microsoft word ^r1_6369-23198-1-5-20220803.docx epidemiology and society health review| eshr vol. 4, no. 2, 2022, pp. 89-90 issn 2656-6052 (online) | 2656-1107 (print) 10.26555/eshr.v4i2.6369 89 viewpoint technological innovation is needed to accelerate stunting reduction in indonesia herman yuliansyah1*, sulistyawati sulistyawati2, surahma asti mulasari2 1 laboratory of artificial intelligence, informatics department, universitas ahmad dahlan, yogyakarta, indonesia 2 faculty of public health, universitas ahmad dahlan, yogyakarta, indonesia * correspondence: herman.yuliansyah@tif.uad.ac.id. phone: +6281328557057 received 29 july 2022; accepted 3 august 2022; published 6 august 2022 the who defines stunting as a low height for age condition in which toddlers have short height due to suboptimal health quality due to inappropriate quantity and quality of food intake (1). in 2019, indonesia's number of children with stunting is still relatively high at 27.67% (2). this situation is still far from the expectation that the national stunting rate will be below 14% by 2024. geographically, in indonesia stunting in children under five is spread across the province, although the number among the area varies. the indonesian government has implemented programs to reduce stunting by targeting several groups, including: pregnant and maternity mothers, toddlers, school-age children, adolescents, and young adults (3). the actions include interventions and efforts to increase knowledge among the related subject – mostly among women. these efforts must still have been carried out until recently. however, along with the development of the digital era, stunting prevention needs to involve technology as an innovation to predict the possibility of a toddler becoming stunted in the future when their intake is insufficient. in indonesia – through the integrated service post (posyandu) – toddlers receive regular monthly check-ups, including their height and weight since birth. this program collects cohort data at the individual level, which is essential to see trends and for developing predictions. considering the magnitude of the benefits of this data, technological innovation is needed to utilize this data further and encourage the sustainability of data input. this innovation should provide alerts for early stunting detection so that program targets can be more accurate. the digitized cohort data can be used as capital to estimate the possibility of a child becoming stunted in their development. thus, prevention efforts can be carried out early if it is known that a toddler is indicated to be suffering from stunting. of course, this innovation cannot be run alone but supports the existing prevention program. the increasing trend of artificial intelligence technology (4) and the internet of things (iot) (5) usage is an opportunity to support stunting prevention. conventional measuring tools commonly used to record the condition of toddlers are transformed into digital instruments as data feeders to be stored in cloud storage by utilizing iot. machine learning learns this data vol. 4, no. 2, 2022, pp. 89-90 10.26555/eshr.v4i2.6369 90 to make predictions as early detection of stunting (6–9). in addition, data in cloud storage can also be processed to become a decision support system in making public policies. keywords: stunting; internet of things; innovation; cohort data, artificial intelligence references 1. world health organization. malnutrition. web. 2022 [cited 2022 jun 5]. available from: https://www.who.int/health-topics/malnutrition#tab=tab_1 2. kementerian kesehatan ri. buletin jendela data dan informasi kesehatan: situasi balita pendek (stunting) di indonesia. kementeri kesehat ri. 2018;20. 3. kemenkes ri. buletin stunting. kementeri kesehat ri. 2018;301(5):1163–78. 4. kugler l. artificial intelligence, machine learning, and the fight against world hunger. commun acm. 2022 feb;65(2):17–9. available from: https://dl.acm.org/doi/10.1145/3503779 5. yang y, wang h, jiang r, guo x, cheng j, chen y. a review of iot-enabled mobile healthcare: technologies, challenges, and future trends. ieee internet things j. 2022 jun 15;9(12):9478–502. available from: https://ieeexplore.ieee.org/document/9686065/ 6. chilyabanyama on, chilengi r, simuyandi m, chisenga cc, chirwa m, hamusonde k, et al. performance of machine learning classifiers in classifying stunting among underfive children in zambia. children. 2022 jul 20;9(7):1082. available from: https://www.mdpi.com/2227-9067/9/7/1082 7. bitew fh, sparks cs, nyarko sh. machine learning algorithms for predicting undernutrition among under-five children in ethiopia. public health nutr. 2021 oct 8;1– 12. available from: https://www.cambridge.org/core/product/identifier/s1368980021004262/type/journal_arti cle 8. islam mm, rahman mj, islam mm, roy dc, ahmed namf, hussain s, et al. application of machine learning based algorithm for prediction of malnutrition among women in bangladesh. int j cogn comput eng. 2022 jun;3:46–57. available from: https://linkinghub.elsevier.com/retrieve/pii/s2666307422000067 9. khan w, zaki n, masud mm, ahmad a, ali l, ali n, et al. infant birth weight estimation and low birth weight classification in united arab emirates using machine learning algorithms. sci rep. 2022 dec 15;12(1):12110. available from: https://www.nature.com/articles/s41598-022-14393-6 microsoft word ^5221-article text-19077-1-15-20220125.edited.edited.docx epidemiology and society health review| eshr vol. 4, no. 1, 2022, pp. 36-37 issn 2656-6052 (online) | 2656-1107 (print) 10.26555/eshr.v4i1.5221 36 viewpoint why is health protocol still needed even though people are getting vaccinated? yanasta yudo pratama1*, elyn arlinda1, marwan rosada1 1 department of biomedical science, faculty of medicine, public health, and nursing, universitas gadjah mada, yogyakarta, indonesia * correspondence: yanasta.yudo.pratama@mail.ugm.ac.id. phone: +6282223635566 received 28 november 2021; accepted 31 january 2022; published 31 january 2022 at the end of 2019, the world was rocked by a disease that spread worldwide. the disease is caused by the sars-cov-2 virus, also known as the novel corona virus called covid-19. this virus is responsible for many deaths; as of november 26, 2021, the total global death toll from covid-19 was more than 5 million deaths. in july of that year, indonesia became a country with the highest death rate and a high number of new cases, with a total of 143.796 fatalities. making indonesia face the problem of poor health situation. in indonesia, until november 29, 2021, the covid-19 vaccination coverage was still below 70%. this number means that the vaccination coverage is still below the requirement to achieve herd immunity. we need to consider that controlling the spread of covid-19 focuses on tracing, and testing and prevention efforts must be carried out by delivering vaccines to society without exception. most of the participants who received the covid-19 vaccine developed a specific humoral response after the second dose. in addition, evidence highlights that the immune response induced by covid-19 vaccination exceeds that caused by natural infection with sars-cov2. however, some aspects of the humoral immune response, the threshold titers of antibodies required for protection, and the immunity resistance induced by natural infection or after the covid-19 vaccine are still under investigation. vaccination potency may decrease sometime after vaccination, which requires us to maintain health protocols that obey the health protocols enforced by the government. the government and related stakeholders should educate the society that even though they have been vaccinated, they should continue to apply health protocols such as: wearing masks, washing their hands regularly with disinfectant or soap and water, keeping their distance from others especially with someone who has symptoms of coughing or sneezing—practicing proper coughing or sneezing etiquette, and seeking treatment if they have complaints that fit the category of suspected covid-19. the use of masks is part of the comprehensive effort to control and prevent covid-19 because masks protect someone from aerosol transmission, particularly in health facility settings. pratama (why is health protocol still needed even though people are getting vaccinated?) vol. 4, no. 1, 2022, pp. 36-37 10.26555/eshr.v4i1.5221 37 to improve society's obedience to the government covid-19 regulation, the government should take some actions such as: strengthening the promotive and preventive lines aimed to increase the society's knowledge of the importance of society's adherence to health protocols even though they have been vaccinated. keywords: health protocols; covid-19; vaccine; immunization microsoft word ss_5705-article text-19650-1-18-20220221.docx epidemiology and society health review| eshr vol. 4, no. 1, 2022, pp. 38-39 issn 2656-6052 (online) | 2656-1107 (print) 10.26555/eshr.v4i1.5705 38 viewpoint emerging challenges in implementing universal health coverage due to covid-19 in indonesia rosyidah rosyidah1,2* 1 centre for intelligent healthcare, faculty of health and life sciences, coventry university, the united kingdom 2 faculty of public health university of ahmad dahlan, yogyakarta, indonesia * correspondence: rosyidahrosyidah29@gmail.com received 31 january 2022; accepted 01 february 2022; published 22 february 2022 the goal of universal health coverage (uhc) means a situation in which all individuals and communities have access to health services, whenever and wherever they need them, without financial barriers to obtaining them. uhc covers a wide range of essential health services, from promotion, prevention, treatment, care, rehabilitation, and palliative care for patients with chronic diseases. on the other hand, the covid-19 pandemic is devastating national health systems in countries that have strived to provide uhc, hampering their efforts to fulfill the ethos of universal health coverage, which is to "leave no one behind." as mentioned in the world economic forum 2021, this issue is interesting because an estimated 400 million people worldwide lack access to essential health services. approximately 100 million people fall into poverty each year due to not paying their health costs. this number has increased with covid-19 and will continue to up as people lose their jobs, health insurance, and health spending rise due to covid-19-related spending on testing, treatment, and vaccines. due to the pandemic, indonesia is experiencing many challenges in implementing uhc. for example, maintaining the quality of health services with various innovations, including; mobile jkn, online queues, online referral systems (p-care), and various efforts supporting the effectiveness of due and post covid-19 health services. socialization on how to use digital health services, especially for laypeople, needs to be improved by bpjs kesehatan as a social health insurance administrator body in indonesia. furthermore, expanding access to health services for the missing-middle group, namely, people who are not included in the government contribution assistance recipients (pbi) but still find it challenging to pay health care services. people in this category have difficulty paying their bpjs kesehatan monthly premiums. mostly, the informal sector's missingmiddle group does not have a permanent income. so, they cannot afford to pay the uhc premium regularly. bpjs kesehatan and relevant stakeholders need to find a suitable strategy to resolve this problem, such as conducting studies on the ability to pay and willingness to pay (atp/wtp). synchronization of premium and health service benefits is also essential and needs re-examining. vol. 4, no. 1, 2022, pp. 38-39 10.26555/eshr.v4i1.5705 39 partnerships and coordination with multiple sectors will make it easier to overcome various obstacles in overcoming the covid-19 pandemic. access to health services in remote areas is also a challenge, to be resolved immediately. at this point, commitment and partnership from all parties are needed, including bpjs kesehatan, the ministry of health, health providers, and policymakers at the regional and central levels. in addition, further studies regarding partnerships are interesting. keywords: universal health coverage, social health insurance, jaminan kesehatan nasional (jkn), bpjs kesehatan, covid-19 microsoft word 6_5814_yasin_2_7 agustus.docx epidemiology and society health review| eshr vol. 4, no. 2, 2022, pp. 87-88 issn 2656-6052 (online) | 2656-1107 (print) 10.26555/eshr.v4i2.5814 87 viewpoint mental health problems during covid-19 pandemic achmad yasin mustamin1*, yanasta yudo pratama2, tri ani marwati1 1 faculty of public health, universitas ahmad dahlan, yogyakarta, indonesia 2 faculty of medicine, public health and nursing, universitas gadjah mada, sleman, indonesia *correspondence: achmadyasin0207@gmail.com. phone: +62 823-2897-5432 received 4 march 2022; accepted 23 june 2022; published 2 august 2022 infection with the sars-cov-2 virus causes severe acute respiratory syndrome and has become a worldwide pandemic. since december 31, 2019, in the city of wuhan, china, human-to-human transmission has caused the world to focus on handling the health crisis. the psychosocial impact of covid-19 in the form on mental health has not been comprehensively identified. one of the evidence is an increase in cell-free genomic dna (ccgdna) and cell-free mitochondrial dna (ccf-mtdna), an increase in hematocrit, calcium and phosphorus after 2 weeks of isolation from 2015 mers-cov infection, which is an indicator of psychophysical stress in patients. this makes the basis for further support or treatment for patients with mental health problems. mental health is essential to achieving a comprehensive degree of health, but it has not become a top priority in some developing countries. the covid-19 pandemic has made it difficult for people to access physical and mental health services. the situation of this pandemic pushes who and mental health services as an integral component of the condition. only a third of healthcare providers in the united states can receive standardized mental health care. in developing countries with low and middle incomes, 75% more people experience neurological disorders, mental disorders, and addictive substance abuse. the prevalence of patients affected by post-traumatic stress disorder (ptsd) is around 4-41%, and the prevalence of major depression due to the epidemic increased by 7%. unfortunately, of those with mental disorders, only a tiny percentage get proper treatment. the covid-19 pandemic in indonesia has brought changes in behaviour in society. the high mortality rate, and massive transmission, cause mental health problems for families, sufferers, and health workers. mental health problems include depression, anxiety, post-covid-19 trauma and fear of reinfection with covid-19. an online study by the association of indonesian mental illness specialists (pdskji) showed that 66% of respondents were depressed, and 63% experienced anxiety due to the pandemic. the main symptoms in respondents who experience anxiety are worries that bad things will happen in their lives, irritability, difficulty sleeping, and difficulty feeling relaxed. the main symptoms in respondents who experience depression are disturbances in starting sleep or waking up suddenly during sleep, lack of confidence, lack of energy and interest in activities, and fatigue. vol. 4, no. 2, 2022, pp. 87-88 10.26555/eshr.v4i2.5814 88 isolation and social distancing, depression experienced by health workers, economic pressure, stigma and discrimination in patients with covid-19 are the main risk factors for patients undergoing depression out of 14 commonly found. the consequences of social distancing and self-isolation have led to feelings of "alienated" or "isolated" and have interfered with normal activities as social beings. in addition, the global economic crisis has triggered a lot of unemployment and financial pressures, thus increasing the risk of suicide among people. not only in the community but also among medical personnel, the potential for depression and suicide is due to stigma and discrimination from the surrounding community. for example, local people avoid and close the door on health workers, they are also prohibited from using public transportation, ostracized by their families, and some are divorced from their husbands or wives. the indonesian government constantly pursues preventive efforts in tackling the mental health impacts of the covid-19 pandemic by compiling mental health guidelines and providing psychosocial support during the covid-19 pandemic, which refers to the policies of the who. the government cooperates with the indonesian psychologist association (himpsi) to provide "sejiwa" services to assist the community in overcoming mental disorders due to the impact of the covid-19 pandemic. the government makes protocols and policies to optimize the integration of mental health services with the main focus on a public health-based approach and strengthening primary health services, especially in preventive efforts in terms of mental health. keywords: mental health; pandemic covid-19 microsoft word 1873-5194-1-rv-ds-revisi-190420.edited.edited.docx epidemiology and society health review| eshr vol 2 no1 2020 31 research article dengue risk factor in banguntapan iii primary health centre, bantul, indonesia devi stevani1*, himatul husna1, muthia ardiyanti1, yuni andira sari1, desi nurfita1, sugiarto sugiarto2, siti nurkhoiriyah3 1faculty of public health, universitas ahmad dahlan, yogyakarta, indonesia 2district health office of kulonprogo district, kulon progo, indonesia 3primary health centre of banguntapan iii, bantul, indonesia * correspondence: devistefani19@gmail.com. tel: +6281332735218 received 11 march 2020; accepted 19 april 2020; published 05 may 2020 abstract background: dengue haemorrhagic fever (dhf) is an infectious disease caused by aedes aegypti mosquito. dhf is widespread in many regions worldwide, with the number of patients continues to increase every year. this study aimed to determine the risk factors for dhf include vector control (3m+) program implementation, residential distance, hanging clothes habit, napping habit, repellent usage, and sunlight conditions. method: analytic observational study with a case-control approach was applied in this study. samples divided into case and control. of 16 cases and 32 controls were participated in this study who purposively selected. data were collected using a questionnaire. univariate and bivariate using chi-square tests were employed to analyze the result. result: three variables are associated with the dengue incidence in research location: napping habit (or=11.667), residential distance (or=1.696), and sunlight condition (or=0.0289). conclusions: napping habits, residential distance, and sunlight conditions are the risk factor of dhf incidence. keywords: dengue, behavior, napping habit, residential distance, sunlight conditions introduction dengue haemorrhagic fever (dhf) is an infectious disease caused by the dengue virus and be transmitted by (aedes aegypti) (1). currently, known four dengue virus serotypes: den-1, den-2, den-3, and den-4. dengue virus raises some symptoms such as high fever accompanied by manifestations of shock and bleeding that could end with death (2). globally, the number of cases and areas infected by dengue continues to increase each year (3). dengue haemorrhagic fever (dhf) are found in the tropics and sub-tropics area. dengue cases arise throughout the year, especially during the rainy season coincided with the optimal conditions for mosquito breeding. at that time, the number of infected people will be increasing in the short period (3). before 1970, only nine countries experienced an outbreak of dengue fever. but currently, dengue is endemic in more than 100 countries, including africa, the americas, the eastern mediterranean, southeast asia, and the western pacific. epidemiology and society health review| eshr vol 2 no1 2020 32 america, southeast asia, and the western pacific have the highest number of dengue cases meaning that dengue increases not only in terms of the number but also the area infected (4). indonesia ministry of health reported that the mortality of dhf by 2016 and 2017 was reduced three folds from 1,598 and 493, respectively. dengue was found first time in indonesia in 1968. since then, dhf spreads across the country. in 2015 showed that dengue has spread in 34 provinces in indonesia (5); one of which is yogyakarta. there are three districts with dengue endemic in yogyakarta: yogyakarta, bantul, and sleman. over the past two years, the dengue cases in bantul were increasing significantly, with 62 cases in 2014 and 1,417 cases in 2015. banguntapan sub-district is one of the dengue-endemic in this location. based on data from the bantul district health office, there was an increase of dengue morbidity in 2014 to 2016, (0.64 ‰), (1.48 ‰), and (2.62 ‰), respectively. the number of dhf cases decreased in 2017 (0.55 ‰) and 2018 (0.18 ‰). banguntapan sub-district consists of 8 villages and served by three health centers: primary health centre i, ii, and iii. the population density of 3,984 people / km2. in 2015, the larvae free rate or called angka bebas jentik in three phc were varied, but all of them were below the national standard (95%). banguntapan i, ii, and iii had 84%, 80%, and 82%, respectively (6). dengue disease transmits through mosquito bites that contain the virus on their saliva. on the other hand, dengue is an environmental disease because environmental conditions influence mosquito development. dengue disease is as well as influenced by socioecological factors (7). some previous research revealed that environmental factors and people's habits strongly influence the increase in dengue incidence. the determinant of dengue fever, namely gender, home environment, mobility, not using mosquito repellent, house walls, dug wells, and the residential density is a risk factor getting dengue infections. besides, people's knowledge, attitudes, and practice are the risk factors for dengue hemorrhagic fever (8–10). research related to a dengue risk factor is essentials to support policymaker in developing dengue prevention efforts. methods this study is observational analytic with a case-control design to study the relationship between risk factors of dengue incidence. the case was defined as people who diagnosed with dhf in puskesmas (phc) banguntapan iii from january-november 2019. there were 30 cases during that period, and we did total sampling to recruited the respondent. control was defined as people who not diagnosed with dhf in the same period with the case. sampling for case and control were selected by purposive sampling with inclusion and exclusion criteria. inclusion criteria for the case are the person recorded in the phc information system as dhf positive and willing to participate in this study. we did a matching with 1:2 ratio case vs. control. control should live in the same neighbourhood as the case. exclusion criteria for case and control were someone moves to another place, so it cannot be interviewed. we used a questionnaire to collect the data. data were analyzed using univariate and chisquare tests in bivariate. results in total, 48 respondents were participated in this study, consist of 16 cases and 32 controls. the characteristic respondent is presented in table 1. most of the respondents are epidemiology and society health review| eshr vol 2 no1 2020 33 in the 20-29 years and 40-49 years. the majority of the respondent is female (60.4%), and the majority of respondents are holding university education (39.6%). table 1. characteristics of respondents characteristics of respondents frequency percentage n % age group 20-29 12 25.0 30-39 11 22.9 40-49 12 25.0 50-59 6 12.5 60-69 5 10.4 70-79 2 4.2 gender male 19 39.6 female 29 60.4 education primary school 7 14.6 secondary school 11 22.9 high school 11 22.9 university 19 39.6 chi square analysis shows, there were three variables associated with dengue incidence: residential distance (p value = 0,020), napping habit (p value = 0,021), and sunlight condition (p value = 0,032) (table 2). table 2. dengue risk factors analysis in banguntapan iii phc, bantul risk factors dbd p-value or confidence interval (ci) lower upper vector control (3m) implementation 0.918 1.296 0.379 4.434 residential distance 0.020 1.696 1.305 2.203 the habit of hanging clothes 1.000 1.140 0.332 3.916 napping habit 0.021 11.667 1.371 99.294 repellent usage 0.460 0.429 0.800 2.308 sunlight conditions 0.032 0.289 0.183 0.457 discussions our research revealed, the current vector control program called 3m (menutup, menguras, and mengubur), meaning covering of water containers, cleaning of water containers, and burying of discarded containers (11), is not associated with dengue infection. our finding is different from other research previously in pare phc, who stated that vector control had a significant association with dengue incidence (12). other studies mentioned that vector epidemiology and society health review| eshr vol 2 no1 2020 34 control contributed positively to the prevention of dengue outbreaks in mataram (p <0.05) (8). vector control is the most appropriate approach to prevent and control dengue outbreaks. vector control can be well implemented when the community has good behavior on dengue prevention. but, in banguntapan iii, phc found that the implementation of vector control is quite low. likewise, who (2000) stated that the elimination of the aedes mosquito larvae with a grain temephos with a dose of 1 ppm with the residual effects for three months is quite effective to reduce aedes mosquito populations or increase the number of larvae free, also reduce the risk of dengue outbreaks (13). based on the bivariate analysis, there is no relationship between the residential distance and dhf incidence, with the odds ratio (or) of 1.696 with a confidence interval (ci) from 1.305 to 2.203 and p = 0.02. it means a person who lives within the adjacent house had 1,696 times greater risk for dhf compared with people who have space between the house. this factor related to the mosquito flight range that is 100 meters. accordingly, when the distance between the house less than 100 m, it could be easy for the mosquito to reach other homes to find people or breeding places. moreover, it will be exacerbated if people have poor behavior, particularly when they less paying attention to the house condition. our result does not correspond to a survey conducted by astuti and lustiyati (2018), who stated that there was no significant relationship (p = 0.662) between the distance of the building with dengue incidence of dengue (14). the bivariate test shows there is no relationship between habits of hanging clothes with the incidence of dhf. this result is different from amrieds et al., who stated that there was a relationship between the practice of hanging clothes with the incidence of dengue in 19 november village, wundulako district of kolaka in 2016 (15). the who says that the mosquito aedes aegypti prefers to rest in a dark place, moist, hidden area of the building, including a bed, toilet, bathroom, and kitchen. this mosquito seldom found rest outside the house, such as in the plantation or shelter (13). in this study, many respondents use mosquito repellent (79.2%) that could influence the presence of mosquito inside the house. the person who has napping habit,11.667 times greater risk for dhf compared with people who do not have napping habit. to see the significance of the coefficient by comparing the value of significance with alpha (5%), the value of significance is 0,021 less than the alpha 0.05, which means that the variable habit of napping is statistically significant with dhf. these findings are consistent with amrieds et al., which states that there was a relationship between napping habits with dengue incidence in wundulako district of kolaka 2016 with pvalue = 0.001. it could happen because aedes has biting time in the early morning and late afternoon when residents nap. accordingly, people who have napping habit without protection: mosquito nets or repellent is at risk of being bitten by mosquitoes aedes while respondents were not napping. people also could be bitten by mosquitoes when they are working (15). we found that there is no relationship between the use of insect repellent with the incidence of dhf. these findings are consistent with research conducted by riana sari et al., who stated that there was no correlation between the use of anti-mosquito habits with the incidence of dengue in mustikajaya village with p = 0.066 (p≤0,05) (16). use individual protection protects people from mosquito bites. these efforts have been undertaken by most of the respondents (79.2) in both the case and control groups. so that in this study, we found no correlation between the use of insect repellent with the incidence of dhf. the results showed that among the 48 respondents, most respondents (93.8%) have a home with proper sunlight conditions, while three respondents (6.3%) had insufficient sunlight. based on the bivariate analysis, it shows there is a relationship between sunlight condition and dengue incidence. but light is rolled as a protective factor for dengue epidemiology and society health review| eshr vol 2 no1 2020 35 incidence. this research is in line with research wijirahayu and sukesi (2019), who stated that no statistical relationship between variable sunlight with dengue incidence (p = 0.39). houses with insufficient sunlight, high-density family member, and poor behavior of sanitation contributed to the proliferation and spread of the mosquito aedes aegypti. conclusions from the results known that residential distance, napping habit, and sunlight conditions are the most potential risk factor in the research location. authors’ contribution ds, hh, ma, and ya are responsible for data collection and manuscript preparation. dn contributed to research permits, data analysis, and manuscript preparation. ss conducted a literature review. sn did research permit application and data collection. funding universitas ahmad dahlan funded this research. conflict of interest there are no conflicts of interest. references 1. chakraborty t. dengue fever and other hemorrhagic viruses. tropical medicine. 2008. 137 p. 2. simmons cp, farrar jj, van vinh chau n, wills b. dengue. n engl j med. 2012 apr;366(15):1423–32. 3. cdc. epidemiology | dengue | cdc. cdc national center for emerging and zoonotic infectious diseases, division of vector-borne diseases. 2014. 4. who. dengue and severe dengue [internet]. who. 2019 [cited 2019 nov 21]. available from: https://www.who.int/news-room/fact-sheets/detail/dengue-and-severe-dengue 5. kemenkes ri. kendalikan dbd dengan psn 3m plus. kementerian kesehatan ri. 2017. 6. dinas kesehatan kabupaten bantul. profil kesehatan kabupaten bantul. kabupaten bantul; 2019. 7. naish s, dale p, mackenzie js, mcbride j, mengersen k, tong s. spatial and temporal patterns of locally-acquired dengue transmission in northern queensland, australia, 1993-2012. plos one. 2014;9(4):1981–91. 8. fakhriadi r, yulidasari f, setyaningrum r. faktor risiko penyakit demam berdarah dengue di wilayah kerja puskesmas guntung payung kota banjarbaru (tinjauan terhadap faktor manusia, lingkungan, dan keberadaan jentik). j publ kesehat masy indones. 2015;2(1):7–12. 9. brady oj, gething pw, bhatt s, messina jp, brownstein js, hoen ag, et al. refining the global spatial limits of dengue virus transmission by evidence-based consensus. plos negl trop dis. 2012;6(8):e1760. 10. dardjito e, yuniarno s, wibowo c, saprasetya a, dwiyanti h. beberapa faktor risiko yang berpengaruh terhadap kejadian penyakit dbd di kab banyumas. media litbang epidemiology and society health review| eshr vol 2 no1 2020 36 kesehat. 2008;xviii:126–36. 11. sulistyawati s, astuti fd, umniyati sr, satoto tbt, lazuardi l, nilsson m, et al. dengue vector control through community empowerment: lessons learned from a community-based study in yogyakarta, indonesia. int j environ res public health. 2019;161013. 12. widyatama ef. faktor risiko yang berpengaruh terhadap kejadian demam berdarah dengue di wilayah kerja puskesmas pare. j kesehat lingkung. 2018;10:417–23. 13. who. pencegahan dan penanggulangan penyakit demam berdarah. terjermahan dari who regional publication searo no.29 : prevention control of dengue and dengue haemorrhagic fever. jakarta: departemen kesehatan ri; 2000. 14. astuti p, lustiyati ed. hubungan kondisi lingkungan fisik terhadap tingkat kepadatan larva aedes sp di sekolah dasar wilayah kecamatan kasihan, bantul, di yogyakarta. j ilmu kesehat masy. 2018;9(3):216–25. 15. amrieds et, asfian p, ainurafiq. faktors correlated to dengue incidence in 19 november village wundulakosub-district kolaka regency in 2016. j ilm mhs kesehat masy unsyiah. 2016;1(3):1–12. 16. rianasari r, suhartono s, dharminto d. hubungan faktor risiko lingkungan fisik dan perilaku dengan kejadian demam berdarah dengue di kelurahan mustikajaya kota bekasi. j kesehat masy univ diponegoro. 2016;4(5):151–9. 17. wijirahayu s, sukesi tw. hubungan kondisi lingkungan fisik dengan kejadian demam berdarah dengue di wilayah kerja puskesmas kalasan kabupaten sleman. j kesehat lingkung indones. 2019;18(1):19. epidemiology and society health review| eshr vol. 3, no. 1, 2021, pp. 15-20 issn 2656-6052 (online) | 2656-1107 (print) 10.26555/eshr.v3i1.3594 15 research article hospital management information systems acceptance at wonosari regional hospital, gunungkidul, yogyakarta, indonesia ahmad samratul aula 1,* 1 department of public health, ahmad dahlan university, yogyakarta, indonesia *correspondence: aulachmad8@gmail.com. phone: +6282141450570 received 31 january 2021; accepted 03 march 2021; published 04 march 2021 abstract background: the hospital management information system (hmis) is a computer system that processes entire health care business processes, including reporting and administrative procedures, to obtain information quickly, precisely, and accurately. the wonosari regional hospital is a type b hospital that has implemented the hmis. this study aimed to analyse the hmis use in the wonosari regional hospital, gunungkidul, yogyakarta. method: this is a quantitative study using a cross sectional design. seventy-nine staffs participated in this study that recruited using the purposive sampling technique. data were collected using a pre-tested questionnaire, then analysed statistically. results: perceived ease of use was found significant associated with hmis use (p-value ≤ 0.05). conclusion: perceived ease of use influenced the use of hmis at the wonosari regional hospital, gunungkidul, yogyakarta keywords: sex; ease of use; usefulness; attitude; simrs introduction information systems are a method to collect, enter, proceed, and store data and manage, control, and report information in such a way to support the organisation goals (1). the information system is a strategy to provide customer-oriented services or health service users, including in hospital settings. hospital customers can be internal and external customers. internal customers are all parties in the hospital environment, including the owner, management, and hospital employees. meanwhile, external customers are more hospital services users, including patients, patient families, partners, suppliers, and the wider community (2). an information system is related to computers usage. the availability of computers used is an essential element for the hospital to run hmis. the hospital unit that runs hmis includes https://doi.org/10.26555/eshr.v3i1.3594 http://creativecommons.org/licenses/by-sa/4.0/ http://crossmark.crossref.org/dialog/?doi=10.26555/eshr.v3i1.3594&domain=pdf aula (hospital management information systems acceptance …) vol. 3, no. 1, 2021, pp. 15-20 16 10.26555/eshr.v3i1.3594 16 patient management, clinical management, medical diagnosis, supply management, financial management, support services, and the education and research section (3). based on the regulation of indonesia minister of health (menkes ri) number 82 of 2013, article 3 about hospital management information systems explains that all hospitals in indonesia are required to use hmis to facilitate the exchange and produce appropriate, accurate, and renewable information within and between the hospital, as well as to the ministry of health. refer to that regulation, the hmis application can be sourced from the ministry of health or can be developed by the hospital but must comply with the ministry of health (4). in the hospital setting, generally, they develop hmis by involving the external it vendor. this cooperation tied in the long term, including upgrading and maintaining software in the hmis (5). apart from that, the functionality of the system is also an essential factor in implementing hmis. the availability of a system will be adequate if it builds based on the hospital staff's necessity. hmis ease of use is one of the consideration during system development (6). the technology acceptance model (tam) is a theory about the use of information systems that are considered very influential and is generally used to explain the individual acceptance of information technology systems. the tam's basic concept is perceived usefulness and ease of use, which means a person's perception of using information systems useful in an organisation. the tam has many advantages, including the behaviour model that is useful for answering why many information systems are not sustained because users do not intend to use technology (7). based on the preliminary study conducted at the wonosari regional hospital, gunungkidul, yogyakarta, it is known that this hospital using hmis for some years. the was shifting of the hmis in term of the improvement process from the vendor to the hospital's internal it. hmis in this hospital is integrated with all unit in the hospital. all this time, some employees feel complaining about operation hmis during the transition. accordingly, an acceptance analysis is needed to see the challenge of system implementation. method a quantitative study with a cross sectional design was conducted in the wonosari regional hospital of gunungkidul, yogyakarta, from march-may 2020. the population for this study was all staffs experienced in operating the hmis (n=260). the sample was calculated using the raosoft sample size calculator with a 95% confidence level and a 10% margin of error. based on the calculation, the minimum sample size was 71, and we added 10% as an alternative sample. thus, in total, we selected and collected 79 samples chosen using incidental sampling. https://doi.org/10.26555/eshr.v3i1.3594 aula (hospital management information systems acceptance …) vol. 3, no. 1, 2021, pp. 15-20 17 10.26555/eshr.v3i1.3594 17 a set of pre-tested questionnaire was used to collect the data from the respective respondent. chi-square test was employed to see the association among the variable involved refer to tam concept. results characteristic of respondent table 1 shows the characteristic among 79 respondents. most of the respondent was male (70.9%). more than half of the respondents stated comfortable using current hmis, but more than 60% said the hmis not beneficial for them. almost 70% of the respondent reported an excellent attitude toward using hmis. table 1. respondent characteristic characteristic n (%) sex male 56 (70.9) female 23 (29.1) perception ease of use challenging 38 (48.1) comfortable 41 (51.9) perception of usefulness not useful 51 (65.8) useful 27 (34.2) attitude poor 24 (30.4) good 55 (69.6) statistical analysis chi-square test in table 2 shows there was no relationship between hmis used in wonosari regional hospital versus sex, perception of usefulness and attitude. the only perception of ease of use was significantly associated with hmis (p-value = 0.03). table 2. relationship between sex and hmis use variable hmis use p-value poor good total n % n % n % sex 0.70 female 29 36.7 27 34.2 56 70.9 male 13 16.5 10 12.6 23 29.1 perception ease of use 0.03 challenging 25 31.6 13 16.5 38 48.1 comfortable 17 21.5 24 30.4 41 51.9 perception of usefulness 0.75 not useful 27 34.2 25 31.6 52 65.8 useful 15 19.0 12 15.2 27 34.2 attitude 0.18 poor 26 32.9 28 35.4 54 30.4 good 16 20.3 9 11.4 25 69.6 https://doi.org/10.26555/eshr.v3i1.3594 aula (hospital management information systems acceptance …) vol. 3, no. 1, 2021, pp. 15-20 18 10.26555/eshr.v3i1.3594 18 discussion this study aims to assess the relationship between the usage of hmis and some variables related to the perception of using the hmis as part of the tam model conducted in wonosari regional hospital, gunungkidul. among the four-variable assessed sex, perceived ease of use, perception of usefulness and attitude on hmis, we found the only perception of ease of use has a significant association with the hmis use, and the three other variables are not associated. perceived ease of use is the primary variable that influencing the acceptance of hmis in the research location. this finding highlighted that during the hmis development, literary procedure to test the system is essential to know the needs and the ease of using the system. our discovery was strengthening by some previous researches that perceived ease of use was determinant for the benefit of hmis in particular hospital (8–10). in our research being male of females do not influence the respondent acceptance of hmis. this study's results follow previous research that showed that gender did not significantly affect perceived usefulness in another word that sex is not an obstacle in the application of technology even though in some settings it could be a problem due to the social norm (11)(12). in our research setting, perception of usefulness is not influenced by respondent sex of the employee because, in the application, all employees are given the same direction on using the hmis. users believe that using an information system improves their performance on completing their job (13). this illustrates the system's usefulness from the user point of views that promising for the hospital management to continue using the hmis. our result is in line with the previous research that showed the higher desire of medical staff to adopt technology because they acknowledge the system's usefulness (14)(15). perceived use among users explained that hmis rolled on accelerating their work, simplifying their medical record data storage, improving performance in managing hospital data, and facilitating patient data management. our result found that respondent reported negatively perceived usefulness related to the hmis in their workplace. our observation supported that the hmis could not facilitate the finding process of the medical record. this research matches previous research that states that user perceptions of the usefulness of information technology affect the acceptance of information technology systems (16). still, it differs from previous research that perceives usefulness as the predictor of technology acceptance (17). this is related to the absence of interest for employees in the organisation's goals as a whole so that the system's usefulness does not increase their desire to use the system. https://doi.org/10.26555/eshr.v3i1.3594 aula (hospital management information systems acceptance …) vol. 3, no. 1, 2021, pp. 15-20 19 10.26555/eshr.v3i1.3594 19 a good attitude towards hmis is related to the feeling that hmis provides a good impact on the hospital, user volunteer using the system, feeling safe storing the data and simplifying their work. in this study, we found that attitude did not influence hmis use. our finding is in line with former research, which states that user attitudes towards use do not significantly affect the acceptance of information technology. this is also consistent with sun's study, which found that attitude was not a predictor of behavioural interest or the use of hmis (18) but in contrast with research in malaysia that found attitude a significant predictor of using the technology (19). conclusion among the four-variable assessed sex, perceived ease of use, perception of usefulness and attitude on hmis usage, we found the only perception of ease of use has a significant association with the hmis use, and the three other variables are not associated. authors' contribution asa contributed to designing the study, collected and analysed the data, and wrote the manuscript's first draft. ss contributed to developing the research and review the analysis and the manuscript draft. funding this research did not receive external funding. conflict of interest the authors declare there is no conflict of interest. references 1. triandini e, jayanatha s, indrawan a, werla putra g, iswara b. metode systematic literature review untuk identifikasi platform dan metode pengembangan sistem informasi di indonesia. indones j inf syst. 2019;1(2):63. 2. hatta g. pedoman manajemen informasi kesehatan disarana pelayanan kesehatan. pedoman manajemen informasi kesehatan disarana pelayanan kesehatan. 2008. 3. vaganova e, ishchuk t, zemtsov a, zhdanov d. health information systems: background and trends of development worldwide and in russia. heal 2017 10th int conf heal informatics, proceedings; part 10th int jt conf biomed eng syst technol biostec 2017. 2017;5(january 2017):424–8. 4. menteri kesehatan republik indonesia. peraturan menteri kesehatan republik indonesia nomor 82 tahun 2013 tentang sistem informasi manajemen rumah sakit. peratur menteri kesehat republik indones nomor 82 tahun 2013 tentang sist inf manaj rumah sakit. 2013. 5. fattig m. implementing a hospital information system: lessons learned. lab med. 2007;38(5):317–8. 