What will be the barriers each country would face when achieving
these targets in 2030’s? How to overcome those barriers? What are the measures that can be
taken? The role of Governments and Industries, and how scientific research can support the
achievement of the targets in 2030’s.

Finally, as agreed during the round table discussions in ICOPH 2017, we need to re-appraise
the following Health Targets for SDG3:
• By 2030, reduce the global maternal mortality ratio to less than 70 per 100 000 live births.
• By 2030, end preventable deaths of newborns and children under 5 years of age, with all
countries aiming to reduce neonatal mortality to at least as low as 12 per 1000 live births
and under-5 mortality to at least as low as 25 per 1000 live births.
• By 2030, end the epidemics of AIDS, tuberculosis, malaria and neglected tropical
diseases and combat hepatitis, water-borne diseases and other communicable diseases.
• By 2030, reduce by one third premature mortality from non-communicable diseases
through prevention and treatment and promote mental health and well-being.
• Strengthen the prevention and treatment of substance abuse, including narcotic drug
abuse and harmful use of alcohol.
• By 2030 halve the number of global deaths and injuries from road traffic accidents.
• By 2030, ensure universal access to sexual and reproductive health-care services,
including for family planning, information and education, and the integration of
reproductive health into national strategies and programmes
• Achieve universal health coverage, including financial risk protection, access to quality
essential health-care services and access to safe, effective, quality and affordable essential
medicines and vaccines for all.
• By 2030, substantially reduce the number of deaths and illnesses from hazardous
chemicals and air, water and soil pollution and contamination.
xv
• Strengthen the implementation of the WHO Framework Convention on Tobacco Control
in all countries, as appropriate.
• Support the research and development of vaccines and medicines for the communicable
and noncommunicable diseases that primarily affect developing countries, provide access
to affordable essential medicines and vaccines, in accordance with the Doha Declaration
on the TRIPS Agreement and Public Health, which affirms the right of developing
countries to use to the full the provisions in the Agreement on Trade-Related Aspects of
Intellectual Property Rights regarding flexibilities to protect public health, and, in
particular, provide access to medicines for all.
• Substantially increase health financing and the recruitment, development, training and
retention of the health workforce in developing countries, especially in least developed
countries and Small Island developing States.
• Strengthen the capacity of all countries, in particular developing countries, for early
warning, risk reduction and management of national and global health risks.

The road to success is not easy. But together and inclusively, we can be part of this global
effort to address many of the health targets for the SDG3. This international conference is,
therefore, an earnest effort to realize our dream of promoting quality and safety in healthcare
towards healthy communities.

Finally, please enjoy our networking dinner and cultural show and the many exciting and
fascinating tourist destinations in and around Bangkok and Thailand in general.

Thank you very much (Khob Khun Mark)!

Prof. Dr. Rusli Bin Nordin

Co-Chair,
Monash University,
Malaysia.

xvi
Table of Contents Page No

01 PREDICTORS OF AND BARRIERS ASSOCIATED WITH HEALTH 1-10

SERVICES UTILIZATION AMONG PERSONS WITH DISABILITY
Billy Jay N. Pedron
02 ABC STRATEGY: HOW UNIVERSITY STUDENTS PERCEPTION 11-22
OF ABC STRATEGY INFLUENCES UPTAKE OF
REPRODUCTIVE HEALTH PROGRAMS
Mary Wanjau, Lucy kathuri-Ogola and Lucy Maina
03 SUB-NATIONAL INEQUALITY OF CAESAREAN SECTION IN 23-32
URBAN-RURAL AREA OF INDONESIA
Suparmi, Nunik Kusumawardhani and Kun Arisanti Susiloretni
04 RELATIONSHIP BETWEEN NUTRITIONAL STATUS, HEALTH 33-39
STATUS, FOOD CONSUMPTION, AND LIFESTYLE TO WORK
PRODUCTIVITY OF COCOA FARMER
Wilda Yunieswati, Sri Anna Marliyati and Budi Setiawan
05 SPATIAL EFFECT OF REFILLING DRINKING WATER DEPOTS 40-48
TOWARD DIARRHEA IN PAGATAN, SUB DISTRICT OF
KUSANHILIR, TANAH BUMBU DISTRICT, SOUTH
KALIMANTAN
Dicky Andiarsa, Dian Eka Setyaningtyas, Syarif Hidayat, Ika
Setianingsih, Hamsyah and Erly Haryati
06 INEQUALITY TRENDS OF ANTENATAL CARE AMONG 49-59
WOMEN IN INDONESIA 2002-2012
Anissa Rizkianti and Tin Afifah
07 IMPROVEMENT STRATEGIES OF JOB PERFORMANCE: A 60-73
PERSPECTIVE ON NURSING PROFESSION IN VIETNAM
Phuong Van Nguyen, Lien Thi Xuan Nguyen and Nhu Huu Thien
Nguyen
08 PALATAL RUGAE AND LIP PRINT PATTERN STUDY AS THE 74-79
ALTERNATIVE METHOD OF MASS NATURE DISASTER
VICTIM IDENTIFICATION
Nila Kasuma, Fildzah Nurul Fajrin, Dewi Elianora, Aida Fitriana and
Haria Fitri

xvii
09 VALIDITY AND RELIABILITY TEST OF MEDICATION 80-88
ADHERENCE RATING SCALE FOR PSYCHOSIS (MARS)
INSTRUMENT INDONESIAN VERSION
Kasmianto Abadi, A.A.A.A Kusumawardhani, Natalia Widiasih and
Khamelia Malik
10 THE CLINICAL PATHWAY IN THE ORAL AND 89-93
MAXILLOFACIAL SURGERY’S SERVICES AS A QUALITY
MANAGEMENT TOOL, IN DR. SOETOMO HOSPITAL,
SURABAYA, INDONESIA
Nining Dwi Suti Ismawati and Setya Haksam
11 THE NUMBER OF MISSING PERMANENT MOLAR TEETH 94-99
BASED ON CHARACTERISTICS OF RESPONDENT ON LUBUK
BUAYA PUBLIC HEALTH CENTER
Murniwati, Susi, Nila Kasuma and Nilma Rawinda

xviii
Proceeding of the 4th International Conference on Public Health, Vol. 4, 2018, pp. 1-10
Copyright © 2018 TIIKM
ISSN 2324 – 6735 online
DOI: https://doi.org/10.17501/23246735.2018.4101

PREDICTORS OF AND BARRIERS ASSOCIATED

WITH HEALTH SERVICES UTILIZATION
AMONG PERSONS WITH DISABILITY
Billy Jay N. Pedron
De La Salle Medical and Health Sciences Institute, The Philippines

Abstract: In the Philippines, despite numerous initiatives and programs that aims to increase
awareness of persons with disability about the different health care benefits intended for them,
majority of them still experiences obstacles particularly in accessing health care services. The
purpose of the study was to identify predictors and barriers associated to health services utilization
among persons with disability. The study used descriptive design, with 77 persons with disability
from 3 hospitals in the province of Cavite as respondents. Regression was used to identify the
predictors for both health services utilization and barriers. The researcher found out that gender and
type of disability has significant differences in terms of health care services utilization, and in terms
of experienced barriers, only educational background has significant difference. Further, the study
also revealed that age, location and monthly income were significant predictor in utilization of health
care services. While, education became significant predictor in predicting barriers in accessing health
care services. Different barriers were identified in low level health care services utilization among
persons with disability. In this context, strong implementation of policy to increase awareness and
knowledge about disability and its prevention in the community level are essential to address the
barriers.

Keywords: Persons with Disability, Health utilization, Health barriers, Health Systems

Introduction

Disability is a complex occurrence, which includes a wide array of interaction between features of a person’s
body and features of the society. Further, it covers a spectrum of various levels of functioning at body level,
person level and societal level. (WHO, 2016)

Disability affects hundreds of millions of families in developing countries. Worldwide, it estimated that around
10% of the total world's population, or roughly 650 million people, live with a disability (WHO, 2010), and
about 80% of the world's population of people with disabilities lives in low-income countries, and most of them
experience social and economic disadvantages and denial of rights. Rates of disability are increasing due to
population aging and increase in chronic health conditions, among other causes. (WHO, 2010)

Philippines is not spared from this. According to the Asia-Pacific Development Center on Disability the
population of persons with disability is estimated at around 942,000 or 1.23 % as to proportion of persons with
disabilities to total population. Half of the PWD in the Philippines are old people (60 years and over). The other
half are below 49 years old. This could only mean that one in 20 households in the Philippines has at least one
member with disability.

In spite of numerous laws and bills passed in the Philippines, people with disability experience different types of
barriers when they attempt to access health care. Health systems frequently fail to respond adequately to both
the general and specific health care needs of people with disability. Comparing persons with disabilities from
the general population, they have both same health care needs. However, they experience unequal access and
greater unmet health care needs and experience poorer levels of health compared with the general population.
This is mainly due to poverty and social exclusion. People with disabilities in developing countries are over

Corresponding Author Email: [email protected]

 Billy Jay N. Pedron / Predictors Of And Barriers Associated With Health….

represented among the poorest people. Poverty causes disabilities and can further lead to secondary disabilities
and complications as a result of the poor living conditions, health endangering employment, malnutrition, poor
access to health care and education opportunities, etc. Together, poverty and disability create a vicious circle
(World Bank, 2010).

Persons with disability are likely to have limited opportunities to earn income and often have increased medical
expenses. Disabilities among children and adults may affect the socioeconomic standing of entire families
(American Psychological Association). Poverty, as a contextual factor, may also increase the likelihood, that a
health condition may result in impairment, activity limitation, or participation restriction. This could be the case
if there is lack of health care and rehabilitation services or lack of resources to access those that are available;
acquire prosthetic, orthotic and mobility devices; get personal assistance at the community level, etc. In poor
communities where such services are not provided or are of low quality, health conditions may be more likely to
lead to disability. Even if such services are available, they may not be affordable (Horner et al. 2003).

Full inclusion of disabled people in society is the solution. To achieve this, we need to remove the barriers that
exclude people with disability from participating in society. Health and education should be the primary focus in
solving the problem. Health is a prerequisite for it increases in productivity while education relies on adequate
health. Both health and education can also be seen as vital components of growth and development. Given their
role as both inputs and outputs gives health and education their central importance in economic development
(Todaro, 2010).

The purpose of the study was to identify predictors and barriers associated to health services utilization among
persons with disability.

Methods

Study Design and Population

This study used the quantitative descriptive type of research. This is non-intrusive and deals with naturally
occurring phenomena. In this study, the phenomena were the experienced barrier and utilization of health care
services of Persons with disability. The participants of the study were the 77 persons with disability who
underwent Inclusion criteria and are currently undergoing rehabilitation care under the Level 3 hospitals in
Cavite.

Research Instrument

The research instruments used were self-made questionnaire. Questionnaire were divided into 2 parts:
demographics and the barriers and utilization of health care services of PWD. Questions were based on RA
10754 An Act Expanding The Benefits And Privileges Of Persons With Disability (PWD) from RA 7277, as
amended, otherwise known as the “Magna Carta for Persons with Disability” and adapted questions from
different journals, related literature and studies that discussed barriers and utilization pattern of persons with
disability as to health services.

The questionnaire is composed of two parts: the first part sought to obtain the demographic data of the
respondents, while the second part includes questions that would determine health care service utilization and
barriers.

In determining the barriers that could affect the utilization of health services, the following elements/factors
were the bases in formulating questions: a. financial barriers, b. cognitive barrier and c. structural barrier. This
part was answered using Likert scale. 5 - very great extent, 4 - great Extent, 3- some extent, 2 - little extent, 1 -
very little extent.

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Correspondingly, in determining the utilization of respondents, the following health care services were taken
into consideration: a. General Health Services b. Dental Services c. Rehabilitative Services d. Psychological
Services. his part was answered by a Likert scale. 5 - always, 4 - very often, 3- sometimes, 2 - rarely, 1 - never.

The results were summarized based on the respondents answers on the questionnaire. The mean of the results
was obtained for each factor as to the experienced barrier and health care services utilization, and were
interpreted using the range below:

Table 1: Arbitrary scale in interpreting Barriers in Healthcare Services

Barriers in Healthcare Services Scale
Range Interpretation
5.0 -4.50 Very Great extent
4.49 -3.50 Great extent
3.49 - 2.50 Some extent
2.49- 1.50 Little extent
1.49 -1.00 Very little extent

Table 2: Arbitrary scale in interpreting Utilization of Healthcare Services

Utilization of Healthcare Services Scale
Range Interpretation
5.0 -4.50 Always
4.49 -3.50 Very Often
3.49 - 2.50 Sometimes
2.49- 1.50 Rarely
1.49 -1.00 Never

Data Analysis

Frequency and percentage were used to describe the profile of the respondents in terms of age, gender, type of
disability, location, monthly income and education. Weighted mean was employed to determined the
experienced barriers and extent of utilization of health care services. Regression Analysis was used to predict
the variables that would affect the barriers and utilization of health services.

Result

Profile of the Respondents

The profiles of the respondents revealed that out of 77 respondents, majority of which are female (53%) and
belonged to the age bracket of 21 - 40 y/o (30%), who are college level (51%), from Tagaytay City (30%), had
an average of Php 9,000 per month (49%), and have orthopedic or mobility disability (70%).

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Age

4% 5%
16%
0-12 years old
13-20 years old
21- 40 years old

32% 43% 41- 65 years old

65- onwards

Figure 1: Profile of The Respondents According to Age

Figure 1 shows the profile of the respondents according to age. It revealed that out of 77 respondents, 43% of
the respondents belonged to the age bracket of 21 - 40 y/o; 32 % were from 41- 65 y/o; 16% from the age
bracket of 65 y/o- on wards; 5% from 13 - 20 y/o and 4% from 0 - 12 y/o bracket.

Gender

Male
53% 47% Female

Figure 2: Profile of The Respondents According to Gender

Figure 2 illustrates the profile of the respondents according to gender. The results revealed that out of 77
respondents, 53% were female and 47% were male.

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Educational Background

13% 15%
Elementary Level
High school Level
21% College Level
Post Grad Level
51%

Figure 3: Profile of The Respondents According to Educational Background

Figure 3 revealed that most of the respondents were at the college level (51%) followed by those at high school
level (21%), then from the elementary level (13%) and lastly those from the post graduate level (13%).

Location

7%
Bacoor City
27% Cavite City
Dasmarinas City
30%
General Trias City
Imus City
7%
Tagaytay City
10% Trece Martirez City
10%
9%

Figure 4: The Profile of the Respondents According to Location

Figure 4 illustrates the profile of the respondents according to location. The results revealed that out of 77
respondents, 30% were from Tagaytay; 27% were from Bacoor City; 10% were from both Dasmarinas City and
Imus; 9% from General Trias and 6% from both Trece Martirez and Cavite City.

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Monthly Income

16%

Average of Php 200,000 per month

49% Average of Php 36,000 per month

Average of Php 9,000 per month
35%

Figure 5: Profile of The Respondents According to Monthly Income

Figure 5 illustrates the profile of the respondents according to monthly income. The results revealed that out of
77 respondents, 49% has an average of Php 9,000 per month; 35% has an average of Php 36,000 per month and
16% has an average of Php 200,000 per month.

Types of Disability

0% Orthopedic /mobility
17%
Communication
1%
3% Visual
4% Hearing
5% Learning
70% Chronic illnesses
Mental

Figure 6: The Profile of the Respondents According to Type of Disability

Figure 6 shows the profile of the respondents according to the type of disability. It revealed that out of 77
respondents, 70% has orthopedic or mobility disability; 17% has disability that resulted from chronic illness. 5%
has communication disability; 4% is visually disabled, 3% were hearing impaired; 1% has learning disability,
and none has been reported with mental disability.

Predictors of and Barriers Associated with Health Services Utilization

Respondents experience “some extent” barriers in accessing health care services in terms of financial (over all
mean of 2.81), structural (over all men of 2.71) and cognitive (over all mean of 2.6) (Table 3).

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Table 3. Barriers Associated with Health Services Utilization among Persons with Disability
Type of Barrier Over all mean Interpretation
Financial 2.81 Some extent
Structural 2.71 Some extent
Cognitive 2.6 Some extent

Meanwhile, based on the evaluation of health care services utilization, general health/ medical services are
“sometimes” utilized (over all mean of 2.67) while, rehabilitative (over all mean of 2.25), dental (2.10) and
psychological (1.55) are “rarely” utilized by the respondents (Table 4).

Table 4. Utilization of Healthcare Services among Persons with Disability

Healthcare Services Over all mean Interpretation
General Health/ Medical Services 2.67 Sometimes
Rehabilitative 2.25 Sometimes
Dental 2.10 Sometimes
Psychological 1.55 Rarely

Based on the results of regression analysis for variables predicting health services utilization among persons
with disability, age, location and monthly income are significant predictors of utilization of health care with p-
value less than 0.05 (Table 5).

Table 5: Regression analysis for variables predicting health services utilization

βj t-statistics Ho Ha p-value Conclusion
Age 2.04 β1 = 0 β1 ≠ 0 0.045 Reject Ho
Gender -0.52 β2 = 0 β2 ≠ 0 0.606 Accepted
Type of -0.61 β3 = 0 β3 ≠ 0 0.547 Accepted
Disability
Location 2.30 β4 = 0 β4 ≠ 0 0.025 Reject Ho
Monthly -4.37 β5 = 0 β5 ≠ 0 <0.001 Reject Ho
Income
Educational 0.07 Β6 = 0 Β6 ≠ 0 0.941 Accepted
Background
F- statistics: 13.93 p-value: 0.0002 RMSE: 0.48829 R-squared: 0.3113

Based on the table above, using F-statistics, it can be concluded that at least one of the independent variables is
a good predictor of utilization of health services. The 31.13% variability of utilization of health services can be
accounted from the given independent (predictor) variables. Furthermore, based on t-statistics, only age,
location and monthly income become statistically significant predictor of utilization of health care with p-value
less than 0.05. Low RMSE value of 0.48829 indicates a well-fitting

Further, the results of regression analysis for variables predicting barriers in accessing health services among
persons with disability only education is statistically significant predictor of utilization of health care with p-
value less than 0.05.

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Table 6: Regression analysis for variables predicting barriers in accessing health services utilization
βj t-statistics Ho Ha p-value Conclusion
Age -0,01 β1 = 0 β1 ≠ 0 0.992 Accepted
Gender 0.78 β2 = 0 β2 ≠ 0 0.436 Accepted
Disability -0.83 β3 = 0 β3 ≠ 0 0.412 Accepted
Location 0.82 β4 = 0 β4 ≠ 0 0.415 Accepted
Mi 0.75 β5 = 0 β5 ≠ 0 0.459 Accepted
Educ -5.83 Β6 = 0 Β6 ≠ 0 <0.001 Reject Ho
F- statistics: 6.71 p-value:< 0.0001 RMSE: 0.72166 R-squared: 0.3652

Based on table shown, it can be concluded that at least one of the independent variables is a good predictor of
the perceived barriers experienced by the respondents. The 36.52% variability of utilization perceived barriers
experienced by the respondents can be accounted from the given independent (predictor) variables. Furthermore,
based on t-statistics, only education become statistically significant predictor of the perceived barriers
experienced by the respondents with p-value less than 0.05.

Discussion

Respondents experienced “some extent” financial barriers in accessing health care services. In low-income
countries (LIC), health care and related expenditures feature prominently as causes of impoverishment.
Moreover, Krishna (2006) identified the cost of treatment for illness to be the cause of 85% of all cases of
impoverishment. Van Doorslaer et al. (2006) found that an additional 78 million people in 11 Asian countries
fall below the extreme. One cause of low patient compliance to physical therapy is financial difficulty. Low
compliance to therapy can prolong the recovery of the patient; thus, increasing the difficulty for both patient and
family. Both the patient and the family experience the financial difficulty brought about by poverty. With regard
to structural barriers, respondents experienced “some extent” difficulty in accessing health care services. The
noted difficulty are coming from the distance of the health care facilities, transportation and the process in
availing health care services and lack of initiatives coming from the government. PWD and providers both
perceive transportation issues as the highest ranked barriers and physical access issues as the lowest ranked
barriers (Mc Doom et. al, 2014). Further, PWD find it difficult to walk to health centers for treatment due to
lack of transport, money to pay for treatment and toilet facilities and the distance is too far for people with
lower-limb disabilities. There is a need to consider the different issues affecting health care access for people
living with disabilities to achieve equitable access to health care services (Van Rooy, 2012). Equally,
respondents generally experience “some extent” difficulty in accessing health care services due to cognitive
barriers. Respondents experience barriers in availing government services, and have limited knowledge as to
the law and provisions and the different services being offered to the persons with disability. This revealed an
agreement with Chopra (2013), where he expressed that lack of information regarding governmental schemes
and policies in favor of disabled people is another major barrier faced by them. In addition, People with
disabilities also had trouble accessing health care facilities and services in part due to lack of access to adequate
rehabilitation devices and services. In the case of people who are deaf or have difficulty of hearing, they have
difficulties communicating with health care professionals and getting emergency services. According to WHO
(2016), policy barriers are frequently related to a lack of awareness or enforcement of existing laws and
regulations that require programs and activities be accessible to people with disabilities. Given these findings,
we can infer that PWDs still experience difficulty in availing health care services due to limited knowledge.
Limited knowledge of PWDs can affect the implementation of the program of the government in addressing the
problems and the needs of PWDs. Government should focus in strengthening its information campaign drive in
reaching PWD not only in the city but also in the far flung areas.

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On health care services utilization, majority of the general health and medical services are utilized by PWD;
services such as checkup, laboratory examination and vaccination are “sometimes” utilized. Regular checkup
and laboratory examination can help prevent problems or secondary complication. Checkups can detect early
problems that can be treated by conservative management. Moreover, vaccination is important not only for
children with disability but also for adult and geriatric patients. Vaccination has greatly reduced the burden of
infectious diseases. Further, benefits of vaccination extend beyond prevention of specific diseases in individuals.
Conversely, Referrals to other health professionals, health education, nutritional counseling as well as surgical
procedure are “rarely” utilized. Referral is considered an important part of patient care especially to the PWD.
PWD should be referred to other specialist for further management, treatment or as needed. Dental services such
as routine checkups, dental prophylaxis, laboratory and diagnostics examination are “rarely” utilized by PWD.
According to National Institute of Dental Craniofacial Research, smaller-scale studies show that the population
with mental retardation or other developmental disabilities has significantly higher rates of poor oral hygiene
and needs periodontal disease treatment than the general population, due, in part, to the limitations in individual
understanding of and physical ability to perform personal prevention practices or to obtain needed services. In
the aspect of Rehabilitative Services, checkups, follow ups and physical therapy services are “sometimes”
utilized by the respondents. Rehabilitation of persons with disability reduces the impact of a broad range of
health conditions. Typically, rehabilitation occurs for a specific period of time, but can involve single or
multiple interventions delivered by an individual or a team of rehabilitation workers, and can be needed from
the acute or initial phase immediately following recognition of a health condition through to post-acute and
maintenance phases. Rehabilitation involves identification of a person’s problems and needs, relating the
problems to relevant factors of the person and the environment, defining rehabilitation goals, planning and
implementing the measures, and assessing the effects. Educating people with disabilities is essential for
developing knowledge and skills for self-help, care, management, and decision-making. People with disabilities
and their families experience better health and functioning when they are partners in rehabilitation. Therapy is
important for immediate recovery after the injury so as to prevent disability. Early rehabilitation interventions
seem to be essential for how well a patient recover after a severe brain injury. It might even increase the chances
for long-term survival. Likewise, Convincing evidence shows that some therapy measures improve
rehabilitation outcomes. Therapy interventions have also been found to be suitable for the long-term care of
older persons to reduce disability. Some studies show that training in activities of daily living have positive
outcomes for people with stroke. Based on the researcher’s experience, patients compliance to treatment is also
affected by the the cost of the therapy, chronic illness and disability usually have a greater financial impact to
the patient and to the family.

Based on the regression model and the inter relationship of the variables (contextual factors, barriers and the
health care services utilization) among persons with disability, only few variables in the respondents
demographics can be used as predictors in both health utilization and barrier. Identifying the needs of the
respondents and increasing its health literacy through health education can directly affect the utilization. In the
same token, identifying the barriers and finding solutions to address those problems can greatly affect the health
care services that can also affect the utilization. Increase in health care services utilization leads to inclusive
health care services.

Conclusion

Generally, persons with disability are still considered part of the vulnerable sector in the country, and rates of
disability were increasing due to population aging and increases in chronic health conditions, among other
causes. In spite of numerous bills and law that are geared towards inclusive society, PWD still face barriers in
everyday activities which have greater impact in their lives particularly on their health. As identified in research
literature, people with disabilities have less access to health care services and therefore experience unmet health
care needs. Like ordinary individuals, they have general health care needs and therefore need access to
mainstream health care services. However, within these constraints, the study has provided much needed

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information on socio economic determinants differences of PWD populations by describing differences in

experienced barriers and health care services utilization. At present, health care service development is based on
the assumption that service provision reflects assessed need. It is therefore suggested that these barrier and
utilization data be used to inform the development of planning, particularly for PWD, where planners often lack
information about the characteristics and service used of their shared care populations.

Recommendation

Identify the persons with disability in the community and develop an up-to-date databank for easy identification
of the PWDs.

Create a Barrier-free environment advocacy or initiatives the enables people with disabilities to perform
independent functioning as an individual so that they can participate without assistance in everyday activities.

Develop Disability Prevention Policy - Disability can be prevented through proper education. Strong policy that
will focus on disease prevention that can result to disabilities. Further, this involves creation of awareness
regarding measures to be taken for the prevention of disabilities during the different stages of pregnancy and
other work related injuries.

References

Chopra, T. (2013). Expanding the horizons of disability law in India: a study from a human rights
perspective. The Journal Of Law, Medicine & Ethics: A Journal Of The American Society Of Law,
Medicine & Ethics, 41(4), 807. doi:10.1111/jlme.12091
Horner-Johnson, W., Dobbertin, K., Lee, J. C., & Andresen, E. M. (2014). Disparities in health care access
and receipt of preventive services by disability type: analysis of the medical expenditure panel survey. Health
Services Research, 49(6), 1980-1999. doi:10.1111/1475-6773.12195
Krishna A. Pathways out of and into poverty in 36 villages in Andhra Pradesh, India, World Development ,
2006, vol. 34 (pg. 271-88)
Mcdoom, M. Maya & Koppelman, Elisa & Drainoni, Mari-Lynn. (2012). Barriers to Accessible Health Care for
Medicaid Eligible People With Disabilities: A Comparative Analysis. Journal of Disability Policy Studies. 25.
10.1177/1044207312469829.
Todaro, M. P., & Smith, S. C. (2009). Economic development. Boston: Pearson Addison Wesley.
Van Doorslaer E, O’Donnell O, Rannan-Eliya R, et al. Effect of payments for health care on poverty estimates
in 11 countries in Asia: an analysis of household survey data, The Lancet , 2006, vol. 368 (pg. 1357-64)
Van Rooy, G., Amadhila, E. M., Mufune, P., Swartz, L., Mannan, H., & MacLachlan, M. (2012). Perceived
barriers to accessing health services among people with disabilities in rural northern Namibia. Disability &
Society, 27(6), 761- 775 15p. doi:10.1080/09687599.2012.686877
World Health Organization (2016) Disability and Rehabilitation . Retrieved from
http://www.who.int/disabilities/en/
World Bank (2016) Disability. Retrieved from http://www.worldbank.org/en/topic/disability

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Proceeding of the 4th International Conference on Public Health, Vol. 4, 2018, pp. 11-22
Copyright © 2018 TIIKM
ISSN 2324 – 6735 online
DOI: https://doi.org/10.17501/23246735.2018.4102

ABC STRATEGY: HOW UNIVERSITY STUDENTS

PERCEPTION OF ABC STRATEGY INFLUENCES
UPTAKE OF REPRODUCTIVE HEALTH
PROGRAMS
Mary Wanjau1*, Lucy kathuri-Ogola2 and Lucy Maina3
1
Kenyatta University and Department of Community Development, Pan Africa Christian University, Kenya
2
Department of Community Resource Management, Kenyatta University, Kenya
3
Department of sociology, Kenyatta University, Kenya

Abstract:

Background: Attitude is what influences all actions an individual undertakes in life. Young adult‟s
attitude on sexual reproductive health has proven to have a significant influence on their sexual
health lifestyle and access to healthcare. Institutions of higher learning have put in place measures to
ensure student have access to youth friendly services yet this has not been matched with students
utilizing the various reproductive health services within the university. To fully understand students
attitude towards uptake of reproductive health services, the current study grounded on the health
belief model builds on previous researches examining on youth attitudes‟ to sexual and reproductive
health. Methodology: Reflecting on 178 structured questionnaire administered to undergraduate
students in Kenyatta University. Results: This paper highlights how students‟ attitude to ABC
strategy influences uptake of reproductive health services. Results indicated that student had a
negative attitude towards abstaining, nearly half had a positive attitude to being faithful to one
partner. Chi square results revealed significant relationships between uptake of reproductive health
services and students attitude to abstinence till marriage (p=0.014), attitude in condom use (p=0.005
Discussion: Findings also showed a positive attitude to condom use contrary to some literature on
the use of condoms among youths. ABC strategy had a significant impact on uptake to reproductive
health progammes. The study established that students‟ attitude to the ABC strategy for protective
sexual behaviour influenced uptake of reproductive health services. Conclusion: In light of these
findings, the study recommends need for reproductive health programmes to redouble their efforts in
strengthening the ABC strategy among university students in order to positively influence students‟
sexual attitudes and behaviour.

Keywords: Attitudes, ABC, Sexual reproductive health, Students, Uptake

Introduction

High risk sexual behaviors (HRSB), include multiple sexual partners, inconsistent condoms use, sex for favors,
drugs and alcohol abuse that culminate in sexually transmitted infection (STI), including Human
Immunodeficiency Virus (HIV), unplanned pregnancy and abortion (Johnson, 2011). Johnson further stipulates
that HRSB, are established during adolescence, and often maintained into adulthood, affecting the health and
wellbeing of an individual later in life. Several studies have noted that university students‟ engage in high risk
sexual behaviors (Sinead et al., 2013; Heeren et al., 2012; Mwangi, Ngure and Thiga, 2012; Adam and
Mutungi, 2007).

High risk sexual behavior of young adults has become of serious concern for institutions of higher learning
because of the adverse consequences that are linked with young adults‟ engagement in HRSB (Moronkola and
Idris, 2013). In addition, Moronkola and Idris noted that in the last two decades, this concern has been marked
by the increasing number of reproductive health interventions aimed at young adults that have been established

Corresponding Author Email: * [email protected]

 Mary Wanjau et al / ABC Strategy: How University Students Perception…..

in different parts of the world. Globally, there has been enormous effort to curb high risk sexual behavior among
university students who are mainly young adults and form a strong pillar of every economy. As students
continue to engage in HRSB it affects their health and well-being which is crucial to economic development and
attainment of Sustainable Development Goals (SDG‟s). HRSB has been categorized as one of the health risk
behaviours consistently found to correlate with increased morbidity and mortality rates among young people
emanating from unplanned pregnancies, abortions, STIs, HIV and AIDS (Sinead et al., 2013, Godia, 2012,
Kirby et al., 2010). The World Health Organization (2009b) reported that HRSB practises are estimated to be
the second most important global health risk factor in the world, and linked to the spread of HIV (WHO 2009a).
According to Schmidt (2015) HRSB also poses the possibility of both emotional distress and has costly physical
health outcomes

Despite the availability of programmes aimed at curbing high risk sexual behavior, studies continue to reveal the
increase in high risk sexual behavior among university student. In addition general uptake of reproductive health
services by the adolescents and youths remains a worrying concern. (Sinead et al., 2013; Heeren et
al.,2012;Mwangi et al., 2012; Kimiywe et al., 2008; Manoti 2015; Miller et al., 2008; Adam and Mutungi,
2007).

Problem statement

Like many public Universities, Kenyatta University (KU) has in place RH programs and services that offer
preventive and curative services on STIs and HIV. These services promote safe sexual behavior among
students‟ through counseling, HIV testing, condom distribution, seminars and workshops on reproductive health
in order to curb HRSB. However, several studies continue to show that HRSB among University students is on
the increase despite the availability of a variety of reproductive health programmes to curb the behavior
(Evidence to Action) (E2A), 2016; Manoti, 2015; Sinead et al., 2013; Mwangi et al., 2012; Kenya National
Bureau of Statistics (KNBS) and ICF Macro, 2010; Kimiywe et al., 2008; Miller et al., 2008; Adam and
Mutungi, 2007). Based on available literature so far, many of the studies conducted in universities have mainly
focused on uptake of HIV and AIDS programmes especially the testing for HIV and AIDS, Voluntary
Counseling and Testing (VCT) programmes. Notably, little has been done to establish the extent of uptake of
programmes such as the peer counseling and mentoring services established to curb HRSB among university
students. Walsh et al., (2010) assert that although the implementation of such services is encouraging, creating
services does not guarantee their use. Walsh et al., 2010 adds that attitude is what influences all actions an
individual undertakes in life. Young adult‟s attitude on sexual reproductive health has proven to have a
significant influence on their sexual health lifestyle and access to healthcare. As a result, the foregoing
discussion provides a background that necessitated the need to undertake this study which assessed how
students‟ attitude influenced uptake of Reproductive Health Services (RHS) in Kenyatta University.

Purpose of the study

The purpose of this study was to determine students‟ attitudes on ABC strategy and how it influences their
uptake of reproductive health services

Objectives of the study

This study was guided by the following specific objectives: 1)To assess influence of students‟ attitude towards
abstinence on uptake of reproductive health services. 2) To establish if students‟ attitude on being faithful to one
partner influenced uptake of reproductive health services. 3) To determine if students attitude on condom use
and influenced uptake of reproductive health services.

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Null hypothesis: The study hypothesised that; 1) there is no significant relationship between students‟ attitude
towards abstinence and uptake of reproductive health services. 2) There is no significant relationship between
students‟ attitude on being faithful to one partner and uptake of reproductive health services. 3) There is no
significant relationship between students‟ attitude on condom use and uptake of reproductive health services.

Delimitations of the Study The study focused on university students who were residents within the KU main
campus. In consideration of this, generalizations of the findings to other students in other universities must be
done with caution.

Limitations of the study The study was confined only to undergraduate students in the regular mode of study
programme thus locking out other students‟ indifferent levels of their studies and other modes of study.

Theoretical framework

This study was based on the Health Belief Model (HBM) by Rosenstock et al., 1988). According to Rosenstock
et al., (1988) HBM is a cognitive model for understanding health risk behaviour including high risk sexual
behaviour among various age groups making it suitable for this study. The HBM predicts whether individuals
undertake preventive health behaviours and is contingent on five factors: (a) an individual‟s perception to
susceptibility to an adverse health outcome; (b) an individual‟s perception of the level of severity of the adverse
health outcome and related consequential outcomes; (c) an individual‟s perceptions of the benefits of given
preventive behaviours in terms of helping them avoid the adverse health outcome; (d) an individual‟s perception
of barriers to (or costs of) implementing given preventive behaviours. The fifth factor is the level of perceived
self-efficacy which refers to the degree to which individuals believe that they are capable of implementing
preventive actions (Rosenstock et al., 1988).

In addition, students‟ attitude was hypothesized to influence students‟ engagement in high risk sexual
behaviours. It was envisaged that students‟ with a positive attitude to behaviours that promoted safe sexual
practises. Such as the ABC strategy will not indulge in high risk sexual behaviour. On the other hand, the study
hypothesized that students‟ who had a negative attitude to adoption of the ABC strategy in their lifestyle most
probably engaged in HRSB. Thus putting them at risk of encountering adverse reproductive health issues.
Hence, refrain from utilizing reproductive health services on campus. Students‟ attitude towards service
provision was also assumed to influence uptake of reproductive health services

Literature review

Students attitudes towards reproductive health services

Students‟ attitudes towards ABC strategy: A study by Liku, et.al (2010) on students‟ attitude towards ABC
strategy at University of Nairobi (UoN) revealed that students attitude towards ABC strategy towards HIV and
AIDS and unintended pregnancy prevention was not entirely positive though knowledge on ABC was relatively
high (over 70%).

A study by Kairu (2006) in Kenyatta university revealed students had a positive attitude towards ABC strategy
on HIV prevention. More than half of the student population interviewed (51%) had a positive attitude on
abstinence, only 20% had a positive attitude to being faithful and only 17% had a positive attitude towards
condom use. However their attitude on practicability of the ABC strategy abstinence was ranked number three,
followed by being faithful to one partner and condom use as most effective. Therefore, this study sought to
further explore if KU students attitude on ABC strategy influenced uptake of reproductive health services.

Health service providers‟ (HSP) attitudes have been identified as a major barrier that discourages young people
from seeking or going back for reproductive health services (Godia, 2012; Obonyo, 2009). A study by Warenius

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et al., (2006) in Kenya and Zambia revealed that reproductive health services were underutilized by youths due
to judgmental attitude of health providers and lack of competence coupled with lack of knowledge in youth
friendly service provision. A study in Ethiopia on health workers attitude toward sexual and reproductive health
services for unmarried youth revealed that some health workers were setting up penal rules and regulations
against premarital sex thus restricting youths from visiting the RHS (Tilahun et al., 2010). Studies also indicate
that HSP influence uptake of reproductive health services as most youth report that they are afraid of HSP
because they ask personal and judgmental questions and sometimes give advice that is scary which discourages
them from seeking services (Godia, 2012). Thus the study sought to examine student‟s attitude of the health
service provider‟s friendliness and how it has influenced uptake of reproductive health services at Kenyatta
University.

Assumptions of lack of anonymity and confidentiality have been seen as a hindrance to access and uptake of
reproductive health services. A study by (Kiran et al., 2015) revealed that majority of student‟s participants
(71%) said the lack of confidential services was a significant barrier to their utilization of Sexual Reproductive
Health (SRH) services. Similarly, 30% believed available services were inadequate to meet their SRH needs
hence did not utilize the service or sought for them elsewhere. Thus the study sought to examine KU student‟s
attitude of the health service provider‟s friendliness and if confidentiality was maintained thus influencing their
uptake of reproductive health services.

Research Methodology

Research design; This study used the survey research design which was cross-sectional because it was carried
at one point in time. According Robson (2011), survey research seeks to obtain information that describes
existing phenomena by asking individuals about their perceptions, attitudes, behaviour or values. The survey
design is also convenient in collecting extensive data from a large scale of respondents within a short period of
time (Mugenda and Mugenda, 2012). It yields reliable quantifiable data as it is collected at one point in time and
conclusions can be inferred to the whole population (Kothari, 2004). For this study, it enabled the researcher to
seek information from students on their attitudes how the attitudes influenced their uptake of reproductive health
services. Independent variables: Students‟ attitude for ABC strategy was measured by a set of five items for
each component scored on a five-point scale ranging from strongly disagrees to strongly agree. The attitude
score was created by calculating the means of the items for each construct. Whereby, a high value score
corresponded with a positive attitude and a low value score corresponded with a negative attitude.

Dependent variable The dependent variable for the study was students‟ uptake of RHS which was measured by
student attesting to use of VCT, YFS, ACU, ICL, peer counseling, mentoring programmes and KU wellness
Centre.

Target population The study targeted only registered undergraduate students‟ on regular mode of study
residing in the main campus hostels during the first semester of academic year 2014/2015 from the month of
September 2014 to December 2014.

Inclusion criteria The study only included registered undergraduate students for academic year 2014/2015 first
semester residing within the main campus hostels from September 2014 to December 2014 as the main
participants for the research. These students were more likely to access and utilize the services that are situated
within the campus compared to nonresident students‟ who may decide to seek services outside the campus.

Exclusion criteria Registered undergraduate students for academic year 2014/2015 first semester who were not
residents within the main campus hostels at the time of study were excluded from the study.

Sampling technique Sampling technique is part of the research plan that indicates how cases are to be selected
for observation. In this study, a combination of purposive sampling, proportionate sampling and stratified and

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 Proceeding of the 4th International Conference on Public Health, Vol. 4, 2018, pp. 11-22

simple random sampling were used. Kenyatta University main campus student residential area is divided into
three zones which were all included in the study. In order to ensure a representative sample, proportionate
random sampling was done from the three residential zones. Stratified random sampling was used to select four
hostels from each zone whereby two were male hostels and two female hostels to ensure gender representation
from where respondents were to be selected. Simple random sampling was used to get to the respondent.

Sample size The population for students residing in main campus was approximately 10,033 students The
sample size for the study was determined using fisher et al., (1995) formula for a population of above 10,000.

n= Z2 p (1-p)
d2
Where;
n- Sample size
Z- Statistic for a level of confidence (95% level of confidence, Z value is 1.962)
p- Expected proportion in the target population. (Assuming 50%, p =0.05)
d- Precision level of statistical significance (7%, d=0.07)

n= (1.962)2 x0.5 (1-0.5)

(0.07)2
n = 200
Therefore, from this equation a total of two hundred students (200) were selected as respondents for this study.

Data collection tool and procedure : Data from the student participants was collected by use of a self-
administered questionnaire since it guaranteed anonymity and confidentiality. Kothari (2004) stipulates that use
of the questionnaire is one of the major ways to elicit self-reports on people‟s opinions, attitudes, beliefs and
values. The questionnaire contained closed-ended questions to provide specific responses and open ended items
for in depth information. Open ended questions permit a greater depth of response and give an insight into the
respondents‟ feelings, backgrounds, hidden motives and intentions (Mugenda and Mugenda, 2012).

For the administration of student questionnaire, the researcher together with the help of two trained research
assistants visited the selected hostels in the evening during weekdays from 5pm to 7pm after classes. Students‟
approached in the selected hostel, were first engaged by creating a rapport between the researcher and student
explaining the purpose of the study. Probing of the student was done to ascertain they were the ones allocated
the given room. Students‟ consent to participate in the study was sought who upon consenting would sign the
consent form and a questionnaire was then handed over for them to fill. Students‟ were also informed the
researcher preferred to wait for them to fill up the questionnaire.

Pre-testing Before commencing the study, pre-testing of the study instruments was conducted. The aim of pre-
testing was to assist in determining accuracy, clarity and suitability of the research instruments and to check
their validity and reliability (Mugenda and Mugenda, 2012). The pre-testing study was conducted at the school
of business and involved a total of fifteen students. The fifteen students were self-sponsored students who were
not residents in the main campus hostel hence could not be duplicated in the main study. Two staff members
employed to offer services at the university programmes were also involved in the pre-testing. Adjustments
were made in order to make to make the research instruments more appropriate before the actual field work
begun. The responses derived from the pretest were used by the researcher to refine the questionnaire by
rephrasing and editing thus ensuring that the questions conveyed the same meaning to all respondents. The
pretest enabled the researcher to test the appropriateness of the study tool by ensuring that items tested what
they were intended to (validity) and that they consistently measured the variables in the study (reliability). It
also helped to estimate the length of time for the administration of instruments.

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 Mary Wanjau et al / ABC Strategy: How University Students Perception…..

Validity of instruments Validity refers to the extent to which an instrument measures what it is intended to
measure based on objectives (Kothari, 2004).To enhance validity of the research instruments, peer review was
done where the study proposal was presented twice at the department. Consistent consultations were done by the
researcher together with supervisors and other expatriates who were knowledgeable in the reproductive health
field of study. This helped in establishing ambiguous questions and missing gaps in the questionnaire, and
corrections were made on research items that were not clear before being used in the actual study.

Reliability of instruments Reliability of measurement is the degree to which a particular measuring procedure
gives similar results over a number of repeated trials thus, pre-testing is a good way to check for reliability of
the data collection instruments (Kothari, 2004).Reliability test was conducted for the likert scale items using
Statistical Package for Social Sciences (SPSS) where internal consistencies were analysed using Cronbachs
coefficient alpha. The results of Cronbachs Coefficient Alpha yielded a value of 0.78 which was acceptable.

Logistical and Ethical considerations

Prior to conducting the study, Permission from relevant authorities‟ in relation to this study was sought.
Approval from the graduate school was sought permitting the researcher to proceed in the area of study.
Permission from Kenyatta University Management was mandatory since the study was based within the
university. An acceptance letter was issued that facilitated the researcher to conduct the study within the
university. Ethical clearance was also sought from Kenyatta University Ethics Review Committee the research
body in the university mandated to review proposals. A research permit to conduct the study was obtained from
the National Commission for Science, Technology and Innovation (NACOSTI) which is the national research
coordinating body in Kenya. Voluntary participation and consent of respondents was sought before
commencement of study and respondents were requested to sign the consent form when they agreed. The
respondents were assured of confidentiality and also informed that they could withdraw from the study, when
they so wished without any consequences.

Data analysis This study generated both qualitative and quantitative data. Quantitative data collected was
analysed using the Statistical Package for Social Sciences (SPSS). Descriptive statistics of means, frequencies
and percentages were used to describe and summarize data. Inferential statistics used included chi-square to test
relationship among variables. Data presentation was done through tables.

The qualitative data obtained from the open ended questions in the students‟ questionnaire was manually
explored, to check for emerging themes. They were then clustered in a patterned order so as to identify variables
that depicted general concepts that occurred repeatedly. Information generated was also statistically analyzed so
as to elaborate on factors influencing students‟ uptake of reproductive health services. Chi-square test of
significance at a significance level of P<0.05 was used to establish the relationship between the dependent and
independent variables. The chi-square test of was preferred since both the dependent and independent variables
used in the study were categorical.

The targeted sample size for this study was 200 students. However, a total of 178 respondents participating in
the study were used for analysis indicating a response rate of 89.0%. According to Timothy and Wislar (2012), a
response rate of 85% and above is considered to be good. The non-response rate by participants was contributed
to the fact that 6% of the questionnaires were not dully filled thus could not be analyzed, and 5% of the students
did not submit back their questionnaires.

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 Proceeding of the 4th International Conference on Public Health, Vol. 4, 2018, pp. 11-22

Research findings

Students attitude of ABC strategy as a safe sex practise

The researcher sought to obtain students‟ attitude on selected safe sex practise that could be attributed to
students‟ uptake of reproductive health services. This was guided by the abstinence, being faithful to one partner
and condom use (ABC) behavioural preventive strategy. ABC strategy was regarded as protective factor for
behaviour change thus resulting to a positive health outcome in curbing high risk sexual behaviour.

Table 1: Students attitude towards ABC strategy

ABC strategy Positive Negative Total
F(n) % f (n) % F (N) %
Abstinence 71 39.9 107 60.1 178 100
Being faithful to one partner 128 71.9 50 28.1 178 100
Condom use 102 57.3 76 42.9 178 100

Findings from table 1 reveal that more than half of the students 60.1% had a negative attitude on abstaining this
indicates the desire to indulge in premarital sex that can lead to high risk sexual behaviours such as early sexual
debut among students. Thus students engaging in premarital sex may fear utilizing reproductive health services
with the attitude that the health service providers will judge them for engaging in premarital sex. Whereas only
39.9% of the students who had a positive attitude in abstaining till marriage.

Students had a positive attitude to being faithful to one partner with nearly three quarters (71.9%) of the students
agreeing it‟s essential to remain faithful to one partner. With only 28.1% of the students having a negative
attitude towards being faithful to one partner. Thus this could result to students utilizing reproductive health
services to seek services such as family planning and counseling seeing on how to have healthy relationships.

Students also had a positive attitude with more than half of the students (57.3%) feeling that it was important for
one to use condom use when engaging in sex. Whereas 42.9% of the students had a negative attitude towards
condom use. Negative attitude towards condom use could result to increased uptake of RHS as individuals may
seek help to avert consequences associated with lack of condom use for example post exposure prophylaxis,
getting emergency pills at the YFS as well as VCT services to check if they have contracted the virus.

Student’s Attitude on Abstinence and Uptake of Reproductive Health Services

The study sought to establish if students‟ attitude in abstinence had any influence on their uptake of reproductive
health services. Results, of these findings are presented in table 4.24.

Table 2 Abstinence and Uptake of RHS

Abstinence Utilized RHS Not utilized RHS Total
Positive 14 57 71
19.70% 80.30% 100%
Negative 65 42 107
60.70% 39.3 100%
Total 79 99 178
44.40% 55.60% 100%
2
χ = 12.432; C=0.256; df = 4; p= 0.014

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 Mary Wanjau et al / ABC Strategy: How University Students Perception…..

Results presented in table 4.24 above reveal that only 19.7% with a positive attitude had utilized reproductive
health services whereas more than three quarter (80.3%) who had a positive attitude did not utilize reproductive
health service. This could mean that students with a positive attitude towards abstinence perceived they were
safe from ill sexual health thus did not find the need to utilize reproductive health services.

Findings indicate that more than half of the students (60.7%) with a negative attitude towards abstaining utilized
reproductive health services. This could be an indication that students perceived themselves at risk and
susceptible to illness due to their engagement in sexual activity thus sought RHS for protective measures or
treatment Whereas, only 39.3% with a negative attitude had not utilize reproductive health services.

Chi-square results (χ2= 12.432; C=0.256; df = 4; p= 0.014) show there was a significant relationship between
students attitude on abstinence and uptake of reproductive health services at a significance level of
0.05.Therefore, the null hypothesis that there was no significant relationship between students‟ attitude and
uptake of reproductive health services was rejected for abstinence.

Being Faithful to One Partner and Uptake of Reproductive Health Services

Being faithful to one partner was an important variable in this study as this would probably reduce students‟
engagement in multiple sexual partners. Moreover, studies have shown that individuals in stable relationships
have high self-efficacy on negotiating for condom use and contraceptives and are most likely to engage in safe
sexual practises (Schimdt, 2015). Hence, the study sought to establish if students‟ attitude in being faithful to
one partner had influence on uptake of reproductive health services.

Table 3 Being Faithful to One Partner and Uptake of RHS

Being faithful to one partner utilized RHS not utilized RHS Total

Positive 56 72 128
43.70% 56.30% 100%
Negative 23 27 50
46% 54% 100%
Total 79 99 178
44.40% 55.60% 100%
2
χ = 1.309; C=0.085; df= 4; p= 0.860

Results presented in Table 3 show that 43.7% students with a positive attitude on being faithful to one partner
had utilized reproductive health services whereas more than half of the students (56.3%) with a positive attitude
did not utilize reproductive health services. Fining continue to reveal that nearly half of the students (46%) with
a negative attitude towards being faithful to one partner utilized reproductive health services thus they perceived
to be at risk of sexual health illness maybe due to their engagement in HRSB such as having multiple sexual
partners. Whereas more than half (54%) with a negative attitude did not utilize reproductive health services

The Chi-square results (χ2= 1.309; C=0.085; df= 4; p= 0.860) reveal there was no significant relationship
between students attitude on being faithful to one partner and uptake of reproductive health services at a
significance level of 0.05. Thus, the null hypothesis that there was no significant relationship on students‟
attitude and uptake of reproductive health services was retained for being faithful to one partner.

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 Proceeding of the 4th International Conference on Public Health, Vol. 4, 2018, pp. 11-22

Students’ Attitude on Condom Use and Uptake of Reproductive Health Services

Students attitude on condom use was assessed and its influence to uptake of reproductive health services.
Results of this study regarding students‟ attitude on condom use and uptake are presented in Table 3.

Table 3: Condom use and Uptake of Reproductive Health Services

Condom use Utilized RHS Not utilized RHS Total
Positive 59 43 102
57.80% 42.20% 100%
Negative 20 56 76
26.30% 73.70% 100%
Total 79 99 178
44.40% 55.60% 100%
2
χ =14.926; C=0.278; df=4; p= 0.005

Findings presented in Table 3 indicate that there was a significant relationship between students‟ attitude on
condom use and uptake of reproductive health service. Results show that more than half of the students (57.8)
with a positive attitude towards condom use had and 42.2% of the students with a positive attitude to condom
use did not utilize reproductive health services. Whereas, nearly a quarter of the students (26.3%) with a
negative attitude towards condom use had utilized RHS and nearly three quarter of the students (73.7%) with a
negative attitude towards condom use had not utilized reproductive health services

This finding could be an indication that students who had a positive attitude to safe sexual practises engaged in
positive sexual behavioural practises such as condom use and utilizing of reproductive health services. On the
other hand, those with negative attitude towards safe sexual practises engaged in negative sexual behavioural
practises like inconsistent/lack of condom use, not utilizing reproductive health services and hence could be at
high risk of suffering from adverse consequences of engaging in high risk sexual behaviour.

The chi-square results (χ2=14.926; C=0.278; df=4; p= 0.005) revealed there was a significant relationship
between students attitude on condom use and uptake of reproductive health services at a significance level of
0.05. Thus, the null hypothesis stating that there is no significant relationship between students‟ attitude and
uptake of reproductive health services was rejected with regard to condom use.

Discussion of findings

Students attitude influencing uptake of reproductive health services

The study established that students‟ attitude to the ABC strategy for protective sexual behaviour influenced
uptake of reproductive health services. Students‟ attitude on condom use had a significant relationship in
utilization of reproductive health services. This could be attributed to the fact that most of the students with a
positive attitude utilized reproductive health services in order to get more information on condom use as well as
get more condoms that are distributed at the RH programmes. Those with a negative attitude towards abstaining
till marriage majority had utilized reproductive health services an indicator that students‟ were engaging in
sexual relations when not married and could also mean student engagement in HRSB.

An association between being faithful to one partner and seeking of reproductive health services was discovered
with majority of those who strongly believed in being faithful to one partner having sought services from the
various programmes. These findings are in agreement with Kairu (2006) and Liku et al., (2010) studies on
students‟ attitude to ABC strategy have called for the need of RH programmes to redouble their efforts in

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 Mary Wanjau et al / ABC Strategy: How University Students Perception…..

strengthening the ABC strategy among university students in order to positively influence students‟ sexual
behaviour.

Conclusion

The study established that more than three quarter (71.9%) of the students had a positive towards being faithful
to one partner. And more than half (57.3%) had a positive attitude to condom use. Nearly half (41.6%) of the
respondents had a positive attitude that reproductive health service providers were friendly and maintained
confidentiality. However, majority of the students‟ more than half (60.1%) had a negative attitude to abstaining.

Uptake of reproductive health services was significantly related to students attitude on abstinence (p=0.014),
condom use (p=0.005), confidentiality is maintained (P=0.001) and service providers were friendly
(P=0.000).Hence, hypothesis there was no significant relationship between students‟ attitude and uptake of
reproductive health services was rejected for this study. Based on the findings, students‟ attitude was found to
greatly influence uptake of RHS.

Recommendations

In view of the findings that emerged from this study, the following recommendations are made with regard to
practise: Programmes need to adopt strategies that strengthen ABC strategy so as to influence students‟ attitude
to adopt safe sex practises. A comparative study could be carried out between students residing off campus and
those residing on campus to establish whether there are differences in their uptake of reproductive health
services in the University.

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Proceeding of the 4th International Conference on Public Health, Vol. 4, 2018, pp. 23-32
Copyright © 2018 TIIKM
ISSN 2324 – 6735 online
DOI: https://doi.org/10.17501/23246735.2018.4103

SUB-NATIONAL INEQUALITY OF CAESAREAN

SECTION IN URBAN-RURAL AREA OF
INDONESIA
Suparmi1*, Nunik Kusumawardhani1 and Kun Arisanti Susiloretni3
1
National Institute of Health Research and Development, Ministry of Health. Indonesia
3
Semarang Health Polytechnic

Abstract: Cesarean section is an important indicator of accessibility to the emergency obstetric care.
The study aims to examine urban-rural inequality and determinant of caesarean section in Indonesia.
Cross-sectional data from national household health survey (RISKESDAS) conducted in 2013 were
used. A total of 49,045 aged 15-49 years having live births in the last 3 years preceding the survey
was included into the analysis. We report absolute difference and ratio of caesarean rates between
urban and rural for each province. The logistic regressions were used to identify determinant of
caesarean section. The caesarean section rates in rural and urban were 5.4% and 13.4%; respectively.
Province estimates of caesarean section rates were ranging from 3.1% in Southeast Sulawesi to
19.1% in DKI Jakarta. Sub-national inequality between urban and rural among province occurs,
accounted for absolute difference between -0.2% (West Papua) to 16.2% (Gorontalo). The logistic
regression indicates determinant of caesarean section includes older ages, higher education level,
currently employed, living in urban area, living in rich household, had any complication during
pregnancy, first child, post-term pregnancy and twin had higher caesarean section rates. This study
provides evidence that sub-national inequalities of caesarean section rates between urban and rural in
Indonesia remain. These inequalities might due to inadequate access to emergency obstetric care
among rural subgroups. Sub-national specific intervention among rural population is deeded to
address these inequalities.

Keywords: caesarean section, sub-national, inequality, Indonesia

Introduction

Vaginal birth among pregnant women is considered when there is no identified risk of complication, either for
the mothers or their babies(World Health Organization, 2018). When complications occur during pregnancy or
labour, a caesarean section is needed as a life-saving surgical procedure(Betrán et al., 2016). However,
caesarean section is often performed for various non-medical reasons and lead to short- and long-term health
problems(Souza et al., 2010). The caesarean section should be assign as an alternative when vaginal delivery
cannot be conducted. However, the current caesarean delivery is not performed only because of medical
indications, but because of patient demand.