6. ismail a, jamil at, a rahman af, abu bakar jm, mohd saad n, saadi h. the implementation of hospital information system (his) in tertiary hospitals in malaysia. https://doi.org/10.26555/eshr.v3i1.3594 aula (hospital management information systems acceptance …) vol. 3, no. 1, 2021, pp. 15-20 20 10.26555/eshr.v3i1.3594 20 malaysian j public heal med 2010. 2010;10(2):16–24. 7. jogiyanto. metodologi penelitian sistem informasi. yogyakarta: andi; 2008. 8. he y, chen q, kitkuakul s. regulatory focus and technology acceptance: perceived ease of use and usefulness as efficacy. cogent bus manag. 2018;5(1). 9. putra dsh, kurniawati r. evaluasi sistem informasi manajemen rumah sakit dengan metode technology acceptance model ( tam ) di rumah sakit x. j rekam med dan inf kesehat. 2019;1(1):31–6. 10. nurhayati, arif ywt, hidayah in. analisis tingkat penerimaan pengguna terhadap teknologi sistem informasi rekam medis di pku muhammadiyah karanganyar. in: prosiding call for paper smiknas. 2019. p. 258–68. available from: https://ojs.udb.ac.id/index.php/smiknas/article/view/694 11. maruo m, young d. leveraging technology to close gaps between men and women. world bank blogs. 2018 [cited 2021 mar 3]. available from: https://blogs.worldbank.org/digital-development/leveraging-technology-close-gapsbetween-men-and-women 12. sánchez-franco mj. exploring the influence of gender on the web usage via partial least squares. behav inf technol. 2006;25(1):19–36. 13. söllner m, hoffmann a, leimeister jm. why different trust relationships matter for information systems users. eur j inf syst. 2016;25(3):274–87. 14. gajanayake r, sahama t, iannella r. the role of perceived usefulness and attitude on electronic health record acceptance. e-health telemed concepts, methodol tools, appl. 2015;1:49–59. 15. alotaibi yk, federico f. the impact of health information technology on patient safety. saudi med j. 2017;38(12):1173–80. 16. santoso b. pengaruh perceived usefulness, perceived ease of use, dan perceived enjoyment terhadap penerimaan teknologi informasi. j stud akunt indones. 2001;(1998):1–15. 17. dyna h, adi wp. technology acceptance model of mobile ticketing. in: proceedings of the 1st international conference on information systems for business competitiveness (icisbc) 2. 2011. p. 117–22. available from: http://eprints.undip.ac.id/36105/ 18. sun h, zhang p. a new perspective to analyze user technology acceptance. working paper syracuse university. 2003. 19. hussein z. leading to intention: the role of attitude in relation to technology acceptance model in e-learning. procedia comput sci. 2017;105(december 2016):159– 64. available from: http://dx.doi.org/10.1016/j.procs.2017.01.196 https://doi.org/10.26555/eshr.v3i1.3594 epidemiology and society health review| eshr vol. 3, no. 1, 2021, pp. 1-7 issn 2656-6052 (online) | 2656-1107 (print) 10.26555/eshr.v3i1.2987 1 research article relationship between preeclampsia and low birth weight (lbw) in wonosari, gunungkidul regional hospital year 2018 dwi wahyuni 1 and elika puspitasari 1,* 1 faculty of health sciences, ‘aisyiyah university, yogyakarta, indonesia *correspondence: elikapuspita@unisayogya.ac.id. phone: +6287738254864 received 26 october 2020; accepted 20 february 2021; published 21 february 2021 abstract background: globally, the infant and maternal mortality rate is still a severe problem because it was an indicator of national health – no exceptions for indonesia. in 2017, the average infant mortality rate was 76 per 1,000 live births, while in yogyakarta, it was 313 cases. the most common causes of infant and neonatal mortality were low birth weight babies (lbw) and sepsis. in 2018 in wonosari, gunungkidul regional hospital found 1,421 new-borns were normal, and 298 infants were experiencing lbw. this study aims to determine preeclampsia's relationship with the incidence of low-birth-weight babies (lbw) in wonosari, gunungkidul regional hospital year 2018. method: this research was conducted in wonosari, gunungkidul regional hospital, using quantitative analysis with a case-control approach. the case population was 280 and using the slovin formula. we recruited 170 controls and 170 cases. inclusion criteria used include (1) babies born with low birth weight <2,500 grams; (2) a single fetus; and (3) recorded in the medical record at the hospital. results: there was a significant relationship between preeclampsia with low-birth-weight babies (lbw) in wonosari, gunungkidul regional hospital 2018 with a p-value of 0.004 (p <0.05) and crude or 2.114; 95% ci (1.268-3.523). conclusion: pregnant women with preeclampsia will be at greater risk of giving birth to a baby with lbw. keywords: low birth weight; preeclampsia; pregnant women; baby with lbw introduction globally, the infant mortality rate (imr) and the maternal mortality rate (mmr) are still a severe problem because it was one of the national health indicators – including in indonesia. neonatal mortality in 2017 was about 2.5 million deaths or about 47% of all under-five mortality rates. premature birth (born before 37 weeks' gestation) was blamed as the cause of low birth weight babies (lbw) (1), which is a new-born whose weight at birth was less than 2500 grams. the global prevalence of lbw is 15.5%, which means that around 20 million lbw infants were born every year, and 96.5% lbw was born in developing countries (2). the definition of lbw could not only occur in premature babies but also in term infants who experience growth retardation during pregnancy (3). https://doi.org/10.26555/eshr.v3i1.2987 http://creativecommons.org/licenses/by-sa/4.0/ http://crossmark.crossref.org/dialog/?doi=10.26555/eshr.v3i1.2987&domain=pdf wahyuni and puspitasari (relationship between preeclampsia and low birth weight (lbw) …) vol. 3, no. 1, 2021, pp. 1-7 2 10.26555/eshr.v3i1.2987 2 the 2012 indonesian demographic health survey (idhs) showed neonatal mortality of 19 per 1,000 live births. the number of deaths in 2017 has decreased compared the neonatal mortality in 2012, which declined to 15 per 1,000 live births. the cause of death in the perinatal group was caused by intra-uterine fetal death (iufd) by 29.5% and lbw by 11.2% (3). according to the special region of yogyakarta's health profile in 2017, the number of infant mortalities from 2014 to 2017 decreased from 405 to 278 in 2014-2016. still, it increased in 2017 as many as 313. the common causes of infant and neonatal mortality in the special region of yogyakarta were low birth weight babies (lbw) and sepsis. the prevalence of lbw in 2017, kulon progo was 6.69%, gunungkidul 5.67%, yogyakarta 5.16%, sleman 4.65%, and the lowest was bantul with 3.79% (4). a previous study mentioned that lbw was caused by disease during pregnancy, one of which preeclampsia/eclampsia. preeclampsia was a typical syndrome in pregnancy that affect the entire organ system due to decreased perfusion due to vasospasm and endothelial activation (5). general criteria for blood pressure preeclampsia ≥ 140/90 mmhg that occur after 20 weeks' gestation and the presence of proteinuria 300 mg or more urine protein per 24 hours or 30 mg / dl (1+ on dipstick) in random urine samples (6). around 12-25% results in limited fetal and small growth for gestational age and premature birth. research in palu, indonesia, found a significant relationship between preeclampsia and lbw events with a p-value of 0.003 and a strength of relationship 0.215 (7). there was a statistically significant relationship, but there were probably other variables that were also more influential than the preeclampsia factor. mothers who have experienced preeclampsia during pregnancy had a 2.48 times greater risk of giving birth to low birth weight (lbw) babies than mothers who did not experience preeclampsia. a preliminary study conducted in january 2019 at wonosari, gunungkidul regional hospital found the number of patients with lbw infants from january december 2018 was 298 babies with a total of 1,421 new-born babies. this research determined preeclampsia's relationship with the incidence of low-birth-weight babies (lbw) wonosari, gunungkidul regional hospital. method this study was quantitative with a case-control approach that figure out in figure 1. the population of the study was 298 new-born babies with lbw in wonosari, gunungkidul regional hospital. the study's sample size was 170 sample cases grouped by the slovin formula with a confidence level of 0.05. the control group was 170 new-borns who did not experience lbw using a ratio of 1: 1 (8). the total sample of the study was 340 infants. inclusion criteria were (1) babies born with low birth weight <2,500 grams; (2) a single fetus; and (3) recorded in the medical record at the hospital. exclusion criteria was (1) intrauterine growth restriction (iugr); (2) twins; (3) lbw history; and (4) maternal age <20 and> 35 years. data analysis uses chi-square statistical tests. https://doi.org/10.26555/eshr.v3i1.2987 wahyuni and puspitasari (relationship between preeclampsia and low birth weight (lbw) …) vol. 3, no. 1, 2021, pp. 1-7 3 10.26555/eshr.v3i1.2987 3 figure 1. data acquisition diagram results table 1 shows respondents' characteristics based on maternal age in the case group; maternal age 20-35 is 170 (100%). in the control group, maternal age of 20-35 years is 125 people (73.5%) more than maternal age> 35 years, which is 39 people (24.1%), and maternal age <20 years is six people (3,5%). table 1. characteristics of respondents in wonosari, gunungkidul regional hospital 2018 characteristics case control n % n % mother’s age age <20 years 0 0 6 3.5 age 20-35 years 170 100 125 73.5 age > 35 years 0 0 39 22.9 total 170 100 170 100 parity primiparous 79 46.5 58 34.1 multipara multiparaous 91 53.5 112 65.9 total 170 100 170 100 age preterm 94 55.3 46 27.1 aterm 76 44.7 124 72.9 total 162 100 162 100 the respondents' characteristics based on parity in the case group, primipara, were 79 people (46.5%) less than multipara, 91 (53.5%). in the control group, primipara was 58 people (34.1%) less than multipara, 112 people (65.9%). of the 340 respondents, the most common gestational age distribution in the case group was preterm gestational age, with 94 people (55.3%) compared to term gestational age with 76 people (44.7%). in the control group, preterm gestational age was 46 people (27.1%), less than at term gestational age was 124 (72.9). https://doi.org/10.26555/eshr.v3i1.2987 wahyuni and puspitasari (relationship between preeclampsia and low birth weight (lbw) …) vol. 3, no. 1, 2021, pp. 1-7 4 10.26555/eshr.v3i1.2987 4 table 2. distribution of lbw and preeclampsia status in wonosari, gunungkidul regional hospital 2018 variable n (%) lbw status lbw 170 50 not lbw 170 50 preeclampsia status preeclampsia 83 24.4 no preeclampsia 257 75.6 table 2 shows that the number of respondents in this study was 340 respondents (100%) with the criteria of 170 respondents (50%) as case samples in lbw infants and 170 respondents (50%) as control samples for non-lbw infants. women with preeclampsia were 83 (24.4%) less than women with no preeclampsia 257 people (75.6%) out of 340 respondents. table 3. distribution of preeclampsia frequency in wonosari, gunungkidul regional hospital 2018 variable lbw no lbw crude or (95% ci) p-value n % n % preeclampsia 53 31.2 30 17.6 no preeclampsia 117 68.8 140 82.4 2.114 (1.268-3.523) 0.004 table 3 shows that the respondents with lbw mostly came from a woman with no preeclampsia that was 117 (68.8%). the same case occurred in infants with no lbw, which is higher than lbw infant 140 (82.4). chi-square test obtained a p-value of 0.004 (p <0.05). the results show a relationship between preeclampsia and lbw in wonosari, gunungkidul regional hospital. odds ratio analysis results, or = 2.114, show that women who have preeclampsia are 2.114 times more at risk of giving birth with lbw than women who do not have preeclampsia. discussion previous studies found that mothers age at risk to give birth to babies with lbw as many as 29 (32.6%) was (<20 and >35 years). simultaneously, a woman at 20-35 years has a low risk of as many as 60 (67.4%). a study result obtained no difference in the proportion of lbw events between age at risk and not at risk (9). the results of this study were consistent with the theory that the risk of age for babies born with lbw is in mothers aged <20 years due to lack of perfection both physically and mentally and at age >35 years because at this age, the functions of the reproductive organs are experiencing setback so that the risk of giving birth to lbw is higher (10)(11). the results of this study showed that not only mothers with multipara parity gave birth to babies with lbw but also mothers with primiparous parity had the opportunity to deliver babies with lbw. in this study, primiparous and multiparous mothers almost had the same opportunity to deliver babies with lbw. primiparous mothers or having a first-time pregnancy do not have pregnancy experience. the abnormalities and complications experienced are quite significant https://doi.org/10.26555/eshr.v3i1.2987 wahyuni and puspitasari (relationship between preeclampsia and low birth weight (lbw) …) vol. 3, no. 1, 2021, pp. 1-7 5 10.26555/eshr.v3i1.2987 5 such as dystocia of labor, low nutritional status, and lack of information about pregnancy that will affect the baby's weight (12). the results of previous studies indicate that gestational age <37 weeks at 143.5 times the risk of having a low birth baby (9). this is in line with a previous study that found a significant relationship between gestational age, multiple pregnancies, hypertension, and severe anemia during pregnancy with lbw events (13)(14). this is due to partial or complete detachment of the placenta from normal implantation, a history of disease during pregnancy, and uterine abnormalities due to genetic factors (15). other causative factors include preeclampsia, acute infection, strenuous physical activity, multiple births, stress, anxiety, and other psychological factors (10)(16). this is consistent with the theory that babies born at less than 37 weeks' gestational age are at risk for lbw birth due to growth imbalances due to impaired placental circulation and chronic nutritional deficiencies. the birth of a baby with lbw at term gestational age can be caused by other factors such as parity 2 or 4, the lack of understanding of mothers regarding pregnancy care, and the mother's nutritional status. age 37 weeks’ gestation is an excellent gestational age for the fetus (10)(17). based on the bivariate analysis conducted to test preeclampsia's relationship with lbw using the chi-square test, the p-value was 0.04. the results show an association between preeclampsia and lbw events because the p-value is smaller than α (0.04 <0.005). this result is in line with previous research with a p-value of 0.001. there is a significant relationship between severe preeclampsia with the incidence of low-birth-weight babies at dr.oen hospital surakarta (18). preeclampsia and eclampsia are a group of diseases directly caused by pregnancy, the cause of which is unclear. in addition to infection and bleeding, preeclampsia and eclampsia are fundamental causes of maternal and perinatal death in obstetrics (19). this study's results are in line with research conducted by hartati in 2018 in wangaya district hospital with a p-value of 0.00, indicating there is a relationship between preeclampsia mothers with low birth weight, with an or value of 4.752 (20). meaning that women with preeclampsia risk their babies will experience babies with lbw. and also supported by previous studies that showed that preeclampsia could increase the risk of iugr and low birth weight due to decreased uteroplacental blood flow, and this will cause the outcome of low birth babies (21). mothers with preeclampsia were at risk of giving birth to a baby with lbw. in preeclampsia, abnormalities of the placenta and vasospasm, and endothelial injury will occur. preeclampsia will fail in the invasion of trophoblasts in both waves of the spiral arteries. there would be a failure of spiral artery remodeling, which results could decrease uteroplacental blood flow. reduced blood flow to the uteroplacental could cause hypoxia and placental ischemia, resulting in stunted fetal growth (22) – supported previous research that states mothers with preeclampsia were four times at risk of giving birth to babies with lbw (20). based on the study, 117 mothers did not have preeclampsia as many as 117 mothers who gave birth to lbw babies. another cause of lbw from maternal factors was the birth spacing that was too short (less than one year), low socioeconomic conditions (23). two previous studies mentioned that the risk factors for giving birth to a baby with lbw had an association with anemia and placental abnormalities to the incidence of premature lbw and desaturation while risk factors for parity, pregnancy spacing, maternal medical illness (hypertension, preeclampsia, diabetes, and infection), obstetric history and maternal https://doi.org/10.26555/eshr.v3i1.2987 wahyuni and puspitasari (relationship between preeclampsia and low birth weight (lbw) …) vol. 3, no. 1, 2021, pp. 1-7 6 10.26555/eshr.v3i1.2987 6 nutritional status that were stated to be no statistically significant relationship between premature lbw and desaturation (24,25). conclusion based on the research results, we conclude that the incidence of preeclampsia frequency in wonosari, gunungkidul regional hospital in 2018 was 83 people (24.4%), while those who did not preeclampsia were 257 people (75.6%). there is a relationship between preeclampsia and the incidence of lbw with a p-value of 0.04 <0.05. authors’ contribution ep contributed to research design and developed the first draft of the manuscript. dw contributed to the data collection and statistical analysis. funding the researcher was grateful to lppm universitas ‘aisyiyah yogyakarta for supporting materially and morally so that this research can be carried out well. conflict of interest there is no conflict of interest. references 1. who. who recommendation on midwife-led continuity of care during pregnancy. 2016. 2. who. newsborns: reducing mortality. 2018. 3. kementerian kesehatan republik indonesia. profil kesehatan indonesia. profil kesehatan provinsi bali. jakarta; 2016. 1–220 p. 4. dinas kesehatan provinsi diy. profil kesehatan provinsi diy. 2017. 5. hasriyani. hadisaputro, s. budhi, k. setiawati, m. and setyawan h. berbagai faktor risiko kejadian bayi berat lahir rendah (bblr) studi di beberapa puskesmas kota makassar. universitas diponegoro semarang; 2018. 6. cunningham f. obstetri williams. edisi 23. jakarta: egc; 2010. 7. mallisa b, towidjojo vd. hubungan antara preeklampsia dengan kejadian bayi berat badan lahir rendah di rsud undata palu. j ilm kedokt. 2014;1(3):1–7. 8. saryono. metodologi penelitian kuantitatif dan kualitatif. bandung: alfabeta; 2010. 9. sujianti. hubungan usia ibu dengan kejadian bayi berat lahir rendah (bblr) di rsud cilacap. j kesehat al-irsyad. 2018;xi(1). 10. manuaba ibg. ilmu kebidanan, penyakit kandungan dan keluarga berencana untuk pendidikan bidan. jakarta: egc; 2012. 11. owa k, eka putra iwga, trisna windiani ig. risk factors for low birth weight infants in east nusa tenggara. public heal prev med arch. 2017;5(1):49. 12. edriana., d.s. indrawati, d.n. and rahmawati a. hubungan umur dan paritas ibu dengan berat badan lahir d rb citra insani semarang. j unimus. 2013;2(1). 13. purwanto ad and wcu. hubungan antara umur keamilan,kelamilan ganda, hipertensi dan anemia dengan kejadian bblr. j berk epidemiol. 2016;4(3). 14. ali aa, rayis da, abdallah tm, elbashir mi, adam i. severe anemia is associated with a higher risk for preeclampsia and poor perinatal outcomes in kassala hospital, eastern sudan. bmc res notes. 2011;4(1):311. available from: http://www.biomedcentral.com/1756-0500/4/311. https://doi.org/10.26555/eshr.v3i1.2987 wahyuni and puspitasari (relationship between preeclampsia and low birth weight (lbw) …) vol. 3, no. 1, 2021, pp. 1-7 7 10.26555/eshr.v3i1.2987 7 15. rahmi. arsyad. and rismayanti. faktor-faktor yang berhubungan dengan kejadian bayi berat badan lahir rendah di rsia pertiwi makassar. j epidemiol fkm univ hasanudin. 16. takiuti nh, kahhale s, zugaib m. stress in pregnancy: a new wistar rat model for human preeclampsia. am j obstet gynecol. 2002;186(3):544–50. 17. insoft rm, todres di. gestational age. science direct. 2009 [cited 2021 feb 18]. available from: https://www.sciencedirect.com/topics/medicine-and-dentistry/gestationalage. 18. utami u. hubungan antara preeklampsia berat dengan kejadian bayi berat lahir rendah (bblr) di rs dr. oen surakarta. universitas muhammadiyah surakarta; 2017. 19. sofian a. sinopsis obstetri fisiologi. yogyakarta: egc; 2013. 20. hartati nn, surinati idak, pradnyaningrum nndv. preeklampsia dengan berat badan lahir rendah (bblr) pada ibu bersalin. gema keperawatan. 2018;11(1):1–9. 21. backes, c.h. kara, m. pamela, m. leandro, c. craaig, a.n. peter j. maternal preeclampsia and neonatal outcomes. j pregnancy. 2011;1. 22. prawirohardjo s. ilmu kebidanan. edisi ke-4. jakarta: pt bina pustaka; 2010. 23. proverawati a and i. bblr (berat badan lahir rendah). yogyakarta: nuha medika; 2010. 24. benedict o ikn. maternal risk factors associated with low birth weight neonates: a multi-centre, cross-sectional study in a developing country. j neonatal biol. 2015;04(03). 25. singh g, chouhan r, sidhu k. maternal factors for low birth weight babies. med j armed forces india. 2009;65(1):10–2. available from: http://dx.doi.org/10.1016/s03771237(09)80045-2. https://doi.org/10.26555/eshr.v3i1.2987 microsoft word 1577-4040-r1-r2-pr.edited.docx epidemiology and society health review| eshr vol 2 no1 2020 23 research article epidemiology of dengue hemorrhagic fever (dhf) in semanu ii primary health centre, gunungkidul from january-june 2019 vidya aries anggraini1, sulistyawati sulistyawati1,2*, desita purnamawati3, siwi pramatama mars wijayanti4 1faculty of public health, university of ahmad dahlan, yogyakarta, indonesia 2 department of epidemiology and global health, umeå university, sweden 3 semanu ii, primary health center, gunungkidul district, indonesia 4 department of public health, faculty of health sciences, university of jenderal soedirman, purwokerto, indonesia * correspondence: sulistyawatisuyanto@gmail.com. tel: +628170402693 received 18 january 2020; accepted 01 april 2020; published 02 april 2020 abstract background: dengue hemorrhagic fever (dhf) is a public health problem in indonesia. the dengue virus causes the disease through mosquito aedes aegypti bite. this study aims to describe dengue hemorrhagic fever (dhf) in semanu ii primary health centre, gunungkidul, yogyakarta. methods: this is a quantitative study with a descriptive approach, describing dhf based variable person, place, and time, using secondary data. data collection was carried out in august 2019 from secondary data reports sp2tp upt puskesmassemanu ii period januaryjune 2019. results: dengue hemorrhagic fever (dhf), which occurred in the region of primary health center semanu ii in 2019, was a total of 18 cases with incidence rate 72/100,000 population. the majority of cases were found in the age group 6-11 years. 67% of the cases occurred in males. 72% of the cases happened in pacarejo village. most of the dhf incidence occurred in march (39%). conclusions: the incidence of dengue hemorrhagic fever in primary health care semanu ii, most occurred in pacarejo village, the majority in the age group 6-11 years. male were the most infected group. and the highest dhf incidence occurred in march 2019. keywords: descriptive, dengue, epidemiology introduction dengue hemorrhagic fever is a mosquito-borne infection caused by dengue virus (denv) that is mostly found in the tropics and sub-tropics. the virus is transmitted to humans through the bite of an infected female mosquito. aedes aegypti is the primary vector, while aedes albopictus is considered as a secondary vector. the period of incubations 4-10 days. people who have been infected with the virus become the host to spread of infection because they possible to transmit the dengue virus to the female mosquito. aedes aegypti mosquito mostly lives in urban areas and breed in human-made containers or thrift (1). epidemiology and society health review| eshr vol 2 no1 2020 24 dengue fever in indonesia generally influenced by the host factors, environmental factors, and the immune response. dengue fever is a disease based on environment-related sanitation. when people have poor habits and do not maintain the cleanliness of the home environment, it will be increasing the risk of getting dengue infection. environmental factors are geographic conditions such as altitude, rainfall, humidity, season. while demographic conditions are the density of residential houses, people mobility, bad behavior, and habits, low socioeconomic, on the other hand, the presence of dengue mosquito in a tropical country such as indonesia is worsening this situation (2). the incidence of dengue fever in recent years has increased significantly. in the eastern mediterranean, the incidence of dengue fever has increased dramatically since 2000, with a total of 16 outbreaks occurred during the period (3). over the two-last decade, the number of dengue cases has to increase 15 folds. in addition, they are increasing not only for the number but also for the region infected. according to who, 2019 was the year with the largest dengue cases (4). research in malaysia showed that there were 10,000 cases of dengue in malaysia every year and lead the country to suffer losses of us $ 13 million per year. this loss is equivalent to 940,000 working days lost (5). asia region stands on the first ranks of dengue fever cases every year. from 1968 to 2009, the world health organization (who) notes that indonesia as the country with the highest dengue fever cases in southeast asia. in this country, dengue hemorrhagic fever is still one of the significant public health problems. dengue fever was first discovered in surabaya in 1968, whereas many as 58 people were infected, and 24 of them died. since then, the disease was spread throughout indonesia (6). the number of people and the distribution area is increasing along with the increasing mobility and population density. in 2016, about 204,171 and 68,407 dengue fever cases were reported for the years 2016 and 2017, respectively (7). while in 2018, dengue fever cases slightly decreased, with 65,600 cases reported (8). yogyakarta province is one of the dengue-endemic areas in indonesia. local health authorities reported in year 2017, there were 1,642 cases of dengue fever (9), and in 2018, it declined to 649 cases (5). meanwhile, for gunungkidul district, which part of yogyakarta province, 208 cases were reported in 2017(9), and it declined to 124 in 2018 (5). semanu ii primary health centre (phc) is one phc in gunungkidul that experience with the variation of dengue fever case number from 2017 to 2019. in 2017, they recorded 12 cases and immensely declined to 4 cases in 2018. however, until the half-year of 2019, reported 18 dengue hemorrhagic fever case in this area. this study aims to describe the dengue hemorrhagic fever (dhf) based on person, place, and time in semanu ii phc during january-june 2019. methods this research located in primary health care of semanu ii, gunungkidul district, yogyakarta. a quantitative method with a descriptive approach was applied to this research. we describe the dengue hemorrhagic fever (dhf) based on people, places, and time. data was collected from secondary data using phc monthly report from january-june 2019. we included patients who diagnosed with dhf, and it reported on the phc report system. epidemiology and society health review| eshr vol 2 no1 2020 25 results from january to june 2019, 18 dhf cases were recorded in the monthly report of semanu ii phc. most of them aged between 6-11 years old (figure 1). while most of the case (> 60%) were occurred in male (figure 2) figure 1. dhf patient by age in semanu ii phc during january to june 2019. figure 2. dhf patient by sex in semanu ii phc during january to june 2019 figure 3 shows that between the two villages in semanu ii phc, most of the dhf cases occurred in pacarejo village (n = 13, 72%). during the time of observation, dhf cases reached a peak in march 2019 with (n = 7, 39%) (figure 4) age group c as e nu m be r epidemiology and society health review| eshr vol 2 no1 2020 26 figure 3. dhf patient by a village in semanu ii phc during january to june 2019 figure 4. dhf patient per month in semanu ii phc during january to june 2019. discussions our result shows that the dhf incidence in semanu ii phc occurred in children aged 5-11 years old and male. children are a vulnerable group to dengue virus infection related to their many outdoor activities that make them exposed to aedes aegypty. this result is similar in the blitar district that found dengue cases pattern during 2015 and 2017 mostly occurred in people aged 5-14 years. the same pattern was found in the united states and venezuela, where the incidence of dengue hemorrhagic fever peaked in children aged 5-9 years old in 2007 with 570 cases per 100,000 population(10). in thailand, dengue occurred in children aged five years and adults in 25 years. during 2000 and 2001, most cases in thailand were dengue hemorrhagic fever (dhf) and dengue shock syndrome (dss) that attacked children at 5 and 14 years old(11). majority dhf occurs in males. this result is consistent with studies in new york city that male has a higher risk than women to get dengue infection (or: 1,878; 95% ci: 1,091 to 3,233) (12). the similar finding stated in thailand refer to the data of the ministry of public health of thailand in 2003, 2006-2008, and 2010 proved that dengue mostly occurred in males compared to females. a similar study carried out in india, saying that more than 60% of dengue found in men (13). however, our finding is not in line with previous research, which stated that jan feb march april may june p eo pl e candirejo pacarejo village p eo pl e epidemiology and society health review| eshr vol 2 no1 2020 27 the female has a 3,333 (or = 3.333; 95% ci: 1.127 to 9.861) times higher chance of having dengue than men (14). the different results among the various settings/countries could be attributed to differences in health behavior between males and females (11), such as outdoor activity and high mobility among the men (15). these findings may serve as an implication of dengue prevention strategy in indonesia that mostly engages the woman in the vanguard of dengue eradication, such as through vector control program or called as jumantik (16). pacarejo is a village with the highest dhf cases in semanu ii phc. the area spreads in poor environmental conditions and it worsened by the optimal humidity that leads to the survival of mosquitoes increases. in humidity less than 60%, mosquito lifespan will be shorter so that it cannot continue to the next life phase to transfer the virus from the stomach into the salivary glands (17). the role of humidity to the mosquito life has been discussed by research in pandeglang, banten, that during 2011-2016 they had 80.46% of humidity, which supports the development of aedes mosquito. research in southern thailand found high humidity, temperature, and rainfall associated with a high risk of dengue transmission (18). in addition, the study in yogyakarta from 2004 to 2011 stated that the increase of dengue cases from january-march, associated with ranged from 80-87%, and the humidity had decreased 7277% in september that coincided that dengue was reducing. so it can be said that the increase in humidity will lead to an increased incidence of dengue (19). it is exacerbated by the poor implementation of vector control activity because they prefer to do farming mainly in the rainy season. the high incidence of dhf in march might be related to the rainy season that categorized as extreme during the time. it was confirmed by the meteorology, climatology, and geophysics agency of yogyakarta. in the wet season, the vector mosquito population has increased because there is an increase of the aedes breeding place that most associated with poor sanitation (20). it is consistent with studies in kendari from 2000-2015 that found there is a significant association between rainfall index with the incidence of dengue (21). research in karangayar, central java of indonesia, stated that the incidence of dengue increased along with the heavy rainfall. the increase of 1 mm rainfall may improve opportunities to change of 0.131 dengue cases (22). conclusions dengue hemorrhagic fever in semanu ii phc needs attention and intervention programs from the related stakeholder. health promotion should be provided to refer to the most risk group, such as males, children, and people live in pacarejo. authors 'contribution va, ss, dp designed the study. va collected the data with the supervision of dp. va, ss drafted the article. dp and sp reviewed the article. funding there is no external funding for this research. acknowledgments we are thankful to semanu 2 phc for assistance during the stages of data collection. epidemiology and society health review| eshr vol 2 no1 2020 28 conflict of interest there are no conflicts of interest references 1. world health organization (who). dengue and servere dengue. regional office for the eastern mediterranean. 2014. p. 1–4. 2. soegijanto s. demam berdarah dengue. ed. kedua. surabaya: airlangga university press; 2012. 3. who. dengue and severe dengue [internet]. web. 2014 [cited 2020 apr 1]. available from: https://apps.who.int/iris/handle/10665/204161 4. who. dengue and severe dengue [internet]. web. 2019 [cited 2020 apr 1]. available from: https://www.who.int/news-room/fact-sheets/detail/dengue-and-severe-dengue 5. dinkes provinsi diy. profil kesehatan d.i yogyakarta tahun 2018. yogyakarta: dinas kesehatan diy; 2018. 6. kemenkes ri. demam berdarah dengue. bul jendela epidemiol. 2010;2:1–48. 7. kementrian kesehatan ri. infodatin situas demam berdarah dengue. 2018. 8. muller j. indonesia: number of dengue cases 2018. statistica.com. 2020. 9. dinkes provinsi diy. profil kesehatan provinsi daerah istimewa yogyakarta tahun 2017. dinas kesehatan diy. daerah istimewa yogyakarta; 2017. 1–224 p. 10. martín jl., brathwaite o, zambrano b, solórzano j., bouckenooghe a, dayan gh, et al. the epidemiology of dengue in the americas over the last three decades: a worrisome reality. am j trop med hyg. 2010;82(1):128–35. 11. limkittikul k, brett j, l’azou m. epidemiological trends of dengue disease in thailand (2000–2011): a systematic literature review. plos negl trop dis. 2014;8(11):1–10. 12. subagia k, sawitri aas, wirawan dn. lingkungan dalam rumah, mobilitas dan riwayat kontak sebagai determinan kejadian demam berdarah dengue di denpasar tahun 2012. public heal prev med arch. 2013;1(1):8–12. 13. mistry m, chudasama rk, goswami y, dalwadi c, mitra a, mehta g. epidemiological characteristics of dengue disease in saurashtra region, india, during year 2015. j fam med prim care. 2017;vol. 6(no. 2):249–53. 14. permatasari dy, ramaningrum g, novitasari a. hubungan status gizi, umur, dan jenis kelamin dengan derajat infeksi dengue pada anak. j kedokt muhammadiyah. 2015;2(1):24–8. 15. mayasari r, arisanti m, nurmaliani r, sitorus h, ambarita lp. karakteristik penderita , hari dan curah hujan terhadap kejadian demam berdarah di kabupaten ogan komering ulu. jhecds j heal epidemiol commun dis. 2019;5(1):23–9. 16. sulistyawati s, astuti fd, umniyati sr, satoto tbt, lazuardi l, nilsson m, et al. dengue vector control through community empowerment: lessons learned from a communitybased study in yogyakarta, indonesia. int j environ res public health. 2019;161013. 17. sucipto pt, raharjo m, nurjazulli. faktor – faktor yang mempengaruhi kejadian penyakit demam berdarah dengue (dbd) dan jenis serotipe virus dengue di kabupaten semarang. j kesehat lingkung indones. 2015;14(2):51–6. 18. promprou s, jaroensutasinee m, jaroensutasinee k. climatic factors affecting dengue haemorrhagic fever incidence in southern thailand. dengue bull. 2005;29:41–8. 19. perwitasari d, ariati j, puspita t. kondisi iklim dan pola kejadian demam berdarah dengue di kota yogyakarta tahun 2004-2011. media penelit dan pengemb kesehat. 2015;25(4):243–8. 20. rismawati sn, nurmala i. hubungan perilaku host dan environment dengan kejadian dbd di wonokusumo surabaya. j berk epidemiol. 2017;5(3):383–92. 21. rasmanto mf, sakka a, ainurafiq. model prediksi kejadian demam berdarah dengue epidemiology and society health review| eshr vol 2 no1 2020 29 (dbd) berdasarkan unsur iklim di kota kendari tahun 2000-2015. j ilm mhs kesehat masy unsyiah. 2016;1(3):1–14. 22. nisaa a. korelasi antara faktor curah hujan dengan kejadian dbd tahun 2010-2014 di kabupaten karanganyar. j ikesma. 2018;14(1):25–32. epidemiology and society health review| eshr vol 2 no1 2020 30 epidemiology and society health review| eshr vol. 3, no. 1, 2021, pp. 21-27 issn 2656-6052 (online) | 2656-1107 (print) 10.26555/eshr.v3i1.3635 21 research article differences of toddler obesity based on exclusive breastfeeding history in tegalrejo health center, yogyakarta suci musvita ayu 1,*, arini mayang fa'uni 1 1 faculty of public health, ahmad dahlan university, yogyakarta, indonesia * correspondence: suci.ayu@ikm.uad.ac.id. phone: +6285261614043 received 05 february 2021; accepted 03 march 2021; published 04 march 2021 abstract background: obesity is a global problem and continues to affect low and middle-income countries, mainly urban areas. in indonesia, the obesity rate of children was 11.5% and was ranked 21st in the world by 2016. even according to who, the number of obese children will continue to increase every year. several studies have shown that a history of exclusive breastfeeding can reduce the risk of obesity in toddlers. this study aimed to determine the differences in the obesity status of children under five based on a history of exclusive breastfeeding in the tegalrejo health center, yogyakarta city. method: this research employed an analytical observational study with a case-control design. the research sample consisted of 34 toddlers aged 6-24 months, calculated using the difference of two proportions: 17 cases of obese children under five and 17 controls under five who were not obese. a questionnaire was used to collect the data. a chi-square test was used to analyse the data. results: there were children under five without exclusive breastfeeding in the group of as many as 41.7% and 29.4% in the control group. 52,9% of children in the case group had exclusive breastfeeding, and 70% in the control group. the bivariate analysis showed no difference in the obesity status of children under five based on a history of exclusive breastfeeding with a value of p = 0.480 and or = 2.133 (95% ci = 0.519-8.751). conclusion: there was no difference in the obesity status of children under five based on a history of exclusive breastfeeding, but children without a history of exclusive breastfeeding were 2.133 times more likely to have obesity than children with exclusive breastfeeding. keywords: obesity; toddler; exclusive breastfeeding introduction obesity is a serious global problem and continues to affect low and middle-income countries, mainly urban areas. the world health organization states that in 2015 there were 24 million children who were overweight, this number increased by 31 million from 2000. trends show that the number will continue to grow that predicted 70 million in 2025 (1). the obesity rate in children in indonesia is 11.5% and is ranked 21st in the world (2). data from the nutrition status monitoring notes that 1.6% of children aged 0-59 months are overweight, with the highest prevalence in jakarta and bali (3.3%) and papua (2.7%)(3). https://doi.org/10.26555/eshr.v3i1.2987 http://creativecommons.org/licenses/by-sa/4.0/ http://crossmark.crossref.org/dialog/?doi=10.26555/eshr.v3i1.3635&domain=pdf ayu and fa'uni (differences of toddler obesity based on exclusive breastfeeding history …) vol. 3, no. 1, 2021, pp. 21-27 22 10.26555/eshr.v3i1.3635 22 the results of nutritional status monitoring in yogyakarta province (diy) from 2013 to 2015 show that overweight toddlers (bodyweight per age) in 2014 were 5.84%, decreasing to 3.81% (2015) and 3.11% (2016) and fell to 2.80 (2017). observations in august 2018 explained that 164 toddlers aged 0-24 months are overweight or obese out of the 5,595 number of toddlers spread across 18 puskesmas yogyakarta city (4). children with obesity have a 1.8 times higher risk to be adult with obesity (5). obesity in children impacts decreased learning achievement and psychosocial effects, such as lack of self-confidence and social withdrawal (6). several factors contribute to obesity in children, including heredity or genetics, food supply, physical activity, feeding histories such as breastfeeding, birth weight, and parental obesity (5). exclusive breastfeeding is an act of giving breast milk to babies without giving fluids or other foods from birth to 6 months of age (7). the who recommended exclusive breastfeeding for six months and continued until two years of age due to the benefit of maintaining the baby's health and survival. it is because babies who are exclusively breastfed have a better immune system than babies who are not. babies rarely attack from disease and avoid nutritional problems than babies who are not given exclusive breastfeeding. lack of breast milk intake results in an imbalance in the baby's dietary needs. the inequality of nutritional fulfilment in infants will harm the quality of human resources, which can be seen from the obstruction of infants' optimal growth and development (8). breastfeeding can also prevent obesity in children because breastfed babies can regulate energy intake concerning the internal response to satiety. the insulin and hormone leptin levels are more balanced in babies who are given breast milk to prevent obesity (5). exclusive breastfeeding coverage worldwide was only around 36% during 2007-2014 (9). this number indicates that globally the number of children that getting breastfeed is still low. based on data from the united nations children's fund (unicef) in 2012, only 39% of babies under six months are exclusively breastfed worldwide. this number is stable in 2015 only 40% success of exclusive breastfeeding worldwide (10). china, one of the countries with a large population globally, has a success rate of exclusive breastfeeding of 28%. in indonesia, the coverage of infants receiving exclusive breastfeeding is 61.33%. this number has exceeded the 2017 strategic plan target of 44%. the highest percentage of complete breastfeeding coverage was found in west nusa tenggara at 87.35%, while the lowest rate was in papua at 15.32%. five provinces have not reached the 2017 strategic plan target, namely riau islands province 44.42%, north sulawesi 36.93%, banten 35.87%, west papua 24.65% and papua 15.32% (11). while in yogyakarta province, where this research was conducted, exclusive breastfeeding coverage 0-6 months in kulon progo district 77.00%, bantul 74.27%, gunungkidul 66.75%, sleman 82.62%, yogyakarta city 66.13% with an average total coverage of exclusive breastfeeding in yogyakarta province was 74.90% (4). according to this data, yogyakarta city had the lowest breastfeeding coverage. one health centre that having the highest toddler obesity was tegalrejo health centre. the actual phenomenon in society is that mothers thought that obese toddlers are healthy because their children have sufficient food supply. obesity will interfere with the development process of toddlers. accordingly, assessing the differences in breastfeeding history and obesity is required to provide evidence to society about the importance of giving exclusive breastmilk to their babies. https://doi.org/10.26555/eshr.v3i1.3635 ayu and fa'uni (differences of toddler obesity based on exclusive breastfeeding history …) vol. 3, no. 1, 2021, pp. 21-27 23 10.26555/eshr.v3i1.3635 23 method this was an analytic observational study with a case-control design conducted in tegalrejo health centre of yogyakarta city from june to july 2019. we used data from the health centre that was body weight standard to see under-fives children with obesity. this measurement uses a standard tool from the indonesia ministry of health – kartu menuju sehat (kms) to know the birth weight and obesity status. a set of questionnaires was employed to know the history of breastfeeding refers to the guttman scale. this study population were all toddlers aged 6-24 month who checked their weight in tegalrejo health centre from january 2018 june 2019 (n=492). the sample was calculated using the lemeshow formula and 17 children in each group – case and control. we selected children in each group purposively refer to our inclusion criteria – for case group children with z-score > 2 sd or obese and control group children with z-score < 2 sd or not obese. data were analysed using the chi-square test with 95% confidence intervals. results table 1 shows that, in total, we recruited 34 respondents for both groups. the highest mother education was graduated from senior high school (76.5%). most of the respondent (mother of the toddler) said they do not have a formal job or as housewives (79.4%). almost half of the observed children in this research aged 19-24 months. more than 50% of the toddler observed were male. nearly 60% of the toddler had birth weigh between 3.30-3.80 kg. among the 34 children, more than 90% of them reported do not have disease history before this research. table 1. characteristics of toddler obesity status data variable case control total percentage n % n % mother's education graduated from elementary school 2 11.8 0 0.0 2 5.9 graduated from junior high school 2 11.8 2 11.8 4 11.8 graduated from senior high school 12 70.6 14 82.4 26 76.5 graduated from diploma three or bachelor 1 5,9 1 5.9 2 5.9 mother's occupation housewife 12 70.6 15 88.2 27 79.4 freelancer 2 11.8 0 0.0 2 5.9 employees 2 11.8 2 11.8 4 11.8 labour 1 5.9 0 0.0 1 2.9 toddlers age in month 6-12 months 0 0.0 14 82.4 14 41.2 13-18 months 4 23.5 0 0.0 4 11.8 19-24 months 13 76.5 3 17.6 16 47.1 toddler sex male 9 52.9 9 52.9 18 52.9 female 8 47.1 8 47.1 16 47.1 toddler birth body weight (kg) 2.50 2.80 3 17.6 2 11.8 5 14.7 2.90 3.20 2 11.8 5 29.4 7 20.6 3.30 3.80 11 64.7 9 52.9 20 58.8 3.90 4.30 1 5.9 1 5.9 2 5.9 toddler disease history yes 1 5.9 0 0.0 1 2.9 no 16 94.1 17 100 33 97.1 https://doi.org/10.26555/eshr.v3i1.3635 ayu and fa'uni (differences of toddler obesity based on exclusive breastfeeding history …) vol. 3, no. 1, 2021, pp. 21-27 24 10.26555/eshr.v3i1.3635 24 table 2 reports the number of children under five with obesity and non-obesity status has the same number, namely 17 (50%), because we used a 1:1 comparison between case and control. among the children observed (n = 34), more than 60% reported exclusive breastfeeding, and the rest were not. table 2. univariate results of toddler obesity status and exclusive breastfeeding history variable n % toddler obesity status obesity 17 50.0 no obesity 17 50.0 exclusive breastfeeding history yes 21 61.8 no 13 38.2 table 3 explains that more than half (52.9%) of a toddler with exclusive breastfeeding were in obese status, and 70.6% of a toddler who received exclusive breastfeeding were in not obese status. from the odds ratio calculation, the or value is 2.13 or > 1 with a confident interval (ci) of 0.51 8.75; this shows that children with a history of not exclusively breastfed have a 2.13 times risk of being obese compared to toddlers with exclusive breastfeeding history. table 3. differences in toddler obesity status based on exclusive breastfeeding history history of exclusive breastfeeding obesity status or 95% ci p-value obesity not obese n % n % not 8 47.1 5 29.4 2.13 0.51-8.75 0.480 yes 9 52.9 14 70.6 however, from statistical test between the history of exclusive breastfeeding and the obesity status of children under five using the chi-square test in table 3, there was no significant association between the obesity status of children under five based on a history of exclusive breastfeeding. discussion in this research, we found that children without exclusive breastfed have a 2.13 times risk of being obese compared to toddlers with exclusive breastfeeding history, even though it was not significantly associated. our finding was not in line with the results of research conducted by ginting, who reported a significant relationship between exclusive breastfeeding and obesity in children under five. toddlers who are not exclusively breastfed have a greater risk of obesity (12). most likely, the statistical results obtained are not significant because our sample involved was small. information from the cadre was different among the village cadre in tegalrejo. in kricak village, which is part of the tegalrejo working area, reported that generally, the breastfeeding coverage in this health centre is sufficient because most of the parents are educated. still, most of them not working in the formal sector and stay at home. accordingly, they have proper time to breastfeed their children. our result is consistent with the research conducted by sarlis and cindy, which shows that there is no significant relationship between exclusive breastfeeding and the normal and abnormal nutritional status of toddlers (13). this is, of course, in contrast https://doi.org/10.26555/eshr.v3i1.3635 ayu and fa'uni (differences of toddler obesity based on exclusive breastfeeding history …) vol. 3, no. 1, 2021, pp. 21-27 25 10.26555/eshr.v3i1.3635 25 to the data obtained from riskesdes 2018 that the number of babies who receive exclusive breastfeeding in indonesia is only 37.3% of 1,100 babies (14). while in bener village, a cadre reported that exclusive breastfeeding coverage in their place was low. this happens because of the mother's lack of knowledge about the importance of giving exclusive breastfeeding to the baby. besides, the child's parents are also busy with daily work activities (15). based on the mother responses to the questionnaire, it was known that all toddlers with a history of not exclusive breastfeeding are toddlers who are fed formula or additional milk. this was because the toddler's mother considers that breast milk alone is not enough for their nutrition. during the first six months of a baby's life, exclusive breastfeeding has been recommended by unicef and who as a key to important child's survival (16). breast milk is the most important source of energy and nutrition for children aged 6-24 months. breast milk meets more than half of the energy needs of children aged 6-12 months and one-third of children aged 12-24 months. breast milk is also an essential nutrient source in the healing process when a child is sick (14). breast milk reduces the risk of being overweight and obese by 10% compared to formula milk (14). children with a history of not exclusive breastfeeding or children who are given formula milk can become obese. toddlers who consume formula milk before six months have a 6.19 times greater risk of being overweight. this is because the provision of formula milk with a high protein content early in life can modulate the concentration of the hormone insulin-like growth factor-1 (igf-1). the hormone igf1 regulates growth and regulates the development of fatty tissue through endocrine pathways. high protein intake such as branched-chain amino acids (bcaas) or bound-chain amino acids increases the secretion of insulin and igf1, which impacts increasing preadipocyte differentiation and increasing the number of adipocytes in the child's body ( 17). this study's results were supported by research conducted previously, which said that infants and toddlers identified as obese were primarily identified as consuming formula milk (41.9%). however, giving formula milk is not automatically considered a trigger for obesity in infants and toddlers because other factors are found to influence, such as consuming junk food (18). the age characteristics showed that the toddler with the highest obesity was the 19–24-month age group with a percentage of 76.5%. previous research states that the older the child needs more intake that will affect the children weight. the gender characteristics showed that the toddler with the highest obesity was male, with a percentage of 52.9%. this is because men need more energy and protein intake than women, and men's body surface area is more expansive than women (19). the findings from the observations show that obese toddlers have obese mothers. one of the toddlers was advised to diet by the health centre because his weight was increasing continuously. this toddler received exclusive breastfeeding, but it was suspected that his obesity is an inheritor of his parents. it is in line with sudiawan's research, on the nutritional status of the mother, the p-value is 0.009 or 0.9% <5% with an or (odds ratio) of 2.322, which shows that children who have a history of overweight or obese mothers have a 2.3 times greater risk of being overweight or obese compared to respondents who do not have a history of fat mothers (20). https://doi.org/10.26555/eshr.v3i1.3635 ayu and fa'uni (differences of toddler obesity based on exclusive breastfeeding history …) vol. 3, no. 1, 2021, pp. 21-27 26 10.26555/eshr.v3i1.3635 26 obesity is a health dilemma. obesity can cause a variety of physical and psychological problems. when obesity in childhood continues into adulthood, it can lead to various diseases such as hypertension during adolescence, hyperlipidaemia, atherosclerosis, coronary heart disease, malignant hypertension in adults, diabetes and pickwickian syndrome (21). accordingly, preventing obesity is much better than treating obesity. prevention should be as early as possible, starting in infancy, namely by giving breast milk. kartu menuju sehat (kms) is needed to monitor children's growth to know any directional deviations from their weight. children as early as possible are introduced to physical activity, either through playing or sports (21). as a developing country and has a diverse population background, to deal with obesity cases in indonesia, the government has compiled the national asian movement plan for the archipelago movement to reduce obesity rates (ran-gentas) (22). besides, many indonesian government policies have been made to tackle obesity in indonesia, one of which is in the school sector. for example, such as assessing the nutritional status of new children entering school, school health program, public health education programs through kadarsi (nutrition-conscious families), development of general health-based obesity management and control programs, obesity prevention and control policies at the school and health centre levels, and school canteen development (23). conclusion in summary, from this research, we know that there is no difference in the obesity status of children under five based on the history of exclusive breastfeeding in the working area of the tegalrejo health center, yogyakarta city, with a p = 0.480 and an odds ratio of 2.133. authors 'contribution all researchers contribute to research design from surveys, data collection, data analysis, and research reports preparation. acknowledgements researchers would like to thank ahmad dahlan university yogyakarta for providing support and funding for this research. conflict of interest there are no conflicts of interest. references 1. world health organization. obesity and overweight. who. 2016. 2. world health organization. the burden of malnutrition. who. 2016. 3. kementrian kesehatan ri. hasil pemantauan status gizi (psg) dan penjelasannya tahun 2016. 2016. 4. dinas kesehatan. profil kesehatan provinsi diy 2017. 2017. 5. saputri el. hubungan riwayat asi eksklusif dengan kejadian obesitas pada anak usia 4-5 tahun. artikel penelitian. universitas diponegoro semarang; 2013. https://doi.org/10.26555/eshr.v3i1.3635 ayu and fa'uni (differences of toddler obesity based on exclusive breastfeeding history …) vol. 3, no. 1, 2021, pp. 21-27 27 10.26555/eshr.v3i1.3635 27 6. world health organization. obesity: preventing and managing the global epidemic. 2000. 7. world health statistics. data, who library cataloguing-in-publication. who press. 2010. 8. bahriyah f, putri. m, jaelani ak. hubungan pekerjaan ibu terhadap pemberian asi eksklusif pada bayi. j endur. 2017;2(2):113–8. 9. world health organization. infant and young child feeding. 2016. 10. united nations children’s fund. mari jadikan asi eksklusif prioritas nasional. pusat media unicef. 2012. 11. dinas kesehatan. profil kesehatan indonesia 2019. 2019. 12. ginting lmb, besral. pemberian asi ekslusif dapat menurunkan risiko obesitas pada anak balita. j penelit dan pengemb kesehat masy indones. 2020;1(1):54–9. 13. sarlis n, netta c. faktor berhuungan dengan status gizi balita di puskesmas sidomulyo pekan baru. j edurance. 2016;3(1):146–52. 14. kementrian kesehatan ri. menyusui sebagai dasar kehidupan. 2018. p. 5. 15. tedhy abdillah. potensi asi eksklusif sebagai faktor protektif obesitas pada anak 6-8 tahun di wilayah kerja puskesmas tebas kabupaten sambas. naskah publikasi. universitas muhammadiyah pontianak; 2016. 16. united nations children’s fund. undernutrition contributes to nearly half of all deaths in children under 5 and is widespread in asia and africa. pusat media unicef. 2018. 17. citra tristi utami. asi & susu formula kandungan dan manfaat asi dan susu formula. universitas diponegoro semarang.; 2016. 18. humune hf, nugroho kp., tampubolon r. gambaran pemberian asi esklusif dan susu formula terhadap kejadian obesitas balita di salatiga. j keperawatan muhammadiyah. 2020;edisi khus:24–9. available from: http://journal.umsurabaya.ac.id/index.php/jkm/article/view/4240 19. fitriarni. hubungan konsumsi asi eksklusif dan faktor lainnya dengan kejadain kegemukan pada anak usia 6-23 bulan di indonesia tahun 2010. universitas indonesia; 2012. 20. sudiawan, dedy. k, lanang g. hubungan status gizi orangtua terhadap status gizi anak. e-jurnal med. 2017;6(6):1–4. 21. soetjiningsih. perkembangan anak dan permasalahannya dalam buku ajar i ilmu perkembangan anak dan remaja. jakarta: sagungseto; 2012. 22. kementrian kesehatan ri. indonesia tekan pentingnya penanganan global untuk atasi tantangan double burden of nutritions. 19 mei. 2015. 23. sataloff rt, johns mm, kost km. pencegahan dan pengendalian obesitas pada anak sekolah. j ilmu gizi. 2015;6(1):33–42. https://doi.org/10.26555/eshr.v3i1.3635 microsoft word 1485-3840-edr1r2-pub.docx epidemiology and society health review| eshr vol 2 no1 2020 1 research article voluntary counselling and testing (vct) services on hiv/aids in private hospital of yogyakarta suci musvita ayu1* and desy riski andriyanti1 1department of public health, university of ahmad dahlan, yogyakarta, indonesia * correspondence: suci.ayu@ikm.uad.ac.id. tel: 08521614043 received 06 january 2020; accepted 30 march 2020; published 31 march 2020 abstract background: data yogyakarta aids commission in 2016 stated the total number of people living with hiv/aids was 4,648 cases consisting of 3,334 hiv cases and 1,314 aids cases. based on the data of pku muhammadiyah hospital, yogyakarta, in october 2016 to october 2017, there were 35 patients with hiv / aids. regulations carried out for any action in the hospital must be following standard operating procedures (sop), including program counseling and testing of hiv/aids or voluntary counselling and testing (vct). this program is the gateway for the community to gain access to all hiv/aids services. this study aimed to explore the implementation of vct services on hiv/aids at pku muhammadiyah hospital in yogyakarta. methods: descriptive qualitative using an observational approach was used in this study to describe the implementation of voluntary counselling and testing (vct) on hiv/aids. as many as ten informants were interviewed, namely: 1 head of vct services in pku muhammadiyah yogyakarta, 3 vct counselors, 1 laboratory staff and 5 clients. they were selected using purposive sampling refers to inclusion criteria. results: implementation of pre-test counseling, testing, and post-test had been good. improper service was identified in the number of counselors and waiting time for the vct test results. conclusions: implementation of vct at pku muhammadiyah yogyakarta is running well and follow the sops. keywords: voluntary counselling and testing (vct), hiv/aids, services introduction indonesia, as a developing country, stands on the 5th country with a high risk of hiv/aids in asia. hiv/aids is a deadly disease because there is no medication until this time. men like men (msm) is the group who at high risk of having sexually transmitted infections (stis) that can be ended with hiv/aids (1). in indonesia, the cumulative cases of hiv/aids in 2016 have increased. at that year, recorded hiv and aids cases were 232,323 and 86,780, respectively. while in 2015 was recorded 191,073 and 77,112 cases of hiv in aids (2). the popular risk factor for getting hiv/aids is unsafe sex in heterosexual (58,846) with the highest age group of 20-35 years at most infected with hiv/aids than other age groups (3). the high number of hiv/aids cases in indonesia is partly due to the low interest of someone at risk for the vct test. it is related to the epidemiology and society health review| eshr vol 2 no1 2020 2 health belief model theory (hbm) contains components that can analyze an individual's response to the prevention of disease (4). the indonesia government develops hiv/aids prevention programs in districts/cities that consist of 4 programs, namely 1) information and education communication program (iec) as an effort to communicate behaviour change communication, 2) program condom 100%, 3) voluntary counselling and testing (vct) program, namely the number and quality of services for voluntary counseling and testing, and 4) care, treatment and support programs for people with hiv/aids (plwha) (5). voluntary counseling and testing (vct) is part of the public health strategy to provide counseling and testing for risky people of getting hiv/aids infection. excellent quality of vct improves people's access to this service and as an effective hiv/aids prevention (6). vct is a reciprocal interaction between counselors and clients aimed at preventing hiv and aids, reducing anxiety, increasing perceptions and knowledge about hiv, and developing behavioral changes. having early vct could be lead client towards service programs and support including access to antiretroviral therapy, and help reduce stigma in the community (7) the primary hiv/aids risk factor is having free sex behavior. accordingly, providing counseling about hiv/aids risk factors, especially sex behavior that can transmit hiv to others and the patient's family quickly, is needed (8). voluntary counselling and testing (vct) is counseling that provides psychological support such as information and knowledge of hiv/aids, preventing the hiv transmissions, promoting the behavior changes, ensuring the arv treatment, and offering the problem solving associated with hiv/aids (9). this program launched by the government to prevent the transmission of hiv/aids voluntary counselling and testing (vct) and provider initiated counselling and testing (pict). program for infant/toddler care (pitc), we consider a relationship-based approach to caring for infants and toddlers essential. provider-initiated counseling and testing (pict) have been introduced to ensure that hct becomes the standard of care in all consultations with health providers. pict promotes universal access to prevention, care, and treatment services for all clients by increasing the utilization and acceptance of hct services. health providers play an essential role in seeing the patient who has symptoms of hiv/aids as well as a high-risk factor exposure to hiv/aids (10). the health provider in vct is a trained counselor who has received a certificate from the ministry of health. the level of knowledge about hiv/aids and vct, attitudes, stigma has a significant relationship to the use of vct services. a low level of knowledge about vct services is leading to limited access to vct services. in addition, attitude is a very significant factor. the low acceptance of vct services increases the higher risk of hiv/aids spreading, and vice versa (11). early case finding, immediate treatment, and increase knowledge and behavior change in hiv/aids prevention. to reduce the hiv/aids epidemic, the government has made various efforts, including free arv treatment, static and mobile vct, which is a prevention program from the hospital (12). considering these problems, we researched about how the implementation of vct on hiv/aids at gemphita clinic, pku muhammadiyah hospital in yogyakarta. methods this is a descriptive qualitative study with an observational approach, aimed to describe the implementation of the voluntary counselling and testing (vct) on hiv / aids. the research was conducted in gemphita clinic, pku muhammadiyah yogyakarta, which provides services related to hiv/aids. there were ten persons who were interviewed, such 1 head of vct services in pku epidemiology and society health review| eshr vol 2 no1 2020 3 muhammadiyah yogyakarta, 3 vct counselors, 1 laboratory staff and 5 clients. they were selected using purposive sampling refers to inclusion criteria: they were: head of vct services, vct counselors, laboratory staff, and clients. they are part of vct hiv/aids team, they certified by the ministry of health of indonesia, have knowledge of vct service flow associated with hiv/aids and the clients who had received vct hiv/aids in pku muhammadiyah yogyakarta data collections were obtained in 2 approaches: 1) primary data, which was divided into two interviews. we collected verbal information from 1 head of vct services in pku muhammadiyah yogyakarta, 3 vct counselors, 1 laboratory staff and 5 clients and observation were employed to observe the vct hiv/aids in pku muhammadiyah yogyakarta. 2) secondary data was taken from the patient register with vct services to hiv / aids. refer to the hospital regulation, the material, and information from the client could not be opened for publication purposes. accordingly, the quote on this research only comes from 2 groups: counselor and laboratory staff. results a. implementation of pre-test counseling implementation of voluntary counselling and testing (vct) begins with a pre-test counseling. from interviews with respondents, all vct clients perform registration procedures beforehand, as the same procedure with other pku muhammadiyah yogyakarta patients. except for pitc services that referred from the emergency unit or inpatient unit. after the registration process, the client is recorded and registered in the medical record, and the staff will contact a counselor who is on duty at the time. afterward, the client waits for a counselor on duty. "vct services, the patient begins to register at the registration desk, as there should be documentation online, in its billing system must be logged in. enter the vct clinic, then been confirmed with the counselors on duty " counsellors 1 according to the counselor's information, the first step on pre-test counseling is an introduction and building the client's self-confidence and delivering information about the confidentiality of the consultation content. subsequently, questions about the client's knowledge about hiv/aids and risk factors are asked to clients. if there is a wrong perception about hiv on the client, it will be corrected by the counselor. "the first step is counseling pre-test; it is technically we approach the patient, communication with patients to improve their self-confidence. we start with an introduction, build trust and relationship first with the patient. we are listeners about the information they provided. usually, he/she will tell us about the particular incidence, risk factors. after that, we come to the essence of counseling " counsellors 2 from interviews with counselors about the constraints experienced in the implementation of pre-test counseling is about knowledge of the client, and they not open to the counselor. "we face time constraints since, for us, this service is our secondary job, we still have other duties. we come here only if there is a patient. in the counseling process, we face barriers such as the ability of the patient, the patient's ignorance, patient education: patients with low education give inaccurate information. but surely, we always use easy language that epidemiology and society health review| eshr vol 2 no1 2020 4 can be accepted by patients. we adjust it based on patient originality " counsellors 3 b. implementation of vct test our results indicate that the implementation of vct tests at pku muhammadiyah yogyakarta voluntarily from clients. in a vct test, informed consent is given to the client to be filled out regarding the test to be taken. prior to the action, the client will be given information and make sure the client understands the instructions provided. after that, the client will be asked to choose to accept or refuse to have a vct or pitc test. if the client is accepting, then the test will be carried out. "client needs to signing the informed consent here; it comes together with the form. if they sign in, meaning they agree to take the test. " counsellor 3 based on the interview with the laboratory staff delivery, he/she said that the test result handed over to the counselor or doctor. laboratory staff responsible only blood sample acquisitions and release the result. "for his sop, all hiv test results gave to the counselors or doctors who refer patients. explanation about the result will be delivered by the counselor or doctor, not by the laboratory staff “laboratory staff. c. implementation of the post-test counseling the counselors said the implementation of the post-test counseling is done after a client undergoes the pre-test counseling and testing of hiv / aids. test results remain in a sealed envelope and should only be opened in front of the client with the client's approval. in the post-test counseling, the counselor should be explaining the results when the client is ready to hear the result. because the client's psychological condition is influencing the course of post-test counseling. "we should handle the laboratory test, because if the client opens on their way. they can be shocked by the result. hence, the results put in the sealed envelope. the counselor asks do they ready to accept the results, otherwise not be forced and the result will deliver when they ready on another occasion" counsellors 1 when an unexpected result is raising from the test, counselors said that they have to support the client to accept the consequences. "so, before a test, we give explanations about hiv/aids, the risk factors, the hazards. we have to make sure that the client ready with the result. " counsellors 2 the counselor's challenge in the post-test is when a patient does not come for post-test counseling, or they could not accept the results. in addition, some of the clients complaining about the duration of the whole process. "time is an obstacle for the counselor. because the counselor is not from the counselor himself but other health workers, so this is a side service, so it does not focus on handling. epidemiology and society health review| eshr vol 2 no1 2020 5 if the obstacle for the counseling process is the patient's ability, patient ignorance, low knowledge. but of course, we use language that is acceptable to patients; the important thing is obviously" counselor 1 discussions the research was conducted in gemphita clinic, pku muhammadiyah yogyakarta, which provides services related to hiv / aids. the service in gemphita clinic of pku muhammadiyah yogyakarta delivered not optimal yet because the counselor has dual tasks, and as the counselor is an additional task only. our finding is not alone; a study of mujiati (2013) at the vct services in bandung reported that similar problems occurred in this place (13). according to the minister of health regulations no. 1507 / menkes / sk / x / 2005 is stated the counselor in the hospital should be at least two persons with minimum holds senior high school education. counselors may come from health or non-health background who have been trained vct, and counselors should deal with 5-8 clients per day divided between the client pre-test counseling and post-test counseling clients. a. implementation of pre-test counseling in delivering vct services are not allowed to write the results in any place, even in the medical records, this note should only be coded to maintain confidentiality. accordingly, in this case, a standard operating procedure (sop) is needed to handle several forms used such as confidentiality statement form, client visit form for hiv testing, daily vct form, pre-testing vct form, test request form of vct to the laboratory, document vct client, reference form, service receipt, hiv test request form in the laboratory and daily / monthly reports of vct antibody tests (13). regarding the stigma and discrimination against vct clients, in the principle of vct services, it has to be professional, respect the rights and dignity of all clients (14). the confidentiality of vct service has to be maintained by doing the service in the close and specific room, according to the hospital regulation. it is also referred to as the research of lawrence (2015) that stated the implementation process of the counseling is part of building trust (15). this study found that implementation of the pre-test hiv counseling has followed the regulation. however, some were not, such as for inform consent. according to the united nations, vct implementation begins with pre-test counseling and any voluntary counseling, including the informed consent statement before blood tests for hiv, confidentiality, and post-test counseling (13). the counselor is one of the critical factors in the succeeds of the vct implementation. counselor knowledge and quality are also waiting times are determining the vct quality. widiyanto's research reported (2009) that women sex workers (fsw) in sunan kuning, semarang, show that long waiting periods and language affected the wps motivation to participate in the vct (16). waiting time for the counselor takes about 15 minutes, due to the counselor might not ready in place related to the other duty. while waiting time for the laboratory result is 1 to 2 hours. indonesia's ministry of health states that the counselor could come to both health practitioners or not as long they certified. this policy is taken because of the insufficient counselor, in term of the number. some clients have complaints about the quality of vct services, such as long waiting times, and the counselor not in place. epidemiology and society health review| eshr vol 2 no1 2020 6 b. implementation of testing vct based on the research shows that hiv testing is done after the counseling process. implementation of vct is voluntary because clients come with their initiative to take a blood test without enforcement. the client put their signature on the informed consent form before taking blood sampling as well as when they refused to take a blood test. in this case, laboratory staff and all people involved should maintain client confidentiality. when patients agree to take blood sampling, they have to state informed consent, the same procedure for the client who refuses blood test. the decision to accessing the vct test depends on client decisions. the task of the laboratory staff is to take the blood sample following the hospital procedure (sop) (16). c. implementation of the post-test counseling this research found that service in the gemphita clinic is good and conducted following the sop, such as it is done after the client takes blood sampling. counsellor first asks the client's readiness before delivering the test result. when the pre-test counseling goes well, it can be built up a good relationship between counselor and client. from the results of research conducted at pku muhammadiyah yogyakarta, constraints experienced in post-test counseling among other clients do not come, the results of old tests or long waiting times, and pre-test counseling that failed. a trusting relationship already established between the client and the counselor will make more meaningful post-test counseling. the research found the equipment, facilities, and infrastructure available in the clinic gemphita to support vct services in counseling rooms to meet the standard. facilities and infrastructure will be very influential in the process of voluntary counseling and testing; vct is a service that promotes comfort and privacy and comfort. the post-test counseling on the research location seems already running well. the counselor delivers the test result when the client ready to listen (17). in case there is a reactive result, the counselor would suggest the client meet with the doctor to get treatment cst (arv). according to gardner (2011) conducted an ongoing arv treatment aimed to reduce the virus population. arv treatment is only successful if the patient complies with the role of medication, which is twice a day. otherwise, the treatment effectivity will reduce significantly (18). the symptoms are headache, fatigue, anemia, itching, nausea/vomiting, diarrhea, lipodystrophy, skin rashes, skin discoloration, neuropathy, and sleep disorders. the problem that could arise on the antiretroviral drugs was reported by previous research such as headache, fatigue, anemia, itching, nausea/vomiting, diarrheal, lipodystrophy, skin rashes, skin discoloration, neuropathy, and sleep disorders (19). the good pre-test counseling is influencing the post-test result, due to the chemistry between the client and counselor. the main challenge during the post-test counseling is when the client is not coming for the result consultation, long waiting time for the test, and the failure of pretest counseling. in addition, the comfort room for counseling also affects the quality of the counseling. generally, the post-test section is important in this cycle of counseling because this stage will confirm the client is negative or positive hiv/aids (20). meanwhile, if the client receives negative results, it can lead them to avoid unfavorable behavior (5). epidemiology and society health review| eshr vol 2 no1 2020 7 conclusions the counseling process in the pre-test and post-test has been running well and the following sop from the hospital. however, some challenges still faced by the terms counselor (a division of labor), the waiting time while waiting for the results of tests vct. vct services, in general, has been running quite well, but some challenges need to be attentive, such as long waiting time to the associated service. authors contribution sm was drafting the manuscript. dr contributed to the data collection. funding this research does not receive external funding conflict of interest there is no conflict of interest. references 1. carmelita, p.d. et al. analisis faktorfaktor yang berhubungan dengan praktik skrining ims oleh lelaki seks lelaki (lsl) sebagai upaya pencegahan penularan hiv. 2017. (studi kasus pada semarang gaya community)’, 5, pp. 486–495. 2. ministry of health. statistics aids cases in indonesia. jkarta: dg & pl moh ri; 2016 3. anwar y, nugroho sadi, wulandari sridwi. profil efek samping antiretrovirus pada pasien hiv/aids di rspi prof. dr. sulianti saroso jakarta. jurnal ilmu kefarmasian indonesia. 2018;16(1):49–55. 4. notoatmodjo, s. 2007. promosi kesehatan dan ilmu perilaku.jakarta: rineka cipta;jakarta 5. susanti, rini. pelayanan klinik voluntary counseling and testing (vct) di rumah sakit umum daerah ambarawa kabupaten semarang tahun 2017. indonesia journal of midwivery (ijm) 2018.vol. 1;no 1 6. komisi penanggulangan aids nasional.(2011).upaya penanggulangan hiv danaids di indonesia 2006-2011 7. nursalam & kurniawati, d. (2011). asuhan keperawatan pada pasien terinfeksi hiv/aids. jakarta: salemba medika 8. sumini, hadisaputro s, anies, laksono b, sofro ma. faktor risiko yang berpengaruh terhadap kejadian hiv/aids pada pengguna napza suntik (studi epidemiologi di kota pontianak). j epidemiol kesehat komunitas. 2017;2(1):36–45. 9. kepmenkes. keputusan menteri kesehatan republik indonesia nomor 1507/meneks/sk/x/2005 tentang pedoman pelayanan voluntary counseling and testing (vct). jakarta: kepmenkes ri; 2005. 10. baroroh i, puspaningtyas m, kusumawardani d, andanawarih p, immune a, syndrome d. analisis upaya penemuan kasus hiv aids di rsud kraton kabupaten pekalongan. j siklus. 2017;6(1):169–75 epidemiology and society health review| eshr vol 2 no1 2020 8 11. umam, husnul, dkk. identifikasi karakteristik orang risiko tinggi hiv dan aids tentang program pelayanan voluntary counseling and testing (vct).2015. riau. jom vol 2. no 1 12. ministry of health. national guidelines for clinical management of hiv infection and antiretroviral therapy. jakarta: ministry of health; 2011 13. mujiati, sugiharti, isakh bm. gambaran pelaksanaan layanan voluntary counseling and testing (vct ) dan sarana prasarana klinik vct di kota bandung tahun 2013. j kesehat reproduksi. 2013;4(3):1–8. 14. departemen kesehatan ri. pedoman pelayanan konseling dan testing hiv-aidssecara sukarela (voluntary counseling and testing). direktorat jenderal pengendalian penyakit dan penyehatan lingkungan, departemen kesehatan republik indonesia, jakarta. 2006 15. st. lawrence js, kelly ja, dickson-gomez j, owczarzak j, amirkhanian ya, sitzler c. attitudes toward hiv voluntary counseling and testing (vct) among african american men who have sex with men: concerns underlying reluctance to test. aids educ prev [internet]. 2015 may 26;27(3):195–211. available from: https://doi.org/10.1521/aeap.2015.27.3.19 16. widiyanto g, widjanarko b, suryoputro a, kesehatan d, grobogan k, tengah j, et al. faktorfaktor yang berhubungan dengan praktik wanita pekerja seks ( wps ) dalam vct ulang di lokalisasi sunan kuning kota semarang. j promosi kesehat indonesia. 2009;4(1):25–35. 17. international fh. vct toolkit [internet]. 2004. available from: http://www.fhi.org 18. gardner em, mclees mp, steiner jf, rio c, burman wj. the spectrum of engagement in hiv care and its relevance to test-and-treat strategies for prevention of hiv infection. hiv/aids cid. 2011;52:793–800. 19. hidayati nr, setyaningsih i, pandawangi s. level of hiv/aids patient adherence to use of antiretroviral (arv) drug in rsud gunung jati cirebon. j ilm farm. 2018;15(2):58–66. 20. perkumpulan keluarga berencana indonesia. 2016. voluntary counseling and testing (vct). https://pkbi-diy.info/voluntary-counseling-and-testing-vct/ microsoft word 2164-6112-1-sm rv ss aw pr -2 final.docx epidemiology and society health review| eshr vol 2, no 2 (2020) 45 research article the different mental health patient quality of life during shackling, treatment, and post treatment arif widodo1* and supratman1 do1 and supratman1 1 department of nursing – health science faculty – universitas muhammadiyah surakarta, central java, indonesia. *correspondence: arif.widodo@ums.ac.id. telp: +628164272436. received may 05, 2020; accepted may 28, 2020; published may 28, 2020 abstract background: mental health is a well-being mental state associated with happiness, joy, satisfaction, achievement, optimism, and hope. good mental health allows a harmonious and productive life as an integral part of one's quality of life by taking into account all aspects of human life. this study aims to assess the different quality of life among mental health disorder patients during shackling, treatment, and post-treatment in sukoharjo regency. methods: quantitative descriptive was used in this study. our population was all mental disorder patient in sukoharjo district who has experienced with shackling and finished the treatment in the rsjd “dr arif zainudin," surakarta during 2011-2015. we took total sampling and excluded patients who died, move to another place, and recover. thirty out of thirty-four post-shackling patients in the sukoharjo regency participated in this study. a tested questionnaire was used to collect the data from the patient. the analysis was performed using univariate analysis – central tendency value analysis. results: we found differences in patients' quality of life during shackling, treatment, and posttreatment. the survivor had the highest quality of life in the post-treatment phase compared to the shackled and treatment period. conclusions: the quality of life of post-treatment patients is better compared during shackled and treatment. keywords: quality of life, post shackling patients, people with mental disorders introduction the indonesia law number 18 of 2014 concerning mental health, in chapter 1, article 1, states that mental health is a condition of an individual who can develop physically, mentally, spiritually, and socially. accordingly, the individual realizes his ability, able to overcome the pressure, work productively, and contribute to the community (1). mental health is a state of happiness, joy, satisfaction with the achievement of its business; it is a prosperous condition when someone enables to realize his potential, has good coping to stressors, productive, and can make a positive contribution to society (2,3). furthermore, according to johnson, mental health is an emotionally, psychologically, and socially healthy, as seen from satisfying interpersonal relationships, effective coping behaviors, positive selfconcepts, and emotional stability (4). epidemiology and society health review| eshr vol 2, no 2 (2020) 46 world health organization (who) report in 2003 stated that there were 450 million people in the world who had mental disorders (5). human rights watch reported, indonesia, that has more than 250 million of citizen only has 600-800 psychiatrists. it means that one psychiatrist should handles 300,000 to 400,000 mental disorder patients (6). according to indonesia basic health research/riskesdas, the prevalence of schizophrenia/psychosis increased from 0.17 % to 0.18% (7,8). the incidence of schizophrenia/psychosis in central java in 2018 was 0.25% among 34,490,835 citizens. this number implies 86,222,709 psychotic patients must be treated (8). the capacity of psychiatric care services in central java is under 1,000 beds. this condition proves that psychiatric services can serve not all patients at the mental hospital in central java. the remaining untreated patients were in the community; they need close supervision by the health authority. mental disorder patients, especially psychosis, will experience a reality orientation disorder, mood changes, personality disorder, habits, and or withdrawal that end up isolating themselves (9). the most psychotic patients are schizophrenic patients, who may initially be calm, but sometimes unexpectedly become aggressive without apparent psychosocial stressors. accordingly, the family and community shackled survivors to avoid unexpected events such as hurt and disturbing themselves and surrounding people. factors that affect the quality of life of schizophrenic patients are essential to be studied to see the indicators of people's mental health. factors which influence the quality of life of schizophrenic patients: 1) socio-demographic variables such as gender, marital status, education level, occupation, and income level, 2) clinical variables, for instance, psychopharmaceutical use, side effects of drugs consumption, delay in getting treatment, and agitation (10). after shackling, survivors may recover from severe mental disorders, get back to the community for work, and live like ordinary people. however, the recovery process does not always run smoothly; sometimes, there are ups and downs. to reach the recovery process well, it needs support from various parties, especially from the survivor family or close friend, health workers, their fellow, and their surrounding communities. based on the above background, we are interested in examining the differences in the quality of life of patients being shackled, the time of care, and post-treatment of patients after shackling in the sukoharjo regency. methods this study aimed to assess the different quality of life of mental health disorder patients during their shackling, treatment in hospital, and post-treatment in sukoharjo, central java of indonesia. we designed this study using quantitative descriptive. a tested questionnaire was employed to collect information from the respondent. questionnaire consist of 23 likert scale items: always, frequently, sometimes, ever, never. the favorable questions were scored from 4 to 0 and vice versa for unfavorable questions. we involved all patients who recorded in mental health hospitals/rsjd “dr arif zainudin” of surakarta and excluded patients: died, move to another place, and recover. the analysis was performed using univariate analysis by central tendency analysis. results thirty out of thirty-four post-treatment patients in rsjd "dr arif zainudin" of surakarta participated in this study. one patient died, two patients were moving to another place, and a patient has been recovering. characteristic of the respondent was presented in table 1. epidemiology and society health review| eshr vol 2, no 2 (2020) 47 tabel 1. the distribution of respondent characteristic frequency characteristic frequency n = 30 % sex female 14 47,7% male 16 53,3% education elementary 10 33,3% junior high school 10 33,3% senior high school 9 30,0% bachelor/diploma 1 3,4% time of being mental health disorder survivor < 10 years 2 6,7% 11 – 20 years 18 60,0% > 20 years 10 33,3% time of being shackled < 10 years 18 60,0% 11 – 20 years 10 33,3% > 20 years 2 6,7% time of being treated in mental disorder hospital < 5 months 12 40,0% 6 – 10 months 13 43,3% > 11 months 5 16,7% the majority of the respondent (53.3%) were male. most of the respondents were graduated from elementary school. sixty percent of respondents were mental health disorders for 11-20 years. more than half of the respondents were being shackled for less than ten years. most of them were being treated in hospital for 6-10 months (table 1). the difference in the quality of life during shackling, treatment, and post-shackling can be seen in table 2. during shackling, we found 37.90 of the mean. the shackling period experienced an increase in quality of life with a mean of 53.56. subsequently, post-shackling experienced an increase in quality of life, marked with the mean 64.73. table 2. statistical data on quality of life scores when being shackled. quality of life mean median score sd minimum maximum being shackled 37.90 33.00 22.00 69.00 10.66 treatment 53.56 53.00 37.00 82.00 10.22 post-treatment 67.30 71.50 42.00 91.00 11.89 table 3 shows the different quality of life of the mental health disorder survivor. we found that the quality of life was different in the 3 different stages. in the shackled epidemiology and society health review| eshr vol 2, no 2 (2020) 48 period, the survivor had a low quality of life. it was different in the treatment period where the survivor in a moderate level of quality of life. last, in the post-treatment, the survivor had a high or good quality of life. table 3. frequency distribution of quality life quality of life being shackled n (%) treatment n (%) post-treatment n (%) high 2 (6.7) 5 (16.7) 15 (25.0) moderate 12 (40.0) 20 (53.6) 11 (36.7) low 16 (53.3) 5 (16.7) 4 (13.3) total 30 (100) 30 (100) 30 (100) discussions people with mental disorders who are depressed can get trauma, feel discarded, inferiority, despair, and hatred to their family (12). they also suffer from stigma and discrimination from other people that produce the worst situation for the survivor. stigma, discrimination, and beatings by families most often experienced by people with mental illnesses (odgj). shackling also occurs due to a lack of understanding of the community