The caesarean section rates has increased worldwide in the last two decades particularly in Latin America and
the Caribbean(Betrán et al., 2016). In Indonesia, the caesarean section rates have significantly increased during
the last five years with 6.8% in 2007 to 12.3% in 2012(Statistics Indonesia (Badan Pusat Statistik—BPS),
National Population and Family Planning Board (BKKBN), Departemen Kesehatan and Macro International.,
2008; Statistics Indonesia (Badan Pusat Statistik—BPS) et al., 2013). In result, Indonesia exceed the upper limit
of 10% caesarean section rates in population level, proposed by the World Health Organization(The World
Health Organization, 2015). Countries with caesarean section rates above 10 percent do not show any benefit in
reducing maternal and neonatal mortality(Ye et al., 2016). Furthermore, high caesarean section rates should be a
concern because caesarean sections can cause complications, disability or death particularly in condition of lack
health facilities to conduct safe surgery(The World Health Organization, 2015). The decision to choose a
caesarean delivery should follow medical procedures based on certain medical indications of the pregnancy.

Corresponding Author Email: *[email protected]

 Suparmi et al/ Sub-National Inequality Of Caesarean Section In……

Additional concerns and controversies surrounding caesarean section include inequities in the use of the
procedure, not only between countries but also within countries and the costs that unnecessary caesarean
sections impose on financially stretched health systems(Boatin et al., 2018). In Indonesia, rapid societal
development presents a considerable risk for disadvantaged populations to be left behind. There is no clear
perspective about how residence differences have contributed towards maternal health intervention in Indonesia,
specifically in caesarean section. Subnational analysis should be done because the provinces have local
autonomy in the decentralization era, including public health autonomy. The aim of this study is to explore
inequality of caesarean section rates stratified by urban-rural and examine socio-demographic determinants of
caesarean section in Indonesia.

Methods

Cross-sectional data from national household health survey (RISKESDAS) conducted in 2013 were used for the
analysis. We obtained official permission from the National Institute of Health Research and Development,
Ministry of Health for analyzing the data. The RISKESDAS collected data on nutritional status, health services
access and utilization, environmental health, infectious and non-communicable diseases, as well as blood sub-
sample.

The survey employed multistage stratified sampling technique. The sampling frame of RISKESDAS 2013
consisted of 12,000 census blocks (cluster) which selected from master sample area from the 2010 population
census. In each selected cluster, 25 household were selected from a complete list of households. There were
294,959 households interviewed from a total of 300,000 selected households from the sample, obtained a
response rate of 98.3%. The samples were representative from 33 provinces (497 districts/cities) in Indonesia. A
total of 1,027,763 household members were interviewed using structured questionnaire and data were collected
through interviews by trained enumerators. In this study, we restricted our analysis to women aged 15-49 years
having live births in the last 3 years preceding the survey (n=49,045).

The outcome variable was birth occurred by caesarean section. The independent variables consisted of mother’s
age, mother’s education, mother’s occupation, place of residence, house hold economic status, complication
during pregnancy, parity, term of delivery and weather the delivery twin or not. Maternal age was into 3
subgroups (15-19 years, 20- 34 years, and 35-49 years). Education was based on the last education obtained by
the respondent (primary education or less education, secondary education and higher education). High school or
above were grouped together into higher education. Working status was divided into unemployed and
employed. Place of living was divided into urban and rural.

Household economic status Socio-economic status was an index constructed from household ownership
information, using polychoric correlation analysis (PCA). Variables forming the index were: 1) the primary
source of drinking water, 2) cooking fuel, 3) defecation facilities ownership, 4) type of toilet, 5) final feces
disposal, 6) illumination source, 7) motorcycles, 8) television, 9) water heater, 10) gas cylinder 12 kg, 11)
refrigerator, and 12) cars. The index then divided into 5 levels, with quintile 5 as the highest quintile and the
lowest or poorest was quintile 1.

Complication during pregnancy was divided into ever had any complication and none. Term of delivery was
divided into 3 subgroups (aterm, preterm and postterm). Women were classified as aterm delivery if they
delivered in 9 months of pregnancy; preterm if they had delivery in 7-8 months of pregnancy; and postterm if
they had delivery in 10 months of pregnancy.

We compare inequality of absolute difference and ratio between urban and rural using Hear Plus. Descriptive
statistics and multilevel logistic regressions were used to identify determinant of caesarean section. The data
were analyzed using STATA version 13.0 for windows. The adjusted Odds Ratio with 95% confidence intervals
was calculated in order to assess the strength of association.

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Results

Table 1 shows the caesarean section rate was substantially higher in urban (13.4%) compared with rural (5.4%)
and was higher among older mothers (12.0% for 35-49 yearolds) compared with younger ones (4.4% for 15-19
year olds and 9.1% for 20–24 year olds). Caesarean section rates was lowest among mothers with the lowest
level of education and increased with increasing education levels, from 5.5% among mothers with primary or
less education to 24.0% among mothers with higher education. Furthermore, caesarean section rates were lower
among mothers from the poorest quintile and increased with increasing economic status, from 2.0% in quintile 1
to 18.4% in quintile 5. The overall difference of caesarean rates between richest and poorest in urban area was
16.4% and the richest were 9.2 times higher than poorest. The rates were higher among mothers experience with
any complication during pregnancy compare to no complication (16.5% and 8.4%, respectively).

Table 1 Prevalence of caesarean section in urban and rural area of Indonesia, RISKESDAS 2013
Characteristics Total (95% CI) Urban (95% CI) Rural (95% CI)
Place of residence
Urban 13.4 (12.7 - 14.1)
Rural 5.4 (5.1 - 5.9)
Mother’s age
15 - 19 years 4.4 (3.0 - 6.4) 7.0 (4.0 - 12.0) 2.9 (1.8 - 4.6)
20-34 years 9.1 (8.6 - 9.6) 12.7 (11.8 - 13.6) 5.2 (4.7 - 5.6)
35 - 49 years 12.0 (11.2 - 12.9) 16.6 (15.2 - 18.0) 7.0 (6.2 - 7.8)
Mother’s education
Primary or less education 5.5 (5.1 - 5.9) 7.6 (6.8 - 8.5) 4.1 (3.7 - 4.5)
Secondary education 13.9 (13.0 - 14.9) 16.2 (15.0 - 17.5) 8.7 (7.7 - 9.8)
Higher education 24.0 (22.2 - 25.9) 26.9 (24.6 - 29.3) 15.1 (12.7 - 17.8)
Mother’s occupation
Unemployed 8.9 (8.4 - 9.4) 11.8 (10.9 - 12.6) 5.4 (4.9 - 5.9)
Employed 11.1 (10.3 - 11.8) 17.3 (16.0 - 18.8) 5.6 (5.0 - 6.2)
Household economic status
Quintile 1 2.0 (1.7 - 2.4) 2.6 (1.7 - 4.1) 1.9 (1.5 - 2.3)
Quintile 2 4.4 (3.9 - 5.1) 5.3 (4.2 - 6.8) 4.0 (3.4 - 4.8)
Quintile 3 7.7 (6.9 - 8.6) 8.7 (7.4 - 10.2) 6.6 (5.7 - 7.6)
Quintile 4 12.0 (11.1 - 12.9) 13.5 (12.4 - 14.7) 8.5 (7.4 - 9.8)
Quintile 5 18.4 (17.2 - 19.7) 21.0 (19.5 - 22.5) 10.8 (9.4 - 12.4)
Complication during pregnancy
None 8.4 (8.0 - 8.8) 11.9 (11.2 - 12.7) 4.6 (4.2 - 5.0)
Any complication 16.5 (15.1 - 18.0) 21.3 (19.1 - 23.8) 10.7 (9.5 - 12.1)
Parity
1 11.2 (10.3 - 12.1) 14.8 (13.5 - 16.2) 6.5 (5.7 - 7.5)
2-3 9.5 (8.9 - 10.1) 13.4 (12.4 - 14.4) 5.3 (4.8 - 5.9)
≥4 7.5 (6.8 - 8.3) 11.0 (9.7 - 12.5) 4.4 (3.8 - 5.1)
Pregnancy
Aterm 8.9 (8.3 - 9.6) 12.8 (11.8 - 14.0) 5.0 (4.5 - 5.5)
Preterm 10.1 (9.5 - 10.7) 13.7 (12.8 - 14.7) 5.8 (5.3 - 6.4)
Postterm 15.4 (10.8 - 21.4) 22.2 (14.1 - 33.3) 8.8 (5.4 - 14.0)

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 Suparmi et al/ Sub-National Inequality Of Caesarean Section In……

Twin
No 9.3 (8.9 - 9.8) 13.1 (12.4 - 13.8) 5.2 (4.8 - 5.6)
Yes 29.6 (23.6 - 36.5) 35.3 (26.3 - 45.5) 23.0 (16.1 - 31.5)

Overall, the caesarean section rate in Indonesia was 9.8%. The rates varied by geographic, socio-economic, and
demographic factors as shown in tables 1 and Figure1. Figure 2 shows provincial caesarean section rates on a
map. Provinces in the eastern part of Indonesia tended to report higher caesarean section rates than provinces in
the west. The caesarean section rates varied between provinces, ranging from 3.1% in Southeast Sulawesi to
19.1% in DKI Jakarta.

Figure 1 Caesarean section rates by Province, Indonesia, RISKESDAS 2013

Figure 2 shows provincial inequality of caesarean section rates between urban and rural. Bali likely overuse
caesarean section reported the prevalence for 17.8 % point estimates and had wide gap between urban and rural
(8.5%). Papua had low caesarean section rates provincial average (5.5%) and wide inequality, accounted for
13.7% point difference between urban and rural. The neighboring province, Maluku reported lower caesarean
section rates (3.5%). However, the inequality between urban and rural in Maluku nearly twice compare to
Papua. Furthermore, the inequality did not see any pattern between eastern and western provinces.

Figure 2:Urban and rural inequality of caesarean section rates by Province, Indonesia, RISKESDAS 2013

Figure 3 shows scatter plots of subnational cesarean section rates and urban-rural inequality. The subnational
inequality between urban and rural accounted for absolute difference between -0.2% (West Papua) to 16.2%

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(Gorontalo). West Papua, West Kalimantan, East Kalimantan, West Sulawesi and Lampung had the lowest
inequality compare to other province. However, those provinces also encounter low caesarean section rates.

Figure 3: Scatter plots of subnational cesarean section rates and urban-rural inequality (difference between
urban and rural) in Indonesia, RISKESDAS 2013

Table 2 presents the adjusted odds ratios from the logistic regression analysis in urban and rural area. The results
show that caesarean section rates associated with household economic status. Mothers from the quintiles 4 and 5
had more than three times the odds of caesarean section from the lowest quintile (OR = 3.50 for quintile 4 and
OR = 4.98 for quintile 5), while mothers from quintiles 2 and 3 had more than 1.5 times the odds of caesarean
section compared with mothers from the lowest quintile (OR = 1.82 for quintile 1 and OR = 2.57 for quintile 3).
There was no evidence for a statistically significant association between caesarean section and mother’s
occupation.

Table 2 Adjusted association between caesarean section and socio-demographic in urban and rural, Indonesia,
RISKESDAS 2013
Total Urban
Characteristics Rural
AOR* 95% CI AOR* 95% CI AOR* 95% CI
Mother’s age
15 - 19 years 1.00
20-34 years 1.52 (0.99 - 2.33) 1.32 (0.68 - 2.55) 1.89 (1.17 - 3.07)
35 - 49 years 2.70 (1.74 - 4.19) 2.33 (1.19 - 4.55) 3.48 (2.05 - 5.91)
Mother’s education
Primary or less
education 1.00
Secondary education 1.69 (1.50 - 1.92) 1.76 (1.50 - 2.07) 1.50 (1.24 - 1.82)
Higher education 2.64 (2.25 - 3.12) 2.69 (2.19 - 3.29) 2.46 (1.86 - 3.26)
Mother’s occupation
Unemployed 1.00
Employed 1.11 (0.99 - 1.24) 1.18 (1.03 - 1.36) 0.94 (0.79 - 1.12)

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Place of residence
Urban 1.00
Rural 0.71 (0.63 - 0.79)
Household economic
status
Quintile 1 1.00
Quintile 2 1.82 (1.42 - 2.33) 1.74 (1.06 - 2.88) 1.83 (1.37 - 2.45)
Quintile 3 2.57 (2.02 - 3.26) 2.46 (1.54 - 3.92) 2.75 (2.06 - 3.67)
Quintile 4 3.50 (2.76 - 4.43) 3.51 (2.21 - 5.58) 3.46 (2.59 - 4.64)
Quintile 5 4.98 (3.92 - 6.34) 5.23 (3.28 - 8.35) 4.20 (3.09 - 5.72)
Complication during
pregnancy
None 1.00
Any complication 2.26 (2.00 - 2.56) 2.13 (1.82 - 2.50) 2.58 (2.16 - 3.09)
Parity
1 1.00
2-3 0.76 (0.67 - 0.85) 0.80 (0.69 - 0.93) 0.65 (0.54 - 0.78)
≥4 0.55 (0.46 - 0.66) 0.59 (0.47 - 0.73) 0.47 (0.35 - 0.63)
Pregnancy
Aterm 1.00
Preterm 1.17 (1.06 - 1.30) 1.16 (1.02 - 1.32) 1.21 (1.03 - 1.41)
Postterm 2.16 (1.36 - 3.45) 2.34 (1.23 - 4.48) 1.87 (1.05 - 3.33)
Twin
No 1.00
Yes 5.57 (3.88 - 8.02) 5.09 (3.17 - 8.16) 6.44 (3.63 - 11.43)

Note: Estimates are also adjusted for province (not shown in the table)

Discussions

There were higher caesarean section rates among urban and lower rates among rural and the rates varied
between provinces. The rates in urban area Indonesia was exceeds the World Health Organization(WHO)
recommendation limit of 10 percent(The World Health Organization, 2015). In addition, the WHO data analysis
results in 159 countries from 1980 to 2012 show that the proportion of caesarean section above 10 percent was
not associated with a reduction in maternal and neonatal deaths(Ye et al., 2016). While caesarean section rates
in urban area nearly bellow recommendation limit of 5 percent.

This study shows the inequalities of caesarean section rates between urban and rural within province remain.
Low level of caesarean section rates and wider inequalities between urban and rural in several provinces, such
as Papua and Maluku may be due to lack of skilled health staff and health infrastructure, including
inavailabilityof emergency obstetric care. Indonesian Health Facility Survey (RIFASKES) showed that nearly
50 percent of public hospital was not accredited and the percentage much higher in Papua and Maluku,
accounted for 78% and 93%, respectively(Badan Penelitian dan Pengembangan Kesehatan Kemenkes RI, 2011).
Absence of obstetrician and surgeon also lead to lower caesarean section rates, where only 29% of public
hospital in Maluku have obstetrician and nearly half did not have surgeon. Other reasons for low level of
caesarean section rates includes economic reasons, urge to vaginal delivery(Chigbu and Iloabachie, 2007;
Boatin et al., 2018). Geographical barriers also lead to inequality in accessing emergency obstetric care, where
most of Maluku province area were consist of oceans while Papua mainly mountains(Hodge et al., 2014).

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This study shows an increasing trend in the proportion of caesarean section delivery in mothers along with
higher level of socioeconomic status. The results of a multivariate analysis showed that women with the richest
economic status were four times more likely to have caesarean section deliveries. This is in line with previous
research in the continued analysis of RISKESDAS 2010(Suparmi and Basuki, 2011) and other studies in
Canada(Leeb et al., 2005), Ethiopia(Gebremedhin, 2014) and China(Sufang et al., 2010) and data analysis of
DHS in 26 countries(Calvello et al., 2015). Higher rates of caesarean section in richest quintile were likely due
to higher proportion of elective caesarean section. Studies conducted in Jakarta show the proportion of elective
caesarean delivery was higher than the proportion of emergency sectional delivery(Andayasari et al., 2015).
Several factors that lead to higher rates of caesarean section includes individual factors such as urge to caesarean
delivery because of fear of pain during labor, fear of death, cosmetic appearance and sexual functioning.
Cultural factor also may lead to high caesarean section rates such as choosing the date of the baby’s delivery on
the basis of luck and fate for the future(Boatin et al., 2018). Health system support may escalate caesarean
section rates such as higher financial incentives and lower tolerance to any complication in health facility.

Several studies have shown that women with a history of caesarean section without a medical indication of
elective caesarean section have a higher risk of abnormal placental attachment in the uterine or uterine part of
the uterine wall part of the uterus (placenta accreta) at subsequent births, this can lead to heavy bleeding during
labor(The Royal Australia and New Zealand College of Obstetrician and Gynaecologist., 2016). In addition,
caesarean section delivery has a cost burden(Borghi et al., 2003), lengths of hospitalization and a higher risk of
illness when compared with a normal delivery(Souza et al., 2010; Siti Maisyaroh Fitri Siregar and Jemadi,
2013).

This study also showed that mothers aged 36-49 years were three times more likely to have caesarean section
delivery than women aged 15-19 years. This is because in mother age over 35 years have a risk of complications
in childbirth. This finding is in line with a study by Zhife He et al in China that the proportion of caesarean
section delivery in mothers older than 35 years is greater than for normal delivery(He et al., 2016).

The results of multivariate analysis showed parity associated with caesarean section, where caesarean section
was more prevalent in the first pregnancy. This finding is in line with research conducted in China(Feng et al.,
2012) and Australia(Toohill et al., 2014). The psychological condition of expectant mothers and there is fear of
childbirth pain was lead to higher rates of caesarean section(Toohill et al., 2014). However, this finding was in
contrast to studies in Africa that show the proportion of caesarean section increased with increasing
parity(Gebremedhin, 2014). The higher parity is associated with risk of complications in labor. This difference
is possible because of the high proportion of sectional births in Indonesia.

This study had potential limitation to be considered in interpreting the findings. Firstly, this inequality analysis
was based on simple measure of ratio and difference which can be use for clarity and ease of understanding.
Secondly, data on caesarean section rates were based on mothers self-reporting from a cross-sectional survey.
Thirdly, the survey did not have detailed information on some predictors related to caesarean section, such as,
on placenta previa, breech position, cord prolapsed, failure to progress in labor, repeated caesarean sections,
cephalopelvic disproportion, fetal distress, birth defects, and demand to have caesarean section from the subjects
as well as from the respective medical doctors. However, despite these limitations, this study had a large sample
size (n=49045) and the data were nationally representative and can be aggregated into province and districts
level data.

Conclusion

The result of this study shows the sub-national inequality of caesarean section rates between urban and rural.
Additionally, factors associated with caesarean section delivery in urban and rural include pregnancy
complications, post-term pregnancy, multiple births/twin, maternal age over 35 years, and high socioeconomic
status. Overall, urban more likely had higher caesarean section rates. This study suggest that it is necessary to

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ensure that pregnant women living in rural area have better access to caesarean section and increase alertness
especially for mothers with high level of economic status in urban area not to conducting caesarean section
without medical indication. In addition, there is a need for health promotion related to the side effects of
caesarean section without medical indication.

Acknowledgements

The authors would like to acknowledge the National Institute for Health Research and Development for
providing the data. The authors also wish to express their most sincere gratitude to Dr. Julianty Pradono for all
her comments during paper development.

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Appendix

Appendix Table 1 Urban and rural inequality of caesarean section rates by Province, Indonesia, RISKESDAS
2013
Difference Ratio
Province Total (95% CI) Urban (95% CI) Rural (95% CI) urban vs
rural urban vs rural

Aceh 9.5 (7.9 - 11.3) 16.9 (13.3 - 21.1) 6.3 (4.8 - 8.2) 10.6 2.7
North Sumatra 11.8 (9.9 - 14.0) 15.9 (12.7 - 19.7) 7.6 (5.7 - 10.0) 8.3 2.1
West Sumatra 12.6 (10.4 - 15.0) 17.4 (13.2 - 22.5) 9.4 (7.4 - 11.8) 8.0 1.9
Riau 9.0 (7.4 - 10.9) 12.6 (9.7 - 16.2) 6.7 (5.1 - 8.9) 5.9 1.9
Jambi 7.6 (5.8 - 9.8) 12.6 (8.9 - 17.4) 5.5 (3.7 - 8.1) 7.1 2.3
South Sumatera 6.2 (4.6 - 8.2) 11.4 (8.2 - 15.6) 2.5 (1.6 - 3.9) 8.9 4.5
Bengkulu 5.4 (3.9 - 7.5) 9.8 (6.4 - 14.5) 3.0 (1.6 - 5.4) 6.8 3.3
Lampung 4.3 (3.2 - 5.9) 6.5 (3.9 - 10.4) 3.5 (2.3 - 5.3) 2.9 1.8
Bangka Belitung 9.2 (6.8 - 12.2) 10.6 (7.3 - 15.1) 7.8 (4.7 - 12.5) 2.8 1.4
Riau Islands 16.6 (12.4 - 21.7) 17.9 (13.2 - 23.8) 6.9 (4.4 - 10.6) 11.1 2.6
DKI Jakarta 19.1 (15.1 - 23.8) 19.1 (15.1 - 23.7) - NA NA
West Java 7.8 (6.8 - 9.0) 9.7 (8.2 - 11.3) 3.8 (2.7 - 5.2) 5.9 2.5
Central Java 9.9 (8.7 - 11.1) 12.8 (11.0 - 14.8) 7.2 (5.9 - 8.8) 5.6 1.8
DI Yogyakarta 15.6 (12.0 - 19.9) 17.8 (13.2 - 23.5) 11.1 (6.7 - 17.8) 6.7 1.6
East Java 12.0 (10.9 - 13.2) 17.3 (15.3 - 19.3) 6.9 (5.7 - 8.3) 10.4 2.5
Banten 11.4 (9.4 - 13.7) 15.1 (12.3 - 18.3) 2.8 (1.6 - 4.9) 12.3 5.3
Bali 17.8 (14.8 - 21.1) 20.7 (16.6 - 25.4) 12.3 (8.8 - 16.7) 8.5 1.7
West Nusa Tenggara 5.2 (3.9 - 6.9) 5.9 (4.2 - 8.3) 4.7 (3.0 - 7.4) 1.2 1.3
East Nusa Tenggara 4.0 (3.2 - 5.0) 9.6 (7.2 - 12.8) 2.7 (1.9 - 3.7) 7.0 3.6
West Kalimantan 4.0 (2.9 - 5.5) 5.2 (3.2 - 8.2) 3.5 (2.3 - 5.3) 1.7 1.5
Central Kalimantan 6.2 (4.5 - 8.4) 10.5 (6.9 - 15.6) 4.1 (2.6 - 6.6) 6.3 2.5
South Kalimantan 8.2 (6.6 - 10.2) 11.1 (8.1 - 14.9) 5.9 (4.2 - 8.3) 5.2 1.9
East Kalimantan 6.9 (5.2 - 9.2) 7.5 (5.1 - 10.9) 6.0 (4.1 - 8.7) 1.5 1.3
North Sulawesi 9.2 (6.9 - 12.1) 12.3 (8.1 - 18.1) 6.7 (4.5 - 9.9) 5.5 1.8
Central Sulawesi 8.2 (6.5 - 10.3) 13.8 (10.2 - 18.3) 6.3 (4.4 - 9.0) 7.5 2.2
South Sulawesi 7.2 (5.8 - 8.9) 11.6 (8.4 - 15.6) 4.4 (3.3 - 5.8) 7.2 2.6
Southeast Sulawesi 3.1 (2.3 - 4.3) 7.6 (5.2 - 10.9) 1.4 (0.8 - 2.4) 6.2 5.5
Gorontalo 13.8 (10.2 - 18.2) 24.2 (17.0 - 33.1) 8.0 (5.0 - 12.6) 16.2 3.0
West Sulawesi 4.1 (2.6 - 6.6) 5.8 (2.7 - 12.0) 3.6 (2.0 - 6.6) 2.2 1.6
Maluku 3.5 (2.1 - 6.0) 7.8 (4.4 - 13.5) 0.3 (0.1 - 1.1) 7.5 24.2
North Maluku 6.4 (4.9 - 8.4) 15.0 (10.9 - 20.1) 2.8 (1.6 - 4.7) 12.2 5.4
West Papua 3.5 (1.9 - 6.2) 3.3 (1.1 - 9.4) 3.6 (1.7 - 7.1) -0.2 0.9
Papua 5.5 (3.8 - 7.9) 14.8 (9.7 - 22.0) 1.1 (0.6 - 1.9) 13.7 13.5
Note: Estimates and 95%CIs are reported as percentages

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Proceeding of the 4th International Conference on Public Health, Vol. 4, 2018, pp. 33-39
Copyright © 2018 TIIKM
ISSN 2324 – 6735 online
DOI: https://doi.org/10.17501/23246735.2018.4104

RELATIONSHIP BETWEEN NUTRITIONAL STATUS,

HEALTH STATUS, FOOD CONSUMPTION, AND
LIFESTYLE TO WORK PRODUCTIVITY OF COCOA
FARMER

Wilda Yunieswati1*, Sri Anna Marliyati1 and Budi Setiawan1

1
Departement of Community Nutrition, Faculty of Human Ecology, Bogor Agricultural University, Indonesia

Abstract: Agricultural sector only contributed 14.43% of total GDP despite labor from this sector is
the largest labor force in Indonesia. Cocoa is one of the leading commodities in agricultural sector,
sub sector plantation. Mengingat besarnya potensi kakao dalam perekonomian, makaOne of the
ways to improve the productivity of cocoa is give an attention about the good nutrition and good
health of the cocoa farmer that have been widely known as a factor to improve work productivity of
farmers. This study is cross-sectional study. The objective of this study was to analyze the
relationship between nutritional status, health status, food consumption, and lifestyle to work
productivity. The subjects were 58 male cocoa farmers in two districts of Polewali Mandar aged 18-
65 years old. Most of subjects (39.7%) have a normal nutritional status and 10.3% of subjects are
central obesity. Then, 46.6% of subjects have a pre-hypertension. There is no relationship between
nutritional status to work productivity. Then, there is a relationship between health status (blood
pressure) and amount of cocoa picked per day (kilograms) and health status (central obesity) and
number of absent days to plantation due to sick.

Keywords: cocoa farmer, health status, nutritional status, work productivity

Introduction

The central bereau of statistics notes that labor from agricultural sector is the largest labour force in Indonesia,
which reached 37.18 million persons per February 2013. This amount represents 32.61% of Indonesian total
labor force (BPS 2014). Despite the large population of agricultural labour, the agricultural sector only
contributed 14.43% of total GDP. This condition indicates that work productivity in agriculture sector is low.
Cocoa is one of the leading commodities in plantation sub sector. The cocoa development has a potential part in
the economy development. Komoditi kakao secara konsisten berperan sebagai sumberCocoa commodities
contribute consistently as a sources devisa negara yang memberikan kontribusi yang sangat penting dalamof
foreign exchange and very important in struktur perekonomian Indonesia (Arsyad et al., 2011 ). Indonesia's
economic structure (Arsyad et al. 2011). Dari sisi luas areal, kakao menempati luas areal keempat Based on the
the economic side, cocoa contributes devisa ketiga terbesar setelah kelapa sawit dan kar et (Hasibuan et al, 20
12). the third largest foreign exchange after palm oil and rubber (Hasibuan et al. 2012). Mengingat besarnya
potensi kakao dalam perekonomian, maka One of cocoa production centers in Indonesia is West
Sulawesi. Development of cocoa in West Sulawesi has been done since the 1980s by the local community in
here. One of the way to improve the productivity of cocoa is give an attention about the good nutrition and good
health of the cocoa farmer

Health status and nutritional status of workers will influence the work productivity of workers. One of the
phenomenon about health status of farmer and people in rural area is non-communicable disease which impacts
rural areas as well as the major urban center. Indonesia Basic Health Research (2013) shows an increase in
prevalence of non-communicable diseases in West Sulawesi in 2007-2013. Based on various study, there is a

Corresponding Author Email: * [email protected]

 Wilda Yunieswati et al / Relationship Between Nutritional Status, Health Status, Food Consumption…..

significant relationship between nutritional status with work productivity in the traditional rice farmers of
Julupamai village. Besides that, there is a strong association between having more health risks and higher
presenteeism (Boles et al. 2014). The mean percentage of presenteeism (percentage of time impaired at work)
rises for each level of cumulative health risks, ranging from 1.3% average presenteeism for individuals with
zero risks to 25.9% presenteeism for individuals with eight risks. Absenteeism also increases as health risks
accumulate, with a clear difference between low levels and high levels of risk, but the range is smaller (0.0% to
6.3%) and fluctuates among mid-level of risk. So, employees who have more health risks will experience more
absenteeism and presenteeism than employees with fewer risks. While the study on farmers in Ahiauzu Imo,
Nigeria shows that poor health status would have a negative impact on the productivity of farmers (Nwaiwu et
al 2017). Various studies above have shown the problem of low productivity with one of the factors is the
nutritional status and health status of farmers. Based on these problems, researcher interested to examine the
relationship between nutritional status, health status, food consumption, and lifestyle to work productivity of
cocoa farmers in Polewali Mandar, West Sulawesi.