toward mental health (13). previous research said that shackling is considered a necessary step to protect patients and others from the aggressive behavior of patients (14). the lack of finances and dissatisfaction with mental health care services forced the family members to seek alternative treatment. poor knowledge and misunderstanding about schizophrenia are common in family members and community leaders. improving mental health services, especially in rural areas and emphasizing accessibility and quality, is very important. health education about schizophrenia, common misconceptions, and timely administration and appropriate treatment are urgently needed. the study results showed that the quality of life of patients during the treatment period was mostly moderate. this indicates that the quality of life of patients during the treatment has not entirely changed better compared to survivor in a shackled period. shackling causes the patient not to be able to stand up, contracture, damage organs, ease for infectious diseases such as tuberculosis, death, separate from family, getting worst of mental disorders, slow healing, alienation, embarrassed, and violate human rights. appropriate care and support to people with mental disorders can individually recover from their illness and have a satisfying and productive life. recovery is the process in which a person can live, work, study, and participate fully in his community. the results are shown with a mean of 53.56 of the patients' quality of life during the treatment period. efforts to restore or rehabilitate people with mental disorders aim to prepare shackling patients in the community; therefore, a psychosocial rehabilitation program is needed. psychosocial rehabilitation service programs for people with a post-shackling mental illness are required to restore individuals both of their rights and functions as independent citizens; and also can improve their social skills both in the family and community. the study results showed that the quality of life of patients after treatment was mostly in the high/good category. this indicates that post-treatment patients have improved their quality of life. problems that still happen after retention are in the form of stigma and discrimination. people with mental disorders often get stigma from the surrounding environment. the stigma is inherent in himself and his family. this is because people with mental illnesses are believed epidemiology and society health review| eshr vol 2, no 2 (2020) 49 to be dangerous and unpredictable, less competent, unable to work, must be treated at the mental hospital, and will never get healthy (15). mental disorders lead to a decrease in productivity, increase maintenance costs, and tend to cause problems, such as persecution and torture. appropriate care and support to people with mental disorders on an individual basis can recover from illness and have a satisfying and productive life. recovery is the process in which a person can live, work, study, and participate fully in his community. return is the ability to live a good and productive life. rehabilitation is a variety of activities in the form of physical activity, psychosocial adjustments, and vocational training to prepare them and obtain a maximum function and adjustment. quality of life is an individual's perception of his position in life, has to do with values and cultural systems related to ideals, hopes, and views, which are multidimensional measurements. they can not be measured only on physical effects and psychological treatment (16). it is explained that the factors related to a person's quality of life are age, sex, level of education, and employment (17). previous research shows that the misuse of human rights shackling cases does not represent the family or society's ignorance or refusal of psychiatric treatment. but it is linked to the neglect of the government and the responsibility to provide essential mental health services for people with mental illness (18). systematic strategies need to be developed to eradicate this practice. this will require the collaborative participation of policymakers, service developers and managers and health professionals, development ngos, bilateral institutions, and civil society organizations, including those who have a vivid focus on promoting and protecting the most vulnerable human rights in low-resource settings. finally, the only effective and sustainable strategy to eradicate this practice is to ensure the families and communities have affordable and equitable access to essential mental health services. provision of basic community mental health services, where none existed before, allows the majority of people who have detained to receive psychiatric treatment and will be released from shackles. this study shows that the majority of post-treatment psychiatric patients have an adequate quality of life. this condition is possibly caused by families' ability to care for and utilize health services to increase the quality of life of patients after treatment. caring for a sick family member is a form of affection that occurs between family members. the study's results are supported by previous findings that families' ability to care for post-shackling patients dramatically influences the quality of life of shackling patients (19). it is supported by the ignorance of the community or family who has a family member suffers from a mental disorder toward the treatment. in simple terms, the community needs to be given an understanding of shackling; it is following all acts of binding and physical restraint that can result in the loss of one's freedom. from this point of view, deprivation includes neglect, is contrary to humanity, and violates human rights (human rights) and to sufferers of mental disorders (19). this research shows the differences in quality of life during shackling, treatment, and postspackling. when on shackling, the mean was 42.06, the shackling period experienced an increase in quality of life with an average of 53.56. subsequently, post-shackling experienced an increase in quality of life, namely the mean obtained 64.73. this study shows that there are differences in the quality of life when shackling, treatment period, and post-treatment in the working area of sukoharjo district health center. this is because post-shackling psychiatric patients are free from restraints and have received proper care, but this also does not rule out recurrence and retention. proper family care for people with a mental health condition affects the success of the patient's treatment. the results of this study are supported by previous research that providing schizophrenia patient relaxation is very effective in epidemiology and society health review| eshr vol 2, no 2 (2020) 50 reducing muscle tension, anxiety, and fatigue experienced by clients, which will affect the client's mental status (20). the family is the main "nurse" and the biggest support system for clients. mental disorders experienced by clients will cause a variety of responses from the family and the environment, one of them is in the form of shackling one by the family of people with a mental health condition when they are deemed dangerous for the environment. shackling done by the family is strongly influenced by family behavior, including predisposing, enabling, and reinforcing factors. the concept of family is elaborated through several aspects, namely ability, function, role, task, and family characteristics. all of these factors affect the ability of families to take care of mental disorder patients. the results of this study are supported by previous research, who stated that there is a relationship between relapses in schizophrenia patients (20). it shows that with a good attitude in the family can prevent the recurrence of schizophrenic patients. the family attitude of schizophrenia patients in this study attitude can be an effective or positive or negative assessment of an object, which is an effort to improve family attitudes in providing support or caring for schizophrenic patients. it is done by increasing their knowledge first because the level of knowledge will determine one's attitude and behavior. in this respect, someone can play a role in improving health at home and their behavior. former research explained that prevention of containment could be carried out with simultaneous efforts to strengthen basic mental health services and health education regarding schizophrenia or mental illness, common misunderstandings, and the importance of timely and appropriate care needed, especially in rural areas (21). generally, family members and the community assume that shackling is required for safety reasons because of the patient's aggressive behavior, such as physical violence against neighbors, stealing food, and others. according to community leaders, families often do not respond to patient requests to be released from shackles. family members have a lack of finance to seek mental health care and are also dissatisfied with the services. health service providers have insufficient knowledge and prevailing misconceptions about schizophrenia in the community. the form of care activities on the simple matter is possible to be carried out by the family; it gives a spontaneous feeling of care done by other family members. furthermore, it can be concluded that the ability of the family to carry out the task of caring for sick family members will minimize the possibility of psychiatric patients who are being shackled. shackling decreases the physical and social abilities of the patient in their life. research shows that the impact of shackling decreases the ability to care for themselves, the cognitive abilities of patients, and the ability of patients to interact with social life. mental illness is still carried out by families nowadays (22). the situation is contrary to the declaration of the minister of health of the republic of indonesia on october 10, 2010, namely towards indonesia free shackling. the reason is that it violates the law owned by the indonesian state because mental disorders can be cured, and people with mental disorders are entitled to humanized treatment and treatment services. thus, indonesia free shackling has the meaning of efforts to make indonesia free nationally from the practice of shackling and neglect of people with mental disorders. another research concluded that psychosocial care for adolescents who live with parents with shackling patients should consider the psychological and social impacts as a result of caring for their parents with shackling (23). using family approaches, we can improve the quality of a person's life. health promotion from the labor force health to family and patients, it is a form of family care with and health workers to improve the quality of life of patients with a fitted mental disorder (24). a study said that there was a strong relationship between saving and household economic status (25). according to indonesia basic health research/riskesdas, the most contributing factor to epidemiology and society health review| eshr vol 2, no 2 (2020) 51 shackling in indonesia is the household financial status (8). this factor is worsened by the lack of health care facilities and the distance from urban areas. conclusions the quality of life of post-shackling patients in sukoharjo regency when being installed has a low quality of life. there is a difference between the quality of life of patients when being shackled, the period of treatment, and post-treatment of shackling patients in the working area of sukoharjo health center, namely the mean at shackling 37.90, the period of treatment 53.56 and post-treatment 67.30. authors’ contribution all authors contributed equally to writing these articles. funding this research was funded by lppm universitas muhammadiyah surakarta. conflict of interest all authors declare that there is no conflict of interest. references 1. ministry of law and human rights/kemenkumham. undang-undang kesehatan republik indonesia, no. 18 tahun 2014 tentang kesehatan jiwa (2014). tidak dipublikasikan tersimpan dalam lembaran negara ri tahun 2014, nomor 185. 2. varcariolis em, carson vb, shoemaker n. foundation of psychiatric mental health nursing: a clinical approach. (5th ed.), st. louis saunders elsevier; 2006. 3. stuart gw and laraia. principles and practice of psychiatric nursing. (8th ed.), missouri: elsevier mosby; 2005. 4. videbeck sl. psychiatric mental health nursing. (3rd ed.), philadelphia: lippincott williams & wilkins; 2006. 5. who. mental health. geneva; 2003 [cited 2020 may 28]. available from: www.who.int/mental_health 6. human rights watch. indonesia: treating mental health with shackles | human rights watch. 2016 [cited 2020 may 28]. available from: https://www.hrw.org/news/2016/03/20/indonesia-treating-mental-health-shackles 7. indonesia ministry of health. indonesia basic health research (riskesdas) 2013. badan penelitian dan pengembangan kesehatan (balitbangkes) ri, jakarta; 2014. 8. indonesia ministry of health. indonesia basic health research (riskesdas) 2018, badan penerbitan dan pengembangan kesehatan (balitbangkes) ri, jakarta; 2018. 9. stuart gw. prinsip dan praktik keperawatan kesehatan jiwa. (bahasa indonesia ed.). singapore: elsevier mosby; 2015. 10. cardoso cs, caiaffa wt, bandeira m, siqueira al, abreu mns, fonseca jop. factors associated with low quality of life in schizophrenia. artigo. 2005;21(5):1338–40. 11. risnawati d. pamungkas iy & suwarni a. hubungan peran serta keluarga pasien gangguan jiwa dengan perawatan pasca hospitalisasi di desa gedangan grogol sukoharjo. jurnal ilmu keperawatan indonesia. 2014; 7(2):103-110 12. lestari w & wardani yz. stigma dan penanganan penderita gangguan jiwa berat yang dipasung. buletin penelitian sistem kesehatan. 2015; 17(2):156-166 13. fitriani. prinsip dasar dan aplikasi penulisan laporan pendahuluandan strategi pelaksanaan tindakan keperawatan. jakarta: salemba medika; 2009. epidemiology and society health review| eshr vol 2, no 2 (2020) 52 14. laila nh, mahkota r, krianto t, shivalli s. perceptions about pasung (physical restraint and confinement) of schizophrenia patients: a qualitative study among family members and other key stakeholders in bogor regency, west java province, indonesia 2017. int j ment health syst. 2018; 12(1):1–7. available from: https://doi.org/10.1186/s13033-0180216-0 15. lestari ip, choiriyyah z & mutgafi. kecenderungan atau sikap keluarga penderita gangguan jiwa terhadap tindakan pasung (studi kasus di rsj amino gandho hutomo semarang). jurnal keperawatan jiwa. 2014; 2(1):14-23 16. siregar ar and muslimah rn. gambaran kualitas hidup pada wanita dewasa awal penderita kanker payudara. psikologia: jurnal pemikiran & penelitian psikologi, 2018; 9(3):142-152. 17. yusra a. hubungan antara dukungan keluarga dengan kualitas hidup pasien diabetes mellitus tipe 2 di poliklinik penyakit dalam rumah sakit umum pusat fatmawati jakarta. tesis. universitas indonesia; 2011. available from: http://lib.ui.ac.id/file?file=digital/20280162-t aini yusra.pdf 18. minas h and diatri h. pasung: physical restraint and confinement of the mentally ill in the community. international journal of mental healthsystems. 2008; 2(1):1-5. doi:10.1186/1752-4458-2-8. 19. mugianti s and suprajitno. prediction of mental disorders deprived by family. j ners. 2014;9(1):118–25. 20. wulansih s and widodo a. hubungan antara tingkat pengetahuan dan sikap keluarga dengan kekambuhan pada pasien skizofrenia di rsjd surakarta. berita ilmu keperawatan. 2008; 1(4):181-186. 21. harry m and hervita d. pasung: physical restraint and confinement of the mentally ill in the community. international journal of mental health systems. 2008; 2(8): doi:10.1186/1752-4458-2-8. http://www.ijmhs.com/content/2/1/8 22. suharto, b. budaya pasung dan dampak yuridis sosiologi (studi tentang upaya pelepasan pasung dan pencegahan tindakan pemasungan di kabupaten wonogiri). ijms indonesia journal on medical science. 2014; 1(2): 1-10. 23. buanasari a, helena n, daulima c, wardani iy. enfermería clínica. enferm clin. 2018; 28:83–7. 24. widodo a, prabandari ys, sudiyanto a, rahmat i. increasing the quality of life of post shackling patients through multilevel health promotion of shackling prevention. bali med j. 2019; 8(2):678. 25. idiaiani s and raflizar. faktor yang paling dominan terhadap pemasungan orang dengan gangguan jiwa di indonesia. buletin penelitian sistem kesehatan. 2015; 18(1):1-17. microsoft word 2217-6250-1-final-8.docx epidemiology and society health review| eshr vol 2, no2 (2020) 53 research article correlations between mother’s knowledge level of exclusive breastfeeding and the pattern in the 6-month child in posyandu of jatimulyo village, petanahan subdistrict, kebumen regency, central java, indonesia hastin ika indriyastuti 1*, wuri utami2, juad juad2 1 midwifery program, sekolah tinggi ilmu kesehatan muhammadiyah, gombong, central java, indonesia 2 nursing program, sekolah tinggi ilmu kesehatan muhammadiyah, gombong, central java, indonesia *correspondence: hastin.myu@gmail.com. telp: +6285292234445 received 05 may, 2020; accepted 25 june, 2020; published 26 june, 2020 abstract background: globally, the infant mortality rate (imr) is still extremely high. one of the efforts to improve children's health is exclusive breastfeeding for six months. exclusive breastfeeding can reduce infant mortality rate caused by various infectious diseases. thus, the community, especially mothers need to have proper knowledge about exclusive breastfeeding, and then they are expected to practice it. this study aims to determine the relationship between mothers’ knowledge of exclusive breastfeeding and the breastfeeding patterns of 6-month children in jatimulyo village, petanahan sub-district, kab, indonesia. kebumen regency, central java province, indonesia. methods: the study was conducted in jatimulyo village using quantitative methods and correlation design with a cross-sectional approach. this study sample consisted of 56 mothers who had children aged 6-24 months selected based on the total sampling approach. data were analyzed using univariate analysis and bivariate analysis using chi-square statistical tests. results: this study found that most of the respondents are 26-30 years old and have a high school education level with multigravida parity and have a moderate level of knowledge. the study showed a relationship between the level of exclusive breastfeeding knowledge and breastfeeding patterns with a p-value of 0.002 (<0.05) and a correlation value of 0.499. conclusions: therefore, it can be concluded that there is a relationship between the level of knowledge about exclusive breastfeeding and breastfeeding patterns with a p-value of 0.002 (<0.05) and a correlation value of 0.499. keywords: mothers’ knowledge, breastfeeding pattern, baby nutrition, exclusive breastfeeding introduction one of the efforts to improve children's health is by providing exclusive breastfeeding for six months of inborn babies. exclusive breastfeeding can reduce infant mortality rate caused by common infectious diseases in children such as diarrhea and pneumonia. moreover, epidemiology and society health review| eshr vol 2, no2 (2020) 54 exclusive breastfeeding can accelerate the recovery from an illness (1). without exclusive breastfeeding, children will quickly get diarrhea 30 times higher than those receiving exclusive breastfeeding, even though they have higher risks of death due to malnutrition (2). breast milk is beneficial for infant to support their lives, such as immunological, psychological, intelligence, and neurological, while for mothers, it can be a method for controlling pregnancy (3). indonesia’s national health survey (susenas) data show that one in two infants aged 0-5 months receives exclusively breastfeeding (4). the percentage of infants receiving exclusive breastfeeding in rural areas is higher than in urban areas, namely 57.22%, compared to 54.77 % (4). the achievement of exclusive breastfeeding in kebumen district is 66.95% (5). it has not met the government's target yet, as stated in the decision of the ministry of health number 450/menkes/sk/iv/2004 concerning the exclusive breastfeeding target in indonesia, 80%. thus, it can be said that exclusive breastfeeding has not yet reached the goal (3). many factors affect the success of exclusive breastfeeding. a study revealed that mothers whose husbands support exclusive breastfeeding would succeed in practicing it twice as much as those without husbands’ support (6). in other studies, education, knowledge, and experience of the mother become a predisposing factor affecting exclusive breastfeeding, and the support of health workers becomes a motivating factor for exclusive breastfeeding (7). world health organization (who) divides breastfeeding patterns into three: sole, predominant, and partial breastfeeding. exclusive breastfeeding is providing breast milk from birth until six months without any supplementary food except vitamins and both oral and injection medicine. the predominant pattern of breastfeeding is to give water or others before the milk comes out. in contrast, the partial pattern provides complementary foods such as formula milk, water, porridge, or other foods before the baby is six months old, either continuously or pre-reactively (8). based on previous research shows there was a relationship between exclusive breastfeeding knowledge and provision of complementary foods (mpasi) for infants aged 6─12 months in the coverage areas of puskemas samigaluh ii. most mothers who provide mpasi have a secondary education level and are aged 20-40 years with multigravida and do not work or housewives. mothers with a moderate knowledge level of exclusive breastfeeding do not provide mpasi (9). based on the preliminary study conducted in april 2019 in petanahan sub-district, jatimulyo village has the lowest exclusive breastfeeding level in 2018, with only 30%. jatimulyo village has 4 rws (a unit area under village) with seven integrated health services post (posyandu) and 56 mothers with children aged 6-24 months. a total of 3 out of 8 interviewed mothers practice exclusive breastfeeding, and 5 out of 8 interviewed mothers used a partial pattern in breastfeeding. the reasons for using partial patterns include feeling tired to get up in the middle of the night to breastfeed, low breast milk production, and working. based on the mentioned background, we formulated a research question "is there a relationship between the mother's level of knowledge about the exclusive breastfeeding pattern in a 6-month-old child in posyandu of jatimulyo village". given the importance of exclusive breast milk, authors want to know if the knowledge is the underlying of exclusive breastfeeding. methods this quantitative research used a correlation research design with a cross-sectional approach. it aims to link a variable with another. the researchers only observed and measured variables at one particular time. the measurement was not limited to one time epidemiology and society health review| eshr vol 2, no2 (2020) 55 simultaneously, but each subject was only subjected to one measurement without any repetition (6). subjects were measured for their knowledge of exclusive breastfeeding and associated with the breastfeeding patterns. we used a knowledge questionnaire adopted from the tri hartatik study that had been tested for validity (10). the study applied a total sampling technique with 56 respondents with children aged 6-24 months in 7 integrated health services post in jatimulya village, petanahan sub-district. data were analyzed using univariate and bivariate analysis. results respondents characteristic thirty-nine of respondents (69.7%) are 26-30 years old. a total of 30 respondents (53.6%) have senior high education levels. most of them (35 respondents or 62.5%) parity status is multigravida (table 1) table 1. demographic characteristic of respondents table 2 shows that 40 respondents (71.4%) have a moderate level of exclusive breastfeeding knowledge. table 2. distribution frequency of respondents based on knowledge of exclusive breastfeeding in jatimulyo village, june 2020 knowledge of exclusive breastfeeding n = 56 percent (%) high moderate low 12 40 4 21.4 71.4 7.2 total 56 100 variable characteristics n = 56 percent (%) age (year) 17-25 26-35 36-45 12 39 5 21.4 69.7 8.9 total 56 100 education ps jhs shs university 5 17 30 4 8.9 30.4 53.6 7.1 total 56 100 parity primigravida multigravida 21 35 37.5 62.5 total 56 100 epidemiology and society health review| eshr vol 2, no2 (2020) 56 table 3 shows that a total of 24 respondents (42.9%) practice predominant breastfeeding patter. table 3. the frequency distribution of respondents based on breastfeeding patterns in jatimulyo village, petanahan sub-district, june 2020 breastfeeding patterns n = 56 percent (%) exclusive predominant partial 21 24 11 37.5 42.9 19.6 total 56 100 table 4 shows that most respondents have a moderate level of knowledge of exclusive breastfeeding with the breastfeeding pattern varied from exclusive (12 respondents or 21.4%), predominant (20 respondents or 35.7%), and partial (8 respondents or 14.3%). table 4. the relationship between the level of knowledge about exclusive breastfeeding and breastfeeding patterns in jatimulyo village, petanahan subdistrict, june 2020 breastfeeding pattern knowledge of exclusive breastfeeding exclusive predominant partial r p n (%) n (%) n (%) high moderate low 9 (16) 12 (21.4) 0 (0) 3 (35.4) 20 (35.7) 1 (1.8) 0 (0) 8 (14.3) 3 (5.4) 0.499 0,002 total 21 24 11 r = coefficient correlation; p = p-value the chi-square test result shows the correlation coefficient value of 0.499 with a p-value of 0.002 (<0. 05). therefore, it can be concluded that there is a significant relationship between mothers' exclusive breastfeeding and breastfeeding patterns in 6-month-old children at jatimulyo village, petanahan sub-district. discussions this research found that mothers aged 26-30 years are not fully aware of the importance of exclusive breastfeeding. individuals in this age group are mature enough and able to manage family and children (11). according to previous research shows the relationship between the age of mothers and the giving of exclusive breast milk with the value p = 0,026 (< 0.05) (12). the study in jatimulyo village obtained that the respondents with sufficient knowledge in early adulthood due to lack of breast milk experience and were also influenced by cultural cultures still detrimental. based on the research result, a person's education level will affect the level of knowledge. the higher education, the higher awareness of the importance of exclusive breastfeeding and vice versa (11). the result of the study in jatimulyo village revealed that most of the respondents have a high school education level. still, most of them do not have sufficient epidemiology and society health review| eshr vol 2, no2 (2020) 57 knowledge about exclusive breastfeeding because of another factor, namely, parent's culture in breastfeeding. a total of 35 respondents (62.5%) in jatimulyo village have multigravida, and 27 (48.3%) had a moderate level of exclusive breastfeeding knowledge. the result of research in jatimulyo village shows that most respondents with primigravida have a moderate level of knowledge due to lack of experience. previous research shows that 18 mothers (54.54%) with multigravida have a level of knowledge and awareness, and 13 mothers (48.18%) do not have the awareness to practice exclusive breastfeeding with a value of 0.043 <0.05. it means that there is a relationship between parity and the level of awareness in breastfeeding (13). based on data on breastfeeding patterns in jatimulyo village, 24 respondents (42.9%) have a predominant pattern; 21 respondents (37.5%) have exclusive breastfeeding patterns, and 11 respondents (19.6%) have a partial pattern in breastfeeding. it indicates that the mother's exclusive breastfeeding awareness is low and has not met the government targets. based on the collected data from jatimulyo village, respondents of productive age do not always apply exclusive breastfeeding patterns. they also apply predominant patterns due to lack of motivation from health workers and families, and the place of delivery. typically, respondents who give birth at the primary health center will be motivated to practice early initiation breastfeeding and to complete the exclusive breastfeeding. adequate education is the basis for developing insight of people as well as produces motivation on practicing knowledge to attitude and practice. mother with low education causes they slow in adopting new knowledge, including about breastfeeding (14). most respondents or a total of 30 respondents (53.6%) in jatimulyo village have a high school education level, and 14 (25%) of them have predominant breastfeeding patterns. although their education is quite high, some of them lack experience in breastfeeding, lack of motivation from health workers and families, and cultural influences. however, only 14 (25%) respondents with high school education practice the exclusive breastfeeding pattern because they have the motivation and ability to absorb the information provided by health workers. meanwhile, 4 (7.1%) out of 5 (8.9%) respondents with low education level or primary school level have partial patterns due to lack of exclusive breastfeeding knowledge. then, four respondents (7.1%) with university education level have the exclusive breastfeeding pattern. many highly educated mothers manage to give exclusive breastfeeding and open and absorb information easily. accordingly, they know more about the importance of exclusive breastfeeding. this is in line with mardeyanti's research in yogyakarta that found a link between nursing mothers' education and exclusive breastfeeding. it was concluded that low maternal education level increases the risk of mothers not giving exclusive breast milk to their babies (15). our result shows that respondents most widely apply the exclusive pattern with primigravida because they have broader information and knowledge about exclusive breastfeeding, health workers, and family support. it is in line with mabud's research, which showed a relationship between parity and the breastfeeding p-value of 0.04 <0.05 (16). based on the result of research in jatimulyo village, petanahan sub-district, the data obtained from the chi-square test shows a p-value of <0.002 (<0.05). the standard for accepting the hypothesis is if the p-value is <0.05, then ha is accepted. it indicates the relationship between exclusive breastfeeding and breastfeeding patterns with a correlation value of 0.499. the current study shows a relationship between exclusive breastfeeding knowledge and breastfeeding patterns in jatimulyo village. the result of research in epidemiology and society health review| eshr vol 2, no2 (2020) 58 posyandu in jatimulyo village shows that 12 (21.4%) respondents with a moderate level of knowledge have exclusive breastfeeding patterns; 20 respondents (35.7%) have a predominant pattern, and eight respondents (14.3%) apply partial breastfeeding pattern. therefore, the higher level of exclusive breastfeeding knowledge, the higher motivation to practice exclusive breastfeeding. this finding is in line with mabud's research, which shows the relationship between knowledge and exclusive breastfeeding (16). however, the success of exclusive breastfeeding is also affected by several factors such as mother's attitude, family support, information from health workers, and culture. conclusions most of the respondents in posyandu of jatimulyo village are 26─30 years old with a high school education level and in the second parity. the knowledge of respondents in posyandu of jatimulyo village, petanahan sub-district about exclusive breastfeeding, is moderate. this can be one of the factors in the failure of exclusive breastfeeding. most of the respondents in posyandu, jatimulyo village, petanahan sub-district, have predominant breastfeeding patterns. it indicates that the failure of exclusive breastfeeding is still high. there is a relationship between the level of mothers’ knowledge about exclusive breastfeeding and breastfeeding patterns in 6-month-old children in integrated health services post of jatimulyo village, petanahan sub-district. authors’ contribution hs, wr, & jd; study design. hs & jd; data collection. hs, wr, jd&sg; data analysis and revisions for important intellectual content. hs; manuscript writing. all authors read and approved the final manuscript. funding this research was financially supported by sekolah tinggi ilmu kesehatan muhammadiyah gombong, central java, indonesia acknowledgments we acknowledge the supported research department of sekolah tinggi ilmu kesehatan muhammadiyah gombong made this research done well. conflict of interest there is no conflict of interest in this research. references 1. putri r, illahi sa. the relationship between breastfeeding patterns and the frequency of illness in infants. j issues midwifery. 2017;1(1):30–41. (in indonesian) 2. indonesia ministry of health. guidelines for implementing world breastfeeding week. jakarta: kementrian negara pemberdayaan ri; 2010 (in indonesian) 3. amran y, amran vya. description of mother's knowledge of breastfeeding and its impact on exclusive breastfeeding. j kesehat reproduksi. 2013;3(1):52–61. (in indonesian) epidemiology and society health review| eshr vol 2, no2 (2020) 59 4. the indonesian ministry of women's empowerment and child protection (pppa). profile of indonesian children 2018. jakarta: pppa and bps; 2018. (in indonesian) 5. kebumen district health office. kebumen health profile. kebumen: kebumen district health office: 2018. (in indonesian) 6. hani ru. relationship of husband's support to the success of exclusive breastfeeding to primipara mothers in the work area of pisangan puskesmas. thesis. universitas islam syarif hidayatullah; 2014. available from: http://repository.uinjkt.ac.id/dspace/bitstream/123456789/25664/1/ratu ummu hani fkik.pdf. (in indonesian) 7. utami nt, abdullah t, sarake m. factors associated with exclusive breastfeeding in the work area of birobuli primary health center. makasar: faculty of public health, department of bio-statistics, universitas hasanudin; 2012. (in indonesian) 8. institute for health research and development agency. report on the central java province, indonesia basic health research 2018. semarang, litbang kesehatan jawa tengah; 2019. (in indonesian) 9. rahmawati na, tyastuti s, widyasih h. relationship between the level of knowledge about exclusive breastfeeding and early breastfeeding. j involusi kebidanan. 2014;4(7):53–66. (in indonesian) 10. hartatik t. the relationship between mother's knowledge and attitudes with the exclusive gifting in gunungpati village, gunungpati district, semarang city in 2009. unnes; 2009. (in indonesian) 11. wowor m, laoh j, pangemanan d. the relationship between knowledge and attitude with exclusive breastfeeding for breastfeeding mothers at puskesmas bahu, manado. j keperawatan unsrat. 2013;1(1):1–7. (in indonesian) 12. wadud ma. relationship of mother age and the parity with exclusive breastfeeding in 06 months baby in pembina health center of palembang year 2013. 2014 [cited 2020 jun 26]. available from: https://www.academia.edu/9755086/hubungan_umur_ibu_dan_paritas_dengan_pem berian_asi_eksklusif_pada_bayi_berusia_06_bulan_di_puskesmas_pembina_palembang_tahun_2013. (in indonesian) 13. lestari ar, nawangsih, edi uh. relationship between the level of knowledge about exclusive breastfeeding and parity of breastfeeding mothers with exclusive breastfeeding at the sewon ii public health center in bantul in 2013. unisa; 2013. (in indonesian) 14. yolanda d. relationship between education and mother's knowledge level about breastfeeding with exclusive breastfeeding. j ilmu kesehat ’afiyah. 2015;2(1):1–7. (in indonesian) 15. the relationship between work status and maternal compliance provides exclusive breastfeeding at rsup dr. sardjito yogyakarta. universitas gadjah mada; 2007. (in indonesian) 16. mabud n, mandang j, mamuaya t. the relationship between knowledge, education, parity and exclusive breastfeeding in puskesmas bahu, malalayang sub-district, manado. j ilm bidan. 2014;2(2):51–56. (in indonesian) epidemiology and society health review| eshr vol 2, no2 (2020) 60 microsoft word rr_2_5038-article text-21196-1-15-20220510.docx epidemiology and society health review| eshr vol. 4, no. 2, 2022, pp. 48-53 issn 2656-6052 (online) | 2656-1107 (print) 10.26555/eshr.v4i2.5038 48 research article knowledge, attitude, and practice of health care workers in management of bio-medical waste – a cross-sectional study priyanka sharma1, rachana raina2, shweta purbi3*, shashi sudhan sharma4 1 department of microbiology, gmc jammu, india 2 department of pharmacology, gmc jammu, india 3 department of ent, gmc jammu, india 4 department of microbiology, gmc jammu, india *correspondence: shwetapurbi070991@gmail.com. phone: (+91) 8825070804 received 12 november 2021; accepted 26 july 2022; published 2 august 2022 abstract background: management of bio-medical waste involves a great concern. therefore, awareness of health-care workers (hcws) becomes very important as improper management leads to injuries and the spread of infection to the staff, patients, and environment. the objective is to assess the knowledge, attitude, and practice (kap) among health care professionals regarding bio-medical waste management (bmwm). method: this cross-sectional survey was conducted among hcws at gmc jammu, india. study participants were divided into iii groups (group i32 doctors, group ii48 paramedical staff including nurses & laboratory technicians, and group iii20 sanitary workers). data was collected using a pre-designed questionnaire regarding bmwm and scored as good, average, and poor. results: in our study, knowledge regarding symbols of bmwm and awareness regarding categories and segregation of bmw was good in i and ii groups but averaged in group iii. none in group iii has attended cme regarding bmwm in the past. in contrast, this percentage was 61% in group ii and 31% in group i. regarding the capping and destroying of needles, 88% of paramedics were doing it correctly. none of the class iv employees received the booster dose of hbv vaccination. conclusion: knowledge regarding bmwm was average in group i and group ii, whereas group iii had the slightest knowledge. attitude regarding the bmw was good in the case of groups i and ii, whereas group iii scored average. practices were scored average in group i, good in group ii, and poor in group iii. keywords: kap studies; bio-medical waste; health care professionals sharma (knowledge, attitude, and practice of health care workers in management of bio-medical waste – a cross-sectional study) vol. 4, no. 2, 2022, pp. 48-53 49 10.26555/eshr.v4i2.5038 introduction bio-medical waste (bmw) is any waste generated during the diagnosis, treatment, or immunization of human beings or animals, research activities, or in the production or testing of biological or health camps (1). this type of waste which has the potential to harm the environment or fitness of a person, is regarded as infectious, and this waste has to be managed as per bmwm rules, 2016 (2), which was further amended in 2018 (3), 2019 (4). it is estimated that out of the total waste generated in healthcare sectors, 85% is nonhazardous, and 15% is bio-hazardous waste. the hazardous part of the waste poses physical, chemical, and/or microbiological risks to the general population and healthcare workers associated with handling, treating, and disposing of waste (5). the waste generation rate ranges from 0.5 to 2.0 kg/bed/day (6). waste includes the materials mixed with the patient’s blood, secretions, infected anatomical parts, biological liquids such as chemicals, medical supplies, medicines, lab discharge, sharps, metallic and glassware, plastics, etc. segregation, collection, in-house transportation, pre-treatment of waste, and storage of waste, before such waste is collected by common bio-medical waste treatment facility (cbwtf) operator becomes very important after waste generation. therefore, the understanding of waste handling needs to be known, understood, and practiced by each staff category according to the updated guidelines (2)(3)(4). due to its potential to spread the infection to patients, attendants, nursing, paramedical staff, and doctors, its effects extend beyond medical establishments' boundaries to the general population and environment (7). and its application became indispensable during the pandemic times like covid-19, where strict awareness and management of bmw are required to halt the spread of infection to the patients, staff, and environment. research on this critical issue has been minimal; therefore, there is an urgent need for planning and policy decisions in the future on this matter (8). with the above objective in mind, this study was performed to assess the knowledge, attitude, and practice (kap) regarding the bmwm among the hcws working in government medical college, jammu, so that policies can be made in the hospital to curb its lack if it is present in any form. method this cross-sectional survey was conducted by the department of microbiology, government medical college, jammu, jammu and kashmir on 100 hcw comprised of 32 doctors, 48 paramedical staff (including technicians and nurses), 20 class iv, i.e., sanitary staff working in the institute dealing with biomedical waste. health care workers (hcws) willing to participate and relatively free during that session were selected randomly and included in the study. three determinants, knowledge, attitude, and practices, were assessed using a pre-designed questionnaire containing 18 questions, eight on knowledge and six on attitude, and four on practice. sanitary staff was asked questions in their native language. the participants were told to return the questionnaire after filling it out immediately. confidentiality of the participants was maintained in every step. the data was compiled on an excel sheet. each correct response was given one mark. the percentage of the score sharma (knowledge, attitude, and practice of health care workers in management of bio-medical waste – a cross-sectional study) vol. 4, no. 2, 2022, pp. 48-53 50 10.26555/eshr.v4i2.5038 was calculated for total correct answers, and then their average rate was categorized as good, average, and poor performance (0-25% poor, 26-75% average, and above 76% as good). the ethical committee granted permission, and informed consent was taken from all study participants. results study participants were divided into iii groups (group i-32 doctors, group ii-48 paramedical staff including nurses and laboratory technicians, and group iii-20 sanitary workers) belonging to our institution. group i and ii were distributed pamphlets, whereas group iii was asked questions verbally. results were compiled in a tabular form on an excel sheet. knowledge, attitude and practice among the groups are presented in table 1, 2 and 3, respectively. table 1. knowledge of health care professionals of bmwm variable group i (n = 32) group ii (n = 48) group iii (n = 20) knowledge about biomedical waste generation 8 (25%) 10 (21%) 0 knowledge of bio-medical waste symbols 26 (82%) 40 (84%) 7 (20%) knowledge of categories of bmw 27 (85%) 39 (82%) 13 (65%) masks (n95, surgical) disposal 24 (75%) 32 (67%) 10 (50%) sharp disposal method 16 (50%) 40 (84%) 6 (30%) time for storing biomedical waste 8 (25%) 2 (5%) 1 (5%) ideas on cleaning of blood spillage 10 (32%) 8 (17%) 0 percentage of hypochlorite for disinfection of glassware 4 (13%) 1 (3%) 0 table 2. attitude of health care professionals of bmwm variable group i (n = 32) group ii (n = 48) group iii (n = 20) bmwm adds to your work burden (yes) 2 (7%) 4 (9%) 5 (25%) bmwm is teamwork (yes) 32 (100%) 48 (100%) 20 (100%) have you attended any cme regarding bmwm in the past (yes) 10 (31%) 29 (61%) 0 (0%) is there any need for further training on biomedical waste management (yes) 32 (100%) 46 (96%) 20 (100%) will you inform to sanitary staff to transport waste once the bag is full (yes) 24 (75%) 46 (96%) 20 (100%) will you advise your sub-ordinates to adopt color coding for waste disposal (yes) 32 (100%) 46 (96%) 7 (35%) sharma (knowledge, attitude, and practice of health care workers in management of bio-medical waste – a cross-sectional study) vol. 4, no. 2, 2022, pp. 48-53 51 10.26555/eshr.v4i2.5038 table 3. practice of health care professionals of bmwm variable group i (n=32) group ii (n=48) group iii (n=20) the practice of capping the needles and using a needle destroyer 2 (7%) 48 (100%) 0 vaccinated against hepatitis b virus booster dose 10 (32%) 24 (50%) 0 practicing hand hygiene in between every activity 32 (100%) 48 (100%) 2(10%) reporting of accidental needle stick injury 22 (69%) 46 (96%) 1(5%) discussion using the three determinants, the management of bmw was analyzed. knowledge regarding the legislature of bmw was found to be poor in all groups, which correlated with the study of bala et al. (9). the knowledge of bmw symbols was found to be good in the case of doctors (82%) and nurses (84%) as compared to sweepers (20%). similar findings were reported in a study by sharma k et al. (10), where 70% of the doctors answered correctly. in our research, awareness regarding categories and segregation of bmw was pretty good in all groups. 75% of doctors, 67% of paramedics, and 50% of class iv knew about the disposal of different types of masks in a yellow bag and the knowledge of sharp disposal; 50% of doctors and 84% of paramedics knew that the needles should be destroyed by needle cutter and syringes have to be discarded in white bags, this finding was in correlation with the study of sharma k et al.(10). majority of our participants didn’t have an idea that bmws should not be stored beyond 48 hours, which was consistent with the findings by malini et al. (11). also, the knowledge regarding the cleaning of blood spills by 10% sodium hypochlorite and disinfection of glasswares was poor in all groups, also observed in the study of sharma k et al. (10). this finding can be attributed to the fewer numbers of departmental lectures or cme on bmwm. the attitude was very positive in all the groups regarding bmwm. the majority of different categories of hcw feel that bmwm is teamwork. it did not create an extra burden on their work, a similar finding by malini et al. (11). none in group iii has attended cme regarding bmwm in the past, whereas this percentage was 61% in group ii and 31% in group i. the study conducted by ananthachari kr et al., srivastav s, and dudi m et al. (12)(13)(14) have shown that 28%, 30%, and 37% of their participants had attended bmwm training, respectively. therefore, for this reason, every group favored enhancing their knowledge, and they are ready to give their 100% attendance on bmw trainings in the future. this finding was similar to the studies by sharma k et al. (10)and sood et al.(15), in which they also concluded that health care staff wanted to attend more training programs. they were also very enthusiastic about informing their sanitary inspector once the bag was full. the motivation to teach the junior staff to follow the bmwm rule was higher in group ii, followed by group i. still, group iii was slightly hesitant, which can be because they had the slightest knowledge about the gravity of the situation. they were never taught the same. during the pandemic of covid-19, the commitment to learn more was tested when we conducted sharma (knowledge, attitude, and practice of health care workers in management of bio-medical waste – a cross-sectional study) vol. 4, no. 2, 2022, pp. 48-53 52 10.26555/eshr.v4i2.5038 different sessions like cme and seminars on wearing and discarding ppe and maintaining hand hygiene. we recorded 100% attendance in other groups. bmwm practices were poor in group iv and average in the case of doctors. paramedics were following the rules religiously. regarding the capping and destroying of needles, 88% of paramedics were doing it correctly. the result can be attributed to the activity being restricted to the nursing staff only. this is similar to the study of sharma k et al. (10), where 80% of paramedics discarded needles by needle cutter. but in a survey by nirupama n et al.(16), 100% of paramedics performed this activity correctly on a routine basis. only 32% of doctors were vaccinated against hepatitis b virus (hbv) booster dose, which is low. this contrasts with soyam gc et al. (17)and vincent s et al.(18), whose percentage was 64.5% and 85.7%, respectively. none of the class iv employees received the booster dose of hbv vaccination. injury reporting due to needle sticks was high among groups i and ii, similar to the mathur et al. (19) study, where approximately 60% of doctors reported injury due to harps. our study showed good hand hygiene practices in between the activity in groups i and ii as compared to group iii, which correlated with the study of sharma k et al. (10). our study showed that sanitary staff had poor kap values among all groups of health care workers which is similar to the findings of madhukumar s et al. (20). conclusion to conclude, it is seen that knowledge regarding bmwm was found to be average in group i and group ii, whereas group iii had the slightest knowledge. attitude regarding the bmw was good in the case of groups i and ii, whereas group iii scored average. practices were scored average in group i, good in group ii, and poor in group iii, and they are needed to be educated in all spheres of bmwm. it was observed that knowledge regarding hospital control practices like cleaning blood spillage and glasswares requires the focus for which everyone was in favor of attending the regular trainings. so continued medical education should be held at regular intervals, hands-on training programs should be held to train all the hcws, and sessions including raising questions and problem solving should be arranged. further booster of hbv dose should be given to all concerned hcws to avoid its risk of exposure. authors' contribution ps did the research design and manuscript. sp did the data collection. rr and ss did the analysis. funding statement this research has not received external funding. conflict of interest there is no conflict of interest in this research. sharma (knowledge, attitude, and practice of health care workers in management of bio-medical waste – a cross-sectional study) vol. 4, no. 2, 2022, pp. 48-53 53 10.26555/eshr.v4i2.5038 references 1. national guidelines on hospital waste management based on the bio-medical waste management and handling rules 1998. bio-medical waste (management and handling) rules. in: government of india, ministry of health and family welfare. 1998. p. 225–30. 2. bio medical waste management (principal) rules 2016. government of india ministry of environment, forest and climate change, 2016. 3. bmwm (amendment) rules 2018. government of india ministry of environment, forest and climate change. notif new delhi, 16th march, 2018. 4. bmwm (amendment) rules 2019. government of india ministry of environment, forest and climate change. notif new delhi, feb, may 2019. 5. li cs jf. physical and chemical composition of hospital waste. infect control hosp epidemioly. 1993;14(3):145–50. 6. anand p, jain r da. knowledge, attitude and practice of biomedical waste management among health care personnel in a teaching institution in haryana, india. int j res med sci. 2016;4:4246–50. 7. nosheen arshad., nayyar s., amin f. mk. pharm. hospital waste disposal. a rev artic sci res. 2011;3(8):1412–9. 8. vincent s, pablo b mn. management of chronic hepatitis b and c in hiv-coinfected patients. j antimicrob chemother. 2006;57(5):815–5. 9. bala s na. awareness of bio-medical waste management among hospital and dental college and hospital employees. a panoramic view. j oral heal comm dent. 2013;7:1– 7. 10. sharma k km and iq. a study on the knowledge, attitude and practice of bio-medical waste management among health care professionals from a rural medical college in north india. intjcurrmicrobiolappsci. 2019;8(12):1238–43. 11. malini a eb. knowledge, attitude and practice of biomedical waste management among health care personnel in a tertiary care hospital in puducherry. intern j biomed res. 2015;6(3):172–6. 12. ananthachari kr dc. a study on assessment of knowledge on biomedical waste management among health care workers of tertiary care hospital. int j community med public heal. 2016;3:2409–13. 13. srivastav s, kariwal p, singh ak sv. evaluation of biomedical waste management practices in multi-speciality tertiary hospital. indian j community heal. 2009;21:46–50. 14. dudi m, sharma r, sharma s jm. assessment of the knowledge, attitude and practices regarding biomedical waste management amongst paramedical staff in a tertiary level health care facility. int j med sci public heal. 2016;5:615–9. 15. sood ag sa. dental perspective on biomedical waste and mercury management: a knowledge, attitude, and practice survey. ind j dent res. 2011;22:371–5. 16. nirupama n, shafee m, jogdand gs rc. knowledge, attitude & practices regarding biomedical waste management. ijcm inst med sci karimnagar, andhrapradesh. 2010;35(2):369–70. 17. soyam gc, hiwarkar pa, kawalkar ug, soyam vc gv. kap study of bio-medical waste management among health care workers in delhi. int j community med public heal. 2017;4:3332–327. 18. vincent s, pablo b mn. management of chronic hepatitis b and c in hiv-coinfected patients. j antimicrob chemother. 2006;57(5):815–8. 19. mathur v, dwivedi s, hassan ma mr. knowledge, attitude, and practices about biomedical waste management among healthcare personnel: a cross-sectional study. indian j comm med. 2011;36:143. 20. madhukumar s rg. study about awareness and practice about health care waste management among hospital staffs in a medical college hospital, banglore. int j basic med sci. 2012;3:8–9. microsoft word 8_5097_amalia_5 agustus_mendeley.edited.docx epidemiology and society health review| eshr vol. 4, no. 2, 2022, pp. 69-75 issn 2656-6052 (online) | 2656-1107 (print) vol. 4, no. 2, 2022, pp. 69-75 10.26555/eshr.v4i2.5097 69 research article factors associated with successful tuberculosis treatment in the primary health care of bekasi kartika putri amalia1, sri rahayu2, erna harfiani2* 1 faculty of medicine, upn veteran jakarta, jakarta, indonesia 2 department of pharmacy, upn veteran jakarta, jakarta, indonesia * correspondence: ernaharfiani@upnvj.ac.id. phone: +6281585042313 received 06 november 2021; accepted 5 august 2022; published 6 august 2022 abstract background: tuberculosis is still a significant disease problem globally as it is one of ten causes of death worldwide and in indonesia. bekasi is the second-largest city with tuberculosis patients after bandung, with 3,355 patients in 2015. the success rate of treatment that has not reached the standard in the primary health care of bekasi, west java, can be related to medication adherence, age, and nutritional status. inadequate nutritional intake in tuberculosis patients will increase the recovery time. the more days of irregularity in taking the drug increases the likelihood of the patient having a default that can lead to drug-resistant tuberculosis. this study aimed to determine the correlation between antituberculosis drug adherence, age, and nutritional status with tuberculosis treatment in new tuberculosis cases in the primary health care of bekasi. method: this was analytic observational research with a cross-sectional design study in 311 new tuberculosis cases at 30 primary health care in bekasi city period 2015. data were analyzed using univariate data and then continued with the chi-square test and logistic regression test. results: the results of the univariate analysis were found to obtain patients' compliance by 84.9% adherent, productive age (91%), and nutritional status with imt under 18.5 kg/m2 (68.8%). chi-square test shown there was a significant relationship between medication adherence (p-value = 0.000; or = 5917.5; 95%ci = 525.57 – 66626.6), age (p-value = 0.003; or = 3.81; 95%ci = 1.63 – 8.90), and nutritional status (p-value = 0.000; or = 7.88; 95%ci = 2.38 – 26.08) with therapeutic outcome. logistic regression analysis showed that anti-tuberculosis drug adherence (p-value = 0.000; or = 5917.5) was the most dominant variable related to tuberculosis treatment success. conclusion: we conclude that the success of tuberculosis treatment in the primary health care of the bekasi period 2015 relates to anti-tuberculosis drug (medication) adherence, age, and nutritional status, while medication adherence has the most significant influence on the success of tuberculosis treatment. keywords: medication adherence; primary health care; tuberculosis treatment; bekasi epidemiology and society health review| eshr vol. 4, no. 2, 2022, pp. 69-75 issn 2656-6052 (online) | 2656-1107 (print) vol. 4, no. 2, 2022, pp. 69-75 10.26555/eshr.v4i2.5097 70 introduction tuberculosis (tb) is one of the significant infectious disease problems closely related to the environment and community behavior. this inflammatory disease of the lung parenchyma is caused by mycobacterium tuberculosis. this disease is one of ten causes of death globally (1). in indonesia, tb cases rose from 331,703 in 2015 to 562,049 in 2019. the new cases of tuberculosis had a mortality rate of 1.8 million people. globally, the reduction in tb incidence between 2015 and 2019 was 9% (from 142 to 130 new cases per 100,000 population) (2). indonesia had an incident rate of 395 cases/100,000 population in 2015, then increased to 845 cases/100,000 population in 2019 (2). the prevalence of tuberculosis in indonesia is mainly found in west java amount 28,901 cases, with a success rate of 82.5%. bekasi is the secondlargest city with tuberculosis patients after bandung, with 3,355 patients in 2015 (3). if we refer to the standard from the who, it means that bekasi has not succeeded in treating tbc. several factors influence the success of tb therapy, including drug adherence, age, and nutritional status of the patient. drug adherence is adherence to tuberculosis treatment regularly and thoroughly without interruption during the treatment period determined by the health worker (4). aulia (2014) stated there was a relationship between age and occupation and successful tuberculosis treatment (5). there was a correlation between nutritional status and recovery of tuberculosis patients (6). the condition of tuberculosis patients can be restored by consuming nutritional foods to fulfill the energy and protein needed to prevent and repair the damage to body tissues, gain weight until it reaches normal, and balance weight and height (7). who’s 2030 target is to decrease 90% the mortality rate of the total death rate in 2015. this target follows the sdgs (sustainable development goals) to end the tuberculosis epidemic by 2030 (2). this research is expected to contribute to understanding the situation of tb in bekasi, which will be helpful for policymakers in creating a proper intervention. method this research was an observational analytic study with a cross-sectional approach. drug adherence is obedience to regular and complete treatment without interruption during the treatment period determined by health workers (yuanasari, 2009). we defined the age group as productive age (18 – 64 years) and non-productive age (more than 64 years). for the nutritional status, we classified as obese (bmi>25kg/m2), normal (18.5 – 25 kg/m2) and underweight (bmi <18.5kg/m2). the population in this study were all new cases of tb patients with bta positive from 30 primary health care in bekasi city in 2015 with 2,925 patients. the sample in this study consisted of new tb patients with bta positive results who took anti-tuberculosis drugs in all primary health care in bekasi city in 2015 and had fulfilled the inclusion criteria, amounting to 311 patients. the inclusion criteria in this study were patients with new cases of pulmonary tuberculosis in bekasi city primary health care who had performed sputum checks with bta positive results who get oat (anti-tuberculosis drugs) at least six months with a complete medical record and are more than 18 years old. epidemiology and society health review| eshr vol. 4, no. 2, 2022, pp. 69-75 issn 2656-6052 (online) | 2656-1107 (print) vol. 4, no. 2, 2022, pp. 69-75 10.26555/eshr.v4i2.5097 71 results this research was conducted in 30 primary health care out of 31 in the city of bekasi because the patient's medical records in one primary health care were incomplete, so the researchers excluded that primary health care. table 1. the characteristic of new cases of tuberculosis patients in bekasi 2015 n = 311 % gender male 195 62.7 female 116 37.3 drug’s adherence yes 264 84.9 no 47 15.1 age productive 283 91 non-productive 28 9 nutritional status obese 4 1.3 normal 93 29.9 underweight 214 68.8 source: secondary data in 30 primary health care in bekasi city, 2015. table 1 shows that among the 311 patients, most were male, 195 patients (62.7%), and 116 female patients (37.3%). the number of patients with medication adherence was 264 (84.9%), and without medication adherence were 47 patients (15.1%). most patients were productive age patients, 283 patients (91%), and new cases of non-productive age were 28 patients (9%). there were 214 patients (68.8%) patients with underweight bmi, 93 patients were in the normal bmi category (29.9%), and four patients were in the obese bmi category (1.3%). we found a significant correlation between medication adherence and successful treatment. table 2 shows the statistical tests of drug adherence using chi-square, obtaining a pvalue <0.005. the odds ratio (or) value in this statistical test is 5917.5, which means that patients who were adherent to taking the anti-tuberculosis drug (oat) have the possibility (odds) of 5917.5 times for successful treatment compared with patients who were not adherent to taking oat. for age versus the success of tb treatment, we found a p-value <0.05, which means that there was a correlation between age and the successful treatment of new cases of pulmonary tuberculosis patients. the or value was 3.81, meaning that new cases of pulmonary tuberculosis patients with productive age have 3.81 times the possibility of successful treatment compared to patients with non-productive age. last, we found a significant correlation between nutritional status and successful treatment. the or value is 7.88, meaning that obese and normal bmi patients are 7.88 times more likely to succeed in therapy than underweight patients. table 3 indicates that drug adherence is the most influential variable in successful treatment, with a p-value of 0.000. epidemiology and society health review| eshr vol. 4, no. 2, 2022, pp. 69-75 issn 2656-6052 (online) | 2656-1107 (print) vol. 4, no. 2, 2022, pp. 69-75 10.26555/eshr.v4i2.5097 72 table 2. association between medication adherence, age, and nutritional status with the success of tb treatment in bekasi 2015 variables successful treatment (n=265) or (95% ci) p-value yes no total n % n % n % drug adherence yes no 263 2 99.6 4.3 1 45 0.4 95.7 264 47 100 100 5917.5 0.000 age productive non-productive 247 18 87.3 64.3 36 10 12.7 35.7 283 28 100 100 3.81 0.003 nutritional status obese and normal underweight 94 171 96.9 79.9 3 43 3.1 20.1 97 214 100 100 7.88 0.000 source: secondary data in 30 primary health care in bekasi city, 2015. table 3. logistic regression result variable p-value or (exp(b)) drug adherence 0.000 7467.18 age 0.503 3.366 nutritional status (obese) 0.179 nutritional status(1) (normal) 0.999 7992312.5 nutritional status(2) (underweight) 0.063 16.252 source: secondary data from 30 primary health care in bekasi city, 2015 discussion the work of oat to kill the bacteria, both dormant and active bacteria, will be maximized in patients of productive age so that successful treatment can be achieved by carrying out treatment to completion. this research is in line with the study conducted by aulia (2014) that there is a correlation between age and successful treatment at the sakti community health center, pidie district (5). the unproductive age patient can affect the drug's effectiveness because drug metabolism and organ function are less efficient in infants and the elderly, so that it can have a more powerful and more prolonged effect in both age groups. the older the age, the more physiological and pathological changes and a decrease in the body's defense system, which affects the body's ability to handle the oat given. in this case, the body must deal with two problems at once, namely the tuberculosis bacilli, which damage the tissues as well as the oat itself, and this situation gets worse if there are diseases that interfere with the function of the kidneys, liver and cardiovascular system (8). elderly patients often become apathetic about their treatment and usually lack the determination or desire to complete a sixmonth treatment program. they are almost three times more likely to react to oat than patients of productive age (9). patient compliance is influenced by the willingness and motivation to recover. in addition, pulmonary tuberculosis patients with medication adherence can have maximum effect of oat, so it causes death to both dormant and active bacteria. according to kurniawan's research epidemiology and society health review| eshr vol. 4, no. 2, 2022, pp. 69-75 issn 2656-6052 (online) | 2656-1107 (print) vol. 4, no. 2, 2022, pp. 69-75 10.26555/eshr.v4i2.5097 73 (2015), of the 43 respondents studied, 30 respondents with medication adherence had negative bta results at the end of treatment (10). oat should be taken regularly according to schedule to avoid treatment failure and recurrence, especially in the intensive treatment phase (11). widiyanto's research (2016) states that medication adherence in tuberculosis treatment is essential. by taking the medication regularly within two weeks, the bacteria have broken down and have no potential to spread (12). therefore, it can be concluded that if medication adherence is high, the recovery rate of positive pulmonary tuberculosis patients will also increase so that the risk of drug-resistant tuberculosis cases can also be prevented. health behavior or a person's level of health is determined by a person's attitude towards health objects. the better a person's attitude towards health, the level of one's health will also be better. a person's adherence to medication is influenced by the person's attitude towards the illness (13)(14). our finding shows a significant correlation between nutritional status and successful treatment. nutritional status can determine the condition of their immune system. a poor nutritional quality that occurs before the patient suffers from tuberculosis can increase the patient's susceptibility to infection with mycobacterium tuberculosis. the poor nutritional status after a patient is infected can be caused by decreased appetite in tuberculosis patients, so the successful treatment is also supported by patient compliance in taking oat. poor nutritional status in tuberculosis patients is caused by anorexia, impaired nutrient absorption, or increased body catabolism (1). there is a correlation between nutritional status (bmi) and recovery in pulmonary tuberculosis patients at the pulmonary clinic of rsud sidoarjo. there is clear evidence that poor nutrition reduces the immunity to tuberculosis. malnutrition in tuberculosis patients can reduce the healing period and increase the mortality rate compared to tuberculosis patients who are not malnourished (6). nutritional status affects the successful treatment of tuberculosis. normal and obese bmi increases immunity so that people can survive pulmonary tuberculosis and accelerate the healing process (15). based on puspitasari et al. (2017), there is a relation between nutritional status and successful treatment in pulmonary tuberculosis patients. good nutritional status has a faster recovery time. balanced nutrition can help to maintain immunity and prevent various diseases, especially pulmonary tuberculosis (12). medication adherence in tuberculosis treatment is essential because by taking the medication regularly for 2 weeks, the bacteria have been divided and have no potential to be transmitted (16). in the intensive (initial) stage, the patient receives medication every day to prevent the occurrence of resistance to all oats, especially rifampicin. if the intensive treatment is given appropriately, usually, the infectious patient becomes non-infectious within 2 weeks. most of the positive bta became negative within 2 months (at the end of intensive treatment). in the advanced stage, the patient gets fewer drugs but for a more extended period. the progressive step is essential to kill the remaining bacteria still in the body, especially persistent bacteria, so the patient can recover and prevent the recurrence. so medication adherence is vital to successful treatment (6)(15). the final result in multivariate analysis with logistic regression is that medication adherence is the most influential variable in the successful treatment, with a p-value of 0.000. patient compliance is influenced by the willingness and motivation to recover (13). health workers epidemiology and society health review| eshr vol. 4, no. 2, 2022, pp. 69-75 issn 2656-6052 (online) | 2656-1107 (print) vol. 4, no. 2, 2022, pp. 69-75 10.26555/eshr.v4i2.5097 74 have conveyed to tuberculosis patients through health promotion and education so that patients take medication according to the type, dose, method, time to drink, and the number of days of taking the appropriate medicine recommended by the doctor. medication adherence is essential because if the treatment is not carried out regularly and does not follow the predetermined time, there will be resistance to the bacteria called multi drugs resistance (mdr) (15). various drugs in standard therapy have different target populations for mycobacterium tuberculosis. isoniazid is an inhibitor of cell wall synthesis, actively kills growing bacteria, and plays a crucial role in eradicating replicating bacteria. rifampicin is an inhibitor of rna synthesis, active against both replicating and non-replicating bacteria. pyrazinamide, considered an inhibitor of proton motive force, only appears in its active form under acidic conditions during the first 2 months of therapy. rifampicin and pyrazinamide played a significant role in shortening the duration of treatment from more than 24 months to only 6 months. each agent's mechanism of action determines the drug's role in the treatment of mycobacterium tuberculosis (10). conclusion based on the results of research analysis and discussion, it can be concluded that the success rate of treatment on 30 primary health care in bekasi city in 2015 was high, with the majority of new cases of pulmonary tuberculosis patients with successful medication on 265 patients (85.2%). in 2015, new cases of pulmonary tuberculosis patients on 30 primary health care in bekasi city were 264 patients (84.9%). most of the new cases of pulmonary tuberculosis patients were patients of productive age, as many as 283 patients (91%). patients with underweight bmi were 214 patients (68.8%). there was a significant correlation between medication adherence (p-value=0.000), age (p-value=0.003), and nutritional status (pvalue=0.000) with the successful treatment at 30 primary health care in bekasi in 2015. medication adherence is the most dominant variable of the successful treatment at 30 primary health care in bekasi in 2015 compared to nutritional status and age variables. acknowledgment the authors would like to acknowledge to medical faculty of upn veteran jakarta and primary health care in bekasi, west java, indonesia. authors' contribution k, e, and s contributed to the research design. k developed the theory, collected the data, and performed the computations. s and e verified the analytical methods. all authors discussed the results and contributed to the final manuscript. funding statement this research has not received external funding conflict of interest there is no conflict of interest in this research. epidemiology and society health review| eshr vol. 4, no. 2, 2022, pp. 69-75 issn 2656-6052 (online) | 2656-1107 (print) vol. 4, no. 2, 2022, pp. 69-75 10.26555/eshr.v4i2.5097 75 references 1. amaliah r. factors associated with failure of conversion of patients with smear-positive pulmonary tb of the intensive phase treatment in the district of bekasi in 2010. universitas indonesia; 2010. 2. who. global tuberculosis report: excecutive summary 2020. genewa; 2019. available from: https://cdn.who.int/media/docs/default-source/hq-tuberculosis/global-tuberculosisreport-2020/execsumm_11nov2020.pdf?sfvrsn=be12e34e_9 3. central statistics agency of west java province. west java in figures of years 2015 (profil daerah propinsi jawa barat tahun 2015). bandung; 2015. 4. widiyanto a. the relationship between compliance with taking medicines healing of smear positive pulmonary tb patients at puskesmas delanggu kabupaten klaten. integr j heal sci. 2016;6:35–40. 5. aulia y. relationship of age, sex, and occupation with the success of tuberculosis treatment in patients who have received treatment in sakti sub-district, pidie, aceh. postgraduate thesis program, syiah kuala university. 2014. available from: https://etd.unsyiah.ac.id/index.php?p=show_detail&id=4522 6. fatimah, s, intiyati, a, mukhis, a ay. the relationship of nutritional status by curing pulmonary tb patients in lung poly at sidoarjo regional hospital. 2012;60–74. 7. darmanto d. respirologi (respirology medicine). egc. jakarta; 2015. 8. salsabela fe, suryadinata h, desy if. overview of nutritional status in tuberculosis patients at hasan sadikin general hospital bandung (gambaran status nutrisi pada pasien tuberkulosis di rumah sakit umum pusat hasan sadikin bandung). j sist kesehat. 2016;2(2):84–9. 9. yuanasari. evaluation of anti tuberculosis drug use and compliance in adult patients with a diagnosis of pulmonary tuberculosis at the mantingan ngawi public health center for the period of february-april 2009. surakarta; faculty of pharmacy, muhammadiyah university of surakarta. universitas muhammadiyah surakarta; 2009. 10. kurniawan, n, hd, sr ig. factors affecting the success of pulmonary tuberculosis treatment. 2015;735–8. 11. irianti t, kuswandi, yasin nm, kusumanintyas ra. mengenal anti-tuberkulosis. grafika indah. yogyakarta: grafika indah; 2016. available from: https://repository.ugm.ac.id/273526/1/draft buku antituberkulosis 14 desember.pdf 12. kementerian kesehatan. pemerintah ri. permenkes ri nomor 67 tentang penanggulangan tuberkulosis. indonesia ministry of health. jakarta; 2016. 13. ministry of health ri. indonesia health profile 2020. jakarta: balitbang kemenkes ri. jakarta; 2021. 14. puspita e. gambaran status gizi pada pasien tuberculosis paru yang menjalani rawat jalan di rsud arifin achmad pekanbaru. jom fk. 2016;3(2):1–16. 15. indonesia ministry of health. tuberculosis finds a cure until healed. indonesia ministry of health. jakarta; 2015. 16. salsabela, fe, suryadinata, h ai. overview of nutritional status in tuberculosis patients at hasan sadikin central general hospital. padjajaran university. 2016. microsoft word 1872-5192-ed-r1-r2-pr.edited.docx epidemiology and society health review| eshr vol 2 no1 2020 15 research article comparative analysis the coverages of filariasis mass prevention drug (popm) in central java year 2018: case study in grobogan, semarang, and wonosobo setya ningrum1, rokhmayanti rokhmayanti1*, mieng nova sutopo2 1 faculty of public health, ahmad dahlan university, yogyakarta, indonesia 2 center for environmental health engineering and disease control, yogyakarta, indonesia *correspondence: rokhmayanti@ikm.uad.ac.id. tel: +6281229517992 received 10 february 2020; accepted 31 march 2020; published 01 april 2020 abstract background: filariasis is a disease caused by filarial worms and transmitted by mosquitoes that contain filarial worms. pemberian obat pencegahan masal (popm) filariasis or mass prevention drug is a program aimed to reduce the number of filariasis. the survey of popm in grobogan, semarang, and wonosobo, shows there are different coverages of 65% and 85%. the purpose of this study is to compare the survey coverage of popm filariasis. seek the reason not to participate, and the characteristics of the respondents who did not take filariasis medicine in grobogan, semarang, and wonosobo. methods: descriptive quantitative study was used in this study by collecting secondary data of popm survey coverage in grobogan, semarang, and wonosobo year 2018. descriptive and comparative analysis was applied to respondent characteristics, filaria popm coverage, and elaborate the unconformity to the filaria medication. results: grobogan coverage is low compared to semarang and wonosobo. the respondent said about traveling, don't know, and age as the reason to not take the filariasis medication. conclusions: among the three districts, grobogan is the district with low filariasis medication coverage compared to semarang and wonosobo. keywords: filariasis, popm, grobogan, semarang, wonosobo introduction filariasis is a chronic infectious disease caused by the filarial worms and transmitted by mosquitoes that contain filarial worms in their body. the worm grows into an adult in the human body and settles in the lymphatic tissue, causing swelling in the feet, legs, breasts, arms, and genital organs (1). currently, globally there are 1.3 billion people at risk of transmitting the filariasis that spreads in more than 83 countries, and 60% of cases are in southeast asia (2). in indonesia, found three species of filarial worms: wuchereria bancrofti, brugia malayi, and brugia timori (3). from 2014-2018, 2014 was the highest filariasis case, recorded 14,932 cases during that year, and declined in 2018 with 10,681 cases. filariasis in indonesia spread across 34 provinces. five provinces with the most cases of chronic filariasis are papua, east nusa tenggara, west java, west papua, and aceh (2). in central java, in 2018, there were 439 cases of chronic filariasis that mostly found in nine districts/cities that became endemic epidemiology and society health review| eshr vol 2 no1 2020 16 areas: pekalongan, pekalongan, brebes, wonosobo, semarang, grobogan, blora, pati and demak (4). indonesia minister of health leads the filaria control program under the regulation no. 94 the year 2014 about filariasis elimination. this regulation states about the main activity on the elimination is implementing a popm (filariasis mass prevention drug) program. filaria elimination goal is reducing the microfilariae number to less than 1% in each district. surveys of the program implementation can identify filariasis popm coverage. the popm filariasis coverage survey was conducted for all people living in endemic filariasis areas. the subject of this survey is divided into two groups, namely popm target, and nonpopm target respondents. popm target is each residence who aged 2-70 years in all education levels. non popm target respondents are every residence outside the target group, such as pregnant women, people with chronic illness, aged less than 2 years, and above 70 years. popm filariasis coverage is measured by two categories: 65% coverage and 85% coverage. 65% coverage is the ratio of the number of respondents taking the drug, with the total number of respondents multiplied by 100%. high coverage for this standard means the proportion of taking medication is above 65% for all respondents. 85% coverage is the ratio of the number of respondents taking the drug with the number of target respondents multiplied by 100%. 85% coverage can be called as high if the proportion of taking filaria drugs is above 85% of the target respondents (5)-(7). 65% / 85% 𝑐𝑜𝑣𝑒𝑟𝑎𝑔𝑒 = 𝑁𝑢𝑚𝑏𝑒𝑟 𝑜𝑓 𝑟𝑒𝑠𝑝𝑜𝑛𝑑𝑒𝑛𝑡 𝑡𝑎𝑘𝑒𝑠 𝑓𝑖𝑙𝑎𝑟𝑖𝑎 𝑑𝑟𝑢𝑔 𝐴𝑙𝑙 𝑟𝑒𝑠𝑝𝑜𝑛𝑑𝑒𝑛𝑠 𝑥 100% in 65% target coverage, grobogan, semarang, and wonosobo are stand in 81%, 84%, 83%, respectively. when in 85% target coverage, they stand in 85%, 91%, and 91%, respectively (5)(6)(7). this study aims to compare the coverage of popm filariasis and people's motivation not to participate, include their characteristics in grobogan, semarang, and wonosobo. methods descriptive quantitative design was applied to illustrate the comparative results popm filariasis coverage in grobogan, semarang, and wonosobo year 2018. the table and graphics were used to display the result. secondary data (popm coverage filariasis) was collected from bbtklpp yogyakarta from 5-31 august 2019. this data based on the bbtkplpp survey year 2018. the population of this research was all people aged 2-70 years living in grobogan, semarang, and wonosobo, they are not pregnant, not sick, aged not less than two years and not more than 70 years were included in this study. in three districts (grobogan, semarang, and wonosobo), we included 1,115; 1,242 and 1,170 respondents, respectively. the analysis was performed using descriptive and comparative analysis. results comparisons of filariasis medication compliance in grobogan, semarang and wonosobo year 2019 according to the data, grobogan, semarang, and wonosobo have reached the national target (65% and 85%) (figure 1). filaria popm coverage in three districts was categorized as high both for 65% and 85 % measure. on 65% target, semarang is the district with the highest epidemiology and society health review| eshr vol 2 no1 2020 17 coverage (84%), and in 85% target, semarang and wonosobo have similar coverage (91%). this result implies in semarang and wonosobo, popm targets have high conformity to take filaria drugs compared to grobogan. source: bbtklpp yogyakarta, 2018 figure 1. results of drinking drug coverage filariasis in grobogan, semarang and wonosobo 2018 the reason to not comply with filariasis medication in grobogan, semarang and wonosobo year 2018 among the three districts, grobogan has the highest number of not conforming people to filariasis medication (208 people) compared to semarang and wonosobo, with 204 people each of them. however, the differences among them are not significant. non-popm targets said about pregnant, sick, and age reason to not adhere to the program. while for popm target they said refuse, don't know, travel and other specific reasons (table 1) table 1. the motivation of people to not comply with filariasis medications in grobogan, semarang and wonosobo 2018 no. reason number of people grobogan semarang wonosobo 1 not popm target pregnant 11 13 16 sick 16 28 46 age 44 62 53 amount 71 103 115 2 popm target refuse 25 18 7 do not know 28 49 9 travel 64 32 54 other: breastfeeding, do not have an id card, forget to drink, without explanation 20 2 19 amount 137 101 89 total 208 204 204 source: bbtklpp yogyakarta, 2018 81 84 83 86 91 91 75 80 85 90 95 grobogan semarang wonosobo p er ce nt ag e cakupan 65% cakupan 85%65% coverage target 85% coverage target epidemiology and society health review| eshr vol 2 no1 2020 18 characteristics of popm target who not take filariasis drugs in grobogan, semarang and wonosobo year 2018 table 2 shows that grobogan is the district with people's popm target but not comply with the program. in three districts, most of the respondents are aged 16-70 years, hold primary school, and the majority of them are male (table 2). table 2. characteristics of popm target who not take filariasis drugs in grobogan, semarang and wonosobo year 2018 no. characteristics number of respondents (people) grobogan semarang wonosobo 1 age group (yo) 3-5 14 3 3 6-15 11 14 7 16-70 112 84 79 amount 137 101 89 2 level of education pre-school 15 12 4 basic school (primary and junior high school) 88 49 59 advance school (senior high school and university) 34 40 26 amount 137 101 89 3 gender male 75 61 46 female 62 40 43 amount 137 101 89 source: bbtklpp yogyakarta, 2018 discussions grobogan is the district with low coverage of popm. some factors are influencing the low coverage of popm filaria. for example, the information does not meet the target due to geographic conditions, inadequate communication facilities, people not in place when the program held, farming, schooling, insufficient knowledge and awareness of the community to take medicine. on the other hand, the popm low coverage shows the weak performance of popm staff. while the little popm coverage compared to the target presents the unsuccessful of the medication (8). the geographical conditions of grobogan may be the reason for this situation. the various geographic area: plains, hills, and plateau could be a barrier for popm staff to deliver information about popm filariasis. another reason, this district consists of mostly by productive age group (15-64 years), which is most of them do the activity away from they reside, such as schooling, laboring in other places. accordingly, they are not in place when popm was held. these results are consistent with research harfaina et al. (2019), which stated there is a significant relationship between job by taking medicine filariasis (9). knowledge among the community in grobogan is categorized as high indicated from the level of education in general. unfortunately, it is in contrast with the low level of awareness on taking filaria medication. this is in line with research nurlaila et al. (2017), who stated that there is a significant relationship between knowledge versus the conformity on medication filariasis (10). epidemiology and society health review| eshr vol 2 no1 2020 19 a similar result was found by rusmini and suryawan (2014), who said there is no significant relationship between education versus filariasis medication. a busy person might neglect to take the filariasis drug (11). however, a person with good knowledge will have better health awareness, such as they comply with taking filaria medications because he knows the benefits of the drug compared to those who are not knowledgeable. indeed, education was influencing the acceptance of health information, but education does not directly influence people to decide on to participate in the health program (12). semarang obtains the highest coverage compared to other districts. it demonstrates the high public awareness of the semarang district to participate in taking medicine filariasis. this achievement shows high awareness among the semarang population and the high performance of the health staff. on the other hand, indeed, the mobility of semarang people is low compared to grobogan due to the industrial setting in semarang (13). accordingly, people easy to meet with the popm staff when the program held because they are in place. in addition, the high coverage of popm filariasis is influenced by community participation on the take the drug, funding efficiency in socialization (14). increasing public knowledge about filariasis and the importance of taking medication is necessary for people who live in areas with filariasis endemic. finding the way out for working people that also need to take medicine is essential to avoid the failure medication among them. if community participation on the popm filaria program is excellent, it is expected the incidence of filariasis in grobogan, semarang, and wonosobo can be reduced (15). in the three districts, people as popm targets have a similar reason for their unconformity to filaria medication. most of them said about children less than 2 years or more than 70 years. it is following the program that targeting people in 2-70 years. some of them talked about the side effect of the filaria drug, such as fever, headache, muscle aches, nausea, and dizziness. another reason for the unconformity is the lack of information about the program that due to people's activities such as working, studying, or temporarily not living in the area. so, when health staff conducts socialization, they not in place. in addition, they talked about breastfeeding and the difference in address between the current location and what is written on the national identity card (ktp) (16). indonesian government uses dec dan albendazole on the filaria program. according to the national guidelines, dec is allowed to be given to pregnant women but not allowed to children under 2 years. while albendazole, totally prohibited for children under 2 years, pregnant woman, and sick person (17). the regulation considers the side effect of the two drugs. for example, albendazole can cause alopecia or hair loss in high consumption of this drug (800mg/day). a pregnant woman is not the popm target because albendazole is embryogenic or embryo growth problem. in children aged under two, the safety is unknown, so the allocation of this drug is prohibited. while at people aged more than 70 years, the forbidden on using this drug-related decreased organ performance in the elderly (18). another reason to not participate in the popm program is not in place or traveling for many purposes, such as work or schooling. in semarang for popm target said that don't know or lack of popm information as to their reason for not participating in the program. this is in line with research astuti, et al. (2014), which states that there is a significant relationship between the socialization of health workers to take medication popm filariasis (19). in this case, the lack of health promotion on popm may lead the inadequate coverage of filariasis. the characteristics of popm filariasis respondents in grobogan, semarang, and wonosobo year 2018 mostly the same: aged 16-70 years, have primary education and are male. people who are holding primary school are the high proportion who not comply with the medications. epidemiology and society health review| eshr vol 2 no1 2020 20 according to alam and marlina (2016), education is not related to filariasis medication; however, knowledge has an association with filariasis medication (20). in this study, males mostly un-conform with filariasis medication. this is in line with the results of research isabella, et al. (2018), which states that there is a significant relationship between the sex by taking medicine filariasis. female found more conform to taking filaria medicine than the male. this is because the majority of men are working while most women are staying at home. as a result, most of the man does not take the medication for his absence related work (21). conclusions grobogan coverage is low compared to semarang and wonosobo. the respondent said about traveling, don't know, and age as the reason to not take the filariasis medication. authors’ contribution sn contributed to the data collection, data analysis, and report writing and manuscript publication, rr contributed to licensing, data analysis, and report writing. mn participated as a provider of data and information, data analysis, and report writing. funding this research has not received external funding acknowledgments thanks to the center for disease control environmental health engineering (bbtkl pp) yogyakarta, which has provided the data and information in the study. conflict of interest there is no conflict of interest in this research. references 1. yamin ra. determinan filariasis. sidoarjo: uwais inspirasi indonesia; 2019. 2. kementerian kesehatan ri. profil kesehatan indonesia 2018. jakarta: kementerian kesehatan ri; 2019. 3. goel tc, goel a. lymphatic filariasis. singapura: springer; 2016. 4. dinas kesehatan jawa tengah. profil kesehatan provinsi jawa tengah tahun 2018. semarang: dinas kesehatan provinsi jawa tengah; 2019. 5. bbtklpp yogyakarta. survei cakupan popm filariasis dan kecacingan terpadu di kabupaten grobogan, jawa tengah tahun 2018. yogyakarta: bbtklpp yogyakarta; 2018. 6. bbtklpp yogyakarta. survei cakupan popm filariasis dan kecacingan terpadu di kabupaten semarang, jawa tengah tahun 2018. yogyakarta: bbtklpp yogyakarta; 2018. 