Methods

This study is cross sectional study design and conducted at cocoa plantation in 2 sub-districts (Anreapi District
and Mapilli District) located in Polewali Mandar Regency, West Sulwesi Province. The study was conducted in
July-August 2017. This study is a part of study entitled Sustainability and Provitability of Cocoa-based Farming
Systems in Indonesia collaboration between AIC (Australian-Indonesian Center) with InterCafe
LPPM Bogor Agricultural University, Hasanuddin University and Syndey University, Australia. The subjects
are 58 male cocoa farmers in 2 sub-districts of Polewali Mandar. The inclusion criteria of the subjects were 1)
men aged 18-65 years, 2) cocoa farmers, 3) in a good condition (not sick) when we do the assessment at that
time 4) willing and stay in the study site during the study to conduct interviews and anthropometric
measurements, body composition and pressure blood directly.

Determination of the minimum number of samples is calculated using the following formula (Sujarweni 2012):

Based on Indonesia Basic Health Research (2013) the prevalence of central obesity among farmers in West
Sulawesi is 11.5%. The absolute precision used is 10% and the confidence level is 95 percent or α = 0.05 so the
minimum number of samples needed in the study after adding 10% of the anticipated drop-out is 45 people.
Minimum sample is 45 people. The sample used in this study was 58 male cocoa farmers who were in
accordance with the inclusion and exclusion criteria set by the researchers.

Primary data include subject characteristic, nutritional status (BMI, waist circumference and waist hip ratio),
body composition, blood pressure, food consumption (food recall 2x24 hours), eating habits
and lifestyle. Data collected through direct interview with subjects.

Anthropometric measurements

To measure anthropometric variables of weight, height, BMI, waist circumference (WC), hip circumference
(HC), waist to hip ratio (WHR) and body compositions, participants were asked to remove their shoes, socks,
hat, jewelry, accessories (e.g. watch, keys, cell phone). Body composition was measured using OMRON HBF-
305 BIA (Bioelectrical Impedance Analysis). The precision of weight, height, and WC was 0.1 kg, 0.1 cm and
0.1 cm, respectively. BMI was computed as follow: weight (kg)/ (height [m] × height [m]) (kg/m2). Obese was
defined as BMI ≥ 25. Central obesity was defined as WC > 90 cm or WHR ≥ 0.9 for men (x).

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 Proceeding of the 4th International Conference on Public Health, Vol. 4, 2018, pp. 33-39

Health status measurement

Health status was measured by case of central obesity and hypertension. Central obesity was defined as Waist
circumference > 90 cm or WHR ≥ 0.9 for men (x). Waist and hip circumference are measured using measuring
tape (meter). WC is measured in light clothing at the narrowest point immediately below the lowest rib and
above the iliac crest; HC was measured at the level of the maximum circumference. WHR was calculated as a
waist to hip ratio (i.e. WC [cm]/HC [cm]). Blood pressure (BP) was measured in a sitting position, and the
subject were rested for at least 5 minutes before the measurement. Systolic blood pressure (SBP) and diastolic
blood pressure (DBP) were measured using an automated measurement device (Omron, Model HEM-7211,
Kyoto, Japan) with a proper cuff size on the left arm. Blood pressure was obtained twice at 1-minute interval,
and the average of two readings was used to represent SBP and DBP, respectively. Subject were classified as
hypertensive if the SBP ≥ 140 mmHg and DBP ≥ 90 mmHg. Subject were classified as pre-hypertensive if the
average SBP if the SBP 120-139 mmHg and DBP 80-89 mmHg.

Food Consumption

Food consumption data includes data intake and type of food using the 2x24 hours food recall method. The level
of adequacy of energy and nutrients (protein, fat and iron) is obtained by comparing the consumption of energy
and nutrients with the adequacy of the energy and nutrients of the subject. Calculation of the level of nutritional
adequacy is calculated according to the recommended nutritional adequacy (Ministry of Health of Indonesia
2013). Food diversity is assessed using the IDDS (Individual Dietary Diversity Score) method. The way to
obtain a food diversity score is to use a 1x24 hour food recall method by paying attention to the weight of food
consumed at least 10 grams. The food diversity score category is low (if consuming ≤3 types of food groups
every day), moderate (if consuming 4-5 types of food groups every day) and high (if consuming ≥6 types of
food groups every day)

Lifestyle

The lifestyle in this study is seen from the subject's habits of several things. These include smoking in a day
(number of stems), daily coffee consumption habits (frequency and amount of coffee consumption), alcohol
consumption habits (frequency and amount of alcohol taken), breakfast habits (yes or no), consumption habits of
fruit vegetables every day (yes or no) and exercise habits (yes or no, frequency per week). Data obtained by
asking directly to farmers using the interview method and filling in the questionnaire.

Work Productivity

Work productivity in this study was obtained by two ways. The first way was the amount of cocoa picked per
day (kilograms) and the second way was the number of absent days to plantation in the last 1 month due to
illness/health reason. Data obtained by asking directly to farmers using the interview method.

Statistical Analysis

The analysis used in this study were spearman-test and pearson-test, based on the normality data and purpose of
the study. The, the normality data test used Kolmogorov-smirnov test.

Ethical statement

The written informed consent was obtained from each participant after explaining the purpose of the study.
Ethical approval was approved by the Ethics Committee at Institut Pertanian Bogor
(4758/IT3.26.1/KEPMSM/PL/2017). Each participant was also informed that s/he had the right to terminate the

35
 Wilda Yunieswati et al / Relationship Between Nutritional Status, Health Status, Food Consumption…..

data collection process at any point. Those who did not provide consent to participate were excluded from the
study. Data were collected anonymously and was only used for study.

Results

Table 1 shows that most subjects had a normal nutritional status (39.7%). Most of the cocoa farmers in the study
had normal abdominal circumference (89.7%) and 10.3% of subjects were central obese with abdominal
circumference greater than 90 centimeters for men. Meanwhile, data from the waist hip ratio measurement, most
subjects had a normal WHR of 58.6% and another 41.4% had WHR at risk category. The higher the waist
circumference and RLPP the higher the risk of non-communicable diseases (NCDs) and chronic diseases such
as cancer, cardiovascular disease, diabetes, hypertension and others. Then, most subjects had a pre-hypertension.
Work productivity in this study defined by 2 ways, the amount of cocoa picked per day (kilograms) and the
number of absent days to the plantation due to health reason in the past 1. Data shows most subjects
(62.1%) picked 1-25 kilograms of cocoa per day and most of subjects (58, 6%) have zero day for absent day
reated to health reason in the last 1 month.

Table 1. Characteristics of subjects

Characteristics of subjects n %
Body mass index
Underweight 6 10.3%
Normal 23 39.7%
Overweight 15 25.9%
Obesity 14 24.1%
22.77 ± 3.18
Waist circumference
Central obesity 6 10.3%
Normal 52 89.7%
78.15 ± 9.51
Waist and hip ratio (WHR)
At risk 24 41.4%
Normal 34 58.6%
0.88 ± 0.05
Blood pressure
Hypertension 20 34.5%
Pre-hypertension 27 46.5%
Normal 11 19.0%
Number of cocoa picked / day (kg)
1-25 kilograms 36 62.1%
26-50 kilograms 17 29.3%
51-75 kilograms 1 1.7%
76-100 kilograms 4 6.9%
Number of days absent due to health reason (days)
0 days 34 58.6%
1-3 days 20 34.5%
More than 3 days 4 6.9%

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 Proceeding of the 4th International Conference on Public Health, Vol. 4, 2018, pp. 33-39

The result of this study shows that there is no relationship between nutritional status, and work productivity of
cocoa farmers. The results of this study are in line with the research of Mahardikawati VA (2008) which shows
that there is no relationship between nutritional status which is reflected by the body mass index (BMI) with the
level of work productivity. This is presumably because the level of work productivity is more influenced by the
consumption of nutrients, especially iron. So that IMT is not directly related to work productivity. The
relationship between nutritional status and work productivity can be shown in Table 2.

Table 2: Relationship between nutritional status and work productivity of cocoa farmers
Number of cocoa picked / dayNumber of days absent due to health reason
Variable r p r P
body mass index 0.087 0.516 -0.230 0.083
Body fat percentage-0.067 0.618 -0,190 0.153

Regarding health status, there is a significant relationship between health status seen by blood pressure and the
number of cocoa picked per day (kilograms). The results of this study indicate that someone who has higher
blood pressure (suffering from pre-hypertension or hypertension) has lower work productivity when viewed
from the number of cocoa picked per day (kilograms). In addition, there is also a significant relationship
between health status seen from the incidence of central obesity with the number absent day to the plantation
due to health reason. Farmers who suffer central obesity have a higher number of absent day due to health
reason compared to farmers who do not suffer from central obesity. Relationship between health status and work
productivity can be shown in Table 3.

Table 3: Relationship between health status and work productivity

Number of days absent due to health
Number of cocoa picked/ day reason
Variable r p R p
Central obesity 0.114 0.392 0.275 0.037 a
Hypertension -0.366 0.005 a -0.085 0.525
a
Correlation test spearman was significantly associated at p <0.05

The result of this study his is consistent with research from Robroek CM et al. (2010) in 10,624 workers in 49
Dutch companies in 2005-2009 which stated that obese workers had higher sick leave compared to normal
weight workers (OR 1.27, 95% CI 1.11-1.46). Another study from Pronk NP et al. (2004) on 683 workers
showed that work performance was related to the body mass index (BMI) category. Regarding hypertension, the
results of this study are in line with the research of Busingye et al. (2014) where it is known that the cause of the
decline in work productivity of a person or group is due to an increase in high blood pressure. However, health
is not a major factor that can reduce work productivity, work motivation is considered to affect someone's
performance.

Table 4 shows the relationship between food consumption and work productivity of cocoa farmers. The food
consumption studied included energy intake, protein intake, fat intake, iron intake and food diversity score using
the IDDS (Individual Dietary Diversity Score).. Statistical test results related to the relationship
between lifestyle and work productivity of cocoa farmers can be seen in table 4.

37
 Wilda Yunieswati et al / Relationship Between Nutritional Status, Health Status, Food Consumption…..

Table 4: Relationship between food consumption and work productivity

Number of cocoa picked / dayNumber of days absent due to health reason
Work productivity of cocoa farmersr p r p
Energy intake -0.035 0.796 -0.005 0.968
Protein intake -0.144 0.281 0.127 0.342
Fat intake -0.061 0.647 0.011 0.936
Iron intake -0.240 0.069 0.029 0.827
Food diversity score (IDDS) -0.092 0.493 0.063 0.641

Statistical test using the Spearman test showed no association between consumption of food seen from an intake
of nutrients to work productivity of cocoa farmers Another study from Mahardikawati VA (2008) on 92 female
tea picking subjects in PTPN VIII, Bandung showed that although the levels of energy, protein, vitamin A and
vitamin C consumption did not correlate with sample work productivity, high levels of iron consumption were
associated with levels high work productivity (r = 0.248, p <0.01). Then, Statistical tests using
the Spearman test showed no relationship between the score of food diversity and the productivity of cocoa
farmers. Results from Mahardikawati study (2008) showed that the level of labor productivity is influenced by
the level of consumption or intake of specific nutrients especially iron. This study showed that the level of food
diversity does not affect the work productivity of cocoa farmers.

Table 5 shows the relationship between lifestyle and work productivity of cocoa farmers. The lifestyle studied
was between smoking habits, coffee consumption, alcohol consumption, exercise breakfast and daily
consumption of vegetables and fruits. Statistical test results related to the relationship between lifestyle and
work productivity of cocoa farmers can be seen in table 5.

Table 5: Relationship between lifestyle and work productivity

Number of cocoa picked / dayNumber of days absent due to health reason
Work productivity of cocoa farmersr p r p
Smoking habits -0,130 0.330 0.182 0.171
Coffee consumption habits 0.077 0.566 0.125 0.658
Alcohol consumption habits 0.219 0.099 0.107 0.426
Breakfast habits 0.228 0.085 -0.152 0.255
Exercise habits -0.038 0.775 0.038 0.774
Fruit and vegetable consumption -0.124 0.355 -0.030 0.822

Statistical tests using the Spearman test showed that there was no relationship between the lifestyle of
the subject and the work productivity of cocoa farmers. This is presumably because the subject's lifestyle has
more influence on health status. Furthermore, health status that will affect the level of work productivity, so that
lifestyle does not directly affect the work productivity of cocoa farmers. The results of this study are not in line
with the research of Robroek et al. (2010) in 10,624 workers in 49 Dutch companies in 2005-2009 showed that
smoking (OR 1.45), obesity (OR 1.29) and lack of fruit consumption (OR 1.22) were associated
with productivity loss when work

Conclusion

There is no relationship between nutritional status to work productivity. But, there is a relationship between
health status (blood pressure) and amount of cocoa picked per day (kilograms) and health status (central obesity)
and number of absent day to plantation due to sick. Recommendations regarding result of this study are

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 Proceeding of the 4th International Conference on Public Health, Vol. 4, 2018, pp. 33-39

improving an education about food diversity, exercise and non-communicable disease (NCDs) and the
importance of health care & nutrition counseling participation in village

Acknowledgements

We respect and thank to Indonesia Endowment Fund for Education (LPDP) and Australia-Indonesia Center
(AIC) for funding and helping us to conduct this study in Polewali Mandar, West Sulawesi

References

Arsyad M, Sinaga BM, Yusuf S. 2011. Analisis Dampak Kebijakan Pajak Ekspor dan Subsidi Harga Pupuk
Terhadap Produksi dan Ekspor Kakao Indonesia Pasca Putaran Uruguay. Jurnal Sosial Ekonomi Pertanian 8 (1):
63-67.
Boles M, Pelletier B, Lynch W. 2004. The Relationship Between Health Risks and Work Productivity. J Occup
Environ Med. 2004; 46: 737-74. Doi: 10.1097/01.jom.0000131830.45744.97
Busingye D, Arabshahi S, Subasinghe AK, Evans RG, Riddell MA, Thrift AG. 2014. Do the socioeconomic and
hypertension gradients in rural populations of low- and middle-income countries differ by geoghrapical region?
A systematic review and meta-analysis. Int J of Epidemiol 43 (5): 1563-1577. doi: 10.1093/ije/dyu112
[BPS] Badan Pusat Statistik. Statistik Ketenagakerjaan Sektor Pertanian tahun 2017. Jakarta (ID): Badan Pusat
Statistik; 2017
Brumby S, Chandrasekara A, McCoombe S. 2012. Cardiovascular risk factors and physiologixal distress in
Australian farming communities. Aus J of Rural Health 29 (1), 131-137. doi: 10.1111/j.1440-
1584.2012.01273.x
Hasibuan AM, Nurmalina R, Wahyudi, A. 2012. Analisis Kinerja dan Daya Saing Perdagangan Biji Kakao dan
Produk Kakao Olahan Indonesia di Pasar Internasional. Buletin RISTRI 3 (1): 57-70
Mahardikawati VA. 2008. Aktivitas fisik, konsumsi pangan, status gizi, dan produktivitas kerja wanita pemetik
the di PTPN VIII Bandung, Jawa Barat. [Skripsi]. Bogor (ID): Institut Pertanian Bogor
Nwaiwu LUO, Obasi PC, Korie OC, Ben Chendo NG, Uhuegbulem IJ, Anyanwu FC. 2016. Effects of
Household Foods on Health Status of Farmers- Implication on Farm Labour Productivity in Ahiazu Mbaise Imo
State, Nigeria. presentation at the 91st Annual Conference of the Agricultural Economics Society, Royal Dublin
Society in Dublin, Ireland
Pronk NP, Martinson B, Kessler RC, Beck AL, Simon GE, Wang P. 2004. The association between work
performance and physical activity, cardiorespiratory fitness and obesity. J Occup Environ Med 46 (5): 19-25.
doi: 10.1097/01.jom.0000105910.69449.b7
Robroek SJW, Berg TIJ, Plat JF. Burdorf A. 2010. The role of obesity and lifestyle behaviours in a productive
workforce. Occup Environ Med 68 (1): 134-139. doi:10.1136/oem.2010.055962

39
Proceeding of the 4th International Conference on Public Health, Vol. 4, 2018, pp. 40-48
Copyright © 2018 TIIKM
ISSN 2324 – 6735 online
DOI: https://doi.org/10.17501/23246735.2018.4105

SPATIAL EFFECT OF REFILLING DRINKING

WATER DEPOTS TOWARD DIARRHEA IN
PAGATAN, SUB DISTRICT OF KUSANHILIR,
TANAH BUMBU DISTRICT, SOUTH
KALIMANTAN
Dicky Andiarsa1*, Dian Eka Setyaningtyas1, Syarif Hidayat1, Ika Setianingsih1,
Hamsyah1 and Erly Haryati1
1
National Agency on Health Research and Development Tanah Bumbu
National Institute of Health Research and Development
Indonesian Ministry of Health, Indonesia.

Abstract: The growth of drinking water refill service business in Indonesia is one of the most
promising and growing business in recent years. On the other hand, along with the conditions of
diarrhea cases in this region remain concerned. This research aimed to identify spatially the
influence of the existence of refilling water depots and the quality of its products to the incidence of
diarrhea in Tanah Bumbu District. The study held in Kota Pagatan, sub district of Kusan Hilir
District of Tanah Bumbu in November-December 2017. Water samples are taken at every depot with
complete procedure and marked spatially then sample was assessed microbiologically to determined
E.coli and Coliform contamination. The bacteria-positive depot on examination of the sample is
categorized as 'contaminated' contrarily no bacteria depot is categorized as 'clean'. Diarrhea case data
in the area of the data was taken from 2016 research data in the form of respondent data, location and
household characteristics related to patient's family status and access to drinking water. Furthermore,
the two types of data are integrated into spatial analysis to analyze the spatial relation of the depot’s
water quality with the distribution of diarrhea cases. There is a spatial suitability between the density
of the depots’ position and the density of the diarrheal cases found. The concentration of
'contaminated' depot has a significant effect on the characteristic profile of the most of patients who
were in the vicinity of the depot.

Keywords: Diarrhea, spatial effect, drinking water access, refilling water depots

Introduction

The growth of refill drinking service business in Indonesia is one of the most promising and growing business in
recent years. Each year there is a significant increase in the number of depots. Various facilities to get ready-to-
drink water at affordable prices become the main choice of middle-income society.(Rahmitha, Utami and
Sitohang, 2018) Tanah Bumbu District itself especially Pagatan City is one of the areas that have increasing
number of depots from many years ago either having license to operate as well which has no operational license.

On the other hand, diarrhea in the Pagatan region has remained high in recent years. Diarrhea data in the pagatan
area is experiencing a downward trend, however the incidence of this disease is still a major public health
problem in this region.(Pagatan City Health Service, 2016) A few years ago before 2010, the Pagatan area was a
slum area and inadequate infrastructure. At present, infrastructure development in Pagatan has increased
significantly including kampong roads and drainage so that the sanitation of the area has improved.(Kuswandi,
2017) The circumstances is in contrast to cases of diarrhea that do not show a significant reduction.

Pathogenic agents that cause diarrhea such as coliform, Escherichia coli, Vibriospp, etc. can contaminate water
and food through some carrier media such as teapots, gallons,(Wandrivel, Suharti and Lestari, 2012)even an

Corresponding Author Email: * [email protected]

 Dicky Andiarsa et al / Spatial Effect Of Refilling Drinking Water……

entire refilling drinking water machine. The existence of these pathogens indicates that poor hygiene and
sanitation also maintenance of equipment related to the provision of drinking water.(Rumondor, Porotu’o and
Waworuntu, 2014)Data on the relation between the contaminated depots and diarrhea cases in Pagatan area is
not yet available and the weakness of drinking water surveillance by the local health office is the basis of this
study held.

It can be hypothesized that the growth of refill depots relates to cases of diarrhea in the Pagatan City. This paper
is expected to provide input for stake holder so that the regulation can be implemented thoroughly for refill
drinking water producers as well as improve the routine inspection of refill depot as a surveillance effort in
maintaining drinking water quality in Pagatan City.

Methods

The study was held in Pagatan City, Subdistrict of Kusan Hilir, District of Tanah Bumbu in November-
December 2017. Area of Pagatan selected because this region has the most refill drinking water depots in Kusan
Hilir Sub district that is numbered 42 Depots which were successfully examined. Water samples taken at each
depot after marked with Global Positioning System (GPS), water retrieval must be complete procedure in
accordance with the suggested by the equipment provider then the samples were checked at the Microbiology
Laboratory of National Agency of Research and Development Tanah Bumbu to determine the contamination of
E. coli and coliform in water sample. The examination technique used Most Probable Number (MPN) and Total
Plate Count (TPC) to calculate the amount of contamination in the sample. Selective media used are TCBS,
McConkey, XLD, EMB agar and IMVIC methods. The bacteria-containing depots on examination of the sample
were categorized as 'contaminated' and that no bacteria in the sample were categorized as 'clean'.

100 Diarrhea case data in the area of the field was taken from research data in 2016 (Andiarsa et al., 2016)
(Andiarsa, Setianingsih and Sulasmi, 2017) in the form of respondent data, location and household
characteristics related to patient's family status and access to drinking water. The data were analyzed
descriptively to present the distribution of the characteristics and access of drinking water of the household of
the patient by referring the P value to determine the significance of each variable to the diarrhea.

Furthermore, the combination of the two data is scored based on the village area or id location to determine the
effect status of the depot in the area. Scores are determined based on the high, medium, or low level of cases and
‘contaminated’depots in the area. The greater the number of cases and ‘contaminated’ depots which were we
marked in red, the higher the risk of the village being exposed to diarrhea due to ‘contaminated’ depots which
was we then refer to as effect status. Effect status score can be viewed in the following scheme:

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Figure 1 Effect status scoring scheme

Both types of data were integrated into spatial analysis to see the spatial linkage of the depot water quality
results with the distribution of diarrhea cases. Spatial analysis was using Quantum GIS open source software
application version of NodeboTM. Spatial analysis used a simple technique of overlay and heatmap techniques.
Heatmap analysis was used to determine depot concentrations and their relation to diarrhea cases. The heatmap
was made at a radius of 500 m from the contaminated depot as the center of analysis, the more dense the number
of depots in a particular area the higher the concentration and the impact that the depot may cause.

Result

Pagatan city is one of the most populous areas in Kusan Hilir Sub District with a population of 46,735 people
and characteristics of the city along the coastline and several rivers close to the sea estuary. Pagatan is
positioned by 3.3300o S- 3.6092o S and 115.5900o E-115.9335o E with an altitude of less than 10 meters above
sea level. Most of the economic activity in the region is a trade area and a small part of agriculture in the
suburbs.

The results of observation and interviewed with heads of households from 100 patients in the city of Pagatan has
a tendency to support diarrhea cases arisen. This shows some risk factors have a significant role to the
occurrence of diarrhea in the household. Table 1 describes some characteristics of the patient and the condition
of the household. The most of the work of the head of household were employees and entrepreneurs or traders
who throughout the day spent at work. Most patients are in the age group 0-5 year old which were have more
vulnerable than other age groups. Most households have a high density of home inhabitants, although
inhabitants’ density was not significant, itwas a main determinant of its impact on household health status.

Table 1 Household characteristics of diarrhea patient.

No Variable N (%) P
1 Gender of diarrhea patient Male 46 0,905
Female 54
2 Work of head of household Employee 25 0,000

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 Dicky Andiarsa et al / Spatial Effect Of Refilling Drinking Water……

Entrepreneur 37
Farmer 18
Labour 10
Unemployed 10
3 Age group of diarrhea patient 0-5 year old 70 0,000
6-15 year old 1
16-55 year old 23
>56 year old 6
4 Number of inhabitants 2 people 4 0,510
3 people 7
4 people 27
5-10 people 51
>10 people 1
5 Number of diarrhea patient 1 people 66 0,075
2 people 22
3 people 11
4 people 1

The availability of drinking water is determined by the ability of households to access drinking water for their
household needs. Table 2 illustrates that the majority of patient households were consumers of refill drinking
water depots, as access affordability and low prices and other convenience factors make the majority of
households considering using refill water as their primary drinking water source. The next fact that some of
these households did not retreat their drinking water such as boiling it before it is consumed also they use a
water jug for storage that is kept refilled without being washed for long time period. However, the physical
quality of drinking water in Pagatan area is quite good.

Table 2 Access of drinking water

No Variable N (%) P
1 Type of drinking water Bottled water 3 0,000
Refilled water 68
Local water provider
(PDAM) 23
Drilled well 1
Dug well 2
River 3
2 Drinking water treatment Boiled 38 0,000
Radiation 3
Filtered 1
Untreated/ not boiled 58
3 Drinking water storage Dispenser 28 0,000
Caldron/teapot 67
Jug 1
Pot/sauce pan 4
4 Drinking water quality Murky/turbid 1 <0,05
Taste 3

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Smell 2

The following table is the result of water quality inspection from all visited refill depots. The 42 samples
examined, 23 depots were declared to be ‘contaminated’ with water products at a large amount of contamination
of average 6,087 (0 ≤ μ ≥ 38) MPN / 100ml and 297,420 (30 ≤ μ ≥ 2330.67) CFU / ml. This indicates that the
quality of refill drinking water was not allowed for consumption based on WHO recommendation which states
that good drinking water is having 0 values on each of MPN or TPC examination.

Table 3 Results of MPN and TPC inspection on refilling water depots

Number of Depots Category Mean MPN (MPN/100ml) Mean TPC (CFU/ml)
19 Clean 0 0
23 Contaminated 6.087 (0 ≤ µ ≥ 38) 297.420 (30 ≤ µ ≥ 2330.67)

The distribution of cases and the presence of refilling water depots in the city of Pagatan have a corresponding
concentration in which the patient was most likely close to the location of the refill drinking water providers.
The proximity of this location determines the accessibility of the urban community so they prefer to use water
refills as their primary drinking water source. Figure 1 shows that the refill drinking water depot is spread
evenly in the residential area of Pagatan City and is very close to the patient.

Figure 2 Distribution of refilling water depots and diarrhea cases

The scoring of effect status (figure 3) shows that there are several villages or id locations that have high effect
status especially Batuah, Kota Pagatan, Pasar Baru, and Wiritasi located in the center of Pagatan area while
some villages on the suburbs of Pagatan such as Mudalang, Muara Pagatan , Sei Lembu, Baru Gelang, Betung
and Beringin have medium effect status and some are low. Heatmap is used to facilitate cluster identification
where there was high risk concentration so that it becomes the influence for the surrounding exposure.

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 Dicky Andiarsa et al / Spatial Effect Of Refilling Drinking Water……

Figure 3 Heatmap of effect status based on id location

Figure 4 below explains that the concentrations of ‘contaminated’ depots were at the center of Pagatan City and
some other suburbs. There is a correspondence between the density of the depots’ position and the density of the
diarrheal cases found. This figure shows ‘contaminated’ depot hotspot having an impact of up to 500 meter
radius toward diarrhea patient with a characteristic access to drinking water that has been described.

Figure 4 : Heatmaps of ‘contaminated’ depots and diarrhea cases

Discussion

The results clearly indicate a significant spatial relationship between cases of diarrhea with the presence of refill
drinking water depots in the City of Pagatan. Pagatan community was one of urban communities which was

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 Proceeding of the 4th International Conference on Public Health, Vol. 4, 2018, pp. 40-48

always have a tendency in choosing the practicality in meeting their needs, including in access to drinking
water. Refill depots have proven to change the pattern of Pagatan community's drinking water access behavior
by providing convenience and affordable prices in obtaining drinking water in a practical way. The data shows
that most respondents choose refilling drinking water as their drinking water even most of them directly drink
the water without processing first. The contrast is shown in research in Jakarta which was refilling water users
were more at no risk of diarrhea.(Sima et al., 2012)

In Indonesia, refilling drinking water is the third largest source of drinking water used by the community with a
percentage of 17.2%.(Kemenkes, 2011; Wandrivel, Suharti and Lestari, 2012)This drinking water refill business
has expanded widely and become a source of income for depot entrepreneurs and become a necessity for
consumers.(Bayer, 2013)This condition created new characteristics for the community behavior in terms of the
ability to seek access to drinking water was easier and cheaper. Government regulation has arranged related to
this refilling drinking water business to accommodate the needs of the community, such as maintaining the
quality and safety of drinking water products, sanitation inspection, and standard operating procedures of the
provision of refillingwater.(Indonesian Ministry of Health, 2014)However, the implementation in the
community was often not in accordance with the directed. In the process of water sampling we witnessed some
depots did not have an operational permits and claimed to have never visited the officer for water inspection.