7. bbtklpp yogyakarta. survei cakupan popm filariasis dan kecacingan terpadu di kabupaten wonosobo, jawa tengah tahun 2018. yogyakarta: bbtklpp yogyakarta; epidemiology and society health review| eshr vol 2 no1 2020 21 2018. 8. habibah z, sungkar s. cakupan pemberian obat pencegahan massal filariasis di kabupaten sumba barat daya tahun 2012-2013. j kedokt indones. 2015;3(3):199– 203. 9. harfaina, hadisaputro s, lukmono dt, sakundarno m. faktor-faktor yang mempengaruhi ketidakpatuhan minum obat sebagai upaya pencegahan filariasis di kota pekalongan. j ilm permas j ilm stikes kendal. 2019;9(1):1–6. 10. nurlaila, ginandjar p, martini. faktor-faktor yang berhubungan dengan kepatuhan pengobatan masal di kelurahan non endemis filariasis kota pekalongan. j kesehat masy. 2017;5(4):455–66. 11. rusmini h, suryawan b. faktor-faktor yang mempengaruhi sikap dan perilaku masyarakat terhadap kepatuhan minum obat anti filariasis di kabupaten bogor. j med heal sci. 2014;1(3):1–15. 12. rahardjo s, kusumawati e. hubungan tingkat pendidikan dan pengetahuan dengan perilaku keluarga sadar gizi (kadarzi) pada masyarakat perkotaan dan perdesaan di kabupaten banyumas. j kesmasindo. 2011;4(2):150–8. 13. bps kabupaten semarang. statistik daerah kabupaten semarang 2018. ungaran: badan pusat statistik kabupaten semarang; 2018. 14. munthe s, suryoputro a, margawati a. kinerja petugas kesehatan program penanggulangan filariasis pada kegiatan pemberian obat pencegahan secara massal (popm) filariasis di kabupaten nagekeo nusa tenggara timur. public helath sci j. 2018;10(2):1–8. 15. anorital, marleta dr, kristina p. studi kajian upaya pemberian obat pencegahan masal filariasis terhadap pengendalian penyakit infeksi kecacingan. j biotek medisiana indones. 2016;5(2):95–103. 16. sulistyaningsih n, musthofa sb, kusumawati a. persepsi masyarakat terhadap program eliminasi filariasis melalui (pomp) sebagai upaya pencegahan filariasis di kecamatan bonang, kabupaten demak. j kesehat masy. 2018;6(1):780–91. 17. kementerian kesehatan ri. kepmenkes ri nomor 893/menkes/skviii/2007 tentang pedoman penanggulangan kejadian ikutan pasca pengobatan filariasis. 2007. 18. wahyono tym, purwantyastuti, supali t. filariasis di indonesia. bul jendela epidemiol. 2010;1(2):15–9. 19. astuti ep, ipa m, wahono t, ruliansyah a. analisis perilaku masyarakat terhadap kepaatuhan minum obat filariasis di tiga desa kecamatan majalaya kabupaten bandung tahun 2013. media litbangkes. 2014;24(4):199–208. 20. alamsyah a, marlina t. faktor-faktor yang berhubungan dengan cakupan menelan obat massal pencegah filariasis. j endur. 2016;1(1):17–21. 21. isabella, fitriangga a, natalia d. determinan kepatuhan minum obat anti filariasis pada masyarakat desa selat remis kecamatan teluk pakedai. j kesehat khatulistiwa. 2018;4(2):640–56. epidemiology and society health review| eshr vol 2 no1 2020 22 microsoft word **r1-624-1428-1-sm_edit01.docx epidemiology and society health review| eshr vol 1 no1 2019 9 epidemiology of diphtheria in purwakarta regency, indonesia siwi pramatama mars wijayanti* and alfianti nur fadillah department of public health, faculty of health sciences, jenderal soedirman university, purwokerto, indonesia *correspondence: siwimars@gmail.com. telp,: +628112522937 received 07 august 2019; accepted 09 september 2019; published 09 september 2019 abstract background: diphtheria is considered as a neglected disease since it was successfully eliminated in many countries. however, there were several sporadic reemergence cases of diphtheria and the peak was outbreak in indonesia in 2017. this research was a descriptive study aimed to explore epidemiology of diphtheria by person, time and place in one of diphtheria endemic area. methods: this was a descriptive study with cross sectional design in purwakarta regency, west java, indonesia in 2018. several data were collected in this study such as diphtheria cases by age, time of occurrence, gender, place and immunization status. the data was collected from purwakarta health office. it was the data from the year of 2015-2017. the data was analysed by using descriptive analysis with percentages displayed in graphs and tables. results: this study reveals that purwakarta regency is an endemic area of diphtheria with fluctuated cases since 2015-2017. more cases of diphtheria occurred from september to december in rainy season. more cases suffered by children in 59 years old, however, this disease also infected adult population. the area with high diphtheria cases in this study also areas with high population densities which is conducive for c diphteriae transmission. low coverage of immunization is highlighted in the result of this study, which could explain why diphtheria cases occurred continuously in this area. conclusions: high number of diphtherias in this area should be an awareness for local health officer to do an effective preventive effort such as increasing the coverage of vaccination. furthermore, optimizing the role of religious and community leader should be made to support diphtheria vaccination programs. keywords: diphtheria, epidemiology, bacteria epidemiology and society health review| eshr vol 1 no1 2019 10 introductions diphtheria is considered as a neglected disease since it was successfully eliminated in many countries. this acute communicable disease is caused by corynebacterium diphtheriae that is transmitted from person to person by airborne droplets. there are three corynebacterium species which caused diphtheria, namely, c. diphtheriae, c. ulcerans, and c. pseudotuberculosis (1). the characteristic of this bacterial infection is the local growth of the bacterium in pharynx. symptoms and clinical signs of this disease are a fever up to 38 degrees celsius, a greyish white pseudo-membrane that is not easily released andan easy bleeding in faring, larynx or tonsils. the incubation period of the disease is 2-5 days and can spread to other people 2-4 weeks from the incubation period. the transmission period reaches 6 months (2). exotoxin of c. diptheriae could inhibit the production of proteins by cells, destroy the tissue at the site of the infection, lead to membrane formation and cause inflammation of the heart and cause nerve damage. besides, it also could affect low platelet counts, or thrombocytopenia, and produce protein in the urine in a condition called proteinuria (3). elimination of diphtheria in indonesia had been successful in 1998 after the implementation of massive vaccination. however, there were several sporadic cases which occurred in indonesia. in 2011, indonesia was the second highest country in the world after india with 806 cases of diphtheria and 4.71% case fatality rate (cfr). in the following years, diphtheria infection also occurred in several parts of indonesia. and in mid-november 2017, the ministry of health of the republic of indonesia (mohri) declared that there was an outbreak of diphtheria in indonesia. since january 1 and week 44 in 2017, it was reported that there were 586 clinically-diagnosed diphtheria cases in 95 regencies among 21 provinces in indonesia. the case fatality rate (cfr) reached 5.03 nationally, and between 0%20% provincially (4). the emergence of this outbreak raises the question whether there has been an epidemiological change in this disease. based on indonesia basic health survey, diphtheria immunization rate in indonesia was only 67.7% in 2007, 61.9% in 2010 and 75.6% in 2013. based on the previous studies, the outbreak of diphtheria was correlated with incompleteness or low coverage of immunization program (4, 5). based on the health ministry data, diphtheria in 2017 outbreak was experienced by different age groups. previously, diphtheria is considered as childhood diseases, and when it affected adults it could create more fatal clinical manifestations (6). indeed, it is important to do routine surveillance to monitor the incidence of diphtheria. one of the districts in west java province with high diphtheria cases is purwakarta regency. this area is located at the intersection of three main strategic traffic corridors, namely purwakarta-jakarta, purwakarta-bandung and purwakartacirebon. the re-emergence of diphtheria cases has occurred in this area for several years. in this study, the author would explore by descriptive study about epidemiology of diphtheria by person, time and place in the area of study. this information would be beneficial for basic data of the diphtheria prevention programme. epidemiology and society health review| eshr vol 1 no1 2019 11 methods study design and area this was a descriptive study with cross sectional design in purwakarta regency, west java, indonesia in 2018. this location of study is approximately 80 km southeast of jakarta. the total area of purwakarta regency is 971.72 km² or approximately 2.81% of the total area of west java province with population of 845,509 people with an average population growth rate of 2.28% per year. the male population is 420,380 people, while the female population is 425,129. climatic conditions in purwakarta regency are included in the tropical climate zone, with an average rainfall of 3,093 mm/year and are divided into 2 rain zone areas, namely: zones with temperatures ranging between 22 0 – 28 0 c and zones with temperatures ranging from 17 0260c. data source and data collection several data were collected in this study such as diphtheria cases by age, gender, place and immunization status. the data were collected from purwakarta health office. they were data from the year of 2015-2017. analysis the data were analysed by using descriptive analysis with percentages displayed in graphs and tables. result based on data from purwakarta health office, diphtheria cases in this area from 2015-2017 were 2, 52 and 33 respectively. the fluctuation of cases could be seen in figure 1. the highest cases were observed in 2016. figure 1. distribution of diphteria cases in purwakarta regency 2015-2017 we also recorded the cases based on the month of occurrence (2015-2017) and observed that more cases of diphtheria occurred from september to december (figure 2). 2 52 33 0 10 20 30 40 50 60 2015 2016 2017 diphteria cases in purwakarta regency 2015-2017 diphteria cases epidemiology and society health review| eshr vol 1 no1 2019 12 figure 2. diphtheria cases by month of occurrence in purwakarta regency (20152017) while based on the age groups, more cases occurred in 5-9 years old children, however, this disease also infected adult population as it can be seen in figure 3. figure 3. diphteria cases by age groups in purwakarta regency (2015-2017) 0 0 0 0 0 0 0 0 2 0 0 00 0 0 0 0 0 0 0 11 14 18 9 1 1 3 2 0 3 1 2 3 1 8 9 0 2 4 6 8 10 12 14 16 18 20 jan feb mar apr may jun july aug sept oct nov dec n um be r o f c as es 2015 2016 2017 0 2 4 6 8 10 12 14 16 18 20 < 1 yearsold 1-4 yearsold 5-9 yearsold 10-14 yearsold 15-19 yearsold 20-44 yearsold 45-54 yearsold 1 11 8 19 5 3 13 3 8 15 4 5 1 2015 2016 2017 epidemiology and society health review| eshr vol 1 no1 2019 13 we also collected data of diphtheria cases by gender and also immunization status (table 1) table 1. frequency distribution of cases of diphtheria by gender and immunization status in 2015-2017 variables frequency (n) precentage (%) n= 87 gender a. male 53 61 b. female 34 39 immunization status a. yes 14 16 b. no/not known 73 84 total 87 100.0 table 1 shows that more cases were experienced by male (61%) and out of 87 people, 73 people (84%) were not immunized. meanwhile, epidemiology of diphtheria cases in purwakarta regency by each sub district could be seen in figure 4. figure 4. diphtheria cases based on sub district in purwakarta regency, west java. figure 4 shows that the highest cases of diphtheria in 2016 were in jatiluhur subdistrict which were as many as 21 cases, while in 2017 there were in purwakarta subdistrict, which were 11 cases. 0 5 10 15 20 25 ke c pu rw ak ar ta ke c ba ba ka nc ik ao ke c ci ba tu ke c su ka sa ri ke c su ka ta ni ke c pl er ed ke c te ga lw ar u ke c m an iis ke c d ar an gd an ke c bo jo ng ke c pa sa w ah an ke c po nd ok sa la m ke c w an ay as a ke c ja til uh ur ke c ca m pa ka ke c ki ar ap ed es ke c bu ng ur sa ri 1 1 17 8 1 1 1 3 21 11 2 7 1 1 8 3 2015 2016 2017 epidemiology and society health review| eshr vol 1 no1 2019 14 discussions information about epidemiology of diphtheria, particularly in outbreak occurrence is undoubtedly important as basic data for its prevention and control program. in purwakarta regency, diphtheria cases from 2015-2017 were 2, 52 and 33 respectively. this fact indicates that diphtheria is endemic in this area, in fact there was also high cases (52 cases) in 2016 before the national outbreak in 2017. in this study, it was found that more cases of diphtheria occurred from september to december in rainy season. according to indonesian meteorology and geophysics agency, the rainy season in indonesia begins in the late october-november while the peak of the rainy season occurs in december-february. this result is in accordance with the previous studies which stated that more diphtheria cases occurred in rainy season because immunity of people tend to decrease in rainy season which affects more susceptibility for infectious diseases (7). several seasonal changing and environmental factors, such as temperature, sunlight, rain, wind and humidity are correlated with the increasing number of infectious diseases (8). based on the age groups, more cases occurred in children between 5-9 years old, however this disease also infected adult population. among 5-9 age groups, 19 cases occurred in 2016 and 15 cases in 2017. this result is also in accordance to the previous belief that diphtheria is childhood disease and responsible for childhood morbidity and mortality in the pre-vaccination era (6, 9). in this study, it was also found that diphtheria cases occurred more in male (61%) than female (39%). meanwhile, based on immunization status, it was found that 84% of cases were caused by not being immunized. low coverage of dpt (diphtheria, tetanus and pertussis) immunization in this area could be an explanation of the diphtheria occurrence. the world health organization had recommended this vaccination since 1974 and resulted more than 90% decrease in number of cases globally between 1980 and 2000 (10). the low coverage of vaccination in purwakarta regency could be due to some communities who refused to bring their children to be vaccinated because of religious reason. the communities’ belief in several areas in purwakarta that the vaccine is haram made parents refuse to vaccinate their children. several studies showed that the number of religious exemptions has been increasing and it is leading to the outbreak of vaccine preventable diseases (11, 12). research in india also found that, muslim children had greater chance of being under-vaccinated or unvaccinated compared to hindus (13). based on the location, the highest cases of diphtheria in 2016 were in jatiluhur subdistrict which were as many as 21 cases, while in 2017 were in purwakarta subdistrict, which were 11 cases. in the research setting, purwakarta regency experienced a sporadic occurrence of diphtheria infection. the first re-emergence of diphtheria case happened in 2007 when the first case was discovered in maniis subdistrict area. the high cases which were observed in jatiluhur sub district could be because this area is a tourism area where there is a reservoir of ir. h juanda so that there are many tourists from outside of the area bring the source of transmission. the first case in 2016 was also the first case appeared in the jatiluhur health center until it spread to the village of cisalada, jatiluhur sub-district. the previous research in indonesia showed that child/parent mobility was the major risk factor of diphtheria epidemiology and society health review| eshr vol 1 no1 2019 15 outbreak (14). other risk factors of diphtheria occurrence were nutritional status of children and the source of transmission (15). the area with high diphtheria cases in this study is also areas with high population densities which is condusive for c diphteriae transmission. in line with it, several previous studies confirmed that high population density is correlated with higher risk of diphtheria infection in certain area (16, 17). conclusions this study revealed that purwakarta regency, west java is an endemic area of diphtheria with fluctuated cases since 2015-2017. a low coverage of immunization is a highlighted finding of this study, which could explain why diphtheria cases occurred continuously in this area. high number of diphtheria in this area should be an awareness for the local health officer to do effective preventive effort such as increasing the coverage of vaccination. besides, optimizing the role of religious and community leaders should be made to support diphtheria vaccination programs. authors’ contribution spmw the conceptor of research, writing paper manuscript anf data collection funding this research received no external funding conflict of interest there are no conflicts of interest references 1. both l, collins s, de zoysa a, white j, mandal s, efstratiou a. molecular and epidemiological review of toxigenic diphtheria infections in england between 2007 and 2013. journal of clinical microbiology. 2015;53(2):567-72. 2. efstratiou a, george rc. laboratory guidelines for the diagnosis of infections caused by corynebacterium diphtheriae and c. ulcerans. world health organization. communicable disease and public health. 1999;2(4):250-7. 3. mcevoy p, hadfield tl, polotsky y, yakovlev aa, tzinserling va. the pathology of diphtheria. the journal of infectious diseases. 2000;181(supplement_1):s116-s20. 4. harapan h, anwar s, dimiati h, hayati z, mudatsir m. diphtheria outbreak in indonesia, 2017: an outbreak of an ancient and vaccine-preventable disease in the third millennium. clinical epidemiology and global health. 5. husada d, puspitasari d, kartina l, setiono p, moedjito i, kartika b. six-year surveillance of diphtheria outbreak in indonesia. open forum infectious diseases. 2017;4(suppl 1):s244-s. epidemiology and society health review| eshr vol 1 no1 2019 16 6. murhekar m. epidemiology of diphtheria in india, 1996-2016: implications for prevention and control. the american journal of tropical medicine and hygiene. 2017;97(2):313-8. 7. m r, m m. diphtheria in andhra pradesh-a clinical-epidemiological study2013. 8. fares a. factors influencing the seasonal patterns of infectious diseases. international journal of preventive medicine. 2013;4(2):128-32. 9. khetsuriani n, zakikhany k, jabirov s, saparova n, ursu p, wannemuehler k, et al. seroepidemiology of diphtheria and tetanus among children and young adults in tajikistan: nationwide population-based survey, 2010. vaccine. 2013;31(42):4917-22. 10. kitchin nr. review of diphtheria, tetanus and pertussis vaccines in clinical development. expert review of vaccines. 2011;10(5):605-15. 11. imdad a, tserenpuntsag b, blog ds, halsey na, easton de, shaw j. religious exemptions for immunization and risk of pertussis in new york state, 2000-2011. pediatrics. 2013;132(1):37-43. 12. wielders cc, van binnendijk rs, snijders be, tipples ga, cremer j, fanoy e, et al. mumps epidemic in orthodox religious low-vaccination communities in the netherlands and canada, 2007 to 2009. euro surveillance : bulletin europeen sur les maladies transmissibles = european communicable disease bulletin. 2011;16(41). 13. shrivastwa n, gillespie bw, kolenic ge, lepkowski jm, boulton ml. predictors of vaccination in india for children aged 12-36 months. american journal of preventive medicine. 2015;49(6 suppl 4):s435-44. 14. muhamad ramdan i, susanti r, hayati ifroh r, noviasty r. risk factors for diphtheria outbreak in children aged 1-10 years in east kalimantan province, indonesia2018. 1625 p. 15. quick ml, strebel pm, sutter rw, wooten kg, kobaidze k, malakmadze n, et al. risk factors for diphtheria: a prospective case-control study in the republic of georgia, 1995–1996. the journal of infectious diseases. 2000;181(supplement_1):s121-s9. 16. mardiana de. the influence of immunization and population density to diphtheria’s prevalence in east java. 2018. 2018;6(2):8. 17. podavalenko ap. estimating the complication risk of epidemic situation with diphtheria in ukraine2018. 26-33 p. microsoft word **r1-kecacingan_edit01.docx epidemiology and society health review| eshr vol 1 no1 2019 1 research article the correlation between worm infections and nutritional status among elementary school students liena sofiana*, erni gustina, yuniar wardani, suci musvita ayu, aniq diya nata maula department of public health, public health faculty, universitas ahmad dahlan, yogyakarta, indonesia *correspondence: liena.sofiana@ikm.uad.ac.id. telp.: +6285875555584 received 07 august 2019; accepted 09 september 2019; published 09 september 2019 abstract background: worm disease is an infectious disease that still becomes a public health problem in indonesia. worm can cause a decrease in health, nutrition, intelligence and productivity of the sufferers. worms as parasitic animals do not only take nutrients in the intestines of children, but they also damage the intestinal wall so that they interfere the absorption of these nutrients, consequently it will impact on the decreasing of one's nutritional status and cause other complex nutritional problems. moyudan health center is a community health center in moyudan sub-district region which has the highest cases of helminthiasis (worm infection). therefore, this study aims to determine the relationship between helminthiasis infection and nutritional status. methods: this was an observational analytic study by using a cross sectional approach. the sample of this study were elementary school students in the work area of moyudan health center with samples of 311 respondents. the sampling technique used by multistage random sampling is the selection of samples consisting of the smallest areas of an area. faecal examination was carried out by using the direct method and nutritional status assessment was carried out by anthropometric method based on the anthropometric index body age index per age (bmi / u). data were analyzed by fisher's test. results: the results showed that there were 8 respondents (2.57%) who were positively infected by worms, 28 respondents had underweight nutritional status (9.01%), and 54 respondents had a nutritional status of fat (17.36%). the results of the study showed no correlation between helminthiasis infection and nutritional status (p value = 0.534). conclusions: there is no relationship between helminthiasis and nutritional status in elementary school students in the moyudan community health center working area in sleman regency with a p value of 0.534 so that it is concluded that helminthiasis infection does not provide any significant contribution to nutritional status even though cases of helminthiasis still occur in elementary school students. therefore, it needs more attention from parents, schools and health facilities in dealing with worm problems. keywords: worm infection, nutritional status, elementary school students epidemiology and society health review| eshr vol 1 no1 2019 2 introduction worm disease is an infectious disease that is still a public health problem in indonesia because it spreads in most regions of indonesia. worm can cause health, nutrition, intelligence and productivity problems. similarly, it can also cause loss of fat and protein and blood loss, thus reducing the quality of human resources (1). worms are part of 17 neglected disease (ntd) (2). the most common types of worm that infect humans are ascaris lumbricoides, necator americanus, ancylostoma duodenale, trichuris trichiura, strongyloides stercoralis, trichinella spiralis and enterobius vermicularis (3). more than 1.5 billion people or 24% of the world's population are infected by earthworms that spread throughout the world. infection is widespread in tropical and subtropical regions with the largest number occurring in sub-saharan, africa, america, china and east asia. more than 267 million preschoolers and more than 568 million school-aged children live in the area while these parasites are intensively transmitted and intervened. therefore, treatment is immediately needed (4). the ones who often get infected are pre-schoolers, school-age children, women of childbearing age (including pregnant women in the second and third trimesters and breastfeeding), and adults with high-risk jobs such as tea pickers or miners are also vulnerable to worm infection (4). this disease generally attacks children because their resistance is still low. the factors that influence it are tropical condition, low awareness of cleanliness, poor sanitation, low socio-economic conditions, and population density (5). worms as parasitic animals do not only take nutrients in the child's intestine, but they also damage the intestinal wall so that they release these nutrients (6). worms get food from tissues including proteins that will cause substances of protein and iron. worms will also increase malabsorption nutrition. some earthworms can also cause reduced appetite and therefore they can reduce nutritional intake and physical fitness (4). the prevalence data of worm infection in 2016 in sleman suggested that there were 559 cases of infection and the highest of all was found in moyudan community health centre with 182 cases (7). meanwhile, the screening data of students’ weight and height from two elementary schools in moyudan sub-district showed that 6 out of 170 students were categorized fat and 136 of them were normal. in addition, 12 students were thin and 16 were very thin. after studying the data, the researcher thinks that it is necessary to research this case further as it is important to know how big this case is and what efforts can be done to control and prevent this case. methods study design this research belongs to analytic observational research with cross sectional approach. setting this research was conducted among the elementary students in the coverage area of moyudan community health centre, sleman, yogyakarta. there were 21 elementary schools from 4 villages. data source and data collection the data collection was done by measuring body weight and height to determine bmi (body mass index) of students in the elementary schools. meanwhile, the nutritional status was measured by using scales and microtoise. worm examination was carried out with a direct method using a microscope conducted at the moyudan community health center laboratory. in addition, examination of the number of worm species in faecal samples was also carried out by counting the number of eggs, larvae or adult worms in the preparation. sample population the research sample were elementary school students in the work area of moyudan health center with a total of 311 samples. the school sampling technique was carried out by using probability sampling by means of multiple stage random sampling. 21 elementary schools from 4 villages were randomly selected and each of them had 3 primary schools which were sampled. thus, the number of primary schools used was 12 schools which consists of grade1 to grade 6. the sample consists of epidemiology and society health review| eshr vol 1 no1 2019 3 286 people so that the total sample taken from each primary school were 24 people. respondent samples were taken randomly by using simple random sampling. variables the independent variable in this research was worm infection while the dependent variable was nutritional status of elementary school students. analysis the analysis was done using chi square test with trust interval of 95%. the value of α was 0.05 which also used fisher as its alternative. the requirement for chi square test is when there is no value of expected count below 5 or maximum 20% in cell. ethical approval number: 011804053 the ethical approval is based on ethical research committee of universitas ahmad dahlan yogyakarta. results table 1. respondent distribution based on gender and age variable frequency percentage (%) age (year) 5 1 0,3 6 8 2,6 7 50 16,1 8 64 20,6 9 64 20,6 10 53 17,0 11 55 17,7 12 15 4,8 13 1 0,3 gender male 150 48,0 female 161 52,0 total 311 100,0 source: primary data of 2018 table 1 shows that the genders of the respondents are different. male respondents consisted of 150 students (48.23%) and female respondents are 161 students (51.77%). in terms of age, the table shows that most of respondents are 8and 9-years old totalling 64 students (20.58%) while the least number is those aged between 5 to 13 years old accounting only 1 person (0.32%). epidemiology and society health review| eshr vol 1 no1 2019 4 table 2. worm infections distribution based on gender variable gender total number percentage (%) male female total percentage (%) total percentage (%) worm infection positive 6 1.93 2 0.64 8 2.57 negative 144 46.30 159 51.13 303 97.43 total 150 48.23 161 51.77 311 100.0 nutritional status thin 11 3.54 17 5.47 28 9.01 normal 111 35.69 118 37.94 229 73.63 fat 28 9.00 26 8.36 54 17.36 total 150 48.23 161 51.77 311 100.0 source: primary data of 2018 table 2 shows that most of respondents infected with helminthiasis were male with a total of 6 respondents, while female who were infected with helminthiasis were only 2. based on the nutritional status and sex of respondents, those with the lowest nutritional status were mostly female by5.47%. respondents with the most normal nutritional status were also female by 37.94%, while respondents with surplus nutritional status were more dominated by male, by 9%. table 3. the distribution of worm infection based on worm type worm type gender total percentage (%) male female ascaris lumbricoides 0 1 1 12.5 necator americanus 1 0 1 12.5 ancylostoma duodenale 2 0 2 25.0 enterobius vermicularis 2 1 3 37.5 trichuris trichiura 1 0 1 12.5 total 6 2 8 100.0 source: primary data of 2018 table 3 shows that of the 8 respondents who were positively infected with helminthiasis, in which most of them were infected with enterobius vermicularis by 37.5% and ancylostoma duodenale by 25%. other types of infecting worms were ascaris lumbricoides, necator americanus and trichuris trichiura, by 12.5% consecutively. table 4. fisher's test results between helminthiasis infection and nutritional status in elementary school students in the work area of moyudan public health center, sleman regency variable worm infection nutritional status total rp 95% ci p value thin normal + fat n % n % n % positive 1 0.3 7 2.3 8 2.6 1.403 0.2179.087 0.534 negative 27 8.7 276 88.7 303 97.4 sum 28 9.0 283 91.0 311 100 table 4 shows that after cell merging and fisher test for a 2x2 table, it is found that there is 1 cell (25%) that has an expected count value of less than 5, so that the chi-square test requirements are not met. therefore, fisher test was used as an alternative. from the results of the fisher test it was known that the p value was 0.534, which means that there was no relationship between helminthiasis infection and nutritional status of elementary school students in the work area of moyudan health epidemiology and society health review| eshr vol 1 no1 2019 5 center, sleman regency. fisher's test results also showed a value of rp 1,403 with confidence interval of 95% (ci) 0.217-9,087 which means that from the existing data it could not be concluded that helminthiasis could really become a risk factor that affects nutritional status. discussions the description of the respondents of the elementary school students in the work area of moyudan public health center sleman regency were mostly 8 and 9 years old with a percentage of 20.58% while the least were students aged 5 and 13 years with a percentage of 0.32%. the percentage of female students was 51.77% which was greater than male students (48.23%). the percentage of students infected with helminthiasis was 2.57%, students with malnutrition status was 9.01%, normal was 73.63% and fat was 17.36%. based on table 5, it shows that out of 311 respondents there were 9.01% of respondents with malnutrition status, 17.36% of respondents were categorized fat while 73.63% of respondents were normal. from the results of this study it is known that there was more normal nutritional status than respondents who were thin and fat. based on table 14, it is known that respondents with more or less nutritional status were experienced by respondents who were female and that is equal to 5.47%. meanwhile respondents with surplus nutritional status were more experienced by male respondents with a percentage of 9%. worm disease is an endemic and chronic disease caused by worms with a high prevalence. it is however not lethal, but it risks the health of the human body resulting in a decrease in nutritional conditions and mostly attacks toddlers and children of primary school age (8). from the results of the study in table 3 it is known that out of 311 respondents there were 8 respondents who experienced helminthiasis or by 2.57%. the results of the study shown in table 4 indicate that helminthiasis experienced by respondents occurred due to infection from several types of worms, namely ascaris lumbricoides by 12.5%, americanus by 12.5%, ancylostoma duodenale by 25%, trichuris trichiura by 12.5% and enterobius vermicularis by 37.5%. based on observations the low prevalence of helminthiasis could be caused by good behaviours that they had such as hand washing habits, defecation in the toilet, nails cutting once a week, fingernails biting prevention, and footwear using. this can also be a cause of low prevalence of worms. behaviour had a relationship with infection with soil transmitted helminth in students at pertiwi lamgarot elementary school in ingin jaya district, aceh besar (9). the difference in the number of helminthiasis infections transmitted through soil can be influenced by differences in risk factors including geography and environment, community behaviour towards environmental sanitation and personal hygiene (10). the results of this study also showed that of the 8 respondents who were positively infected with helminthiasis, there were 6 respondents who were male and 2 females. this is in line with the previous studies which said that male sex can be a risk factor for infection with helminthiasis (or = 1.27). this can be due to the fact that a boy more often plays outside the house, so he interacts more frequently with the soil. boys usually play soccer, play marbles or make toys from the ground (10). based on table 6, it is known that out of 8 respondents infected with worms, there were 1 respondent who had underweight nutritional status, 6 respondents had good nutritional status and 1 respondent had fat nutritional status. this is in line with previous studies which showed that respondents who were positively infected with helminthiasis with a status of malnutrition were less compared to students who experienced helminthiasis with a good nutritional status (8). students with malnutrition status were 36.4% and 63.6% were nutritionally good. previous research showed that there was no relationship between sex and nutritional status (p value = 0.550). the results of statistical tests using fisher's test for 2x2 tables or after cell merging that can be seen in table 16 which shows that the relationship between helminthiasis infection and nutritional status in elementary school students in the moyudan health center work area shows that statistically there was no significant relationship between infection with nutritional status (p value = 0.534). the results epidemiology and society health review| eshr vol 1 no1 2019 6 of this study's test can be concluded that helminthiasis was a risk factor that affects nutritional status but was not statistically significant (rp = 1,403, 95% ci = 0.217-9,087). the absence of a relationship between helminthiasis infection and nutritional status in elementary school students in the working area of moyudan health center sleman regency could be due to the low number of children infected with helminthiasis, this is supported by the finding of the previous studies that the low intensity of helminthiasis was a factor that caused the absence in the relationship between helminthiasis and nutritional status (11). besides, a good environmental condition around might also contribute to this case where most of the respondents’ homes had already have the availability of latrines in the category of fulfilling the conditions. in addition, the distance of the source of water from the disposal of faeces was ≥ 10 m. moreover, most of the respondents’ houses had used the type of floor that meets the requirements (12). other studies also shown that many underweight children lived in slum areas with poor water sources, unhealthy latrines and poor sources of drinking water (13). the results of this study suggest that children who had poor nutritional status were not always due to helminthiasis infection, but there were other factors that affect the nutritional status. previous research also shown the same thing that there was no relationship between helminthiasis infection and nutritional status based on bmi / u in children in barabai darat 2 primary school with a value of p value = 1,000. the results of the study showed that there was no significant influence between helminthiasis infection and nutritional status. one reason was because it was not only an infection that could affect the state of human nutrition, but it could also be caused by many other factors. in addition, the process from helminthiasis to a decrease in nutritional status requires a certain period of time and with the severity of certain infections (14). theoretically, helminthiasis, which is one of the infectious diseases, is one of the direct causes that will affect one's nutritional status. this worm can lead to a decrease in the condition of health, nutrition, intelligence and productivity of the sufferer so that it causes many economic losses. worms can cause loss of carbohydrates and proteins and blood, thus reducing the quality of human resources. worms as parasitic animals do not only take nutrients in the child's intestine, but also damage the intestinal wall so that they disturb the absorption of these nutrients (6). nutritional loss is calculated based on the behaviour of each species of worm which harms the sufferer (15). calculation of nutrient loss and economic loss in 3 worm species, namely ascaris lumbricoides, trichuris trichiura and hookworm was done because these three species provide the greatest loss to sufferers. food intake and infectious diseases are the direct causes of malnutrition (15). nutritional and blood loss is likely to increase as the worm's intensity increases in the patient's body, the rapid development of worms requires immediate treatment to prevent new infections from occurring (2). conclusions based on the results of the research and discussion, it could be concluded that there is no correlation between helminthiasis infection and nutritional status in elementary school students in the moyudan health center working area in sleman regency. authors’ contribution all researchers contributed to conducting research ranging from surveys, data collection, data analysis to the preparation of research reports. funding institute for research and community service. acknowledgements the researcher would like to thank universitas ahmad dahlan yogyakarta for providing support and funding for this research. epidemiology and society health review| eshr vol 1 no1 2019 7 conflict of interest there are no conflicts of interest. references 1. kementerian kesehatan republik indonesia. peraturan menteri kesehatan republik indonesia nomor 15 tahun 2017 tentang penanggulangan kecacingan [internet]. jakarta; 2017 [cited 2018 dec 28]. available from: www.peraturan.go.id 2. kesehatan bp dan p. penyakit menular neglected kajian program dan penelitian. buku 1. tjitra, emiliana., sudomo, mohammad., karyana m, editor. jakarta: kementerian kesehatan republik indonesia; 2013. 43 p. 3. sutanto i, ismid i., sjarifuddin p., sungkar s. buku ajar parasitologi kedokteran. jakarta: balai penerbit fakultas kedokteran universitas indonesia; 2009. 4. organization wh. soil-transmitted helminthiases: eliminating soil-transmitted helmnthiases as a public health problem in children [internet]. progress report. france: world health organization; 2012. 1-90 p. available from: http://apps.who.int/iris/bitstream/handle/10665/44804/9789241503129_eng.pdf;jsessionid=08a 9c47002d754e4c5cd704d24c26420?sequence=1 5. kementerian kesehatan republik indonesia. penyakit kecacingan masih dianggap sepele [internet]. kementerian kesehatan republik indonesia. 2010 [cited 2018 dec 28]. p. 1. available from: http://www.depkes.go.id/article/print/1135/penyakit-kecacingan-masihdianggap-sepele.html 6. kementerian kesehatan republik indonesia. pedoman pengendalian kecacingan. jakarta: kementerian kesehatan republik indonesia; 2012. p. 1–48. 7. dinas kesehatan kabupaten sleman. data sekunder dinas kesehatan kabupaten sleman. yogyakarta: dinas kesehatan kabupaten sleman; 2016. 8. m ar, nelly m, franly o. hubungan kecacingan dengan status gizi pada murid sekolah dasar di kabupaten bolaang mongondow utara. ejournal keperawatan. 2013;1(1):1–6. 9. rahmayanti, razali, mudatsir. hubungan pengetahuan, sikap dan tindakan dengan infeksi soil transmitted helminths (sth) pada murid kelas 1, 2 dan 3 sdn pertiwi lamgarot kecamatan ingin jaya kabupaten aceh besar. j biot [internet]. 2014;2(hubungan pengetahuan,sikap,dan tindakan dengan infeksi soil transmitted helminths (sth) pada murid kelas 1.2 dan 3 sdn pertiwi lamgarot kecamatan ingin jaya kabupaten aceh besar):77–137. available from: https://jurnal.arraniry.ac.id/index.php/biotik/article/view/244 10. sandy s, sumarni s, soeyoko. analisis model faktor risiko yang mempengaruhi infeksi kecacingan yang ditularkan melalui tanah pada siswa sekolah dasar di distrik arso kabupaten keerom, papua. media litbangkes. 2015;25(1):1–14. 11. kamila ad, margawati a, nuryanto. hubungan kecacingan dengan status gizi dan prestasi belajar pada anak sekolah dasar kelas iv dan vi di kelurahan bandarharjo semarang. j nutr coll. 2018;7(2):77–83. 12. mahmudah u. hubungan sanitasi lingkungan rumah terhadap kejadian infeksi kecacingan pada anak sekolah dasar. j kesehat. 2017;10(1):32–9. 13. suprapti, hapsari d. status gizi balita berdasarkan kondisi lingkungan dan status ekonomi ( data riskesdas 2007 ). j ekol kesehat. 2007;10(2):103–13. 14. azizaturridha a, istiana, hayatie l. pengaruh infeksi kecacingan terhadap status gizi pada anak di sdn 2 barabai darat kalimantan selatan tahun 2015. berk kedokt. 2016;12(2):165– 73. 15. indriyati l, waris l, luciasari e. kerugian finansial akibat kecacingan: studi di kabupaten nunukan. penelit gizi makan. 2014;37(2):155–60. epidemiology and society health review| eshr vol 1 no1 2019 8 microsoft word 3865 editing new4.docx epidemiology and society health review| eshr vol. 3, no. 2, 2021, pp. 31-35 issn 2656-6052 (online) | 2656-1107 (print) 10.26555/eshr.v3i2.3865 31 viewpoint reform of maternal and child health services during the covid-19 pandemic: is it necessary? yuniar wardani1,2* and ichtiarini nurullita santri2,3 1 special branch of ‘aisyiyah taiwan, taipei taiwan 2 faculty of public health, universitas ahmad dahlan, yogyakarta, indonesia 3 school of public health, college of public health, taipei medical university, taipei, taiwan * correspondence: yuniar.wardani@gmail.com. phone: +886902327548 received 17 march 2021; accepted 30 july 2021; published 10 august 2021 abstract the covid-19 pandemic has impacted the health crisis and led to significant government policy changes with the maternal and child health care system. long-term termination of essential services affects the risk of losing trust in the health system, decreasing services use. health service reform is carried out to maintain the sustainability of health services. priority services aim to ensure access to sexual and reproductive health, growth monitoring, screening for acute malnutrition in children, mothers, and pregnant women. furthermore, implement a health information system to support maternal and child health and a robust system to monitor and respond to real-time data during covid-19. keywords: maternal; child health; covid-19; health reform the new coronavirus (sars-cov2) that causes covid-19 has spread rapidly since emerging in late 2019 in wuhan, china. covid-19 data in southeast asia indicates more than 222,231 confirmed cases with 6,374 deaths (1, 2). as a result, the world health organization declared the disease a global pandemic on march 11, 2020 (3). the covid-19 pandemic is causing a humanitarian crisis in every country globally that has claimed many lives and has threatened people's health, social and economic environment (4). several countries in america and the caribbean have imposed restrictions on international travel, bans on mass gatherings, recommendations for social distancing, non-essential commercial activities, curfews, and mandatory quarantine and national lockdowns (5, 6). pandemics also impact the health crisis and cause significant government policies regarding the health care system (7). nepal is a country that does not know for sure the impact of a pandemic on access to maternal health (8). however, many allegations that the pandemic had a particular effect on maternal and child health care systems. the ebola pandemic in west africa might undermine maternal health services in standard resilience health systems (9). the corona virus (covid-19) has caused women to face more barriers to accessing maternal health care, including restrictions, transportation challenges, and anxiety over the possibility of being exposed to the coronavirus. women do not want to seek health care for fear of catching the virus or passing it on to their unborn baby (10). wardani (reform of maternal and child health services during the covid-19 pandemic: is it necessary?) vol. 3, no. 2, 2021, pp. 31-35 10.26555/eshr.v3i2.3865 32 situation of the mother and child health service system in indonesia the indonesian government has confirmed 257.388 cases of covid-19 in 34 provinces, with 9,977 deaths reported. on april 13, 2020, the indonesian government declared covid-19 a national non-natural disaster. since may 29, 2020, the government has managed the emergency response to the covid-19 outbreak through presidential regulation no.11 of 2020 concerning establishing a public health emergency for covid-19. hospitals must be adaptive and prepare to face changes in several maternal health services (11). this change in maternal and child care methods ultimately triggers anxiety and confusion for mothers and families accessing health services (1). evidence has shown that poor quality of facility-based care for these women and newborns is one of the major contributing factors for their elevated morbidity and mortality rates (12). the study conducted at rsud dr. soetomo reported 110 cases of maternal referral of covid19, 63 rapid tests (+), and 23 covid-19 cases confirmed by pcr. furthermore, universitas airlangga academic hospital received about 47 cases of covid-19 referral in mothers: 24 confirmed cases of covid-19. another report from the universitas airlangga academic hospital confirmed one baby with pcr + was born from the mother through a rapid test (+) (11). health workers have reported disruption of health services at the community level due to physical distancing, with nearly 76% of village health posts (posyandu) closed and more than 41% postponed home visits (13). safe delivery and the care of the newborn are also likely to be compromised. women and adolescents may not access sexual and reproductive health services such as contraception, and pregnant women may neglect antenatal care and even give birth unsupervised. unwanted pregnancies increased, and the potential risk of sexual and reproductive health-related morbidity and mortality. as a result, there is a long-term termination of essential services and the population losing confidence in the health system, leading to decreased use of services. finally, a continuing epidemic has possible adverse psychological impacts on vulnerable groups such as mothers and children (4). even though midwives have become the leading health personnel in providing maternal and infant health services, it is not easy to maintain service quality (1). if you look at the current conditions, in the end, a question arises, is there a need to reform the maternal and child health service system during covid-19? talking about reforming the health care system means talking about the components that exist in the system. one of them is about quality. although it is not easy to define quality, particularly maternal and child care rate, one definition provides a helpful basis. the institute of medicine defines quality care as comprehensive. it includes three main components of quality: clinical (safe and effective), interpersonal (patient-centered), and contextual (timely, efficient, and fair) (14). a maternal and child, health care framework is needed to outline the needs at different health system levels leading to quality care delivery during the covid-19 pandemic. referring to the concept of mother and child care, donabedian revealed the importance of three main components as parameters, namely structure, process, and outcome (15). in detail, it can be explained as follows: structure refers to the context in which health care is provided at the community, district, and facility health system levels. the separation of the structural components is used for decision-making to provide quality maternal health services at each level. a better understanding of the interactions between structural factors at the community, district, and health facility levels will wardani (reform of maternal and child health services during the covid-19 pandemic: is it necessary?) vol. 3, no. 2, 2021, pp. 31-35 10.26555/eshr.v3i2.3865 33 ensure better quality services. ultimately, this will successfully implement interventions to improve maternal and child health status (16). without the interaction between these three levels, it is difficult for indonesia to facilitate quality services, considering that indonesia has tens of provinces and hundreds of districts. process refers to whether the medical practice is well followed and quality care such as clinical, interpersonal, and contextual. timely, efficient, and fair treatment will mandate: without waiting, dangerous delays for those receiving or giving attention; and not wasting equipment (14). services using modern technology such as telemedicine with cell phones are an alternative for providing timely assistance, especially for antenatal care, family planning, and immunization results refer to the results of evaluations about positive user experiences (17), increased demand for services (16), and timely utilization of health services (18). data on measures of maternal and child health is power during a pandemic. data can reflect the strength and be used to improve global health (19). the three keys that maintain maternally and child health services form the basis for the ministry of health in indonesia to ensure health services' sustainability during the covid 19 pandemic. various strategies can be implemented, such as 1) capacity building to support health workers, especially for local health workers who are difficult to access and stay in a remote area; 2) increasing knowledge about health services; 3) involving the community to increase the utilization of maternal and child health which are essential services during the covid-19 pandemic (13); and 4) cross-sectoral cooperation to understand the collaboration between sectors, to carry out activities more efficiently, effectively and fairly and to ensure equality and differences across contexts (20). guarantee the sustainability of maternal and child health services can be done by prioritizing actions on: 1. sexual and reproductive health, including optimal access to contraception, care during pregnancy, childbirth, postpartum and obstetric complications; 2. growth monitoring, screening, and treatment of acute malnutrition in children, women, and pregnant women; 3. it is essential to introduce the new digital approaches to accelerate the access of health information and services for maternal health care and contraceptives such as telemedicine using mobile phones and social media (5). 4. implement a robust health information system that tracks, monitors, and responds to real-time data collection during covid-19, including a surveillance system for maternal and infant mortality and a surveillance and response system to collect data on pregnant women and children born with covid-19. even though the minister of health has compiled a health protocol, the spike in covid-19 in pregnant women and infants still occurs. likewise, disruption services at the community level and posyandu will remain disrupted. however, the health service system's reform must be carried out to ensure maternal and child health services sustainability and achieve sustainable development goals. wardani (reform of maternal and child health services during the covid-19 pandemic: is it necessary?) vol. 3, no. 2, 2021, pp. 31-35 10.26555/eshr.v3i2.3865 34 author’s contribution yw is the single author for this work; she is responsible thorough the content. funding this work has not received external funding. conflict of interest there is no conflict of interest in this research. references 1. johariyah, zubaedah dsn, widyawati, margaretha sepm. how maternal and neonatal services at the community level during the covid-19 pandemic in indonesia? syst rev pharm. 2020;11(11):237–42. 2. who. coronavirus disease 2019 (covid-19): situation report, 69 [internet]. geneva: who; 2020 [cited 16 march 2021]. available from: https://apps.who.int/iris/handle/10665/331615. 3. who. coronavirus disease 2019 (covid-19) situation report 44 [internet]. geneva: who; 2020 [cited 16 march 2021]. available from: https://www.who.int/docs/defaultsource/coronaviruse/situation-reports/20200304-sitrep-44-covid19.pdf?sfvrsn=93937f92_6. 4. ocha., rco. indonesia multi sectoral response plan to at covid-19. [internet]. ocha, rco; 2020. [cited 16 march 2021]. available from: https://www.humanitarianresponse.info/sites/www.humanitarianresponse.info/files/docu ments/files/msrp_extension_final_20201208.pdf. 6. kimani rw, maina r, shumba c, shaibu s. maternal and newborn care during the covid-19 pandemic in kenya: re-contextualizing the community midwifery model. hum resour health. 2020;18(75):2-5. 7. goyal m, singh p, singh k, shekhar s, agrawal n, misra s. the effect of the covid-19 pandemic on maternal health due to delay in seeking health care: experience from a tertiary center. international journal of gynecology & obstetrics. 2021;152(2):231-5. 8. oluoch-aridi j, chelagat t, nyikuri mm, onyango j, guzman d, makanga c, et al. covid-19 effect on access to maternal health services in kenya. frontiers in global women's health. 2020;1(19). 9. delamou a, el ayadi am, sidibe s, delvaux t, camara bs, sandouno sd. effect of ebola virus disease on maternal and child health services in guinea: a retrospective observational cohort study. the lancet global health. 2017;5(4):448-57. 10. pant s, koirala s, subedi m, amgain e. access to maternal health services during covid-19. europasian journal of medical sciences. 2020;2:48-52. 11. laksana mar, habibie ph, wardhana mp, gumilar ke, yusuf m, rahmadhany p. situation report maternal health management during. systematic reviews in pharmacy. 2020;11(8):467-71. 12. austin a, langer a, salam ra, lassi zs, das jk, bhutta za. approaches to improve the quality of maternal and newborn health care: an overview of the evidence. reprod health. 2014;11 (2):2-9. 13. unicef., ministry of health r. report of rapid health assessment: ensuring sustainability of essential health services for children and mothers during the covid19 pandemic in indonesia. jakarta; 2020. [cited 16 march 2021]. available from: https://www.unicef.org/indonesia/reports/report-rapid-health-assessment. 14. institute of medicine committee on quality of health care in a. crossing the quality chasm: a new health system for the 21st century. crossing the quality chasm: a new health system for the 21st century. washington (dc): national academies press (us copyright 2001 by the national academy of sciences). all rights reserved.; 2001. wardani (reform of maternal and child health services during the covid-19 pandemic: is it necessary?) vol. 3, no. 2, 2021, pp. 31-35 10.26555/eshr.v3i2.3865 35 15. donabedian a. the quality of medical care. science (new york). 1978;200(4344):856-64. 16. dogba m, fournier p. human resources and the quality of emergency obstetric care in developing countries: a systematic review of the literature. hum resour health. 2009;7:7. 17. maxwell rj. dimensions of quality revisited: from thought to action. qual health care. 1992;1(3):171-7. 18. stephen r. health service quality an introduction to quality methods for health services. quality in health care. 1993;2(1):67-67. 19. marchant t, boerma t, diaz t, huicho l, kyobutungi c, mershon ch. measurement and accountability for maternal, newborn, and child health: fit for 2030? bmj global health. 2020;5(7):1-3. 20. hinton r, armstrong c, asri e, baesel k, barnett s, blauvelt c. specific considerations for research on the effectiveness of multisectoral collaboration: methods and lessons from 12 country case studies. globalization and health. 2021;17(1):18. microsoft word 1507-3882-r1-r2-pr.docx epidemiology and society health review| eshr vol 2 no1 2020 9 research article traveler’s knowledge and attitudes to access tourism health centre at gunungkidul: case study at indrayanti beach noval ali lating1 and liena sofiana1* 1faculty of public health, university of ahmad dahlan, yogyakarta, indonesia * correspondence: liena.sofiana@ikm.uad.ac.id. tel: +6285875555584 received 09 january 2020; accepted 30 march 2020; published 05 may 2020 abstract background: indrayanti beach located at gunungkidul district, yogyakarta. the number of tourists visited this beach has increased each year, meaning that it increases the health risks for the tourist and people involved such as infectious diseases, blisters, lost, injured by objects or marine animals, seawater irritation. however, according to the previous study, a traveler who is accessing the tourism health centre is low. this research aimed to identify the relationship between knowledge and attitude of the travelers in indrayanti beach to the traveler’s access to the tourism health centre. method: quantitative analytical approach with a cross-sectional study design was applied in this study. of 106 travelers was participate in this study that was recruited through accidental sampling. a tested questionnaire contained knowledge, and attitude was asked to the indrayanti visitor. a chi-square test was used to analyze the result. results: there is a significant association between knowledge level (p=0.027) and attitude (p = 0.000) to the willingness to access the tourism health centre. conclusion: knowledge and attitude are the primary aspects of the willingness to access the tourism health centre. keywords: knowledge, attitude, travelers, usage, tourism health centre introduction tourism is each tour activity supported by facilities and services provided by the public, employers, government, and local government (1). tourism in indonesia is part of a socialeconomic activity. indrayanti beach is one of the famous tourist destinations in the yogyakarta special region, both for the domestic and foreign visitors. this beach located in gunungkidul district, in the east of yogyakarta. according to the tourism statistics from yogyakarta tourism office, the number of visitors to gunungkidul is increasing since 2016 with 1.9 million visits or equal with 160,000 visitors per month, and it continues the year after. in 2017, recorded 2,2 million visitors or 180,000 people per month (2),(3). today, the development of tourist sectors prioritizes the comfort and safety of the visitors. along with the increasing number of tourists, it is followed by a rising of health risks, although it depends on the physical condition of the tourists (4). hence, attention to facilities, in particular, the health facilities or called tourism health centre is needed. epidemiology and society health review| eshr vol 2 no1 2020 10 information about this facility is essential to guide the visitor on seeking help when they have a problem in a particular resort. several factors could be influencing a person's behavior on accessing service in the tourism health center. according to the health behavior model of health services utilization, there are three factors that influence the utilization of health services: predisposing and enabling need (5). predisposing is a factor that facilitates one's interaction, such as knowledge, attitudes, traditions and beliefs, value systems, educational levels, socioeconomic and enabling is a factor that allows behavior including the availability of infrastructure or health facilities for the community. previous studies stated, there is a relationship between knowledge and attitudes of domestic and foreign tourists with tourism health center utilization (6). in addition, it was known that there was a relationship between knowledge and utilization of health services also the association between level of emergency travel knowledge with the utilization of tourism health center (7),(8). considering the importance of the topic, this research aimed to analyze the association between knowledge and attitudes of indrayanti visitor to the usage of indrayanti tourism health center, which is provided by the district government of gunungkidul. methods this study carried out at indrayanti beach, gunungkidul, by using an observational study with a cross-sectional approach (9). accidental sampling was applied to recruit the respondent. the samples were travelers who were in indrayanti beach with minimum hold senior high school educations. the sample size was 106 respondents based on a sample calculation with an unknown population. the independent variable in this study is the knowledge and traveler attitudes, while the dependent variable is the utilization of gunungkidul tourism health centre. we used a questionnaire that had previously been tested for validity and reliability—respondents filled in the questionnaires by themselves. data was administered with cleaning, editing, coding, and entering the software for the chisquare test. results respondent characteristic is presented by gender, age, education, and occupation (table 1). the majority of the respondents are female (n = 67; 63.2%). eighty respondents or (75.5%) of respondents come from outside of gunungkidul. as to education, more than half of the respondents belong to the age group of 17-25 years old (n = 54; 50.9%. more than 40% of respondents are students (n = 47; 44.3%). most of the respondent (n = 65, 61.3%) hold university educations. chi-square test between the level of knowledge to the utilization of gunungkidul tourism health centre obtains p-value = 0.027 with pr = 1.237 (95% ci= 1.027–1.490), meaning that the significant associated. visitors who have good knowledge have 1.237 times as likely to use the tourism health centre compared to people who have insufficient knowledge. while for attitude, we found p = 0.000 with pr= 1.549 (95% ci= 1.206–1.989), meaning that the people who have a positive attitude, they have 1.5949 times as likely to use the tourism health centre compared to people with negative attitudes (table 2). epidemiology and society health review| eshr vol 2 no1 2020 11 table 1. demographic characteristics of the respondents characteristics frequency percentage (%) gender male 39 36.8 female 67 63.2 age 17-25 54 50.9 26-35 33 31.1 36-45 19 17.9 address gunungkidul 26 24.5 outside of gunungkidul 80 75.5 education high school 41 38.7 university 65 61.3 occupation government employees 13 12.3 private employees 21 19.8 entrepreneur 11 10.4 labour 14 13.2 student 47 44.3 total 106 100 source: primary data, 2019 table 2. correlation between level of knowledge, attitudes and the utilization of tourism health centre variables utilization of tourism health centre pr (95% ci) p-value yes no n % n % knowledge high low 43 42 50.6 49.4 5 16 23.8 76.2 1.237 (1.027-1.490) 0.027 attitude positive negative 59 26 69.4 30.6 4 17 19 81 1.549 (1.206-1.989) 0.000 discussions the level of people's knowledge and behavior is influenced by the level of education. in this study, most of the respondents hold university education (61.3%). levels of education is an external factor that influences a person's knowledge level. travelers who have high education will have a good knowledge level (10). low levels of education are more likely to not access health services because of the lack of understanding about the benefits of health services when conditions are emergency (11). these results are in line with previous research stated there is a relationship between community knowledge and health care utilization (phc) (12). a person's knowledge is related to education and age; in this research, several respondents aged between 17-25 years, which is a period of taking education. the age of someone may affect the mindset of information acceptance (10). epidemiology and society health review| eshr vol 2 no1 2020 12 our results are consistent with previous studies that said there are relationships between knowledge and utilization of health services (7),(13). the results of this study were consistent with the theory of behavior model of health services utilization, that knowledge is one of the predisposing factors that affect a person in the use of health services (5). people who have not used health services at tourist sites can be caused by a lack of information regarding the existence of these health service locations. simply and accurate information are needed to inform the visitor about the presence of these health services. the information form can be various media, both print, and electronic media, that provide health information and health services (14). the attitude is the driving force to perform or not a particular behavior, and attitude is more to an individual's awareness process. a good attitude influences the actions in the utilization of the tourism health centre. traveler attitude in this study belongs to the category quite well; this is good for the tourist administrators to increase the media to inform the existence of the tourism health centre (15). knowledge relates to a person's attitude in the utilization of health services after people know the importance of health services; a good attitude will be formed. such as, people agreeing to use health services or even giving advice to others to be able to use health services when needed (15). the travel environment also affects the visitor’s attitude. visitors generally susceptible to microorganisms because they visit a new area. environmental hygiene is an essential aspect of visitors. the cleanliness tourist spot is the most important thing for the visitor because it affects their health. it corresponds to the theory that all the conditions surrounding people is affecting the development and attitudes. through mutual interaction will affect the practice of someone on hygiene sanitation (16). having a high level of knowledge and a positive attitude may indicate the level of compliance with the use of the tourism health centre is excellent. thus, tourists expected to be able to recognize potential hazards in the tourist destination and able to understand what they should do to protect the health and minimize the risk of accidents when traveling especially coastal tourism. the satisfaction of foreign tourists to visit tourist sites is also influenced by the quality of services provided, such as the presence of health services at tourist sites. the better quality of medical services leads the higher tourist satisfaction (17). the presence of clinics or health services, search and rescue teams (sar), and proper infrastructure is influencing visitor satisfaction (18)-(20). conclusions based on the results of this study concluded that there is a relationship between the level of knowledge and attitudes to the use of the tourism health centre at indrayanti beach, gunungkidul. authors contribution nal contributed to the data collection and analysis of the data. ls contributed to the data analysis and manuscript preparations. funding epidemiology and society health review| eshr vol 2 no1 2020 13 this research does not receive external funding. conflict of interest there is no conflict of interest. references 1. undang-undang ri no 10 tahun 2009 tentang kepariwisataan. 2009. 2. dinas pariwisata diy. statistik kepariwisataan 2015. yogyakarta: dinas pariwisata diy; 2016. 3. dinas pariwisata diy. statistik kepariwisataan 2017. yogyakarta: dinas pariwisata diy; 2018. 4. ismayanti. pengantar pariwisata. jakarta: grasindo; 2011. 5. f m. memperkenalkan sosiologi kesehatan. jakarta: universitas indonesia press; 2014. 6. nurjanatun d. hubungan tingkat pengetahuan dan sikap wisatawan terhadap pemanfaatan klinik swasta. universitas diponegoro; 2012. 7. singal hi v, kandou gd, rumayar aa. hubungan antara pengetahuan, sikap dan pendapatan dengan pemanfaatan puskesmas oleh masyarakat desa kima bajo kecamatan wori. kesmas. 2018;7(5). 8. syaifudin a, sapuwan. hubungan tingkat pengetahuan tentang kegawatdaruratan wisata dengan pemanfaatan klinik di area water blaster semarang. semin nas dan call pap. 2014;24:132–49. 9. notoatmodjo s. metode penelitian kesehatan. jakarta: rineka cipta; 2016. 10. budiman dan riyanto. kapita selekta kuesioner pengetahuan dan sikap dalam penelitian kesehatan. jakarta: salemba medika; 2013. 11. napirah mr, rahman a, tony a. faktor-faktor yang berhubungan dengan pemanfaatan pelayanan kesehatan di wilayah kerja puskesmas tambarana kecamatan poso pesisir utara kabupaten poso. j pengemb kota. 2016;4(1):29–39. 12. junaidi h, yunita a. staf pengajar program studi s1 keperawatan stikes yarsi sumbar bukittinggi mahasiswa program studi s1 keperawatan stikes yarsi sumbar bukittinggi. 2012; 13. nurjanatun d, pramono d. hubungan tingkat pengetahuan dan sikap wisatawan terhadap pemanfaatan klinik wisata. media med muda. 2012; 14. fatimah s, indrawati f. faktor pemanfaatan pelayanan kesehatan di puskesmas. higeia j public heal res dev. 2019;1(3):84–94. 15. pratiwi a, raharjo bb. pemanfaatan pusat pelayanan kesehatan (puslakes) universitas negeri semarang. higeia j public heal res dev. 2017;1(4):49–60. 16. anom p, baiqurul m, sunarta n, adikampana m. pariwisata berkelanjutan dalam pusaran krisis global. bali: udayana university press; 2010. 17. nugraha ye, paturusi sa, wijaya n. kualitas layanan wisata medis yang mempengaruhi kepuasan dan loyalitas wisatawan mancanegara di bali. jumpa. 2019;5(2):348–70. 18. suharmiyati, handayani l, maryani h. analisis diskriptif perbandingan kelayakan puskesmas wisata pantai dan puskesmas non-wisata pantai di provinsi bali (analisis lanjut rifaskes 2011). bul penelit sist kesehat. 2014;17(3):267–74. 19. ristiani iy. pengaruh sarana prasarana dan kualitas pelayanan terhadap kepuasan pasien. coopetition. 2017;vii(2):155–66. 20. wijono d. tingkat kepuasan pengunjung obyek wisata pantai kuwaru sanden bantul yogyakarta. j maksipreneur manajemen, koperasi, dan entrep. 2014;4(1):22–35. epidemiology and society health review| eshr vol 2 no1 2020 14 microsoft word 2245 pb.docx epidemiology and society health review| eshr vol 2, no 2 (2020) 69 research article epidemiology of dengue in jetis public health centre, yogyakarta 2013-2016 azip hasbi asidik1,2, rokhmayanti rokhmayanti1, sri supraptiningsih3, yudha puratmaja4 1 faculty of public health, universitas ahmad dahlan, yogyakarta, indonesia 2 master of public health program, faculty of medicine, public health and nursing, universitas gadjah mada, yogyakarta, indonesia 3 jetis primary health centre, yogyakarta, indonesia 4 master of public health, faculty of public health, khon kaen university, khon kaen, thailand *correspondence: rokhmayanti@ikm.uad.ac.id. telp: +6281229517992 received 02 june 2020; accepted 09 july 2020; published 19 february 2021 abstract background: dengue disease is found in tropical and sub-tropical climates worldwide, especially in urban and semi-urban areas. of 70% of actual cases exist in asia. the incidence of dhf in indonesia during 2018 amounted to 24.73 per 100,000 inhabitants. yogyakarta city is one of the dengue susceptible areas that receive serious attention from the health authorities. jetis public health centres is one of the phc in yogyakarta with high dengue incidence with one mortality. the purpose of this study was to describe the epidemiology of dengue cases based on time, place, people, observe dengue trend, and assess the larva free rate target’s achievement. methods: this research was descriptive quantitative using secondary data obtained from jetis primary health centre's health information system, yogyakarta. dengue data year 2013-2016 was analysed using descriptive epidemiology (time, place, and people) to show the dengue trend. last, the larva free rate was compared between targets and achievements. results: in 2016, the dengue case increased from 81 to 104 in 2014 with one mortality. out of 104 cases, 37 cases occurred in the bumijo village, 33 cases in cokrodiningratan village, 34 cases in gowongan village. 85.58% of dhf cases occur at age ≥ five years, and 57.69% happen in women. the achievement of larvae free rate was 67.73% and had not reached the determined target. there was a tendency for an increase in dengue cases from may to june during the observed year. conclusions: 2016 was the peak of dengue cases during 2013-2016. women and people aged more-equal to five years were the most infected group. most of the cases were found in bumijo village. larva's free rate in jetis was not achieving the target. june was the peak of the case in 2016. keywords: dengue fever, dengue haemorrhagic fever, epidemiology, yogyakarta epidemiology and society health review| eshr vol 2, no 2 (2020) 70 introduction dengue fever is a viral infection transmitted by aedes aegypti mosquitoes. the latest who estimates 390 million dengue infections per year, 96 million with severe disease levels. globally, the who estimated the prevalence of dengue fever 3.9 billion people spread over 129 countries, 70% of the burden was in asia (1). the disease is found in tropical and subtropical climates worldwide, especially in urban and semi-urban areas (2). the climate change phenomenon that changes weather patterns is believed to contribute to the death, injury of some infectious diseases (3). globally, the dengue incident has risen 30 times over the last 50 years, and the climate is a driving force on the distribution and incidence of dengue fever (4). some literature review discusses the inconsistent relationship between climate variability and the transmission of dengue fever and needs advanced research about that (5). aedes aegypti mosquitoes are susceptible to environmental conditions, especially temperature, rainfall, and humidity (6)-(7). previous research indicates there was no correlation between precipitation and humidity with dengue fever [6]. another study has shown that dengue fever cases were correlated with rainfall but not the case for temperature (8). research in indonesia shows that higher temperatures have led to shorter incubation periods and virus replication (7). these factors affect the pattern of dengue cases, the time of the incident, the number of people involved, and the case's location or area. meteorological and climatology agency (bmkg) estimates that indonesia is experiencing an increased rainfall in early february and faces a long rainy period in february-march. this situation leads to flooding in some areas, including in yogyakarta (9). program to preventing outbreaks has been developed through the decree of the indonesia minister of health. its main activity is mosquito nests eradication as part of early awareness in society (10). dengue prevention and control success depends on effective vector control measures and sustainable community involvement (11). besides, it is essential to detect the dengue diseases associated with severe dengue fever and access to appropriate health care to reduce the mortality rate from severe dengue to below 1% (11) dengue incidence in indonesia reached 24.73 per 100,000 population in 2018 (12). in 2016, 90.08% of indonesia's regions were infected with dengue fever. this number increased to 84.44% in 2017, and a continuous increase in 2018 with 85.60% with a mortality rate due to dengue was 0,70% (12). five yogyakarta provinces suffer from dengue every year; one of them was yogyakarta city (12). one of the phc in yogyakarta city categorized as high dengue incidence in 2016 was jetis phc with 104 dengue cases and one mortality. the following year – 2017 and 2018, there were 32 and 5 cases, respectively (13). the purpose of this study was to describe the epidemiological of dengue cases based on the time, place people, observe the dengue trend and assess the achievement of larva free rate in jetis phc of yogyakarta. methods quantitative descriptive was applied in this research. we used tables and graphs to present our analysis. secondary data set (2013-2016) from simpus (information system management system) in the health centre, manual report and case registry were obtained from the jetis primary health centre, yogyakarta city. the data was collected from residence who diagnosed with dengue positive in jetis health center during that periods. data was analyzed using descriptive epidemiology (time, place, and people), trend, and comparative analysis. epidemiology and society health review| eshr vol 2, no 2 (2020) 71 results epidemiology descriptive 1) case distribution by time based on the case report, dengue disease in the work area of jetis phc occurs every year. in 2013 dengue case in this area was 56, and in 2014 was 19 cases. however, in 2015 there was an increase in the case of more than twice higher compare with last year (81 cases). 2016 was the year with the highest cases compared to the previous 2 years (figure. 1 and 2). figure 1. number of dengue case in jetis phc, 2013 2016 during 3 years of observations, most dengue cases occurred in 2016, with 1 case of death in january. the dengue case peak occurred in june that increased significantly from 2 cases in june to 21 in june. (figure. 2). figure 2. number of the monthly case and mortality jetis phc year 2016 time-based analysis can be seen from trends using maximum and minimum patterns during the 3-years of data set. the year 2013 2015, the increase of dengue cases occurred in april, and the peak was in june. then it decreased and fluctuated in the following month. the same happened in 2016, where there was an increase in the case after april to june (figure 3). 56 19 81 104 65 0 20 40 60 80 100 120 2013 2014 2015 2016 n um be r o f c as e (n ) year cases mean 5 4 8 2 18 21 3 11 11 8 7 5 1 0 0 0 0 0 0 0 0 0 0 0 9 0 5 10 15 20 25 jan feb mar apr may jun jul aug sep okt nov des n um be r of c as e (n ) case death mean epidemiology and society health review| eshr vol 2, no 2 (2020) 72 figure 3. dengue case trend in jetis phc, during 2013-2016 2) case distribution by place figure. 4. dengue case per village in jetis phc year 2016 jetis district is part of the city of yogyakarta, located near the code river. the jetis community health center's work area consists of three villages: bumijo, cokrodiningratan, and gowongan. of the 104 dhf cases in 2016, the highest case occurred in bumijo village (figure 4). 3) case distribution by people most of the dengue cases in the research area occurred in people aged ≥ five years (85.58%). more than half of the dengue cases were infecting women (57.69%) (table 1). jan feb mar apr mei jun jul agu sept okt nov des minimal 2 4 1 4 1 2 0 1 0 0 0 0 maksimal 6 14 5 12 15 18 8 6 6 6 1 2 diamati (2016) 5 4 9 2 18 21 3 11 11 8 7 5 0 5 10 15 20 25 37 33 34 31 32 33 34 35 36 37 38 bumijo cokrodiningratan gowongan d en gu e ca se n um be r (n ) epidemiology and society health review| eshr vol 2, no 2 (2020) 73 table 1. dengue case distribution by sex in jetis, 2016 age sex n (%) male female < 5 years 7 8 15 (16,42) ≥ 5 years 37 52 89 (85,58) n (%) 44 (42,31) 60 (57,69) 104 (100) comparative analysis one indispensable indicator in dengue prevention is larva-free rate (abj). jetis phc targeted the abj coverage of ≥ 95%. however, the implementation merely reached up 67.73% or still under the target (figure 5). figure 5. comparison between target and achievement of larva free rate discussions this research discusses the epidemiology of dengue cases in jetis phc, yogyakarta city by time, place, and people during 2013-2016, followed by trend and comparative analysis for larva free rate for 2016. case distribution by time dengue cases were increasing during the three years of observation in the research area (2013-2016). most cases occurred in 2016 (104 cases), most of which occurred in june. several previous types of researchers observed the relationship between the dengue increases and the rain intensity that potentially raises aedes’ aegypti breeding habitat, such as puddles (14)-(15). a high mosquito population supported with proper air humidity increases people's risk of contact with the mosquito (16). dengue peak in jetis phc, which occurred in june, is following literature that reported in some big cities in indonesia dengue transmission season occurred in march to august with peak happened in june (16). however, a previous study showed the relationship between the dengue case and the climatic variable was not consistent (5). in 2017 and 2018, dengue cases in jetis phc were declining from 32 to 5 cases. the decline of dengue cases in the period is probably related to the decrease of vector existence because of the development of larva free rate achievement (13). 67,73% 95% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% a ng ka b eb as j en tik target capaianachievement la rv a fr ee r at e epidemiology and society health review| eshr vol 2, no 2 (2020) 74 trend analysis during 2013-2016, dengue cases occurred throughout the year that mostly dengue peaks occurred in june, then decreasing and ups-down in the following month. some references reported the association between dengue and rainfall (14)-(15). climate change means changing climate pattern is recognized as a factor that leads to death, injury, and fatality for some climate-sensitive infectious diseases (3) indonesia is experiencing high rainfall intensity from february to march and potential flooding in some areas, including yogyakarta (9). yogyakarta has a dengue transmission season from march to august, and usually, the peak occurred in june (16). this situation is following the case that happened in the work area of jetis phc. however, the literature indicates no direct correlation between monthly dengue cases with monthly rainfall and the average temperature (17). therefore, it is necessary to maximize the early warning system and conduct appropriate studies to reduce future cases. literature mentions that proper bayesian spatio-temporal models allow the identification of various regional groups and climate covariate impact. prediction of high-risk areas and the mutual influence between areas, climate variables, and temporal data will help policymakers retrieve dengue prevention measures (18). case distribution by place the increasing dengue case could be associated with the rising vector existence, closely related to human risk factors such as population density, mobility, and housing (19). in 2016, population densities in jetis phc were 16,074 per km2, categorized as high density (20). rapid urban population growth, population mobilization, and low population control allow the dengue outbreak to increase the probability of more fabulous mosquito presence in populated areas, with habitat expansion in the future (21). jetis sub-district is among five other subdistricts in yogyakarta city with a high dengue case (13) because it has increased population density and is located on the riverbank. case distribution by the people dengue disease in the jetis health center area mainly attacks people aged over five years (85.58%). literature states that there has been a change in dengue patterns from children under 5 to all age groups, even more in the productive age or adolescent and adult groups (22). changes in dengue epidemiology are also influenced by environmental health factors (16). our research also found that most of the dengue cases occur in the female of 57.69%, it might be because women spend more time with their domestic affairs than men who primarily work out the region. comparative analysis the dengue transmission dengue is closely related to vector control measures implemented to speed up community participation (23). the process requires persistence of patience, and effort to continuously provide understanding and motivation to individuals, groups, and society. a study showed that the public's counselling does not affect the community's behaviour in vector control activities (psn) because the community has various characteristics that potentially influence their understanding, making them unable to implement dengue vector control (22 independently. as a result, psn activities need to be run maximally with guidance from the key stakeholders, such as the primary health centre. on vector control (psn), education and economic status are important factors that influence community participation. education and financial situation have a positive correlation to the prevention behaviour of dengue (24). moreover, the family size, the adults, the income, and perception are significantly associated with reducing dengue cases (25). people who have suffered from dengue fever are very likely to use adaptation measures than people who do not experience dengue fever. noting that factors may be beneficial to public health authorities epidemiology and society health review| eshr vol 2, no 2 (2020) 75 to develop an awareness of dengue fever in the community and population sensitivity to use measures adaptation (25). mosquito-nest eradication (psn) is part of the dengue early warning system under the health regulation ministry (10). labours in improving dengue early warning systems and control need to be improved, especially on systematic surveillance of diseases and vectors in phc, city/district, provincial, and central government levels. cooperation across sectors requires finding a proper approach aimed to reach a broader community (26). conclusions dengue case in 2016 was the highest case during 2013-2016, with a peak that occurred in june. most of the dengue cases happened in women and people aged ≥ five years. bumijo was the hotspot of dengue during that period. larva free rate (abj) in the jetis sub-district has not reached the target. active early warning systems between primary health center staff and the community need to be done to achieve abj targets and maximize efforts to prevent and reduce dengue cases. authors’ contribution aha contributed to the data collection, data analysis, report writing, and manuscript publication, rr contributed to licensing, data analysis, and report writing. ss participated as a provider of data and information, data analysis, and report writing. yp participated in data analysis and writing. funding this research has not received external funding. acknowledgments thanks to jetis primary health center, yogyakarta city, which has provided the study's data and information. conflict of interest there are no conflicts of interest. references 1. bhatt s, gething pw, brady oj, messina jp, farlow aw, moyes cl, et al. the global distribution and burden of dengue. nature. 2013 apr 25;496(7446):504–7. available from: http://www.nature.com/nature/journal/v496/n7446/full/nature12060.html 2. world health organisation. dengue fever. who fact sheet. 2016; 3. hashim jh, hashim z. climate change, extreme weather events, and human health implications in the asia pacific region. asia-pacific j public heal. 2016 mar; 28:8s14s. 4. ebi kl, nealon j. dengue in a changing climate. environ res. 2016 nov [cited 2017 sep 8];151:115–23. available from: http://linkinghub.elsevier.com/retrieve/pii/s0013935116303127 5. zhang y, bi p, hiller je. climate change and the transmission of vector-borne diseases: a review. asia-pacific journal of public health / asia-pacific academic consortium for public health. 2008. 6. rozilawati h, zairi j, adanan cr. seasonal abundance of aedes albopictus in selected urban and suburban areas in penang, malaysia. trop biomed. 2007; jun; 24(1):83-94. epidemiology and society health review| eshr vol 2, no 2 (2020) 76 7. bangs mj, larasati rp, corwin al, wuryadi s. climatic factors associated with epidemic dengue in palembang, indonesia: implications of short-term meteorological events on virus transmission. southeast asian j trop med public health. 2006;37(6):1103–16. 8. sia su gl. correlation of climatic factors and dengue incidence in metro manila, philippines. ambio. 2008; 37(4):292-294s 9. bmkg. rainy season development 2019-2020 and the prediction of 6 months onward. 2020. 10. indonesia ministry of health. kepmenkes no.581 year 1992 about tentang eradication of dengue fever disease. 11. who. dengue and severe dengue fact sheet. world heal organ. 2020; 12. ministry of health of republic indonesia. indonesia health profile 2018. profil kesehatan provinsi bali. 2019. 190 p. available from: http://www.depkes.go.id/resources/download/pusdatin/profil-kesehatan-indonesia/profilkesehatan-indonesia-2016.pdf 13. yogyakarta city health office. profil kesehatan tahun 2019 kota yogyakarta (data tahun 2018). yogyakarta. kota yogyakarta; 2019. 14. priharyati nz, widyanto a. deskripsi epidemiologi dan pengendalian demam berdarah dengue (dbd) di kecamatan purbalingga kabupaten purbalingga tahun 2012-2016. bul keslingmas. 2018;37(2):144–50. 15. lusianah e, utomo b. studi epidemiologi penyakit demam berdarah dengue di wilayah kerja puskesmas purwokerto selatan kabupaten banyumas tahun 2018. bul keslingmas. 2019; 38(2):141-147 16. wowor ribka. effect of environmental health on the change in dengue epidemiology in indonesia. j e-clinic. 2017;5(2):105–13. 17. thi tuyet-hanh t, nhat cam n, thi thanh huong l, khanh long t, mai kien t, thi kim hanh d, et al. climate variability and dengue hemorrhagic fever in hanoi, viet nam, during 2008 to 2015. asia-pacific j public heal. 2018. 18. aswi a, cramb s, duncan e, hu w, white g, mengersen k. climate variability and dengue fever in makassar, indonesia: bayesian spatio-temporal modelling. spat spatiotemporal epidemiol. 2020;33(junepresent and future incidence of dengue fever in ecuador nationwide and coast region scale using species distribution modeling for climate variability’s effec):100335. 19. azlani a dkk. relationship to eradication of mosquito nests with the existence of mosquito larva of dengue in lubuk buaya village. j kesehat andalas. 2016;5(1). 20. ministry of agrarian and spatial/ national land agency. law number 56 year 1960. 2017. 21. jácome g, vilela p, yoo ck. present and future incidence of dengue fever in ecuador nationwide and coast region scale using species distribution modeling for climate variability’s effect. ecol modell. 2019;400(24 may):60–70. 22. indonesia ministry of health. surveilans epidemiology and data centre. buletin jendela epidemiologi. jakarta; 2010. 23. who. dengue and severe dengue. web. 2020 [cited 2021 feb 16]. available from: https://www.who.int/news-room/fact-sheets/detail/dengue-and-severe-dengue 24. hardayati w dkk. public behaviour analysis of the larva free rate and dengue fever in pekanbaru subdistrict, riau city. j ilmu lingkung. 