Lack of supervision from health workers is very influential on this business work system and will directly affect
the quality of the product. 42 depots examined, 23 of depots’ water product claimed to be ‘contaminated’ with
high levels of contamination (mean 6,087 (0 ≤ μ ≥ 38) MPN / 100ml and 297,420 (30 ≤ μ ≥ 2330.67) CFU / ml).
This was not in accordance with government regulations that do not allowed drinking water contaminated with
E.coli or Coliform at all.(Indonesian Ministry of Health, 2010)

Pagatan city is one of the most densely populated cities in Tanah Bumbu and the capital city for Kusan Hilir sub
district. Increasing population growth every year seems to trigger the growth of this refill depot business.
Increasing the need for drinking water is not accompanied by an increase in efforts to maintain the quality of
drinking water product by doing according to the procedure. Several depots were found serving by delivered
drinking water using plastic jerry cans and then transferred to consumers’ gallon without have to wash the
gallon first. Some depots also did not have the equipment to wash gallons and there were moss grew inside of
the gallon of the seller's inventory that would normally be exchanged for the consumer's gallon. This has
become a normal sight in the drinking water refill business in the region.

By the distribution of cases, we overlay with a heatmap ‘contaminated’ depot in the Pagatan area. At a radius of
500 meters from a ‘contaminated’ depot is an area of impact for the user community around the depot. It can be
seen that the densest cluster of diarrhea cases was at the centre of the Pagatan area (Batuah, Pasar Baru, Kota
Pagatan and Wiritasi) as well as the corresponding density of the ’contaminated’ depots in the same area. This
area is the center of economic activities of Pagatan city where in this area there are traditional markets, fish
market and most shops and densely populated settlements are also concentrated in this area. Most depots were
also found to be close to sources of contaminants such as markets, sewers, landfills, rivers, slums and so on.
Some of these factors become one of the determinants of hygiene and sanitation in business in the region.
(Sulistyandari, 2009; Puspitasari, 2018)Scores of effect status and heatmap indicate that there is a significant
spatial influence of ‘contaminated’ depots on the occurrence of diarrheal cases in the Pagatan area.

This refilling drinking water business is considered very helpful if reflected from the side of the economy and
accessibility to improve the welfare of the community.(Sima and Elimelech, 2013) It will be even more valuable
if compensated by consistent quality control of this business product. The regulation properly implemented,
good equipment and maintenance operations, sanitary hygiene of the place of business, and good personal
hygiene from the handlers (Rahmitha, Utami and Sitohang, 2018) would be able to contribute well to the quality
of products provided to the community. However boiling water before drinking may reduce the risk of diarrhea
in the community.(Hairani et al., 2017)

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Conclusion

There is a spatial correlation between the density of the refill depots and the distribution of the diarrheal cases
found. The concentration of 'contaminated' depot has a significant effect on the characteristic profile of the
majority patients which were being around in the area of the depot.

Recommendation

 For refilled water provider: standard procedure to operate the refilled water machine should be done,
use improved water source, good maintenance of entire machine routinely, good personal hygiene of
handlers and change the filter regularly.

 For consumer: water should be boiled before consume and clean up the water dispenser regularly.

 For government: local regulations on refilled drinking water management need to be applied properly.

Author Contribution

DA design concept of analysis, design study, perform spatial analysis, writing manuscript; DES, IS and SH
perform analysis and writing manuscript; EH and H prepare equipment and assist technical activities in the field.

Acknowledgement

Thank you for Head of District Health Office of Tanah Bumbu and Head of PagatanLocal Health Service for
technical assistance and data provision so that this study can be done. Thanks to Head of National Agency on
Health R&D Tanah Bumbu for the support of facilities and funds so that this activity can be done. As well as the
respondents and owners of the depots who were willing to participate in this study, their valuable information
helps to improve policy and its implementation.

References

Andiarsa, D., Setianingsih, I., Setyaningtyas, D. E., Hidayat, S., Sulasmi, S., Meliyanie, G., Fadilly, A., Hariati,
E. and Arianti, D. C. (2016) Analisis faktor penyebab diare di Kabupaten Tanah Bumbu dengan pendekatan
Geographical Information System (GIS). (Report). Batulicin.
Andiarsa, D., Setianingsih, I. and Sulasmi, S. (2017) ‘Kebijakan pengendalian diare berdasarkan analisis spasial
faktor penyebab diare di Kabupaten Tanah Bumbu’, Jurnal Kebijakan Pembangunan, 12(1), pp. 9–21.
Bayer, R. (2013) Drinking water as a source of income. Lund University.
Hairani, B., Andiarsa, D., Suriani and Juhairiyah (2017) ‘Correlation among mother ’ s knowledge and practice
of boiling drinking water to the incidences of toddler diarrhea in Puskesmas Baringin Kabupaten Tapin year
2014’, Journal of Health Epidemiology and Communicable Diseases, 3(1), pp. 10–14.
Indonesian Ministry of Health (2010) Ministry of Health Regulation Number 492 Year 2010 about Concerning
the Quality of Drinking Water.
Indonesian Ministry of Health (2014) Ministry of Health Regulation Number 43 Year 2014 about Sanitation
Hygiene Dinking Water Depot. Indonesia.
Kemenkes (2011) Basic Health Research (RISKESDAS) 2010 (Report). Jakarta.
Kuswandi (2017) ‘Vice Gorvernor of South Kalimantan apreciated the achievement of the development of
Tanah Bumbu’, Merdeka.Com, April. Available at: https://tanahbumbu.merdeka.com/info-tanahbumbu/wagub-
kalsel-apresiasi-keberhasilan-pembangunan-tanbu-1704105.html.
Pagatan City Health Service (2016) Diarrhea case register 2013-2015. Pagatan City.

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Puspitasari, E. K. A. (2018) ‘Analysis of the factors affecting the quality of the chemical and microbiological
drinking water at the depot drinking water refill Tulungagung District’, Journal for Quality in Public Health,
1(1), pp. 104–112.
Rahmitha, A., Utami, E. S. and Sitohang, M. Y. (2018) ‘Implementation of Geographical Information System
for Bacteriological Contamination Analysis on Refill Drinking Water Depot (Study in Tembalang District)’, in
ICENIS 2017. EDP Sciences, pp. 1–5.
Rumondor, P. P., Porotu’o, J. and Waworuntu, O. (2014) ‘Identifikasi bakteri pada depot air minum isi ulang di
Kota Manado’, e-Biomedik, 2(2), pp. 1–4.
Sima, L. C., Desai, M. M., McCarty, K. M. and Elimelech, M. (2012) ‘Relationship between use of water from
community-scale water treatment refill kiosks and childhood diarrhea in Jakarta.’, The American journal of
tropical medicine and hygiene, 87(6), pp. 979–84. doi: 10.4269/ajtmh.2012.12-0224.
Sima, L. C. and Elimelech, M. (2013) ‘More than a drop in the bucket: Decentralized membrane-based drinking
water refill stations in southeast Asia’, Environmental Science and Technology, 47(14), pp. 7580–7588. doi:
10.1021/es304384n.
Sulistyandari, H. (2009) Faktor-faktor yang berhubungan dengan kontaminasi deterjen pada air minum isi
ulang di depot air minum isi ulang (DAMIU) di Kabupaten Kendal. Diponegoro University.
Wandrivel, R., Suharti, N. and Lestari, Y. (2012) ‘Kualitas air minum yang diproduksi depot air minum isi
ulang di Kecamatan Bungus Padang berdasarkan persyaratan mikrobiologi’, Jurnal Kesehatan Andalas, 1(3),
pp. 129–133.

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Proceeding of the 4th International Conference on Public Health, Vol. 4, 2018, pp. 49-59
Copyright © 2018 TIIKM
ISSN 2324 – 6735 online
DOI: https://doi.org/10.17501/23246735.2018.4106

INEQUALITY TRENDS OF ANTENATAL CARE

AMONG WOMEN IN INDONESIA 2002-2012
1
Anissa Rizkianti* and 1Tin Afifah
1
Centre for Research and Development of Public Health Efforts, National Institute of Health Research
Development, Indonesia

Abstract: Antenatal care (ANC) is a major component of maternal health services for preventing
adverse pregnancy outcomes. As one of maternal health indicator for universal health coverage and
Sustainable Development Goals (SDGs), it is important to monitor the distribution of the coverage
among social dimension stratification. The study aims to examine inequality trends in the use of
ANC services of Indonesian women aged 15-49 years based on the data from the Indonesia
Demographic Health Surveys (IDHS) 2002, 2007 and 2012. Inequalities are measured using
socioeconomic and demographic stratification variables such as urban-rural, mother’s education and
household wealth index. We also performed analysis of social determinants of health and their
relationship with ANC. The trend of ANC utilization shows narrower gap according to social
dimension stratification. The urban-rural difference for ANC has been reduced from 15 to 10.5
percentage points. The education-related inequality in ANC also declined nearly 40% from 2002 to
2012. A similar downward trend was observed for wealth-related inequality merely between the last
two periods of survey. The trend in ANC use was entirely confounded by socioeconomic and
demographic changes over time. The adjusted odds ratios for wealth quintile and education
substantially decreased. A reduction in the inequality dimension through time suggests that both
access and equality are improving in ANC use. Monitoring of trends needs to be continuously done
among disadvantaged groups so that programs are in place for more targeted health development
plans.

Keywords: antenatal care, inequality, health services, IDHS, Indonesia

Introduction

Antenatal care contributes to achieving Sustainable Development Goals by monitoring the progress on the target
to reduce maternal mortality. Antenatal care (ANC) plays an important role in preventing adverse pregnancy
outcomes. The importance of ANC lies in its capacity to identify risks and detect complication and educate
women with information on danger signs and symptoms. It enables monitoring of the well-being of mother and
fetus as well as the signs of any obstetric complications that might be treated (Chalmers et al., 2001). While the
SDG strategy in expanding coverage of antenatal care (ANC) was notable in Indonesia, improvements in
maternal health outcomes did not always follow. Maternal mortality ratio(MMR) remains unacceptably high
representing 305 per 100,000 live births (Badan Pusat Statistik, 2016) or estimated to be nearly ten times higher
than its closest neighbors, Malaysia and Brunei Darussalam (Adashi et al., 2013).

The slow pace of reduction in maternal mortality has urged many nations to begin addressing inequalities in
maternal health with regard to both access to care and levels of MMR. The inequalities in maternal health care
show discrepancies between the richer and poorer populations, as well as between different socioeconomic
statuses (World Health Organization and Ministry of Health of Indonesia, 2017). Indonesia, across its rich and
diverse ethnic groups, economic and geographical landscapes, faces challenges in addressing inequalities. While
some population groups have better access to healthcare services, others are disadvantaged. Monitoring of such
inequalities is therefore a fundamental part to improve access to health care of those who are disadvantaged and
to ensure that Indonesia fulfils its commitment of leaving no one behind (Hosseinpoor et al., 2016).

Corresponding Author Email: * [email protected]

 Anissa Rizkianti and Tin Afifah / Inequality Trends Of Antenatal Care Among…..

Within-country inequalities, however, should be described for a broad range of dimensions. At the same time,
having comparable disaggregated data is essential to track inequalities at subnational level (Hosseinpoor et al.,
2016). Demographic and Health Survey (DHS) serves as one of the main data sources for monitoring trends and
inequalities in the use of maternal health care services due to the quality of the data and comparability over time
(Corsi et al., 2012). In this study, we assess data from three consecutive Indonesia Demographic and Health
Surveys (IDHSs) to explore the trends of inequalities in ANC uptake among women of reproductive age. The
aim is to understand further the extent to which inequality in the coverage of ANC across socioeconomic and
geographical dimension vary over time. A better understanding of the magnitude and determinants of
inequalities in maternity care may help contribute to tackling these disparities and offering insights to
policymakers about potential public health strategies towards a more integrated and accessible health care for
all.

Methods

Data sources
This study was performed using secondary data of IDHS for the periods of 2002, 2007 and 2012. All were
nationally representative household survey conducted by the Statistics Indonesia in collaboration with the
National Population and Family Planning Board and the Ministry of Health of Indonesia. The dataset was
retrieved from the DHS website at http://dhsprogram.com and reported in aggregate. The IDHS collects
information on demographic and population, health indicators, such as contraceptive knowledge and use,
maternal and child health, and nutritional status of mothers and children to assist in the country’s monitoring
and impact evaluation. It ensures comparability across regions, countries and time using globally standardized
questionnaire.

Study population
Ever-married women age 15-49 who gave their last birth in the preceding five years of each survey were
included as eligible participants.

Variables
Women who received ANC at least four visits (ANC 4+) in their last pregnancy were considered as outcome
variable, recorded as a binary variable (yes/no) in the dataset. The World Health Organization (WHO)
recommends that every pregnant woman should have a minimum of four focused ANC visits (Carroli et al.,
2001). The inequality dimensions used in this study were as follows: educational level, wealth status and place
of residence (rural/urban). Other independent variables included age at birth, birth order and subnational region.
Demographic characteristics of each respondent, their housing conditions and household wealth indicators were
recorded in the Household Questionnaire, whereas reproductive history and ANC information for women was
captured in the Women’s Questionnaire. Table 1 describes the variables and how they were defined.

Statistical methods and analysis

Trends of ANC 4+ utilization was calculated from frequency percentages by the survey years to observe the
changes over time. Inequalities in ANC 4+ coverage was estimated across wealth quintiles and educational
attainment and compared by using slope index of inequality as absolute measure among the subgroups of
population. Slope index of inequality is a complex measure to quantify the absolute difference in predicted
values of a health indicator between the most and least advantaged group, while taking into consideration the
entire distribution of subgroups using an appropriate regression model (Hosseinpoor et al., 2016). It is calculated
as:

SII = v1 − v0, for favorable health intervention indicators(1)

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Difference was also used to measure disparities in ANC 4+ coverage between urban and rural areas. The
inequality analysis was done by using WHO Health Equity Assessment Toolkit Plus (HEAT Plus) software.
Database was generated from disaggregated data of IDHS which were uploaded to HEAT Plus in a specific
format. Once uploaded, these data were used to explore inequalities within socioeconomic and demographic
dimensions in graphs.

We generated frequency tabulation to describe socio-demographic characteristics and their distributions over
three consecutive survey periods of 2007, 2012 and 2017, which were compared by using a chi-squared test.
Binary logistic regression was performed to obtain both crude and adjusted odds ratio (OR) for the outcome
variable using the Wald test to assess the statistical significance at 95% confidence intervals (CI), taking into
account survey design (sampling weights and strata). The analysis was adjusted for all the other variables (age at
birth and birth order) which might have any confounding effect. SAS Studio was used for analyzing data.

Table 1 Summary of the variables used in this study

Variable name Definition

ANC at least four visits Percent of women age 15−49 with a live birth in five years period preceding the
(ANC 4+) survey who received antenatal care four times or more. The indicator is based
on standard questions that ask if, how many times, and by whom the health of
the woman was checked during pregnancy.
Educational level The highest level of education attended by the women. It is categorized into ‘no
education’, ‘primary’, ‘secondary’ and ‘higher’.
‘No education’ refers to women who confirmed having no formal education.
‘Primary’ refers to women with some level of formal education or completed
primary education, including those with middle school. Women who completed
up to 12 years of formal education or those whose education ended at the upper
secondary/high school level consider as having ‘Secondary’ level. Women who
were having ‘Higher’ level are those who completed at least 15 years of formal
education, including those with college, polytechnic or university level studies.
Wealth status Wealth status was calculated using household assets data collected from IDHS
surveys, such as televisions and bicycles; materials used for housing
construction; and types of water access and sanitation facilities. It is categorized
into 5 wealth quintiles: Lowest, Second, Middle, Fourth, and Highest.
Place of residence The civil subdivision of a country in which the individual resides. It is
traditionally distinct by urban and rural.
Age at birth The age of women at birth of last child. It was coded into three categories as
follows: < 20 years, 20-34 years, 35+ years.
Birth order The order in which a child is born. It was coded into four categories as follows:
1, 2-3, 4-5 and 6+.

Results

Table 2 shows the socio-demographic characteristics among Indonesian women age 15-49 years who had their
last birth within 5 years prior to the surveys. A total of 41,945 women were included in the last three IDHS,
where 2002 IDHS, 2007 IDHS and 2012 IDHS included 12,760, 14,430 and 14,782 women, respectively. The
majority of women delivered their babies at the age of 20-34 (74.2% in 2002, 75.1% in 2007 and 74.7% in
2012). The proportion of women who gave the last birth at the younger age group decreased from 11.7% in
2002 to 9.0% in 2012. The same is true for birth order, where the proportion of multiparous (6+) women
declined in the year 2012 compared to 2002. The percentage of women having no education reduced by more

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than 50% (4.5% in 2002 and 1.9% in 2012) and higher level of education was almost doubled from 6% in 2002
to 11.9% in 2012. However, there is no clear pattern for the percentage of women by wealth status.

Table 2 Socio-demographic characteristics among women age 15-49 in Indonesia, IDHS 2002-2012
Socio-demographic characteristics 2002 2007 2012
N = 12,760 N = 14,403 N = 14,782
Age at birth
<20 11.7 9.9 9.0
20-34 74.2 75.1 74.7
35-49 14.0 15.0 16.3

Birth order
1 33.6 34.6 37.5
2-3 46.1 46.8 48.1
4-5 12.9 13.2 10.7
6+ 7.4 5.4 3.6

Place of residence
Rural 53.2 58.0 50.2
Urban 46.8 42.0 49.8

Education level
No education 4.5 3.3 1.9
Primary 48.6 41.2 32.2
Secondary 40.8 47.7 54.0
Higher 6.0 7.9 11.9

Wealth status
Poorest 22.3 21.4 20.5
Poorer 19.5 19.9 19.5
Middle 20.5 20.0 19.9
Richer 19.6 19.5 21.0
Richest 18.3 19.1 19.1

Trends in ANC 4+ coverage

Figure 1 depicts an increasing trend in ANC 4+ utilization from 2002 to 2012. Proportion of utilizing ANC 4+
showed a tendency to increase overtime with the increasing status of household economic. A huge gap between
poorest and richest was reported in 2002, whereas in 2012 the gap was quite decreasing. Similar to economic
status, the proportion of ANC 4+ coverage by education level rose between 2002 and 2012. Although gradients
of its use among women with no education and women with higher education widened from 2002 to 2007, the
gradients of ANC use among women who completed primary education and those with higher education
decreased from a difference of 25% point in 2002 to 16.7% point in 2012.Furthermore, the trend in ANC 4+
utilization did not change much across type of residence, marked by confidence intervals that were still in the
same range. Over the past 10 years, the urban-rural difference for ANC 4+ coverage reduced from 15% point to
10.5% point, showing that the gap between urban women and their rural counterparts was slightly narrower.

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Figure 1 Trends in ANC 4+ coverage according to economic status, education and residence, 2002-2012 IDHS

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In multivariable analysis, when the effects of covariates were controlled statistically using binary logistic
regression model, all socio-economic, maternal and demographic factors remained significant predictors of
ANC 4+ use, except place of residence (Table 3). Among socio-economic variables, household economic status
and mother’s education were both powerful predictor for ANC 4+ use. However, adjusted ORs for economic
status tend to decrease overtime. In 2002, mothers with higher education were almost nine times more likely
(OR: 8.67; 95% CI: 3.54-21.24) to use ANC 4+, while in 2012, the likelihood was smaller (OR: 2.57; 95% CI:
1.45–4.57).Women with older age of birth also tend to get access to ANC 4+ services. In contrast, negative
association was found between birth order and ANC 4+ use as the utilization was less common among women
with birth order six or above.

Table 3 Associations between socio-demographic characteristics and antenatal care visits among women age
15-49 in Indonesia, IDHS 2002-2012

ANC 4+ utilization
Socio-
2002 2007 2012
demographic
characteristics Adj. P- Adj. P- Adj. P-
95% CI 95% CI 95% CI
OR* value OR* value OR* value
Age at birth
<20 1.00 1.00 1.00
1.18 - 1.37 - 1.19 -
20-34
1.74 2.57 0.00** 1.82 2.43 0.00** 1.58 2.09 0.00**
1.46 - 1.55 - 1.24 -
35-49
2.18 3.27 2.26 3.29 1.80 2.63

Birth order
1 1.00 1.00 1.00
0.58 - 0.50 - 0.59 -
2-3
0.74 0.95 0.61 0.74 0.72 0.89
0.32 - 0.00** 0.33 - 0.00** 0.41 - 0.00**
4-5
0.44 0.60 0.43 0.55 0.55 0.72
0.20 - 0.14 - 0.24 -
6+
0.27 0.38 0.20 0.29 0.36 0.54

Place of residence
Rural 1.00 1.00 1.00
0.62 - 0.57 0.93 - 0.20 0.90 - 0.35
Urban
0.90 1.30 1.15 1.43 1.10 1.34

Education level
No education 1.00 1.00 1.00
0.95 - 1.05 - 0.84 -
Primary
1.56 2.56 1.66 2.61 1.34 2.13
1.58 - 0.00** 1.54 - 0.00** 1.20 - 0.00**
Secondary
2.48 3.90 2.50 4.06 1.91 3.04
3.54 - 2.33 - 1.45 -
Higher
8.67 21.24 4.87 10.17 2.57 4.57

Wealth status
Poorest 1.00 1.00 1.00
0.00** 0.00** 0.00**
Poorer 1.93 1.54 - 1.86 1.54 - 1.94 1.56 -

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 Proceeding of the 4th International Conference on Public Health, Vol. 4, 2018, pp. 49-59

2.42 2.24 2.42

1.57 - 1.69 - 2.41 -
Middle
2.21 3.09 2.16 2.75 3.09 3.96
2.26 - 2.43 - 2.99 -
Richer
3.20 4.54 3.21 4.23 4.11 5.65
3.03 - 4.65 - 4.36 -
Richest
5.54 10.15 7.21 11.19 6.47 9.61

Trends in ANC 4+ inequalities

Figure 2 shows the changes in inequality of ANC 4+ utilization across economic status and education level from
2002 to 2012. The following figure is the result of inequality calculation using slope index of inequality (SII) as
a summary measure of inequality. The SII indicated existence of inequalities in ANC 4+ utilization for two
different dimensions. As shown in the figure, the coverage of ANC 4+has increased substantially as inequalities
declined. The general downward trend for SII by economic status was seen A reduction of SII for ANC 4+ was
observed across economic status, although the value slightly increased between 2002 and 2007. The absolute
inequalities in ANC 4+ across education level also declined overtime. A slight decrease of SII was observed
from 2002 to 2007, but the trend was reduced sharply between 2007 and 2012.The gap between the richest and
poorest varies by province (Figure 3). Most provinces in Java and Bali region has narrower gap between poorest
and richest in the use of ANC 4+ over the past decade. As seen in the figure above, Jakarta, Banten and West
Nusa Tenggara have successfully reduced the gap more than 65%.

Economic status Education level

50 90 50 90
43.6 44.9
45 42.4 45 42.6

40 40
85 85
35 32.5 35
28.3
30 30
25 80 25 80
20 20
15 15
75 75
10 10
5 5
0 70 0 70
2002 2007 2012 2002 2007 2012

SII Coverage of ANC 4+ SII Coverage of ANC 4+

Figure 2 Inequality trends in ANC 4+ coverage across economic status, education and residence,
2002-2012 IDHS

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Figure 3 Inequality trends in ANC 4+ coverage across subnational region, 2002-2012 IDHS

Discussion

This study revealed that Indonesia is experiencing a substantial progress in the reduction of health inequalities
and positive change in the social determinants of health over the past decade. Socioeconomic, urban-rural and
geographical inequalities in ANC were particularly pressing. Utilization of ANC services has also increased,
reflecting improved coverage and access. Nevertheless, women who are rich, well-educated and living in urban
settings still have greater opportunity to access ANC 4+. Our findings are in line with evidence on several low
and middle-income countries which reported low utilization of ANC 4+ among poor and uneducated women
(Nababan et al., 2018; Rahman et al, 2017; Anwar et al, 2015; Molina et al., 2013).A systematic review
identified that financial constraints are barrier for poor people in developing countries to access care. Women’s
education was also the best predictor of ANC visits as better educated women were more likely to receive the
recommended number of ANC visits (Simkhada et al., 2008)

Reductions in the inequality of ANC 4+ services reflected substantial use among women at rural areas in
Indonesia. This can be explained by the increasing role of private sector in maternal health services, especially
midwives. Heywood and Choi (2010) found that among women who received antenatal care, they mostly
received it from a private sector provider, such as midwife and village midwife. In Indonesia, the expansion of
public and private facilities began before the 1990s. By then, the government allowed facilities to be established
and staffed in many remote areas, resulting a rapid expansion of public health facilities and medical staff
(Heywood and Harahap, 2009). Since decentralization in 1999, the deployment of medical professionals is in
the hand of local authorities. They have focused on increasing the availability of health care and health
professionals by improving community access to services through auxiliary health centers, including community
health centers (Puskesmas) (Heywood and Choi, 2010).

However, uneven distribution of health facilities and labors brings an impact to the variation of healthcare
coverage among provinces. The finding of this study is not much different from the results of inequality analysis
of access to drinking water and sanitation across subnational regionsdone by Tin Afifah et al(2018). The wider
gap found in the Eastern provinces of Indonesia which is known to be a geographically challenging. Another

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problem is the distribution of labor and facilities that are not evenly distributed throughout Indonesia. Most
provinces in Java regions have easier access and sufficient number of health workers who are able to serve ANC
4+. To define responsibilities towards basic health services in local governments as well as to ensure the equity
in access, Minister of Health has therefore launched a regulation number 43/2016 that consists of minimum
standard of services in health sector, including the coverage of ANC 4+ (Ministry of Health of Indonesia, 2016).
Given the growing number of private health provider, the standards in quality have been a great concern. Thus,
further quality improvements at this provider are still upmost.

Another contributing factor is the government’s commitment to improving the country’s health system through
the provision of social healthinsurance for the poor. Until the end of 2013, the main pro-poor social health
insurance in Indonesia was Jamkesmas, financed by the central government. Jamkesmas was managed by the
Ministry of Health and provided beneficiaries with free health services in Puskesmas and hospitals. Another
type of insurance for the poor is Jamkesda, which is funded by the local government (province/district level).
Such insurance programs enable the poor to gain access to health services (Achadi et al., 2015). In addition, an
insurance scheme for maternal healthcare or Jampersal provides comprehensive maternal health service
coverage to those who are not covered by Jamkesmas, Jamkesda, or any other health insurance scheme. The
benefit packages of Jampersalinclude the coverage for antenatal care, delivery care, postpartum care for mother
and newborn, and family planning (Achadi et al., 2015). An assessment study in two districts in Indonesia –
Garut and Depok - showed that nine in 10 (93.9% and 96.3%, respectively) women used Jampersal for antenatal
check, increased slightly after three years of implementation (Achadi et al., 2015).

The findings of this study indicated that women’s education was associated with ANC 4+ use. The likelihood of
women using those recommended maternal healthcare services increased along with the increased educational
attainment among women. Likewise, another study found increased odds of not attending ANC services among
women with a low level of education (Titaley et al., 2010). Thaddeus and Maine (1994) suggested a theoretical
framework explaining that social factor, such as education, as a key factor determining care-seeking decision
and ultimately influencing the utilization of maternal healthcare services.Empowering women with formal
education enhancewomen’s capacity in recognizing their rights to health and making proper decisions for their
health (Achia andMageto, 2015). Women with a proper education also have capability to seek andobtain
healthcare information and use it accordingly (Rai et al., 2012). Hence, higher schooling years may contribute to
improving adequate maternal healthcare (Kurniati et al., 2018).

A 9-year compulsory education policy has increased length of school years as well as improved knowledge for
both men and women. This also has an impact on women's capability in seeking health services for themselves.
This is consistent with the results of the study conducted by Samarakoon and Parinduri (2015) which is shown
that education increases contraceptive use and promotes reproductive health practices. Moreover, education
allows women to gain literacy skills, enables them to process information, and develops their cognitive
behavior. Therefore, when a woman is educated, she is able to take better care of herself (Duflo, 2012).
Nonetheless, education may be insufficient to change deeply rooted societal attitudes or improve gender
relations such as decision-making authority. Many parts of Indonesia are still governed by local tribes and
norms (Kevane and Levine, 2003), which may hinder women to make household decisions by themselves.
Moreover, patrilineal kinship in Indonesia often inhibits women’s access their inheritance rights after marriage
(Rammohan and Johar, 2009). The 2012 IDHS results show that having no permission from husband is reported
as one reason for not accessing health care encountered by 5% women in Indonesia (Statistics Indonesia et al.,
2013).

A great emphasis has been made on the state of health inequality in Indonesia in accordance with the spirit of
SDGs to leave no one behind. On the one hand, ANC 4+ coverage is reaching better, and inequalities are
decreasing, yet the main challenge in Indonesia is the high maternal mortality rate. Antenatal check is a tool for
early detection of high risk and complications. It helps women to recognize delivery preparation in order to give

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birth safely. Various efforts have been made by the Ministry of Health, such as pregnancy class and birth
preparedness program which allow women to plan for delivery, including referral system during pregnancy and
delivery complications (Ministry of Health, 2015). However, the implementation of such programs has been
continued to be a challenge for Indonesia to improve access to ANC services which requires increasing public
health awareness.

Conclusions

The current study indicates improved social determinants of health in Indonesia, which at the same time also
reduces health inequalities. Our findings imply the need for research solutions to reduce inequality in maternal
health services, and to determine the factors responsible for the persistence of inequality in maternal health
services, particularly recommended ANC services. Recognizing reproductive health as a basic right of women
regardless of sociodemographic and economic status is important in formulating national policy and programs to
address inequality in maternal health service utilization. Thus, it is important to monitorutilization trends among
disadvantaged groups and consider ways to incorporate adequate and quality service delivery with
comprehensive financial scheme (universal health coverage).Promoting women’s empowerment and awareness
to their needs of maternal healthcare has another imperative strategy to reduce the cultural barriers.

Acknowledgements
The authors wish to express gratitude to the DHS Program for allowing authors to analyze the IDHS data sets.

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Copyright © 2018 TIIKM
ISSN 2324 – 6735 online
DOI: https://doi.org/10.17501/23246735.2018.4107

IMPROVEMENT STRATEGIES OF JOB

PERFORMANCE: A PERSPECTIVE ON NURSING
PROFESSION IN VIETNAM
Phuong Van Nguyen1*, Lien Thi Xuan Nguyen2 and Nhu Huu Thien Nguyen1
1
International University, Vietnam National University HCMC, Vietnam
2
Hospital Accountant, Heart Institute HCMC, and MBA Student, Van Hien University HCMC, Vietnam

Abstract: As an increase in overloaded general hospitals in Vietnam, nurses are under intensive
pressure but receive little opportunities for learning new technical skills and for developing an
obvious career path. Meanwhile, nurse performance is essential to quality outcomes of healthcare
services. Therefore, this study aims to investigate primary drivers of nurse performance by using the
structural equation model approach to analyze a survey of 366 nurses working in four hospitals in Ho
Chi Minh City and Bac Lieu province, Vietnam. The results show the facilitating effects of affective
commitment and self-leadership on job performance, but not continuance commitment and
communication competence. Also, the empirical evidence supports that perceived organizational
support and psychological safety indirectly impact job performance through affective commitment.
Job resources, however, are insignificantly related to affective commitment. The study indicated that
nurses with a high degree of self-leadership and affective commitment to the organization are prone
to attain high job performance. Therefore, managers should implement strategies to enhance nurses’
conception of self-leadership and affective commitment, which would be an efficient approach to
improve quality healthcare services. This study also makes some explanations for the divergence
between the previous literature on factors affecting nurse performance and that in Vietnamese
hospital context.

Keywords: job performance, nurses, affective commitment, self-leadership

Introduction

In most professions, human resource management has been catching great attention as its direct influence on the
prosperity and sustainable development of the organization (Becker and Gerhart, 1996, Rogers and Wright,
1998, Sheehan, 2014). Particularly in the healthcare field, managerial practices are increasingly applied to
promote the competency of nurses. According to Lee and Ko (2010), nurses are on the front line of caregiving to
patients in partnership with various positions like physicians, medical technologists, and administrative staff.
Hence, the performance of nurses is closely associated with services quality and organizational outcomes. The
identification of factors boosting nurses’ job performance (JP) has become an essential research topic in the
field of healthcare in different economic and cultural backgrounds.

Currently, scholars have explored a large number of factors impacting job performance such as work
environment, job satisfaction, leadership styles (Kacmar et al. 2009, Platis et al. 2015, Manning, 2016). In this
research, we aim to analyze the effect of organizational commitment on raising job performance. Organizational
commitment (affective, continuance and normative commitment) is among the most critical elements due to its
role in anticipating organizational goals, absenteeism, turnover, and productivity (Wasti, 2003). It is crucial to
recognize the positive outcomes of high organizational commitment and to encourage nurses’ participation in
organizational activities to improve the operational effectiveness (Liou, 2008). Previous studies showed that
affective commitment (AC) and normative commitment have a positive interconnection, meaning that they have
the same pattern of correlation (Meyer et al. 2002). While the other dimension, continuance commitment
(CCM), seems to have particular patterns. Hence, this research will place focus only on the significance of
affective and continuance commitment.

Corresponding Author Email: * [email protected]

 Phuong Van Nguyen et al / Improvement Strategies Of Job Performance…..

Furthermore, affective commitment has been found as the strongest predictor of nursing performance (Meyer et
al. 2002, Qaisar et al. 2012). As a result, our study will examine its possible drivers including perceived
organizational support (POS), psychological safety (PS), and job resources (JR). In particular, employees’
positive feeling at work can be boosted under the environment where they perceive greater organizational
support (Lee et al. 2010) and a sense of psychological safety (Kark and Carmeli, 2009). Also, the provision of
job resources was proved as an important element to create a positive work setting, which in turn increases
employees’ affective commitment (Kirk-Brown and Van Dijk, 2016). Although previous studies have confirmed
the significant contribution of these factors on raising affective commitment, further investigation in different
contexts is still necessary to evaluate the generalization of these findings.

In today hospitals' setting, nurses are holding the major responsibilities for the internal management of patient
care. Therefore, self-leadership (SL) should be considered as an essential factor in the construct of job
performance. The implication of self-leadership might encourage the ability of self-control and responsibility
among nurses, which results in favorable organizational outcomes (Manz, 1983). Prussia et al. (1998) showed
that the relationship between self-leadership and performance outcomes is mediated by nurses’ self-efficacy.
Likewise, Lee and Ko (2010) revealed that self-efficacy is a facilitator of high-quality nursing care. However,
few researchers have examined the direct contribution of self-leadership in determining nurse performance.

According to Moreland and Apker (2016), nursing practices involve executing care services to patients on the
most frequent basic and also interacting with patients’ families and other nursing teams. Moreover, Commission
(2012) shows that communication-related problems account for 50% of confliction among nurses. Taken
together, these suggested that the nursing job is highly based on interpersonal communication. Yu and Ko
(2017) asserted that a high level of effective communication could reduce such negative events occurred in
hospitals, which positively influenced job performance. Thus, it is necessary to improve communication
competence (CCP) in the nursing organization.

The purpose of this study is to confirm the significance of nurse performance’s drivers in Vietnamese hospitals
with distinctive characteristics. The findings enable us to suggest some practical implications to enhance nursing
competencies, which in turn helps promote quality and safety in the healthcare community.

Literature Review

Perceived organizational support, affective commitment, and continuance commitment

Perceived organizational support refers to the extent to which employees believe that their organizations value
their contributions and care for their well-being. According to Shore and Wayne (1993) and El Akremi et al.
(2014), under the perception of organizational support, nurses may expect that hospitals would reward their
increased effort towards work goals and satisfy their needs of praise and approval. The perceived organizational
support can satisfy emotional needs in the workplace such as esteem, approval, and partnership; thus, affective
commitment is regarded as its major outcomes (Rhoades et al. 2001). The previous studies also show that the
recognition of organizational support is the predictor of continuance commitment, which refers to the cost
associated with leaving the organization. The more benefits receive from the current employment, the more
valuable organizational membership is; therefore, employees need to keep attached with the organization as they
acknowledge the noticeable sacrifice on quitting the job (Shore and Tetrick, 1991, El Akremi et al. 2014).
Nurses are more likely to create a bond with their hospitals in the presence of high organizational support
because they see a more favorable interrelationship between their contributions and comparable rewards (Shore
and Tetrick, 1991). Hence, the following two hypotheses are proposed:

H1: Perceived organizational support has a significant direct effect on affective commitment.
H2: Perceived organizational support has a significant direct effect on continuance commitment.

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Psychological safety and affective commitment

Psychological safety is the perception where an individual can express his or her self without worrying about
negative effects on self-image, status or career (Kahn, 1990). In other words, a work environment characterized
by a high level of psychological safety can encourage employees' interpersonal risk-taking. With the perceptions
of interpersonal trust and mutual respect, they feel safe to raise questions, seek feedback, report mistakes, or
express new ideas without fear of vulnerability (Edmondson, 1999, Kark and Carmeli, 2009). Therefore,
psychological safety can foster learning behavior, productive problem resolution as well as positive work
experiences which lead to positive organizational outcomes and increased work engagement (Baer and Frese,
2003). Under such a work setting where they can perform their job autonomously with the sense of comfort,
nurses tend to get more involved with their organization, thereby being pleased to maintain their membership as
they desire. In general, psychological safety is expected to impact the affective commitment of nurses
positively, thus coming up with the following hypothesis:

H3: Psychological safety has a significant direct effect on affective commitment.

Job resources and affective commitment

Job resources refer to those physical, psychological, social, or organizational aspects of the job that are
instrumental in reducing job demands, attaining work goals and nourishing personal growth, learning and
development (Bakker and Demerouti, 2007, Demerouti et al. 2001). In this research, we assess job resources
through two dimensions: job complexity and job autonomy. There is an increasing demand for complete
autonomy in the workplace for employees to meet the requirement of more advanced work (Chung-Yan, 2010).
Job resources are either intrinsically stimulative as they fulfill the primary desire for autonomy, competence, and
belongingness; or extrinsically stimulative as they provide conditions to obtain work success (Schaufeli and
Bakker, 2004). Through this prompting process, the provision of valued job resources provokes positive
outcomes like work involvement (Demerouti et al. 2001), to which employees are likely to respond with a
highly affective commitment to their organization (Kirk-Brown and Van Dijk, 2016). Thus, job resources are
hypothetically assumed to have a positive effect on nurses’ affective commitment:

H4: Job resources have a significant direct effect on affective commitment.

Affective commitment, continuance commitment, and job performance

Affective commitment refers to an employee’s emotional attachment to, identification with, and involvement in
the organization (Meyer and Allen, 1991). Whereas, continuance commitment, the less common but still equally
applicable approach, is viewed as the remaining with the organization stemmed from the perceived losses
incurred when the employment relationship is discontinued. Committed employees will remain with the current
organization as their wish; but for those with high continuance commitment, it is based on their need. Like Tett
and Meyer's (1993) findings, some recent studies have indicated that three dimensions of organizational
commitment, including affective, continuance and normative commitment, are linked to job performance. Fu
and Deshpande (2014) had revealed the significant correlation between organizational commitment and job
performance through a study of Chinese employees in an insurance company. Likewise, Khan et al. (2010)
found the significance of organizational commitment in determining Pakistan employees’ work performance.
Hence, the following hypotheses are proposed:

H5: Continuance commitment has a significant direct effect on job performance.

H6: Affective commitment has a significant direct effect on job performance.

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 Phuong Van Nguyen et al / Improvement Strategies Of Job Performance…..

Self-leadership and job performance

Self-leadership refers to the act of self-influencing to monitor actions and cognitions in a direction that
encourages the desired behavior (Manz, 1983, Manz, 1986). In other words, in the presence of autonomy and
responsibility, self-leadership appears as an intrinsic motivation to manage oneself to perform must-be-done
tasks even if they are naturally motivating or not. It is indicated that nurses’ self-leadership and job performance
are closely correlated with each other (Chang et al. 2006). Stewart et al. (2011) also suggested that enhanced
self-leadership at the individual level is significantly associated with promoting job performance as such
employees are more likely to generate higher productivity at work. In addition, self-leadership appears as a
facilitator to employees’ effective goal-setting process that in turn should lead to the improvement of the whole
organization performance (Neck et al. 2003). Therefore, the following hypothesis is proposed:

H7: Self-leadership has a significant direct effect on job performance.

Communication competence and job performance

Communication competence refers to the ability to align the manner of speaking appropriately through good
grammatical and social knowledge. Communication competence, one of the valuable resources, is expected to
foster job performance among nurses in healthcare organizations (Bae, 2008, Im et al. 2012, Park et al. 2015).
Kang and Yu (2016) reported that in the presence of communication competence, the correlation between self-
leadership and job performance seemed to be more strengthened. Previous studies also found that employees
equipped with adequate training to build up communication skills would display more positive outcomes (i.e.,
reduced anger, decreased emotional stress, improved mental wellness, and low level of burnout) (Swain and
Gale, 2014). In addition, communication is reported as the most difficult task in the clinical setting, indicating
the necessity of ensuring that adequate strategies are implemented to boost nurses' communication ability (Park
and Lee, 2003). Accordingly, the following hypothesis is proposed:

H8: Communication competence has a significant direct effect on job performance.

Research Methodology

Measurement

To measure the latent variables observed in this study, we construct the measurement scale which contains 36
items with reference to the scales developed in previous researches. First, job resources are assessed through the
one-item Decision Authority scale and two-item Skill Discretion scale from Karasek Jr (1979), which examines
its two dimensions: job autonomy and job complexity respectively. Then, the three-item scale is adopted from
Baer and Frese (2003) to assess psychological safety. This scale evaluates nurses’ perceptions of safety and
mutual respect in working place. To measure perceived organizational support, we use five items from
Eisenberger et al. (1986) scale which investigates whether nurses acknowledge the assistance from their
hospitals. Next, affective commitment with five items and continuance commitment with three items are
adopted from Tett and Meyer (1993). The four-item scale developed by Houghton and Neck (2002) is applied to
measure self-leadership among nurses, which examines the ability to manage oneself towards work goals. The
communication competence measure is based on the measurement of Canary and Spitzberg (1987), consisting of
four items which evaluate the success in nurses’ workplace interaction. Finally, job performance is assessed
through a nine-item scale proposed by Ko et al. (2007), which investigates its two subscales of competency (the
first six items) and attitude (the last three items). A five-point Likert scale (1 = strongly disagree, 5 = strongly
agree) is used to evaluate respondents’ extent of agreement with each statement on the questionnaire.

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Questionnaire design

According to Green (1991), the minimum sample size is determined by the formula 8*m + 50, where m is the
number of measurement items. In this study, the survey spreads out over 366 participants so that it sufficiently
satisfies the requirement corresponding to 36 items. The questionnaire is designed into two main sections, which
are (1) demographic characteristics, including respondents’ name, gender, age, number of working year in
healthcare field, number of working year in the current organization, number of organizations that they have
been worked for; and next (2) 36 items measuring eight latent variables in the hypothetical model. Besides, for
best fitting in Vietnam context, all items in the questionnaire are translated into Vietnamese language and partly
adjusted for respondents’ better understanding.

Data collection

The survey is conducted in Ho Chi Minh City and Bac Lieu Province, Vietnam by a paper-based questionnaire
administered directly to participants. There are two phases in data collecting procedure, including pilot test and
official survey. First, the pilot test with a sample size of 36 nurses is carried out to evaluate the measurement
scale before spreading to a larger scale. After being adjusted based on the pilot test’s results, the final
questionnaires are distributed to the nursing staffs of four hospitals. After the deletion of invalid questionnaires,
the data extracted from 366 valid observations are used in the final analysis.

Results

Demographic characteristics

Table 1 indicates the demographic data of 366 respondents. Most of them are women, and the majority of
respondents are under 40 years old (78.1%). In addition, their experience in the nursing industry varies from less
to more than eight years, with the rate at 50.3% and 49.7%, respectively. Most of them have served their current
hospitals for under 20 years (nearly 91.8%), and the number of hospitals for which they have worked is mostly
under 2 (at 95.9%).

Table 1 Demographic characteristics.

Characteristics Number (N = 366) Percentage
Gender
Male 150 41.0%
Female 216 59.0%
Age
21 – 40 286 78.1%
Above 40 80 21.9%
Experience
1 - 8 years 184 50.3%
Above eight years 182 49.7%
Number of working years in
the current hospital
Under 20 years 336 91.8%
Above 20 years 30 8.2%
Number of hospitals
Under two hospitals 351 95.9%
Above two hospitals 15 4.1%

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Reliability analysis

Exploratory Factor Analysis (EFA) is carried out to verify the underlying relationships among measured
variables (i.e., whether a set of variables consistently load on the same factor based on strong correlations).
First, the coefficient of Cronbach’s alpha is computed for each factor to evaluate the internal consistency of the
measurement items. According to Hair et al. (1998), the Cronbach’s alpha value, which ranges between 0 and 1,
reveals better reliability among items if it is relatively higher. More specifically, the value of around 0.9 is
considered as excellent, around 0.8 as very good, from 0.6 to 0.7 as adequate and below 0.5 as unreliable. In this
study, all measured variables present good values of Cronbach’s alpha which are nearly or above 0.8, except for
JR valuing at 0.637 (see Table 2). Nevertheless, it is suggested that the value over 0.6 is also acceptable in
exploratory research (Fornell and Larcker, 1981).

The KMO measure (0.805) satisfies the recommended acceptable level which must be higher than 0.5. Barlett’s
Test of Sphericity, Sig. (0.000) is less than 0.05 and total variance explained (69.836%) is larger than 50%,
which is within the recommended acceptable level. According to Hair et al. (1998), observed variables are
considered valid when their factor loadings are over 0.5, and there are no major cross-loadings between factors
(the difference between the loadings should be more than 0.3). In this study, most items have significant factor
loadings, which are illustrated in Table 2. However, the two items JP6 and JP7 are removed because of major
cross-loadings. JR1 is also erased as its loading is considerably lower than 0.5, while JR2 (factor loading is
0.474) is still acceptable since it is very close to the requirement.

Confirmatory factor analysis

The next step is to validate the measurement model through confirmatory factor analysis (CFA). The acceptable
level for Composite Reliability (CR) and Average Variance Extracted (AVE) is 0.7 and 0.5 respectively as
recommended by Hair et al. (1998). While the values of most items are acceptable, we need to eliminate SL2 to
better its value (see Table 3).

In addition, a measurement model with high values of model fit indices is suggested to present a higher level of
goodness-of-fit. These indices (shown in Table 4) are the normalized chi-square, root mean square error of
approximation, goodness-of-fit index, incremental index of fit, and comparative fit index. Most of the model fit
indices exceed the requirement of acceptance, except for GFI is less than but very close to the standard,
indicating that the measurement model in this research obtains a considerable goodness-of-fit.

Structural equation modeling and Hypothesis testing

Structural equation modeling (SEM) is an approach to assess the overall fit of the structural model by using
Maximum likelihood estimate which is conducted in the software AMOS 20.0. All the fit indices observed in
this analysis is measured based on the same reference standards in CFA. As shown in Table 4, most indices are
within the range of acceptance, while some nearly satisfy the requirement.

Moreover, the hypothesis will be accepted if its path coefficient is presented as statistical significance. The
summary of the estimated standardized path coefficients is presented in Table 5. At the 0.05 level of confidence,
most of the path coefficients are positively significant, except for those from JR to AC, CCM to JP, and CCP to
JP. As observed from the result, POS has a significant impact on both CCM and AC. Thus, hypothesis H1 and
H2 are supported. The impact of PS on AC is statistically significant, indicating that H3 is supported; while H4
is not accepted because of the insignificant coefficient from JR to AC. Moreover, the result shows that both AC
and SL are significantly positively related to JP, but there is no significant impact of CCM and CCP on JP.
Hence, hypothesis H6 and H7 are accepted, while H5 and H8 are rejected.

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Table 2 Factor loadings in EFA, CFA, and Cronbach’s Alpha.

Variables Measurement EFA CFA Cronbach’s
Items Alpha
Perceived POS1 0.712 0.750 0.871
organizational support POS2 0.685 0.734
(POS) POS3 0.791 0.827
POS4 0.757 0.780
POS5 0.685 0.681
Affective commitment AC1 0.734 0.785 0.877
(AC) AC2 0.749 0.780
AC3 0.771 0.839
AC4 0.669 0.710
AC5 0.678 0.711
Continuance CCM1 0.655 0.697 0.801
commitment (CCM) CCM2 0.734 0.835
CCM3 0.722 0.734
Psychological safety PS1 0.786 0.858 0.789
(PS) PS2 0.695 0.756
PS3 0.637 0.667
Job resources (JR) JR2 0.474 0.479 0.637
JR3 0.977 1.014
Self-leadership (SL) SL1 0.629 0.601 0.781
SL3 0.780 0.880
SL4 0.756 0.738
Communication CCP1 0.641 0.662 0.826
competence (CCP) CCP2 0.802 0.837
CCP3 0.773 0.788
CCP4 0.655 0.666
Job performance (JP) JP1 0.692 0.727 0.866
Competence JP2 0.684 0.710
JP3 0.780 0.766
JP4 0.840 0.877
JP5 0.694 0.673
Job performance (JP) JP8 0.611 0.632 0.756
Attitude JP9 0.938 1.034

Table 3 Composite Reliability and Average Variance Extracted.

Variable CR AVE
Perceived organizational support (POS) 0.872 0.577
Affective commitment (AC) 0.879 0.594
Continuance commitment (CCM) 0.816 0.597
Psychological safety (PS) 0.801 0.573
Job resources (JR) 0.673 0.514
Self-leadership (SL) 0.786 0.554
Communication competence (CCP) 0.830 0.552
Job performance (JP) - Competence 0.830 0.710
Job performance (JP) - Attitude 0.866 0.566

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Table 4 Model fit indices in CFA and SEM.

Model fit Thresholds CFA SEM References
indices
χ2/df 1-3 2.215 2.377 Barbara (2001)
RMSEA <0.08 0.058 0.061 Bentler and Bonett (1980)
GFI ≥0.90 0.863 Tabachnick et al. (2001)
IFI ≥0.90 0.904 0.887 Bentler and Bonett (1980)
CFI ≥0.90 0.903 0.886 Bentler and Bonett (1980)

Table 5 Results of the model in SEM.

Hypothesis Path Path S.E. C.R. P
coefficient
H1 CCM ← POS 0.304 0.053 5.709 ***
H2 AC ← POS 0.270 0.055 4.936 ***
H3 AC ← PS 0.275 0.072 3.806 ***
H4 AC ← JR 0.137 0.081 1.684 0.092
H5 JP ← CCM 0.014 0.037 0.388 0.698
H6 JP ← AC 0.089 0.039 2.284 0.022
H7 JP ← SL 0.216 0.050 4.294 ***
H8 JP ← CCP 0.061 0.041 0.133 0.133
*** Statistically significant at the 0.001 level of confidence.

In this study, it is found that the effect of SL on JP (path coefficient is 0.216) is more considerable than other
three predictors including CCM, AC, and CCP (0.014, 0.089, and 0.061, respectively). The path coefficient of
PS to AC (0.275) reveals its better contribution compared to that of POS (0.270) and JR (0.137).

Discussion

The results indicate that affective commitment is significantly related to job performance among nurses, which
is consistent with previous studies of Jaramillo et al. (2005), Fu and Deshpande (2014), and Khan et al. (2010).
This implies that when nurses feel a greater sense of emotional connection with their hospital, they will put
more concern in the organization’s welfare, which intrinsically motivates themselves to generate higher
performance. Also, the findings of our study reveal the mediating effect of perceived organizational support on
the correlation between affective commitment and job performance due to the significant path coefficients of
POS to AC and AC to JP. In line with Darolia et al. (2010), the care of employees’ well-being and the tendency
to reward increased efforts from the organization would facilitate nurses’ affective bond to their hospitals, which
make them feel an obligation to contribute more for the collective benefits. Comparatively, psychological safety
is observed as a more significant mediator between affective commitment and job performance. Under the sense
of safety, comfort and mutual respect, positive work experiences and work engagement are easily witnessed
from those whose performance is affected by positive attitude and behavior towards the organizational
optimization (Kirk-Brown and Van Dijk, 2016). For example, in the psychologically safe environment where
nurses can freely make contributions to the group discussion on treatment methods for patients, they are inclined
to feel strong involvement with the job and then generate higher productivity. With the aim of promoting job
performance through enhanced affective commitment, managerial strategies like anti-discrimination approach
and the principles of social inclusion (being included within a group) are necessarily implemented to reduce
psychologically and socially harmful manners such as bullying or harassment (Shain, 2009).

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The results, however, show that the provision of job resources (job autonomy and job complexity) does not
necessarily induce a higher level of affective commitment. This is incompatible with existing findings that job
resources can reinforce employees’ affective attachment with organizations (Salanova et al. 2005). This
insignificance of job resources might come from the particular characteristics held in Vietnam, which considers
nursing as a professional career that requires the advanced level of knowledge or expertise rather than creative
works. Indeed, nurses are required to follow the guidelines for proper documentation and appointments from the
physician in any given task (Frank-Stromborg et al. 2001). Therefore, it might not be a bothersome constraint to
nurses when they must adhere to the exacting standards to provide care services, indicating a minimal demand
for autonomy in the workplace. However, the level of nursing training quality and the scope of practice in the
future will observe many changes. Nurses will be able to take in in-depth training programs on a local and
global scale, thus creating incentives for them to contribute valuable ideas as well as participate directly in the
process of improving nursing service quality. This warrants further investigation into the granting of job
autonomy, the recognition of the nurses’ role, and their effect on nursing performance in Vietnam. In addition,
future studies examining other dimensions of job resources in various hospital scales are also necessary.

This study reveals that continuance commitment emerges as an insignificant driver of job performance, which
aligns with Gong et al. (2009) study that although enhanced performance may be explored in the organization
characterized by high level of affective commitment, it may not when it comes to continuance commitment.
This is somewhat opposed to the study of Fu and Deshpande (2014) who showed that organizational
commitment through its three dimensions (affective, continuance and normative) is a major predictor of job
performance among Chinese employees. Meanwhile, Schrock et al. (2016) addressed an adverse effect of
continuance commitment on job performance. They found continuance commitment weakening the positive
association between affective commitment and job performance. In the Vietnamese healthcare industry, the
insignificance of continuance commitment may result from the inadequate enthusiasm for the job. This means
that nurses with high continuance commitment may perceive the maintenance with their organization simply as
a need because they want to avoid the side bets associated with leaving the current job. For these individuals, the
likelihood of engaging in supportive behaviors towards organizational goals is uncertain (Shore and Wayne,
1993). In general, there exists a disparity in these findings; consequently, future studies should be conducted to
clarify the role of continuance commitment in determining job performance and other possible drivers in
different economic, cultural and occupational backgrounds.

The findings of our study show that the facilitating effect of communication competence on job performance
does not exist. This is antithetical to previous researches announcing communication competence as the
important driver of job performance (Im et al. 2012, Yu and Ko, 2017). They pointed out that nursing
performance is notably promoted as a consequence of the improved interpersonal competence. These findings
imply that the degree of communication competence’s influence may vary by job characteristics among
different work settings. Indeed, in today’s hospitals, every department requires its employees to meet specific
skills. Nursing staffs in Clinical or Internal Medicine Department mainly interact with patients and their
guardian day by day. Thus they are expected to be able to communicate well because obtaining communication
capacity are inclined to facilitate their performance. However, it does not necessarily mean that nurses who
acquire the average or lower level of communicating skills are constrained away from the advancement in work
outcome. For example, nurses working in Department of Surgery, Department of Anesthesiology, or
Department of Resuscitation, are not obliged to be excellent at cooperation because of their distinctive
occupational characteristics which are not mainly based on direct intercommunication with patients. This infers
that their evolved performance might derive from other potential variables such as their increased effort to boost
technical skills. Therefore, it is not so startling that the development of communication competence may bring
about minor improvement in Vietnamese nursing services.

Extracted from the results, it is observed that self-leadership is the significant predictor that makes the greatest
contribution to the enhancement of nursing performance. These findings support the study of Chang et al.

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(2006) who reveals that job performance can be improved through the appropriate programs boosting self-
leadership. Of particular importance is what should be implemented to improve self-leadership among nurses;
thereby, the provision of various training programs and education that pursue such improvement is necessary. In
particular, the knowledge acquired from courses investigating self-assertion and self-expression could be
practiced to efficiently deal with typical and specific cases in daily tasks (Yu and Ko, 2017). Besides, it also
calls for the organization’s interest in forming a work setting that inspires nurses to present their innovative and
active self-leadership. Additionally, the potential approach to horn nurses' capacity of self-leading is to regularly
encourage their straightforward self-reflection on previous experiences and their openness to adapt in the future.
The method of reviewing with a trusted partner or mentor and getting appropriate feedback from parties might
work here (Angelucci, 2005).

Conclusion

As an important element related to a hospital’s effectiveness and reliability, service quality assessed through
nurses’ job performance has been examined in many previous studies. This study focuses on exploring
determining factors in improving job performance among nurses in Vietnamese hospitals. The results show that
affective commitment and self-leadership are the direct and significant predictors of job performance, but not
continuance commitment and communication competence. It also reveals that perceived organizational support
and psychological safety are indirectly related to job performance under the mediating role of affective
commitment. Furthermore, improvement in self-leadership is proved as a more efficient method to raise nursing
performance because of its better influence than that of affective commitment.

These findings suggest some useful procedures to cultivate nurses with required competence to provide high-
quality care services. Firstly, approaches targeting a work setting that gives employees a sense of inclusion,
safety, and interpersonal respect should be pursued. Besides, if nurse managers apply proper rewarding policies
to praise nurses’ increased efforts and take good care of their development, it is possible to reinforce nurse
performance through a strong affective bond with the organization. Secondly, the managerial approach should
aim to strengthen nurses’ ability in self-leadership. Results-Based Management style is suggested as an
advanced method which sets specific goals and tightly keeps pace with the work to attain desired outcomes.
After that, the process of reviewing on both individual and collective scale is necessary to strive for
improvement in later performance. Additionally, various education programs and training activities tailored to
each nursing department’s characteristics should be provided to raise the awareness of the necessity to stimulate
productivity through self-leadership. In short, the expected outcomes of these programs would be the delivery of
proficient and reliable care services by qualified nurses in the environment with high professional ethics.

Our study also makes some explanations for the divergence between previous literature on factors affecting
nurses performance and that in the Vietnam context. However, regarding the generalizability of the findings,
future researches need to be conducted to investigate other potential job performance’s predictors in various
hospital size and characteristics. Another limitation of this study is that the possible effect of the disparity
between countries on the quality of health care services is not considered. Hence, an international research
comparison would be worthwhile.

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Proceeding of the 4th International Conference on Public Health, Vol. 4, 2018, pp. 74-79
Copyright © 2018 TIIKM
ISSN 2324 – 6735 online
DOI: https://doi.org/10.17501/23246735.2018.4108

PALATAL RUGAE AND LIP PRINT PATTERN STUDY AS

THE ALTERNATIVE METHOD OF MASS NATURE
DISASTER VICTIM IDENTIFICATION
Nila Kasuma1*, Fildzah Nurul Fajrin2, Dewi Elianora 3, Aida Fitriana 1 and Haria Fitri1
1
Andalas University , Faculty of Dentistry, Indonesia
2
Andalas University , Faculty of Medicine , Indonesia
3
Baiturahmah University , Faculty of Dentistry, Indonesia

Abstract: The most common method of forensic identification is dental, fingerprint, and DNA.
However those have a limitation such as high price , and limited cases. Palatal fold (rugae) and lip
print pattern are a unique, stable and resistant morphological landmark for identification. The
purpose of this study is to examine the characteristic of rugae palatina and lip print pattern and the
resemblance to the Minangkabau family relationship. This cross-sectional study, in 27 pure blood
Minangkabaunese families. The sample was taken randomly. Palatal rugae was extracted from
alginate printing. Lip print was taken on white paper after lips colored with red lipstick. IBM SPSS
17 is used for statistical analysis. The results show that there is similarity of rugae palatina based on
family relationship. The circular male rugae has similarities to that of the father (p <0.05). Circular
rugae in girls is derived from the mother, wavy ones are derived from both parents (p <0.05).. Lip
print pattern doesn‟t show the significant result. Conclusion is similarities of rugae palatina are
influenced by genetic factors. Rugae palatina is good alternative identification method in forensic
science. Palatal rugae pattern can be considered to be taken in routine dental medical record.

Keywords: palatal rugae, lip print pattern, odontology forensic

Introduction

After the tsunami in the northern island of Sumatra, Indonesia in 2004, earthquakes occurred periodically
moving southward to the Sunda Strait. The Province of West Sumatra is located in the western part of Sumatra
island which has become an international focus because of frequent disasters and the discovery of seismic gaps
that could potentially cause an earthquake of magnitude 8.8 - 8.9 SL (Imamura et al., 2012). The most common
ethnic groups in West Sumatra are Minangkabau ethnic. Minangkabau has the only matrilineal lineage in
Indonesia (Fanany, 2014). A total of 7 districts and cities are disaster prone areas with 921,349 people living in
the red zone (Imamura et al., 2012) .

Identification of disaster victims is a very challenging process in forensic science. At this time the most
commonly used methods are fingerprint, dental and DNA identification. DNA is the most accurate but very
expensive, especially in large natural disasters.Dental identification is very useful in natural disasters that cause
very many casualties, even success reaches 75%(Rath and Reginald, 2014). However there are certain case
when these methods cannot be done, therefore the secondary method need to be conducted .

Rugae palatina is a unique and potential oral cavity landmark if a dental method cannot establish identification
(Sharma, Saxena and Rathod, 2009). “Rugae Palatina” is terminology which refers to a series of irregular
elevated ridges produced by folding of palatal mucose membrane on hard palate anterior part, spreading from
papilla incisivum transversely.In 1932 , Trobo Hermosa, a Spanish investigator proposed the study of palatal
rugae is called “Palatoscopy” or “Rugoscopy”(Pillai et al., 2016) .

For the first time ,in 1932 Edmond Locard proposed an identification method using lip print pattern. This
method is called cheiloscopy (Narwal et al., 2014). Lip print pattern is the cracks (sulci labiorum) in the form of

Corresponding Author Email: * [email protected]

 Nila Kasuma et al / Palatal Rugae And Lip Print Pattern Study As The Alternative…..

wrinkle and groove on the lips transition zone between labial mucosa and skin (vermilion border) (Khanna,
2015). Because of the accuracy, simplicity, efficiency, lip print pattern is considered as the alternative
secondary forensic identification method. Lip print pattern is usually collected by various ways. Cottone (1981)
introduced using lipstick as the easiest way to trace the pattern (Sandhu et al., 2012).

The uniqueness of the structure of the rugae palatina and lip print patterns can be questioned whether it can
determine the similarity between relatives in one family. The purpose of this study is to examine the similarity
of palatal and lip print pattern among family members in native Minangkabau ethnic groups

Method

This cross sectional study included 27 families consist of father, mother, and biological daughter and son which
is chosen randomly in 3 native Minangkabau district : Luhak 50 Kota, Luhak Agam , and Luhak Tanah Datar.
This study have qualified the ethical clearance on September 2017 (ethical clearance No. 080/KEP/FK 2017).
Respondent signed informed consent after being informed about the purpose and instructions of this study . Data
were collected from October 2017 – February 2018 .

Maxillary impression was made with irreversible hydrocolloid impression material (alginate) (©GC scent) on
impression tray . Dental cast was made with mixture of dental stone type 3 and water which is mixed based on
W:P ratio . The cast was analyzed twice by 2 observers,. Palatal rugae on the cast were measured and classified
according to shape with Thomas - Kotze method and size with Sunita Kapali method.

Thomas- Khotze

Curved

Wavy

Straight

Unification

Circular

Sunita Kapali

Primary A – 5 to 10 mm

B – 10 mm or more

Secondary Secondary rugae (3-5 mm)

Fragmentary Fragmentary Rugae (< 3 mm)

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Lip print pattern were collected with lipstick method. The respondents were asked to put a red lipstick (©Pixy)
on their lips and let it drier for 1 minute. Lip prints were taking on a 10 cm length cellophane tape with
respondents open their lips slightly and press evenly from central to lateral part of lips for seconds. The tape was
removed then attached in a piece of white paper . The paper was scanned by scanner then analyzed and
classified according to Suzuki-Tsuchihashi lip print pattern classification as follows : (Tsuchihashi, 1974)

Table 1. Lip print pattern classification by Suzuki- Tsuchihashi (Tsuchihashi, 1974)

Type I Clear-cut grooves running vertically across the lip
Type I‟ The grooves are straight but disappear half-way instead of
covering the entire breadth of the lip
Type II The grooves fork in their course
Type III The grooves intersect
Type IV The grooves are reticulate
Type V The grooves do not fall into any of the Types I-IV, and cannot be
differentiated morphologically

Data were analysed using IBM SPSS 15 statistical software . Goodness of fit test was used to examine the
similarities between pattern among family members .

Result

This study took place in 3 native Minangkabau districts (Luhan Nan Tigo). Guguak , Situjuh and Tanjung
represented Luhak 50 Kota. Luhak Tanah Datar was represented with Tanjung Baru and Baso, Banuhampu and
Tanjung Raya in Luhak Agam . Twenty seven families were observed, but only 13 families had complete family
consist of father, mother and son, and 11 families had father, mother and daughter.

Table 2. Similarities of palatal rugae pattern

p-value
Rugae Shape Rugae Size
Curve Straight Wavy Unification Circular Primary Secondary Fragmenter
β₀ ,148 ,038 ,083 ,177 ,635 ,007 ,144 ,168
Son β₁ ,749 ,699 ,119 ,684 ,005 ,434 ,385 ,647
n=13 β₂ ,370 ,356 ,466 ,903 ,326 ,197 ,194 ,538
Y ,612 ,577 ,270 ,916 ,011 ,216 ,176 ,761
β₀ ,257 ,108 ,027 ,142 ,316 ,004 ,095 ,465
Daughter β₁ ,516 ,303 ,093 ,456 ,018 ,289 ,480 ,797
n=13 β₂ ,855 ,167 ,032 ,720 ,015 ,827 ,299 ,094
Y ,791 ,151 ,085 ,601 ,043 ,547 ,342 ,202

The shape and size of rugae do not show a significant similarity relationship between children - father and child
- mother. But there are specific patterns that can be derived. Circular rugae on boys tends to be inherited from
father (p = 0,011). Circular rugae pattern on girls is derived from father and mother, wavy rugae come from the
mothers (p <0.05). Meanwhile in lip print analysis, the pattern doesn‟t show the significant similarity between
children and parents .

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Table 3. Similarities of lip print pattern

Goodness of fit
p-value
Quadrant I II III IV
Son
β₀ ,526 ,879 ,289 ,084 ,270
n=13
β₁ ,322 ,051 ,235 ,728 ,881
β₂ ,659 ,195 ,160 ,446 ,106
Y ,589 ,066 ,243 ,629 ,247
Daughter
β₀ ,697 ,093 ,436 ,566 ,839
n=13
β₁ ,477 ,955 ,305 ,790 ,083
β₂ ,076 ,355 ,498 ,939 ,946
Y ,111 ,618 ,500 ,962 ,200

Discussion

Serving legal matters and community services are another tasks for dentist aside doing examination, diagnosis,
and treatment of oral and maxillofacial lesions. Forensic identification is one of humanity service dentists can do
to help victim investigation and legal affairs .

Postmortem reports, Finger prints, DNA and dental record are known to be successful primary method to
identify victims in forensic science field. If the primary method is not sufficient, secondary method is needed.
Lip print and palatal rugae pattern can be instrument in forensic identification and verification of a person
presence on the crime scene (Sharma, Saxena and Rathod, 2009)

This current study was carried out to find out whether there is any association between parents and children lip
print patterns. The result of our study is there‟s no significant similar lip print pattern inherited from parents to
children means there are no patterns which is very identical . The pattern was completely different from parent ,
and this difference is considered to be individualistic and unique . Our result is in concordance with Silpha et al
study who find no significant association among family members(Shilpa Patel, IshPaul, Madhusudan.A.S.,
Gayathri Ramesh, 2010) . This study use lipstick to record the pattern . This method is have weakness because
the oil and moisture secretion from sebaceous and sweat gland on the edges of the lips can change the prints.
Also the smudging of lip prints because of uneven pressure on the lips while taking the records leading to
unidentified pattern.(Sharma, Saxena and Rathod, 2009) . While recording the pattern , observer should pay
more attention when pressing the tape to avoid smudging . Therefore further study should be carried out with
larger sample size and latest imaging technologies .

From this study it can be concluded that the shape of rugae can be used to determine the relationship and
similarity between relatives. On boys, the most shape derived from his father is circular pattern. This is similar
to our previous pilot project (Kasuma et al., 2014) states that the rugae circular pattern is similar between
children and parents. This result is in concordance with Pasiga and Hardianti's (Daeng Pasiga and Hardianti,
2017) who did study on Bugise ethnic. The form of rugae is more similar between father and child than mother
and child. In girls, the circular pattern is inherited from father and mother, while the wavy pattern come from
mother. This result has similarities with the study (Patel et al., 2015) which states the relationship of the rugae
pattern shows a positive correlation between the child and his parents. Wavy rugae patterns are derived more
from the mother than from the father.

The shape of the rugae palatina pattern is derived by the parents. Genetics affects the formation of morphologic
characteristics so that the pattern is not the same for everyone. According to Mendel's theory, each parent's gene

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will be passed to his child. The inherited properties will be seen if the gene is the dominant gene. Environmental
factors influence the formation of palatine rugae, and are determined by genes. Genes regulate the orientation of
collagen fibers during embryogenesis and the diversity of palatine rugae patterns in different populations.
Palatine rugae is formed in the 3rd intrauterine month, its growth is regulated by epithelial-mesenchymal
interactions in which extracellular matrix molecules are expressed during this development(Kasuma et al.,
2014).

Palatal rugae shape is stable and the quality and quantity doesn‟t change due to aging . This characteristics is
caused by the rugae position in oral cavity . Palatal rugae is protected by tongue , teeth , cheecks, and alveolar
process, ensure it to be not impaired by trauma, orthodontics treatment and finger sucking (Pillai et al., 2016).
Palatal rugae is unique topography , no one have similar pattern . Because of the uniqueness and accuracy that
match fingerprints identification, palatal rugae pattern is taken as medical record document in South America,
especially in certain case where fingerprints cannot be collected(Paliwal, Wanjari and Parwani, 2010;
Wichnieski et al., 2012). Another specialty of palatal rugae is the durability .Palatal rugae can last up to 7 days
after death and can withstand heat, for example degree 3 burn. Because of its uniqueness, stability, and
resistance to damage it is this that causes rugae palatina to be a very potential anatomical landmark (Pillai et al.,
2016).

Conclusion

There is a hereditary factor in the pattern of palatal rugae. Lip print pattern doesn‟t show the significant
similarities among family members but the pattern is different from each other‟s . Palatal rugae can be a genetic
marker for identification in the future. We hope this research can contribute to the forensic odontology
especially in the Minang and Deutro Malays

Acknowledgement

This research was supported supported and funded by Ministry of Research, Technology and Higher Education
Republic Indonesia . We thank our colleagues from Andalas University who provided insight and expertise that
greatly assisted the research.

Reference

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bugise – South of Sulawesi Indonesia)‟, International Journal of Research, 04(13), pp. 1310–1315.
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Copyright © 2018 TIIKM
ISSN 2324 – 6735 online
DOI: https://doi.org/10.17501/23246735.2018.4109

VALIDITY AND RELIABILITY TEST OF

MEDICATION ADHERENCE RATING SCALE
FOR PSYCHOSIS (MARS) INSTRUMENT
INDONESIAN VERSION
Kasmianto Abadi1*, A.A.A.A Kusumawardhani1, Natalia Widiasih1 and Khamelia
Malik1
1
Department of Psychiatry University Indonesia - Cipto Mangunkusumo National Referral Hospital, Indonesia

Abstract: Assessment of medication adherence is an important part of pharmacological treatment of

psychotic disorders. This study aims to obtain a valid and reliable instrument to assess medication
adherence in psychotic patients. This is a cross-sectional study conducted in the Psychiatric
Outpatient Clinic of Cipto Mangunkusumo Hospital from January to July 2017. Subjects were
recruited through consecutive sampling (n = 100, aged 18-59 years old). Psychotic disorders were
diagnosed using Structured Clinical Interview and Diagnosis DSM-IV. The instrument was
translated, adapted to Indonesian culture, and back-translated. Content validity and test-retest
reliability (n = 35 using systematic sampling) of MARS Indonesian version were evaluated. All
items in the instrument are relevant to theory, as showed by content validity coefficient of 0.90.
Construct validity test showed that the items represent theoretical as well as conceptual construction
of medication adherence. Internal consistency reliability was good, with Cronbach’s alpha of 0.80
and 0.798 in the test-retest evaluation. This study produced a valid and reliable MARS Indonesian
version. Currently there is no other instrument assessing medication adherence in psychotic patients
in Indonesia.

Keywords: medication adherence rating scale, psychosis, reliability, validity

Introduction

The World Health Organization in 2001 estimated 450 million people worldwide suffered from mental illness,
as well as about 10% of adults suffering from mental disorders today and 25% of the population is expected to
experience mental disorders during their lifetime. This disorder generally occurs to young adults aged 18-21
years. According to the National Institute of Mental Health, mental disorders account for 13% of the overall
disease and are expected to increase to 25% by 2030. The incidence will contribute to the increasing prevalence
of mental disorders in different countries (World Health Organization, 2011, World Health Organization, 2016,
Rössler, et al., 2005). According to Indonesia Ministry of Health Research in 2013 the highest prevalence of
mental disorders in Indonesia is found in Yogyakarta and Aceh Provinces of 2.7 per mil each, while the lowest
in West Kalimantan are 0.7 per mil. The prevalence of severe national mental disorder is 1.7 per mil. The
prevalence of severe psychiatric disorders in Indonesia is 0.3 to 1% and usually occurs between 18 and 45 years.
Psychosis is a mental disorder characterized by distortions of thoughts, feelings, ability to judge reality and the
ability to communicate with others (Sadock and Sadock, 2009).

Psychosis includes schizophrenia, schizophrenia-like disorder, schizoaffective disorder, delusional disorders,

severe depression with psychotic symptoms, and bipolar affective disorder with psychotic symptoms (American
Psychiatric Association, 2005). Noncompliance with medication becomes a problem of / with the management
of psychotic patients, resulting in the frequent recurrence of re-hospitalization, prolonged hospitalization,
shortened non-hospitalization time and worsening morbidity (Lacro, et al., 2002). Non-adherence to
psychotherapy patients based on meta-analysis studies are 20-50% (Kane and Kishimoto, 2013). This
disobedience resulted in patients resistant to the drugs given, requiring higher doses of drugs or drug

Corresponding Author Email: * [email protected]

 Kasmianto Abadi et al / Validity And Reliability Test Of Medication Adherence….

replacement, and causing relapses in 80% cases within the first two years after discontinuation of the drug
(NIMH, 2016). Noncompliance may also result in longer hospital admissions and shorten the non-
hospitalization time , which in turn will increase the burden of medical expenses. The support of the family or
friends as well as the immediate environment is required for the patient to adhere to treatment (Rössler, et al.,
2005).

Given that poor adherence is a problem that needs attention on the management of psychosis, it is necessary for
clinicians to detect non-adherence problems in taking antipsychotic medications. Medication Adherence Rating
Scale (MARS) is one of the measuring tools which, according to the research has good validity and reliability to
measure the compliance of psychotic patients in taking medication. MARS has now been used in several
countries, including Australia, United States of America, United Kingdom, Portugal, and France (Fond, et al.,
2016, Zemmour, et al., 2016, Thompson, et al., 2000, Cohen and Swerdlik, 2005). Currently in Indonesia,
especially in the Department of Psychiatry Faculty of Medicine University of Indonesia, Cipto Mangunkusumo
Hospital does not yet have a valid and reliable instrument for measuring medication adherence in psychotic
patients, therefore investigators aim to test the validity and reliability of MARS Indonesian version.

Methods

The samples were recruited based on inclusion and exclusion criteria.

Inclusion criteria:
1. Psychotic patient respondents were assessed with Structured Clinical Interview For
DSM (SCID);
2. Respondents aged more than 18 to 59 years of age group;
3. Respondents are psychotic patients in a cooperative state for testing;
4. Respondents can understand the Indonesian language well with the parameters of
education level graduated from Junior High School (Junior High School);
5. Respondents can read and write;
6. Respondents were conscious and able to focus, maintain, and divert adequately with
Glasgow Coma Scale (GCS) examination;
7. Respondents were willing to be a respondent and fill out informed consent.

Exclusion criteria:
1. Subjects with mental retardation, which data were obtained from medical record
information;
2. Subjects with impaired central organic nervous system, history of head trauma, and
substance abuse, data obtained from medical records.

Results

Translation of the Medication Adherence Rating Scale instrument was performed by two translators who never
seen or known this instrument. Translated results were then discussed by a group that consisted of the researcher
and Mental Health experts. In the process of discussion, there were some questions that are considered difficult
to be understood by the samples, for example question number 9. The initial translation of question number 9
reads "I feel strange, like the zombiw, when taking medicine". This statement was considered confusing because
the majority of Indonesians are not familiar with the words "zombie." The discussion then agreed to replace the
words "zombie" with "robot." The results of the discussion were then back translated and sent to the original
authors of the MARS instruments, who are Kathrine Thompson, Jayashri Kulkarni, Alex A. Sergejew of the
University of Melbourne, and they finally approved the adaptation (Thompson, et al., 2000).

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The process of translation translation (Back translation) Instruments into English

The translations in Indonesian were translated back to English by two different bilingual translators, who had
not previously known about the MARS instrument. The results were then compared with the original version.
This was done in order to see whether there was any significant differences in the items of the instrument’s
questions. The results of the reverse translation were sent to the instrument creator of MARS for approval.

Process of Testing Instruments

The trial process of MARS Indonesian version was performed on 10 samples. The samples were the patients of
Psychiatry Outpatient Clinic in Cipto Mangunkusumo Hospital.

Test Validity and Reliability

The validity test of MARS Indonesian version was tested in a sample of 100 people, based on the instrument
validity test recommendations that stated that samples could range from 30-500 samples. To test the reliability
of MARS instrument, the researcher used a sample of 35 people based on the calculation of minimum sample
with correlation coefficient of 0.5 at 95% degree of confidence and 80% power, with a result of 29 people.

Demographic Characteristics of Research Subjects

Table 1 described the demographic characteristics of the samples of this study. The samples had an average age
of 31.3 years with age range of 18 to 55 years. Based on the normality test using Kolmogorov-Smirnov test, it
was known that the sample had a p value of 0.006 which indicated that the data was not normally distributed. A
total of 62 samples was male while the other 38 samples were female. The sample had a diverse level of
education with the highest distribution was high school education level of 56 people. Data on marital status
indicated that 87 samples were married while 13 were not married at the time of the study. Data on employment
indicated that the majority sample did not have a job (49 people). The majority of samples’ diagnosis in this
study was schizophrenia (64 people). Throughout the course of the study, no patients were excluded; all samples
filled out the questionnaire completely.

Table 1 Demographic Characteristics of the Samples (n=100).

Characterisstic Median Min-Max
Age 30 18-55
Sex Male 62 62
Female 38 38
Education Primary School 4 4
Secondary High School 20 20
Senior High School 56 56
Mechanical School 1 1
Diploma 4 4
Undergraduate 9 9
Postgraduate 6 6
Marital Status Married 87 87
Unmarried 13 13
Pekerjaan Labor 2 2
Teacher 2 2

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 Kasmianto Abadi et al / Validity And Reliability Test Of Medication Adherence….

Housewife 5 5
Worker 15 15
Farmer 2 2
Entrepeneur 25 25
Unemployed 49 49
Diagnosis Bipolar 2 2
Depression 10 10
Acute Psychosis 4 4
Schizoaffective 20 20
Schizophrenia 64 64

Internal Consistency Reliability Test

The internal consistency reliability of the MARS Indonesian version was determined by calculating the value of
Cronbach's Alpha. The value of Cronbach's Alpha was calculated for every instrument subscale.

Table 2 Internal Consistency Reliability of the Medication Adherence Rating Scale Indonesian version, First
Test.
Scale Mean if Item Deleted Scale Variance if Item Deleted Cronbach's Alpha if Item Deleted
q1 3.9100 5.962 .704
q2 4.1900 5.085 .740
q3 4.1800 5.644 .779
q4 4.3400 6.368 .803
q5 4.1900 5.085 .740
q6 4.1800 5.644 .779
q7 3.6200 6.097 .788
q8 3.7600 5.477 .767
q9 3.7600 6.043 .701
q10 4.1900 6.216 .710

Table 3 Internal Consistency Reliability of the Medication Adherence Rating Scale Indonesian version, Second
Test.
Scale Mean if Item Deleted Scale Variance if Item Deleted Cronbach's Alpha if Item Deleted
q1 3.8100 5.754 .711
q2 4.1690 5.075 .740
q3 4.1950 5.654 .779
q4 4.3430 6.388 .798
q5 4.2960 5.055 .740
q6 4.3800 5.654 .779
q7 3.6700 6.077 .788
q8 3.7700 5.372 .767
q9 3.7900 6.042 .701
q10 4.1800 6.316 .712

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 Proceeding of the 4th International Conference on Public Health, Vol. 4, 2018, pp. 80-88

Content Validity Test

Testing the content validity was done based on the assessment by two Mental Health experts. Each of the
experts gave an qualitative assessment for each statement on the MARS Indonesian version, using a scale of 1 to
4, i.e. 1 (irrelevant) scale, 2 (somewhat relevant), 3 (quite relevant), and 4 (very relevant). After the assessment
was completed, the data was processed in a 2x2 table.

Based on the 2x2 table above, it was deduced that the content validity coefficient for the MARS Indonesian
version was 0.9. The formula produced values that range from +1 to -1, positive values indicate that at least half
the value of valuing items as important/essential. The larger the Content Validity Ratio (CVR), the more
"important" and the higher the validity of the content. The CVR value obtained in this study was 0.9, which
indicated that the items used has good content validity (Zygmunt, et al., 2002).

Construction Validity Test Using Factor Analysis Method

Factor analysis was performed to know the factors that make up the MARS Indonesian version. Prior to
performing factor analysis, it was ensured that the requirements for performing factor analysis were fulfilled.
The first requirement was the inter-item correlation value ranging from 0.07 to 0.72. These results indicated that
there was no strong correlation between items which showed multicollinearity. The Kaiser-Meyer-Olkin Test
Measure of Sampling Adequacy gave a value of 0.896 indicating that the sample was adequate for factor
analysis. Bartlett's Test of Sphericity gives P <0.01 which indicated the correlation matrix was not an identity
matrix. Based on these results, it was known that the requirements for performing factor analysis were fullfilled.

Table 4 Determination of adequate sampling by Kaiser-Meyer-Olkin Test and Bartlett’s Test.

Kaiser-Meyer-Olkin Measure of Sampling Adequacy .896

Approx. Chi-Square 1360.654
Bartlett's Test of Sphericity Df 99
Sig. 000

Factor analysis was done by using Principal Component Analysis method which extracted four factors. The
method is used to determine the minimum number of factors that play a role in achieving maximum variance in
the data. This method can also be used to reduce data. The method used in this research is Varimax rotation
method with Kaiser Normalization. Based on preliminary research conducted by Kathrine et al, it is known
there were 4 factors that made up the MARS instrument. These factors included attitude towards treatment,
behavior towards treatment, antipsychotic side effects, and attitude toward antipsychotic treatment.

Table 5 Factor Analysis of MARS Indonesian Version Using Varimax Rotation Method.
Item No. Factor
1 2 3 4
Q2 .896 .259 .056 .065
Q3 .870 .261 .086 .148
Q1 .730 -.076 -.082 .006
Q4 .724 .579 .338 .147
Q5 .110 .871 .039 .238
Q6 .000 .864 .220 .189
Q8 .356 .672 -.252 -.447

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 Kasmianto Abadi et al / Validity And Reliability Test Of Medication Adherence….

Q7 .047 .863 -.052 .045

Q9 .080 .234 .861 .019
Q10 .171 .226 .060 .877

Based on the matrix above, the researcher obtained the composition of statements in the Indonesian version of
MARS that could be divided into the following four factors:
 Factor 1, including item number 1, 2, 3, and 4. The division of those four items to the
attitude toward treatment subscale was in accordance with the original version of
MARS.

 Factor 2, including items 5, 6, 7, and 8. The division the four items to the behavior
towards medication subscale was in accordance with the original version of MARS.

 Factor 3 consisted of item number 9 corresponded to the antipsychotic side effects

subscale in the original version of MARS.

 Factor 4 consisted of item number 10 which corresponded to the attitude toward

antipsychotic treatment subscale in the original version of MARS.

Discussion

The validity and reliability test of the MARS Indonesian version in psychotic patient showed a valid and reliable
result. The study was conducted at the Cipto Mangunkusumo Hospital (RSCM) Jakarta Psychiatric Outpatient
Unit, taking into account that RSCM is a national referral hospital that receives patients from all economical
levels and educational background. It is considered to be representative of the clinical population and can be
applicable to similar settings.

The MARS instrument is an instrument composed of 10 questions that can be used to assess medication
adherence in patients with psychosis (World Health Organization, 2016). In the process of translating the MARS
instrument into Indonesian, there was one question that the community finds difficult to be understood by
Indonesian in general, that is question number 9. The result of the initial translation of question number 9 reads
"I feel strange, like the zombie, when taking medicine." This statement was considered confusing because the
majority of Indonesians are not familiar with the words "zombie." The discussion then agreed to replace the
words "zombie" with "robot." The results of the discussion were then confirmed to the original authors of the
MARS instruments, namely Kathrine Thompson, Jayashri Kulkarni, Alex A. Sergejew of the University of
Melbourne and they approved the adaptation (Thompson, et al., 2000).

This study was conducted in as many as 100 people with abnormal distribution. The internal consistency
reliability test in this study showed the Cronbach's Alpha of 0.8, while the retest test showed internal
consistency value of 0.798. Meanwhile, Cronbach's Alpha values for the instrument subscale show values in the
range 0.74 to 0.81. This indicates that the MARS Indonesian version had a good internal consistency. The
results of this study did not vary much with the results of original version of MARS instrument by Kathrine et al
that reported Cronbach's Alpha value of 0.75. Validity and reliability tests are also conducted in several other
countries, like Australia and France. The tests conducted by Zemmour et al. in France used a sample of 319
people consisting of 53 women and 266 men with sampling location in homes for schizophrenic patients. As for
data analysis, they were using software PASW 17.0.2 and MPLUS 7.2.2 (Zemmour et al., 2016). Unlike
research conducted in Indonesia, the study by Zemmour et al used the Richard Formula-20 coefficient to
determine the reliability value of the instrument, and found a reliability coefficient of 0.7. Research using 66
research subjects consisting of 51 women and 15 men was performed in outpatient clinics in Australia. The
validity test used in Thompson et al.'s research is multimethod matrix (Thompson, et al., 2000). The reliability
test in that study used Cronbach's Alpha (internal consistency) and the test-retest method with Cronbach's alpha

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 Proceeding of the 4th International Conference on Public Health, Vol. 4, 2018, pp. 80-88

at 0.75, this is not much different from the research done in Indonesia with Chronbach's alpha score 0.8.1 There
are similarities of method and characteristics between current study and study by Kathrine et al, such as
location of sampling at outpatient clinics, inclusion criteria of respondents with psychosis, average age of
respondents 37.6 years (SD = 11.09 years) and data analysis using multitrait multimethod matrix.

The content validity test gave the results of content validity coefficient of 0.9. These results suggest that the
MARS Indonesian version is relevant in assessing adherence to drug consumption in psychotic patients. Two
experts have only a difference of relevance, i.e. the statement number 6 where expert 1 gives a good rating
(score = 3) while expert 2 gives a bad rating (score = 2). The statement reads "Unnatural for my mind and body
to be controlled by drugs." However, since there is no significant difference (different 1 score between the
assessment of the two experts), statement number 6 is retained in the final version.

The construction validity test using factor analysis method, it is found that the MARS Indonesian version
composed of four factors: attitude towards treatment, behavior towards medication, antipsychotic side effect,
and attitude towards antipsychotic treatment. These four factors are consistent with the results of initial research
conducted by Thompson et al. (Thompson, et al., 2000).

Strengths in this study are that the researchers received training by mental health experts to make the diagnosis
psychosis using SCID. The strength of the MARS Indonesian version has been tested for content validity, test-
retest reliability and factor analysis to assess the internal consistency of the instrument after a retest within two
weeks after the first test with good test results. The weakness of this research is that the sampling is randomly
selected. The weakness of this instrument is that there is no comparable instrument for drug compliance
assessment in Indonesia that has been validated. Moreover, the questionnaire is a self-rated form which can
overestimate compliance by 30% (Thompson, et al., 2000).

Conclusion

The MARS Indonesian version has been tested for validity and reliability, question items tailored to the culture
of Indonesia. The results of validity and reliability test of the instrument are at a good level and repeated tests
produced consistent results. The medication compliance assessment instrument in an Indonesian version for
psychotic patients may be used as a baseline screening routine to find out medication adherence in psychotic
patients by assessing factors including attitude towards treatment, behavior towards medication, antipsychotic
side effect, and attitude towards antipsychotic treatment to increase treatment outcomes.

References

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Washington DC), pp. 463-468.
Azwar, S., 2012, Reliabilitas dan Validitas. Vol. 4th Edition. Yogyakarta.
Babiker, I.E., 1986, Noncompliance in schizophrenia. Psychiatr Dev, 4(4), 329–37.
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Cohen, R., Swerdlik, M., 2005, Psychological testing and assessment: an introduction to test and measurement (
New York: McGraw-Hill).
Direktorat Jenderal Kesehatan RI, 2011, Standar Antropometri (Jakarta:Kementerian Kesehatan RI).
Erwina, I., 2011, Faktor-Faktor yang berhubungan dengan kepatuhan minum obat pasien Skizofrenia di RSJ.
Prof. Dr. Hb. Saanin Padang (Padang: Universitas Andalas).
Fond, G., Boyer, L., Boucekine, M., Aden, L.A., Schürhoff, F., Tessier, A., et al., 2016, Validation study of the
Medication Adherence Rating Scale. Results from the FACE-SZ national dataset. Schizophr Res.

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Gregory, R., 2007, Psychological testing: History, principles, and applications, Vol. Fifth Edition (New York:
Pearson).
Hogan, T.P., Awad, A.G., Eastwood, R., 1983, A self-report scale predictive of drug compliance in
schizophrenics: reliability and discriminative validity. Psychol Med, 13(1), 177–83.
Jaeger, S., Pfiffner, C., Weiser, P., Kilian, R., Becker, T., Längle, G., et al., 2012, Adherence styles of
schizophrenia patients identified by a latent class analysis of the Medication Adherence Rating Scale (MARS): a
six-month follow-up study. Psychiatry Res, 200(2–3), 83–8.
Jin, J., Sklar, G.E., Min Sen Oh, V., Chuen, L.S., 2008, Factors affecting therapeutic compliance: A review from
the patient’s perspective. Ther Clin Risk Manag, 4(1), 269–86. Kane, J., Kishimoto, T., 2013, Non-adherence to
medication in patients with psychotic disorders: epidemiology, contributing factors and management strategies.
World J Psychiatry.
Joyce, A., Cramer, B., Anuja, R., 2011, Medication Compliance and Persistence: Terminology and Definitions.
Yale Univ Sch Med, 11.
Kemp, R., Hayward, P., Applewhaite, G., Everitt, B., David, A., 1996, Compliance therapy in psychotic
patients: randomised controlled trial. BMJ, 312(7027), 345– 9.
Lacro, J.P., Dunn, L.B., Dolder, C.R., Leckband, S.G., Jeste, D.V., 2002, Prevalence of and risk factors for
medication nonadherence in patients with schizophrenia: a comprehensive review of recent literature. J Clin
Psychiatry, 63(10), 892– 909.
Magura, S., Mateu, P.F., Rosenblum, A., Matusow, H., Fong, C., 2014, Risk factors for medication non-
adherence among psychiatric patients with substance misuse histories. Ment Health Subst Use Dual Diagn, 7(4),
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Maldiyono, Sastroasmoro, S., Budiman, I., 2002, Dasar-dasar Metodologi Penelitian Klinis (Jakarta: CV Sagung
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Michael, B., Robert, L., Gibbon, M., 2002. Structured Clinical Interview for DSM-IV-TR Axis I Disorders.
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Rössler, W., Salize, H.J., van Os, J., Riecher-Rössler, A., 2005, Size of burden of schizophrenia and psychotic
disorders. J Eur Coll Neuropsychopharmacol, 15(4), 399–409.
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Rating Scale (MARS) for the psychoses. Schizophr Res, 42(3), 241–7.
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BMJ, 317(7167), 1181–4.Toll, B.A., McKee, S.A., Martin, D.J., Jatlow, P., O’Malley, S.S., 2007, Factor
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Zemmour, K., Tinland, A., Boucekine, M., Girard, V., Loubière, S., Resseguier, N., et al., 2016, Validation of
the Medication Adherence Rating Scale in homeless patients with schizophrenia: Results from the French
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Copyright © 2018 TIIKM
ISSN 2324 – 6735 online
DOI: https://doi.org/10.17501/23246735.2018.4110

THE CLINICAL PATHWAY IN THE ORAL AND

MAXILLOFACIAL SURGERY’S SERVICES AS A QUALITY
MANAGEMENT TOOL, IN DR. SOETOMO HOSPITAL,
SURABAYA, INDONESIA
Nining Dwi Suti Ismawati 1* and Setya Haksam 1
1
Faculty of Public Health, Universitas Airlangga, Surabaya, Indonesia

Abstract: A Clinical Pathway is a comprehensive method of planning, delivering, and monitoring

patient care. As efforts continue to streamline the delivery of services at all levels of care and
settings, it is essential that quality management and utilization management professionals respond in
a proactive manner to facilitate quality outcomes while decreasing cost and increasing efficiency.
The aim of a Clinical Pathway is to enhance the quality of care across the continuum by improving
risk-adjusted patient outcomes, promoting patient safety, increasing patient satisfaction, and
optimizing the use of resources. However, there has not been any report on the implementation of
the Clinical Pathway in Oral and Maxillofacial Surgery services in Indonesia. This research used
observational methods and cross sectional design, with observational analysis and binary logistic
regression. The population of this research was Clinical Pathway of Odontectomy were collected
from medical records during January to December 2017 in ward surgery room of Dr. Soetomo
hospital in Surabaya Indonesia. The Result obtained in this study, mostly completeness of Clinical
Pathway were filled as the pattern. The amount of the sample in this research were 41 Clinical
Pathway, which 87,8 % were fit according to the quality and cost indicator. The Variation in drug
administration, treatment, and operator did not significantly influence ( chi square = 0,93 ; df= 0 ; p
value =1,00000 )

Keywords: clinical pathway, clinical variation, continuous quality improvement, evidence-based

medicine, health care processes, integrated care pathways

Introduction

Clinical Pathway(CP) also known as critical pathway critical pathway, care maps, integrated care pathway is an
integrated management planning with the purpose of the patient’s interest and provide sequence and exact time
of action to achieve optimum effeciency (Panela et all, 2005, Every NR et all, 2000)

With the publication of the Indonesian Health Act No 24 2011 regarding about the Social Security
Administration Agency or “Badan Penyelenggaraan Jaminan Sosial(BPJS)” where the rule states that the
implementation of Health BPJS has to be done since the 25th of November 2012 and operational by the 1st of
Januari 2014 and does not operate under the Ministry of Health, according to the Minister of Home Affairs
Regulation article61 2007. ( Dody F, 2010)Dr. Soetomo Regional Public Hospital as a Regional Public Service
Agency provides service to society based on the principal of effeciency and productivity prepares steps and
strategies to carry out the Clinical Pathway for every diagnosis.( Nining D.S. Ismawati and Nugroho Setyawan,
2013)

Clinical Pathway as a service guideline in Soetomo hospital has been used since 2011 until now,( SK Direktur
RSUD Soetomo, 2010, SK Direktur RSUD Soetomo, 2013) however there has been no report of research on the
effectiveness and efficiency of clinical pathway at the service of Oral and Maxillofacial Surgery both in
Indonesia and in International.

Corresponding Author Email: * [email protected]

 Nining Dwi Suti Ismawati and Setya Haksam / The Clinical Pathway In The Oral And……

The purpose of this study is to determine the clinical pathway used by the Oral and Maxillofacial Surgery
Division in odontectomy service during 2017 as a tool for quality control and cost control. The benefit of this
research is that it can be used as a clinical pathway audit material that is being used in the service guidance
whether it is appropriate and effective in quality control and cost control so that improvement can be done to
improve service quality.

Method

The type of this research is observational analytic research and cross sectional design, The population of this
research was Clinical Pathway of Odontectomy were collected from medical records during January to
December 2017 in ward surgery room of Dr. Soetomo hospital in Surabaya Indonesia.

The sample in this study is the entire population data ie the treatment of odontectomy with general anesthesia
using clinical pathway in daily care in the room at the surgery ward which is treated by Oral and Maxillofacial
Surgery Division from January to December 2017. We evaluate applying clinical pathways to process and
outcome indicators , and to the costs sustained to assist the patient through the activity-based costing. This
research uses technique non-probability sampling which is purposive sampling.

The data collection time of this study is estimated to take 2 weeks in June of 2018.The type of data used is
secondary data, data processing is done with SPSS 20, the data is presented in the form of tables and
drawings.Ethical clearance has been proposed with number 0459/124/VI/2018 as the cornerstone of research
ethics that focused the hospital patients are subdued in patients in the hospital.A tool for evaluating clinical
pathways using clinical pathway sheets of odontectomy procedures (surgical removal of embedded wisdom
teeth).

Figure 1: the current lenght of stay on odontectomy procedure

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 Proceeding of the 4th International Conference on Public Health, Vol. 4, 2018, pp. 89-93

Figure 2: ICD of the procedure during treatment

Figure 3: Column of variant

Research Result

From the evaluation and recording of the Clinical Pathway sheet during January to December 2017 it was found
that the sheet was filled completely by a medical service provider according to the point / item that was loaded.
From the observation, there were 41 clinical pathway samples with observation on variation: drug difference,
length of hospitalization, operator change.

Table 1 Likelihood Ratio Test

Model Fitting Criteria Likelihood Ratio Test
Effect -2 log likelihood of Reduced Model Chi - Square Df Sig
Intercept 9.274a .000 0 .
Varobat 13.938 4.664 2 .097
Tindakan 11.022b 1.748 4 .782
Operator 10.634b 1.360 2 .507

In the likelihood ratio of the table, the observed variables were the type of drug, the type of action and the
difference of the operator.

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 Nining Dwi Suti Ismawati and Setya Haksam / The Clinical Pathway In The Oral And……

Tabel 2 Model Fitting Information

Model Fitting Criteria -2 Log Likelihood Ratio Tests
likelihood
Model Chi Square Df Sig.
Intercept Only 17.696
Final 9.274 8.422 8 .393

In the table above obtained sig figure is 0.393 greater than the value of p (0.05)

Discussion

From the results of research on 41 clinical pathway odontectomy in the oral and maxillofacial surgery division
at Dr. Soetomo hospital Surabaya which is the total population of clinical pathway odontectomy procedure,
meaning no samples that dropped out.

The result of statistical calculation with binary logistic regression found significance value equal to 0,393 which
is bigger than p value <0,05, which can be interpreted that the variable measured have a meaningful influence to
its dependent variable that is length of hospitalization. The length of hospitalization is used as a measure /
indicator of service quality where with the assured quality of service, the length of treatment can be controlled
according to the therapy guidelines. The length of hospitalization in addition to reflecting the quality of service
can also be used as a tool for the control of patient care costs in hospitals. ( Yangga D Nur and Setya Haksama,
2016)

Figure 4: Path analysis

Quadratic number obtained from each variable on length of stay: the influence of the number of actions on
length of hospitalization = 13,16; type of drug = 11.22; operator difference = - 10.74. Medium between vriable
independent against one another is small

In the path analysis of each variable shows the effect on the length of hospitalization. In the clinical pathway has
been determined all items / points to be done both examination, treatment and action, including the type of drug
to be given. If there is a discrepancy with the items on the clinical pathway sheets are allowed if there are
exceptions due to the patient's special condition, collision on administrative difficulties and the number of
human resources. However, on path analysis of clinical pathway data of oral and maxillofacial surgery showed
that all of these variables did not affect the duration of hospitalization, where variation of drug type resulted in
11.22 (1.25%) variation of action of 13.16 (1.73%) and operator variation of -10.74 (1.15%) where chi square is
0.93, df = 0 and p = value = 1,00000

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 Proceeding of the 4th International Conference on Public Health, Vol. 4, 2018, pp. 89-93

Conclusion

Clinical Pathway samples studied were 41 cases, with observed procedures being odontectomy, with observed
variables being drug type, operator variation, and variation in the number of measures. From the calculation of
statistical analysis of binary logistic regression, it is found that the variation of three variables is not significant
to the length of hospitalization.

References

DodyFirmanda, dr., sp.A., MA., RSUP Fatmawati, Jakarta. 2010., Mutupelayananmedisdengankepastianbiaya.

http://www.scribd.com/Komite Medik.
Panela, Massimilano., Maxwell asia. 2005. Essential of Medical Law., Singapore Journal of medical studies.
P.471-3.
SK DirekturRumahsakitUmum dan Pendidikan Dr. Soetomosurabayanomor 188.4/7252/301/2010 tentang
Clinical Pathway.
SK DirekturRumahsakitUmum dan Pendidikan Dr. Soetomosurabayanomor 188.4/2989/301/SK/2013 tentang
Audit Medis Clinical Pathwaydan PPK
Every NR, Hochman J, Becker R, Lopecky S, Cannon CP. Critical pathways. A review. Circulation ,2000, 5
Nining D.S.Ismawati , Nugroho Setyawan. The Clinical Pathway in The Oral and Maksillofacial Surgery’s
services as a Quality Management Tool, in Dr. Soetomo General and Teaching Hospital, Surabaya, Indonesia :
A Review Article, science meeting of Oral maxillofacial , 2013, Malang, Indonesia.
Yangga D Nur and Setya Haksama. Inpatient Performance Assesment Based on Balanced Score Card , Jurnal
Administrasi Kesehatan Indonesia Volume 4 Nomor 1 Jan-June 2016

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Copyright © 2018 TIIKM
ISSN 2324 – 6735 online
DOI: https://doi.org/10.17501/23246735.2018.4111

THE NUMBER OF MISSING PERMANENT

MOLAR TEETH BASED ON CHARACTERISTICS
OF RESPONDENT ON LUBUK BUAYA PUBLIC
HEALTH CENTER
Murniwati1*, Susi1, Nila Kasuma1 and Nilma Rawinda1
1
Faculty of Dentistry, Andalas University, Padang, Indonesia

Abstract: Permanent molar are the teeth that mostly missing. In Padang, the Caries Index is 2.78,
Missing-Teeth Index is 2.29, Missing Teeth Index percentage is 82.4% with 9.2% of denture usage.
Lubuk Buaya Public Health Center has the highest number of permanent tooth extraction in Padang.
The purpose of this study is to look at the relationship of number of missing permanent molar teeth
with the characteristics of respondent. The design of this study is using descriptive method. The
number of samples are 97 respondents with age range between 25-44 years-old, who live in Lubuk
Buaya Public Health Center working area that meet inclusion criteria. About 90,7% of respondents
lost 1-4 permanent molar while 9,3% respondents lost 5-8 molar. Most of male (84.6%) and female
(97,8%) lost 1-4 molar teeth. Almost all of age range lost 1-4 molar. All respondent with only
elementary school level of education lost 5-8 molar teeth, while other level of education lost 1-4
molar. Gender, age and the level of education affect the number of missing permanent molar teeth on
Lubuk Buaya Public Health Center working area. Lower education level lead to the higher number
of missing permanent molar teeth.

Keywords: permanent molar teeth, characteristics of respondent

Introduction

Tooth loss increases with age as a cumulative impact of caries, periodontal disease, and treatment failure or
trauma. Nicola et al., stated that permanent molars are the most missing teeth compared with premolars, canines
and incisors (Damyanov, 2012).

The impact of losing one permanent molars if it not replaced with dentures are the pathological migration of the
adjacent teeth and antagonists, periodontal trauma, interdental caries, loss of contact points due to migration,
gingival recession, calculus, and premature occlusion. The mastication function will be disrupted if it loses some
permanent molars. If 4 teeth are missing it will cause 8 teeth that are not working for mastication. If the total
number of teeth is 32 then 25% of chewing efficiency decreases so that interrupt nutrient intake (Arifzan, 2010).
Omar states that the loss of all or most of the molar teeth will have an occlusal impact, decreasing the vertical
dimension of the face. If tooth has been loss for a long time period, it may cause interference with
Temporomandibular Joint (Omar, 2001).

Basic Health Research (Riskesdas) stated that to achieve the target of health services in 2010, various programs
such as promotive, preventive, protective, curative and rehabilitative have been conducted. World Health
Organization set indicators, including 5 years old children 90% are caries free, 12 years old children has dental
caries damage (DMF-T index) of one tooth, the dental-extraction-free of 18-year-old population (component M
= 0), the population aged 35-44 had at least 20 teeth by 90%, the population aged 65 and older still had teeth
works by 75%, and people without teeth is ≤ 5%.

The DMF-T index in Indonesia is 4.8 with the M-T (Missing Teeth) index of 3.9. This means that on average 5
tooth damage per person, an average of 4 teeth per person is extracted. The percentage of MTI (Missing Teeth

Corresponding Author Email: * [email protected]

 Murniwati et al / The Number Of Missing Permanent Molar Teeth Based…..

Index) in Indonesia is 79.6%, while the percentage of fixed and removable denture usage is only 4.5%. In West
Sumatra the DMF-T index is 5.3, M-T 4.3, MTI 81% and the percentage of denture usage is 5.8%. In Padang
City, DMF-T index was 2.78, M-T 2.29, MTI 82.4% with percentage of denture

usage is 9.2% (Riskesdas, 2007). The most permanent dental extraction from 20 Puskesmas in Padang City in
2011 is the Lubuk Buaya Health Center.

Materials and method

This study describes the number of missing permanent teeth based on the characteristics of respondents, such as
gender, age, and education of respondents with descriptive research design. Sampling was done by purposive
sampling method. Data were obtained from 97 respondents with age range 25-44 years. The data were collected
through interview method by using questionnaire which consisting independent variable (characteristic) and
dependent variable (number of permanent molar tooth loss) at Lubuk Buaya Public Health Center from Koto
Tangah Sub-district office. To see the relationship of the two variables, Chi-square test was used with p value
0.05.

Results

The frequency distribution of respondents based on characteristic of gender is shown in Table 1.

Table 1 Frequency distribution of respondents based on characteristic of gender

No Gender F %

1 Male 42 43,3

2 Female 55 56,7

Total 97 100

The number of female respondents were more than male respondents.

Distribution of respondent characteristics by age can be seen in Table 2.

Table 2 Distribution of respondent characteristics by age

No Age (y.o) F %
1 25 - 29 40 41,2
2 30 - 34 18 18,6
3 35 - 39 12 12,4
4 40 – 44 27 27,8
Total 97 100

Most of respodents are coming from 25-29 years age group as shown in Table 2.

The frequency distribution of respondents based on education level characteristics can be seen in Table 3.

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Table 3 The frequency distribution of respondents based on education level characteristics

No Education Level F %
1 SD 6 6,2
2 SMP 10 10,3
3 SMA 46 47,4
4 DI 1 1,0
5 DII 1 1,0
5 D III 3 3,1
6 S1 29 29,9
7 S2 1 1,0
Total 97 100

The highest education level of most respondents is high school level.

The frequency distribution of the number of permanent tooth loss respondents can be seen in Table 4.

Table 4 Number of Permanent Molar Dental Losses in Community Aged 25-44 y.o. in Lubuk Buaya Public
Health Center

Number of
Permanent Molar F %
Losses
1-4 permanent
88 90,7
molars
5-8 permanent
9 9,3
molars

Total 97 100

Most of respondents lost 1-4 permanent molars

Table 5 Relation of Gender of Respondent to Number of Molar Teeth Loss

Number of Molar Loss

Gender Total P
1-4 teeth 5-8 teeth

Female 84,6% 15,4% 100%

0,035
Male 97,8% 2,2% 100 %

Table 5 shows the results of the analysis of the relationship between the gender with the number of permanent
molar tooth loss, as many as 44 (84.6%) female respondents and 44 (97.8%) of male respondents lost 1 to 4
permanent molars. From the result of chi square statistic test, obtained the p value = 0.035 with p <0,05, hence
there is significant relation between gender with amount of permanent molar tooth loss.

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Table 6 Relation of Age of Respondents With Number of Molar Teeth Loss

Number of Molar Loss Total P
Age (y.o)
1-4 teeth 5-8 teeth
25-29 97,5% 2,5% 100%
30-34 100% 0 100%
0,005
35-39 91,7% 8,3% 100%
40-44 74,1% 25,9% 100%

Based on table 6, it can be seen the results of the relationship analysis between age with the number of
permanent molar tooth loss. The data show that 18 (100%) of respondents with age range 30-34 years lost 1-4
permanent molars. Then 7 (25.9%) of respondents with age range 40-44 years lost 5-8 permanent molars. From
the results of chi square statistical tests, obtained p value = 0.005, then there is a significant relationship between
age with the number of permanent molar tooth loss.

Table 7 Relation of Education Level of Respondent with Number of Molar Teeth Loss

Number of Molar Loss

Education Level Total P
1-4 teeth 5-8 teeth
Elementary Shool
0% 100% 100%
(SD)
Junior High School
100% 0% 100%
(SMP)
0,000
Senior High School
93,6% 6,4% 100%
(SMA)
College / University
100% 0% 100%
(PT)

Based on table 7, it can be seen the result of the relationship analysis between the level of education with the
number of permanent molar tooth loss. The data show that 6 people (100%) of respondents with Elementary
School Education level (SD) lost 5-8 permanent molars. While 100% of respondents the level of Junior High
School Education level and College level lost 1-4 permanent molars. In the high school education group there
were 44 people (93.6%) losing 1-4 permanent molars. From the results of chi square statistical test, it obtained p
value = 0.000, p <0.05, then there is a significant relationship between education level with the number of
permanent molar tooth loss.

Discussion

Based on the number of tooth loss, 9 respondents (9.3%) lost 5 to 8 permanent molars and 88 respondents
(90.7%) lost 1 to 4 permanent molars. The first permanent lower left molars are the most commonly extracted
teeth, with as many as 87 (20%). This is because permanent molar are the first teeth to erupt also are the longest-
used teeth, so they are often destroyed/decayed and then extracted. In addition, there are still many people who
think if the first permanent molars are extracted then there will be a replacement due to eruption in the period of
mixed teeth (Hedge, 2011).

Based on the annual report of Padang City Health Office 2014, dental disease is one of 10 most common
diseases in the Public Health Centers. People usually comes after the tooth has pulp disorder. This led the ratio
of fill and extraction in the city of Padang to 0:28 while the target is 1:1.7

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The cause of permanent tooth loss according to research conducted by Montandon (2012) is caries. The molar
teeth are the largest and have pits and fissures. This surface is the most sensitive part to caries. The sensitivity of
the occlusal surface to caries is due to the morphology of the pits and fissures. Food debris and bacteria will be
trapped in a narrow and deep pit and fissure, not allowing toothbrush fibers to be able to clean it so caries will
occur in that area.

Based on the result of chi square statistic test, it is obtained that the p value <0,05, this means there is a
significant relation between characteristic of respondent with amount of permanent molar tooth loss in Work
Area of Lubuk Buaya Health Center.

Respondents of male and female gender have the same pattern which mostly have lost 1-4 permanent molars, as
reflected in 44 female respondents (84.6%) and 44 male respondents (97.8%).

Respondents aged 35-44 years who lost 5-8 permanent molars were 8 respondents (88.9%). Respondents aged
30-34 years who lost 1-4 permanent molars were 18 respondents (100%). Respondents aged 25-29 years lost 1-4
permanent molars were 39 respondents (97.5%). This is in line with Agtini research (2010) which states that
tooth loss increases in the age group of 35-44 years.9 Permanent molar loss increases with age because
permanent molar are the first teeth to erupt so they are often destroyed/decayed and then extracted.

Based on education level, most of the respondents came from high school education level, which is 46
respondents (47,4%). All respondents with elementary school education lost 5-8 tooth. While all respondents
with the final education is junior high level and college level, lost 1-4 teeth. This indicate that number of tooth
loss is increasing if the final level of education is lower.

Higher level of education will lead to higher level of people knowledge about the impact of permanent molar
loss. This is because the role of education is to increase knowledge, generate positive traits, and community
capacity (Notoadmodjo, 2003). Higher level of education will lead to higher level of people awareness to
maintain oral health. If a person maintains good oral hygiene then the amount of tooth loss can be minimized,
because the teeth with extraction indication will also be minimized.

Knowledge is essential to the formation of person’s actions, knowledge will affect a person in adopting behavior
(Notoatmodjo, 2003). In addition, according to Zaini et al (2002) knowledge is the memory of the material
studied, which includes the memory of the material of the facts and complete theories, will be reflected from
someone’s actions.

Based on the results of this study, it is found that there is a significant relationship between gender, age and
education level of society with the number of permanent molar tooth loss in the Work Area of Publick Health
Center Lubuk Buaya.

Conclusion

The number of permanent molar tooth loss is affected by gender, age, and final education level. Loss of 5-8
permanent molars was experienced by most of the respondents with elementary school education level.

Acknowledgements

The authors would like to thanks to Andalas University and the Ministry of Research, Technology and Higher
Education of Indonesia for all support given to this research.

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