2011;5(1). 25. bakhsh k, sana f, ahmad n. dengue fever in punjab, pakistan: knowledge, perception and adaptation among urban adults. sci total environ. 2018 dec 10;644(dec 10):1304– 11. 26. sukowati, supratman 2010. vector dengue challenges and the control in indonesia. buletin jendala epidemiologi. 2010;2(agustus):27-30. microsoft word rr_1_4669-article text-21197-1-18-20220510.docx epidemiology and society health review| eshr vol. 4, no. 2, 2022, pp. 40-47 issn 2656-6052 (online) | 2656-1107 (print) 10.26555/eshr.v4i2.4669 40 research article biofilm formation by uropathogens and its impact on antimicrobial susceptibility pattern priyanka sharma1, sandeep dogra1*, bella mahajan2, shashi sudhan sharma3 1 department of microbiology, govt. medical college, jammu, india 2 department of microbiology, ascoms & hospital, jammu, india 3 department of microbiology, govt. medical college, jammu, india * correspondence: sandeepdogra@gmail.com. phone: (+91) 9906091412 received 14 august 2021; accepted 06 october 2021; published 2 august 2022 abstract background: out of all hospital-associated infections (hais),urinary tract infection (uti) is the second most common infection that accounts for approximately 34%, and 80% are associated with indwelling catheters and hence with biofilm formation, which invites multi-drug resistant microorganisms. the present study was designed to study in-vitro biofilm forming uropathogens and their antimicrobial susceptibility in a tertiary care hospital in north india. method:the present cross-sectional study consisted of 200 urine specimens collected over one year from patients with symptoms of urinary tract infection. following their isolation and identification, all the isolates were subjected to screening for biofilm formation by congo red agar (cra) and the tube adherence (ta) methods. subsequently, the kirby bauer-disk diffusion method performed the antimicrobial susceptibility test. results: out of the total samples (n = 200), a total of 46 (23%) were positive by the cra method, while 33 (16.5%) were positive by the ta method. twenty-one (21%) isolates came positive by both methods. biofilm formation was seen more commonly in females (82%). biofilm-forming uropathogens develop a significantly higher resistance to antimicrobial drugs than non-producers. conclusion: the correlation was significant between biofilm production and multidrug resistance. also, it was concluded that the cra method could be employed to detect biofilm formation in resource-limited countries. keywords: urinary tract infections; tube adherence method; congo red agar method; antibacterial agents introduction talking of morbidity worldwide,urinary tract infections (utis) is one of the leading causes of which is caused by different microorganisms. worldwide, uti has a prevalence of 11%(1), sharma (biofilm formation by uropathogens and its impact on antimicrobial susceptibility pattern) vol. 4, no. 2, 2022, pp. 40-47 10.26555/eshr.v4i2.4669 41 and according to an indian study, it is 36.68% (2). these uropathogens tend to colonize the mucous membrane of the bladder and form micro bacterial communities called biofilms. the colonization by these microcolonies makes them impermeable to many antibiotics. it resultsin the evolution of multidrug-resistant strains, which is the leading causeof relapses in untreatable uti. biofilms consist of different layers of cells embedded in a matrix of extracellular exopolysaccharide – eem (slime), which helps adhereto biomedical surfaces and protects them from the host immune system and antimicrobial therapy (3), and provides a survival strategy to the uropathogenic. the slimeconsists of extracellular dna, proteins, polysaccharides, adhesin, and autolysin. it starts with the attachment of free-floating microorganisms to a surface. initially,these areattached through weak van der waal forces. later, if left undisturbed, they anchor themselves more firmly via cell adhesion structures such as pili. repulsion to water plays an essential role in determining the ability to form biofilms(4).using his simple microscopes, van leeuwenhoekobserved microorganisms on tooth surfaces and can be regarded with the discovery of biofilms. costertonet al., in 1978, explained the mechanisms ofmicroorganisms' adherence to living and nonliving materials and the help provided by ecologic niche (5). biofilms aremainly formed in the prostate stones, urothelium, and implanted foreign bodies (6). predisposing host factors are age, diabetes, long-term hospitalization, and catheterization (7). national institute health (nih) says that among all the microbial infections, 80% are caused by biofilms (8). according to the center for disease control and prevention (cdc), usa, biofilms on indwelling medical devices consistof gram-positive or gram-negative bacteria or yeasts. the most common gram-positivebacteria isolated are enterococcus faecalis, staphylococcus aureus, staphylococcus epidermidis, streptococcus viridans, and gramnegative bacteriaescherichia coli, klebsiella pneumonia, proteus mirabilis, and pseudomonas aeruginosa. these bacteriacan originate from the skin of patients or healthcare workers or be some other source like the environment (9).biofilms are composed of single or multiple species depending on the device and its duration of use in the patient.biofilm on the urinary catheter is initially composed of single species, but with time, multispecies predominates(10). biofilm-causing uropathogens have an inherent resistance to antibiotics, disinfectants, and antiseptics. unlike planktonic populations, bacterial cells embedded in biofilmsshow intrinsic resistance to antibiotics which can be due to the inactivation of antimicrobial agents by exopolysaccharide (eps), overexpression of stress-responsive genes, presence of oxygen gradients within the biofilm matrix, and differentiation of a subpopulation of biofilm cells into resistant dormant cells(11)(12). in this study, our goal was to detect the biofilm-forming uropathogens and study their antimicrobial susceptibility pattern among patients suffering from uti in a tertiary care hospital in northern india. this study will help the clinicians to decide method this cross-sectional study was performed for one year on 200 urine specimens from outpatients (n=15) and in-patients (n=185) who were clinically diagnosed with uti and fell under the inclusion criteria. semi-quantitative urine culture was performed on uti agar (himedia labs) as per standardized sops of the department. as described by freeman dj et al., 1989 (13), cra was performed. cra medium was prepared by mixing brain heart infusion broth (oxoid, uk) 37 g/l, sucrose 50 g/l, agar no. 1 (oxoid, uk) 10 g/l, and congo red indicator (oxoid, uk) 8 g/l. the congo red stain (himedia labs) was prepared separately as a concentrated aqueous solution and autoclaved (121°c for 15 min) from the rest of the other constituents. it was later added to the autoclaved brain heart infusion agar (himedia labs) with sucrose at 55°c. cra plates were then inoculated with test isolates and left for aerobic incubation at 37°c for 24 hours. for all positive isolates, cra and ta methods detected biofilm formation. black colonies with a dry crystalline sharma (biofilm formation by uropathogens and its impact on antimicrobial susceptibility pattern) vol. 4, no. 2, 2022, pp. 40-47 10.26555/eshr.v4i2.4669 42 consistency indicated biofilm formation, whereas no-biofilm formation was identified as red or pink crystalline colonies (figure 1). figure1. congo red agar method shows biofilm producers (black crystalline colonies) & non-producers (pink colonies) tube adherencemethod, as described by christensen gd et al. (14), 1982 is a quantitative method for biofilm detection. test organisms were inoculated in 10 ml of trypticase soy broth with 1% glucose in test tubes and incubated at 37°c for 24 hours. after incubation, tubes were decanted, washed with phosphate-buffered saline (ph 7.3), and dried. tubes were then stained with crystal violet (0.1%). the excess stain was washed with deionized water and dried. the scoring for the tube method was done according to the results of the control strains. biofilm formation was considered positive when a visible film lined the wall and the bottom of the tube (figure 2). figure2. tube adherence method showing biofilm producer (tube a) & non-producer (tube b) antimicrobial susceptibility testing was performed using the kirby bauer disk diffusion method on mueller hinton agar (himedia labs) according to the clinical laboratory standard institute sharma (biofilm formation by uropathogens and its impact on antimicrobial susceptibility pattern) vol. 4, no. 2, 2022, pp. 40-47 10.26555/eshr.v4i2.4669 43 (clsi 2019) guidelines (15). the antimicrobial discs used for gram-positive isolates were penicillin g 10 units, gentamicin 10mcg, ciprofloxacin 5mcg, vancomycin 30mcg, linezolid 30mcg, nitrofurantoin 300mcg, and norfloxacin 10mcg. the antimicrobial discs used for gram-negative isolates were piperacillin-tazobactam 100/10mcg, cefuroxime 30mcg, cefepime 30mcg, amikacin 30mcg, imipenem 10mcg, gentamicin 10mcg, tobramycin 10mcg, ciprofloxacin 5mcg, cotrimoxazole 1.25/23.5mcg, chloramphenicol 30 mcg, tetracycline 30 mcg, nitrofurantoin 300mcg, norfloxacin 10mcg, amoxicillin/clavulanic acid 20/10mcg and aztreonam 30mcg. results a total of 185 (92.5%) were indoor patients, while 15 (7.5%) were from the outdoor department. out of 200 urine specimens, 64 (32%) were females, and 36 (18%) were males. most patients belonged to 51 to 70 years (36%), followed by those above 70 years (29.5%). of all, 102 (51%) patients were catheterized. gram-negative dominated 70% of the positive isolates, whereas gram-positive constituted 30%. out of 200 uropathogens, 94 (47%) were escherichia coli, followed by enterococcus sp. 37(18.5%) (table 1). table 1. bacterial uropathogens among uti patients from out patient department (opd) and in-patient department s. no. uropathogens opd (n=15) ipd (n=185) total (n=200) 1 escherichia coli 11 83 94 (47%) 2 enterococcus spp. 0 37 37 (18.5%) 3 klebsiella pneumoniae 0 28 28 (14%) 4 staphylococcus aureus 4 18 22 (11%) 5 acinetobacter spp. 0 7 7 (3.5%) 6 pseudomonas aeruginosa 0 6 6 (3%) 7 klebsiella oxytoca 0 4 4 (2%) 8 proteus mirabilis 0 1 1 (0.5%) 9 morganella morganii 0 1 1 (0.5%) out of 102 catheterized patients, biofilm formation was observed in 72 (36%), which was way more than in community-acquired uti cases 18 (9%). table 2 shows biofilm production by different methods. cra method detected 83 isolates(46%) as biofilm producers, whereas ta method detected only 59(33%) isolates as biofilm producers. table 2. biofilm production by different methods methods congo red agar method (%) tube adherence method (%) both methods (%) total number of isolates 83 (46%) 59 (33%) 38 (21%) sharma (biofilm formation by uropathogens and its impact on antimicrobial susceptibility pattern) vol. 4, no. 2, 2022, pp. 40-47 10.26555/eshr.v4i2.4669 44 amoxicillin (99%) and amoxy-clavulanic acid (100%) were resistant in most biofilmpositiveisolates. the highest degree of drug resistance was seen in biofilm-forming acinetobacter spp. followed by klebsiella sp. and pseudomonas aeruginosa. resistance to antibiotics like cefuroxime, aztreonam, imipenem, tobramycin, norfloxacin, cotrimoxazole, chloramphenicol, gentamicin and tetracycline, vancomycin was more in biofilm positive isolates (table 3). biofilm-forming gram-negative bacilli (gnb) uropathogenic developed significantly higher resistance towards antimicrobial drugs. discussion urinary tract infectionspresenta severe health threat concerning antibiotic resistance, especially with biofilm production. during the period covered by our study, 200 samples were studied, 92% of which were received from different wards, operation theatre (ot), cardiac care unit (ccu), intensive care unit (icu), while opd samples were only 15% of the total and maximum samples fell into the age group of 51 – 70 years. this finding was also depicted in madigan e & neff d (16). our study observed that the infected patients were primarily women (82%), which can be because of anal proximity and the shorter length of the urethra. a similar finding was also reported by kashef n et al. (17).the age group of 61 – 75 years predominated in catheterized patients(n=102). the maximum number of patients were on catheterization for >4 days, a similar finding by niveditha s et al. (18). the detection of bacteriuria within one week of the catheterization in this study pertains to the inadequate precautions taken while handling catheters. escherichia coli was isolated from 94 (47%) specimens, followed by klebsiella pneumonia (16%) and enterococcus spp. (18.5%), pseudomonas aeruginosa (3%), staphylococcus aureus (11%), acinetobacter spp. (3.5%), proteus mirabilis and morganella morganii (0.5% each). these findings were similar to the studies conducted by noor af et al. (19). escherichia coli was responsible for the maximum number of uti casesbecause of the ability of uropathogenicescherichia coli (upec) to express a variety of virulence factors like adhesins (e.g., type 1 and p fimbriae) and toxins like hemolysin. biofilm detection by cra and ta methods was (46%) and (33%) respectively,and this correlates with the study of hassan a et al.(20). cra is a rapid, sensitive, and reproducible method and can be recommended in resource-limited countries. a similar finding was reported by rewatkar ar and wadher bj et al. (21). quantification of biofilms done by the ta method showed that only 9% were strong producers, whereas 20% were moderate producers. the rest of the isolates (71%) were weak producers. this was also observed by panda ps et al. (22). biofilm formation on cauti was observed more than community-acquired uti because bacteria survive on catheters easily as cauti creates an ideal environment for bacterial attachment and biofilm production. antibiotic resistance was more among biofilm producers in comparison to non-producers. similar results were obtained by rewatkar ar and wadher bj et al. (21). a possible explanationis the persistence of the organism, decreased bacterial growth rate in a biofilm, and increased expression of resistance genes. restricted penetration of antibiotics into the biofilm and the proximity of cells within a biofilm results in plasmid exchange and leads to the spread of antimicrobial resistance. sharma (biofilm formation by uropathogens and its impact on antimicrobial susceptibility pattern) vol. 4, no. 2, 2022, pp. 40-47 10.26555/eshr.v4i2.4669 45 table 3. antibiogram of biofilm and non-biofilm producing isolates antimicrobial agent percentage resistance p-value biofilm producers non-biofilm producers amoxicillin 72/73 (99%) 50/53 (94%) 0.019 amoxy clavulanic acid 73/73 (100%) 51/53 (96%) 0.024 piperacillin-tazobactam 40/77 (52%) 27/64 (42%) 0 cefuroxime 71/73 (98%) 44/53 (83%) 0.004 cefepime 77/97 (80%) 56/64 (87%) 0.004 aztreonam 66/76 (87%) 39/56 (70%) 0 imipenem 67/73 (92%) 35/53 (66%) 0 amikacin 64/77 (84%) 54/64 (85%) 0.022 tobramycin 47/77 (61%) 17/64 (27%) 0 norfloxacin 94/103 (92%) 67/88 (77%) 0.002 cotrimoxazole 62/74 (84%) 28/61 (46%) 0 cefoxitin 58/100 (58%) 25/85 (30%) 0 chloramphenicol 46/73 (63%) 26/53 (50%) 0.022 gentamicin 98/104 (94%) 77/96 (80%) 0.022 tetracycline 64/74 (86%) 35/61 (57%) 0 ciprofloxacin 23/30 (77%) 31/35 (88%) 0.449 penicillin 24/27 (89%) 27/32 (84%) >0.5 vancomycin 10/27 (37%) 5/32 (17%) 0 nitrofurantoin 14/27 (52%) 6/32 (19%) 0 linezolid 0/27 (0%) 0/32 (0%) 0.001 in the case of escherichia coli, biofilm producers showed maximum resistance toamoxyclavulanic acid followed by cephalosporins, gentamicin, co-trimoxazole amikacin, and least resistance to piperacillin-tazobactam (37%). it was similar to the finding observed by tiwari aa &ghnawate n et al. (23). in the case of klebsiella pneumonia, resistanceto multiple antibiotics was observed in biofilm producers, which also correlates with the study of tiwari aa &ghnawate n et al. (23). drug tobramycin was more effective in the case of non-biofilm producers with 83% sensitivity, while it was 25% sensitive for biofilm producers. our study concluded that klebsiella sp. was maximum resistant to antibiotics, maybe because of the high prevalence of resistant strain in our region or the exhaustive use of antibiotics. pseudomonas aeruginosa was highly sensitive to tobramycin in the case of biofilm producers and non-producers. so it may be considered the antibiotic of choice for pseudomonas aeruginosa. our study had only one strain of acinetobacter baumannii, a biofilm producer and sharma (biofilm formation by uropathogens and its impact on antimicrobial susceptibility pattern) vol. 4, no. 2, 2022, pp. 40-47 10.26555/eshr.v4i2.4669 46 resistant to all the antibiotics. on the other side, no biofilm-producing strain was isolated in the case of morganella morganii and proteus mirabilis. however, the insufficient sample size makes it impossible to draw practical conclusions from this data. in the case of gram-positive cocci, linezolid was 100% sensitive in both biofilm producers and non-producers, which shows that it can be a good reservoir. this finding correlates well with the study of panda ps et al.(22). 86% of staphylococcus aureusismrsa strains, a finding similar to a study by yousefi m et al. (24). our study highlights a broad range of uropathogens and multi-drug resistant (mdr) isolates among biofilm-forminguropathogens. this study was concerned with a single tertiary setting. thereforebroader surveillance is needed to determine the local resistance profiles of prevalent biofilm-forminguropathogens so that an optimal empirical therapy can be documented. conclusion this study showed a considerable opportunity foruropathogens to form biofilms. we observed asignificant correlation between biofilm production and multi-drug resistance compared to non-biofilm-forming isolates. finally, the cra method can be employed as the routine laboratory test for in-vitro biofilm detection as it is cost-effective also. authors' contribution bm and sss contributed to the data collection and interpretation. ps, sd contributed to the data article writing and its publication. funding statement this research has not received external funding. conflict of interest there is no conflict of interest in this research. references 1. chu cm, lowder jl. diagnosis and treatment of urinary tract infections across age groups. am j obstet gynecol [internet]. 2018;219(1):40–51. available from: https://doi.org/10.1016/j.ajog.2017.12.231 2. m. mehta, s. bhardwaj and js. screening of urinary isolates for the prevalence and antimicrobial susceptibility of enterobacteria other than escherichia coli. int j life sci pharma res. 2013;3(1):100–4. 3. o′gara jp and humphreys h. staphylococcus epidermidis biofilms: importance and implications. j med microbiol. 2001;50(582):7. 4. v s, ali f, lokare n, matew j. diabetic foot ulcers and biofilm formationthe culprits. int j biomed adv res. 2016;7(9):428. 5. heukelekian h ha. relation between food concentration and surface for bacterial growth. j bacteriol. 1940;40:547–58. 6. costerton jw, geesey gg ck-j. how bacteria stick. sci am. 1978;238:86–95. 7. tenke p, kovacs b jm and ne. the role of biofilm infection in urology. world j urol. 2006;24(1):13–20. 8. joo h.s. om. molecular basis of in vivo biofilm formation by bacterial pathogens. sharma (biofilm formation by uropathogens and its impact on antimicrobial susceptibility pattern) vol. 4, no. 2, 2022, pp. 40-47 10.26555/eshr.v4i2.4669 47 chem biol. 2012;19(12):1503–13. 9. l k. riddle of biofilm resistance. antimicrob agents chemother. 2001;45:999– 1007. 10. donlan rm. biofilms and device-associated infections. emerg infect dis. 2001;7(2):277–81. 11. stickler dj. bacterial biofilms and the encrustation of urethral catheters. biofouling. 1996;94:293–305. 12. keren i, kaldalu n, spoering a, wang y lk. persister cells and tolerance to antimicrobials. fems microbiol lett. 2004;230:13–8. 13. freeman dj, falkiner fr kc. new method for detecting slime production by coagulase-negative staphylococci. j clin pathol. 1989;42(8):872–4. 14. christensen gd, simpson wa, bisno al be. adherence of slime-producing strains of staphylococcus epidermidis to smooth surfaces. infect immun. 1982;37(1):318–26. 15. institute cls. performance standard for antimicrobial susceptibility testing. 24th information supplement. nccls document m100-s24. wayne, pennsylvania. usa clin lab stand inst. 2014. 16. madigan e and neff df. care of the patients with long-term indwelling urinary catheters. online j issues nurs. 2003;8(3):7. 17. kashef n, djavid ge ss. antimicrobial susceptibility patterns of communityacquired uropathogens in tehran. iran j infect dev ctries. 2010;14(4):202–6. 18. niveditha s, pramodini s, umadevi s, kumar s ss. the isolation and the biofilm formation of uropathogens in the patients with catheter-associated urinary tract infections (utis). j clin boil res. 2012;6(9):1478–82. 19. noor af, shams f, munshi sk, hassan m nr. prevalence and antibiogram profile of uropathogenic isolated from hospital and community patients with urinary tract infections in dhaka city. j bangladesh acad sci. 2013;37(1):52– 63. 20. hassan a, usman j, kaleem f, omair m, khalid a im. evaluation of different detection methods of biofilm formation in the clinical isolates. braz j infect dis. 2011;15(4):305–11. 21. rewatkar ar and wadher bj. staphylococcus aureus and pseudomonas aeruginosabiofilm formation methods. j pharm biol sci. 2013;8(5):36–40. 22. panda ps, chaudhary u ds. study of biofilm production and antimicrobial sensitivity pattern of uropathogens in a tertiary care hospital in north india. int j community med public heal. 2016;3(9):2421–6. 23. tiwari aa and ghnawate n. detection of biofilm forming bacterial communities from urinary catheter of patients with change in its antibiotic susceptibility pattern and triclosan effect from different hospitals of amravati city maharashtra, india. open j med microbio. 2017;7(3):51–66. 24. yousefi m, pourmand mr, fallah f, hashemi a, mashhadi r n-aa. characterization of staphylococcus aureus biofilm formation in urinary tract infection. iran j public heal. 2016;45(4):485–93. microsoft word 6216-approved-cek 2.docx epidemiology and society health review| eshr vol. 5, no. 1, 2023, pp. 32-40 issn 2656-6052 (online) | 2656-1107 (print) http://journal2.uad.ac.id/index.php/eshr/index eshr@ikm.uad.ac.id 10.26555/eshr.v5i1.6216 32 research article association between close contact history and the risk of covid-19 in purwakarta district, indonesia jihan srikandhia purnama1, liena sofiana1* 1 faculty of public health, universitas ahmad dahlan, yogyakarta, indonesia * correspondence: liena.sofiana@ikm.uad.ac.id. phone: +62274563515 received 25 june 2022; accepted 02 february 2023; published 11 march 2023 abstract background: covid-19 pandemic is a global problem. one of the risk factors for covid19 is close contact, which has a greater risk of being confirmed because virus transmission generally occurs directly through droplets. based on regional risk zoning mapping, purwakarta district is categorized as a moderate risk zone, and most of the confirmed cases are caused by a history of close contact. still, people with a history of close contact only sometimes become established patients. this study aimed to determine the relationship between close contact status and the incidence of covid-19 in the purwakarta district year 2020. method: this study used observational analysis and a cross-sectional study design. the research data is secondary data from the purwakarta regency health office. purposive sampling was used to select 2,650 people for the study. the data analysis method used is chi-square. results: according to the respondents' characteristics, most are in their early adulthood (26.8 %) and male (52.3 %). according to bivariate analysis, there is a p-value = 0.002 relationship between close contact status and the incidence of covid-19. people with close contact status are 1.040 times more likely than people who do not have close contact status to get covid-19 (95 % ci = 1.013-1.069). conclusion: close contact status is a risk factor for covid-19 transmission in purwakarta regency during 2020. keywords: covid-19; close contact; risk factor. introduction coronavirus disease 2019 (covid-19) is an infectious disease caused by the severe acute respiratory syndrome coronavirus-2 (sars-cov-2).1 symptoms that arise due to covid purnama et al. (association between close contact history and the risk of covid-19 in purwakarta district) vol. 5, no. 1, 2023, pp. 32-40 33 10.26555/eshr.v5i1.6216 19 infection include fever, cough, and shortness of breath. the average incubation period is about 5-6 days, with the longest being 14 days. coronavirus is a family of viruses that can cause mild to severe symptoms. in extreme cases, covid-19 can cause pneumonia, kidney failure, acute respiratory syndrome, and even death.2 several types of coronavirus are known to have severe symptoms, namely middle east respiratory syndrome (mers) and severe acute respiratory syndrome (sars). the urgency of the covid-19 disease was marked by the who's determination of pandemic status on march 12, 2021.1 the first report received by who on january 3, 2020, explained that the case originated in wuhan, china, with 44 patients diagnosed with severe pneumonia.3 the emergence of extraordinary events in wuhan, hubei province, china, marked this disease spreading. the problems caused by covid-19 are not only local problems for residents of wuhan, china. but also a severe problem worldwide due to increased cases that continue to increase daily.4 in 2020, there were 83,060,276 confirmed cases of covid-19, with the death toll reaching 1,812,046 worldwide. the increase in covid-19 cases is relatively fast; the spike evidences this in occasional cases. based on the who report, the united states is one of the regions with the most confirmed cases, namely 20,216,991 cases with 350,778 deaths. meanwhile, in the asian region, the countries with the highest number of confirmed cases were india, turkey, iran, and indonesia.5 the first 5 cases in indonesia were confirmed on march 2, 2020. the increase in covid-19 cases is still increasing every day. based on a report from the indonesian ministry of health, as of august 30, 2020, there were 172,053 confirmed cases with a higher mortality rate than global data, which was 4.3% or 7,343 deaths. the province with the highest number of confirmed cases is dki jakarta, with 39,037 cases. meanwhile, the province with the lowest number of cases was east nusa tenggara, with 177 cases.6 according to the indonesia national disaster management agency (bnpb), daily data on covid-19 showed the five provinces with the highest number of cases: dki jakarta, east java, central java, south sulawesi, and west java, which counted up to september 5, 2020.7 the number of confirmed cases in indonesia recorded throughout 2020 was 743,198 cases. this number continues to increase in cases every day. twenty-five provinces experienced an increase in cases, one of which is west java province, with 83,579 cases. based on the national covid-19 case fatality rate, there has also been an increase of 22,138 people who died.8 risk factors for covid-19 infection included comorbid conditions in patients, such as comorbid hypertension and diabetes mellitus. in addition, close contact factors, age, gender, and smoking habits also potentially risk covid-19. close contacts are suspected of having a greater chance of being confirmed because exposure to confirmed cases carried out continuously for more than 15 minutes will make people with close contact status more susceptible to contracting the virus.9 people with a history of close contact with confirmed cases are at high risk for exposure to the virus through droplet transmission. this generally occurs in cases of close household contact. droplets from respiratory fluids can happen when a person is within one meter of an infected person. at the same time, contact transmission that occurs indirectly can be through the transmission of contaminated object surfaces or is called fomite transmission.10 purnama et al. (association between close contact history and the risk of covid-19 in purwakarta district) vol. 5, no. 1, 2023, pp. 32-40 34 10.26555/eshr.v5i1.6216 the case report showed that the confirmed cases are related to transmission from covid-19 patients and generally have a history of close contact with confirmed covid-19 patients.11 people who have closed contact with covid-19 patients are considered to be most at risk for contracting the sars-cov-2 virus. the same goes for people caring for patients, medical personnel, and family members.12 the results of research conducted in 2020 show that the sars-cov-2 virus has a transmission rate of 5% to 6% in people with a history of close contact with patients with confirmed covid-19. transmission rates are higher when close contacts are in the family environment, up to 10%.13 the health workforce is one of the close contact groups most susceptible to catching the virus; previous research found a substantial correlation between a history of close contact and verified covid-19 cases in makassar city, with close contacts having a 6.802 times higher probability of being diagnosed with covid19 than those without a history of close contacts. 11 confirmed cases of covid-19 in west java continued to increase every day until december 20, 2021; there were 73,948 confirmed cases of covid-19, with a cumulative incidence of 163.49 per 100,000 population.8 the number of deaths in west java due to covid-19 infection was 1,095 people. based on the regional risk zoning mapping in 2020, purwakarta district was categorized in the moderate risk zone.8 purwakarta district is one of the regencies in west java's province. during the pandemic, the purwakarta district was not spared from confirmed cases of covid-19. the first confirmed case occurred on march 15, 2020, with an increase in cases weekly. however, the incidence of covid-19 in purwakarta district is relatively unstable; this is because, in june 2020, purwakarta district had reached zero cases which also coincided with the implementation of large-scale social restrictions called psbb in several areas in purwakarta district.14 according to information from the purwakarta district health office, most confirmed cases were also caused by prior close contact with patients who tested positive. apart from the frequent interactions between workers at the same workplace, it is believed that the covid19 virus was spread when workers went home without realizing it had already entered their bodies. so that interactions taking on in the environment around us become unrestrained. the purwakarta district health office claimed that exchanges take place regularly. the chance of covid-19 cases being transmitted to family members and coworkers is increased by a history of close interaction with relatively long-term confirmed patients (most of them are asymptomatic). a history of close interaction with positive patients, primarily from household and business clusters, increases the number of confirmed cases. however, not all individuals with a history of close interaction are verified sick. a small percentage of close contact cases only sometimes progress to confirmed cases, as observed from the covid-19 surveillance report of the purwakarta district health office. this study aimed to determine the relationship between a history of close contact and the prevalence of covid-19 in purwakarta. this investigation will contribute to efforts to prevent and control covid-19. method this was an analytic observational study with a cross-sectional design using secondary data from the purwakarta district health office between march and december 2020, recorded in surveillance data at the purwakarta district health office. we collected 4,986 data during that period. based on a calculation of the minimum sample, we needed 357 samples. purposive purnama et al. (association between close contact history and the risk of covid-19 in purwakarta district) vol. 5, no. 1, 2023, pp. 32-40 35 10.26555/eshr.v5i1.6216 sampling was used to select the sample with inclusion criteria purwakarta district residents who screened for covid-19 in 2020 by conducting a pcr swab test, rapid antibody, and antigen tests. the exclusion criteria in this study were respondents with incomplete data. two thousand six hundred fifty people were obtained based on the inclusion and exclusion criteria, and all were included in this study. the chi-square test was used to analyze the data. results a few percent of the respondent (28.9%) of the cases of close contact belonged to the early adult age group, and 53.1% were male (table 1). table 1. distribution of respondents with close contact status by age and gender in purwakarta district in 2020 with (n=2,650) characteristics close contact history yes no n % n % age toddler (0-5) children (5-11) early teenager (12-16) late teenager (17-25) early adult (26-35) late adult (36-45) early elderly (46-55) late elderly (56-65) elderly (>65) 33 33 45 227 531 430 326 167 43 1.8 1.8 2.5 12.4 28.9 23.4 17.8 9.1 2.3 14 13 12 108 179 136 165 114 74 1.7 1.6 1.5 13.3 22.0 16.7 20.2 14.0 9.1 gender male female 974 861 53.1 46.9 412 403 50.6 49.4 table 2. frequency distribution of respondents with confirmed covid-19 status by age and gender in purwakarta regency in 2020 (n=2,650) characteristics covid-19 confirmation status yes no n % n % age toddler (0-5th) children (5-11th) early teenager (12-16th) late teenager (17-25th) early adult (26-35th) late adult (36-45th) early elderly (46-55th) late elderly (56-65th) elderly (>65th) 39 39 53 302 657 519 449 260 112 1.6 1.6 2.2 12.4 27.0 21.4 18.5 10.7 4.6 8 7 4 33 53 47 42 21 5 3.6 3.2 1.8 15.0 24.1 21.4 19.1 9.5 2.3 gender male female 1,280 1,150 52.7 47.3 106 114 48.2 51.8 purnama et al. (association between close contact history and the risk of covid-19 in purwakarta district) vol. 5, no. 1, 2023, pp. 32-40 36 10.26555/eshr.v5i1.6216 the description of respondents based on the confirmed status of covid-19 shows that most of the confirmed cases of covid-19 also belong to the early adult age group of 27.0% and males at 52.7% (table 2). the contact status variable was closely related to the incidence of covid-19 with a value of sig = 0.002. the prevalence ratio (pr) = 1.040 (95% ci = 1.0131.069), which means that people with close contact status have a 1.040 times greater risk of contracting covid-19 than people without close contact status (table 3). table 3. the results of the bivariate test of the relationship between close contact status and the incidence of covid-19 in purwakarta regency in 2020 close contact history status of covid-19 sig pr (ci 95%) yes no n % n % yes 1,704 70.1 132 69.2 0.002 1.040 (1.013-1.069) no 727 29.9 88 30.8 total 2,430 100 220 100 discussion covid-19 is transmitted from person to person with close relationships with family members, friends, relatives, or direct contact with patients confirmed to be covid-19,15, especially for those in close contact with confirmed cases. a person who is declared to have close contact is if he has a history of contact with a probable covid-19 case, he can be caught because he is close to a possible case within a 1-meter radius for 15 minutes or more, direct physical touch, people who provide direct care without using tools self-protection.16 it increases the risk of covid-19 transmission in the community, particularly for those in close contact with confirmed cases. this is confirmed by the who statement, which states that the transmission of the sars-cov-2 virus occurs through droplets and close contact with asymptomatic infected cases.10 public awareness of maintaining their distance and implementing health protocols is the primary key to breaking the chain of transmission of covid-19. public knowledge and awareness about the coronavirus can provide deeper insight into current perceptions and practicing habits to prevent covid-19.17 people may have gained awareness and learn about the disease and its transmission via television, newspaper, and other platforms, to protect themselves and their families.18 low public awareness in accessing health services will also exacerbate the situation, causing high cases of covid-19.19 the main transmission occurs through droplets originating from the respiratory tract. in addition, the transmission also occurs due to close contact with covid-19 sufferers. thus, people with a history of close contact have a high risk of exposure to the sars-cov-2 virus.20 people at risk of contracting covid-19 have close contact with covid-19 patients, including those who care for patients.21 in direct close contact, indicating that a healthy person accidentally touched a person infected with the sars-cov-2 virus or the person touched the surface of an object that a person touched with confirmed covid-19 (fomite transmission). in general, the surface of these objects has been contaminated with droplets containing the sars-cov-2 virus from covid-19 patients. the virus can remain stable for a certain period. purnama et al. (association between close contact history and the risk of covid-19 in purwakarta district) vol. 5, no. 1, 2023, pp. 32-40 37 10.26555/eshr.v5i1.6216 therefore, it can support the entry of the virus into the body of healthy people, and the infection process will continue.22 the household member number is the most significant proportion of the risk of exposure to covid-19. the analysis results in china also found that 78-85% of the clusters occurred within the household. this proves that the transmission occurred in long, close contact.23 confirmation cases originating from the company cluster occurred due to close contact with the same activity in a closed room for an hour or more with confirmation cases, which can pose a high risk for the infected.10 seventy percent of the cases identified were from close household contacts. close household contact is also considered one of the most dangerous contacts.24 this is due to the relatively small scope of the household, which allows high-speed person-to-person transmission. of the proportion of close contacts diagnosed with covid-19, 44.2% were asymptomatic. this is more concerning because the risk of spreading the virus to others is greater and uncontrollable. according to who, the community's asymptomatic infection rate is still unknown. the proportion of asymptomatic cases may vary according to age and the presence of coexisting conditions.24 however, efforts made to trace contacts and epidemiological investigations of cases and close contacts can provide information for disease management planning. information gleaned from contact tracing suggests that asymptomatic people are less likely to transmit the virus than symptomatic people.10 the sars-cov-2 virus is more likely to be transmitted between household members through droplets or direct contact with contaminated surfaces. people with confirmed patients have a higher risk of infection than those who do not live in the same environment as confirmed patients. patients demonstrated as symptomatic or asymptomatic are advised to perform independent isolation at home. on the other hand, implementing self-isolation for exposed family members allows for much greater exposure and risk for other family members, which causes close contact status, especially for families unable to provide a particular room for patients to isolate properly.23 we observed that most confirmed and close contact cases in purwakarta district are dominated by early adulthood. according to the health office of purwakarta district, this is most likely caused by transmission due to close contact in the work environment. exposure to viruses in the workplace can occur anytime and anywhere, whether on business trips or while working in a room. close contact in the work environment is related to age and can be exacerbated by comorbid diseases in patients. according to who, the risk of occupational exposure to covid-19 depends on the likelihood of close contact (distance between people of less than 1 meter) or the frequency of contact with an infected person. transmission can also occur through contact with surfaces contaminated with the sars-cov-2 virus.25 respiratory tract secretions released from infected persons can contaminate objects in the surrounding environment, causing the formation of fomites (contaminated surfaces). people who come into contact with contaminated surfaces often have close contact with infectious people, so droplet and fomite transmission are challenging to distinguish.10 the importance making efforts to break the spread of the covid-19 virus can be done by complying with existing health protocols as a preventive measure in the spread of covid-19. efforts that all parties can take include social distancing, using masks outside the home, purnama et al. (association between close contact history and the risk of covid-19 in purwakarta district) vol. 5, no. 1, 2023, pp. 32-40 38 10.26555/eshr.v5i1.6216 washing hands with soap, and immediately cleaning up after activities outside the home.26 social distancing has a vital role in efforts to minimize interactions and crowds with many people. social distancing is also one way to prevent the spread of the sars-cov-2 virus in a social group. this is because social distancing behavior will limit the reproduction rate in the spread of the virus among communities. in maintaining social distancing, people are strongly advised to postpone/avoid traveling to densely populated areas because they have a high risk of exposure.22 another thing that can be done is a regional quarantine, also stated in the health emergency regulations. regional quarantine is a restriction on the population in an area, including the entrance area and its contents suspected of being infected with a disease, to prevent the possibility of a more massive spread of covid-19.21 conclusion the conclusion is made in one paragraph without any citation. the conclusion should not merely repeat points made in the preceding sections. acknowledgment based on the results and discussion, it can be concluded that contact is closely related to covid-19 and is a risk factor. the community is expected to have the awareness to properly implement health protocols and minimize exposure by continuing to use masks if it requires activities with many people as an effort to reduce risks due to close contact. declarations authors' contribution the first and second authors contributed to the research design, data collection, analysis, and manuscript. funding statement this research has not received external funding conflict of interest there is no conflict of interest in this research. references 1. susilo a, rumende cm, pitoyo cw, santoso wd, yulianti m, herikurniawan h, et al. coronavirus disease 2019: tinjauan literatur terkini. j penyakit dalam indones. 2020;7(1):45–67. 2. kemenkes. pedoman pencegahan dan pengendalian coronavirus disease ( covid19). 5th ed. jakarta: kementerian kesehatan ri; 2020. 1–214 p. 3. handayani d, hadi rd, isbaniah f, burhan e, agustin h. penyakit virus corona 2019. j respirologi indones. 2020;54(10):871–7. 4. wulandari a, rahman f, pujianti n, sari ar, laily n, anggraini l, et al. hubungan karakteristik individu dengan pengetahuan tentang pencegahan coronavirus disease 2019 pada masyarakat di kalimantan selatan. j kesehat masy indones. 2020;15(1):42. purnama et al. (association between close contact history and the risk of covid-19 in purwakarta district) vol. 5, no. 1, 2023, pp. 32-40 39 10.26555/eshr.v5i1.6216 5. who. coronavirus disease (covid-19) [internet]. 2020. available from: https://covid19.who.int/ 6. fitriani ni. tinjauan pustaka covid-19: virologi, patogenesis dan manifestasi klinis. j med malahayati. 2020;4(3):194–201. 7. bnpb. data harian kasus per provinsi covid-19 indonesia [internet]. 2020. available from: https://bnpb-inacovid19.hub.arcgis.com/datasets/data-harian-kasus-per %0aprovinsi-covid-19-indonesia/data?geometry=58.717%2c %0a17.592%2c177.281%2c12.779&amp;orderby=kasus_posi&amp;page=4&amp;sel ectedatt%0aribute=kasus_posi 8. satgas covid-19. analisis data covid-19 mingguan satuan tugas pc19 per 20 desember 2020. jakarta : satgas covid-19 [internet]. 2020; available from: https://covid19.go.id/p/berita/analisis-data-covid-19-indonesia-update-20-desember 2020 9. cdc. people at increased risk and other people who need to take extra precautions [internet]. 2020. available from: https://www.cdc.gov/coronavirus/2019-ncov/need-extra %0aprecautions/index.html 10. world health organization. transmisi sars-cov-2 : implikasi terhadap kewaspadaan pencegahan infeksi. pernyataan keilmuan. 2020;1–10. 11. sirajuddin n, samsualam, haeruddin. pengaruh kontak erat terhadap kasus konfirmasi covid19 di kota makassar tahun 2020. muslim community heal. 2020;100–10. 12. khasanah k, anindhita ma, desiani e, rusmalina s. edukasi dan evaluasi tingkat pengetahuan warga sekitar masjid di daerah pekalongan barat mengenai penggunaan handsanitizer guna pencegahan covid-19. j abdimas. 2021;2(1):47–55. 13. ding j, tuan wj, temte jl. managing close contacts of covid-19 confirmed cases in metropolitan areas in china. j public heal manag pract. 2020;26(4):345–8. 14. satgas purwakarta. covid-19 kabupaten purwakarta [internet]. 2020. available from: https://covid19.purwakartakab.go.id/.%0a%0a 15. nugroho wd, c wi, alanish st, istiqomah n, cahyasari i. literature review : transmisi covid -19 dari manusia ke manusia di asia. j bionursing. 2020;2(2):101–12. 16. kementerian kesehatan republik indonesia. keputusan menteri kesehatan republik indonesia nomor hk.01.07/menkes/413/2020 tentang pedoman pencegahan dan pengendalian corona virus disease 2019 (covid-19). kementerian kesehatan republik indonesia 2020 p. 1–207. 17. podder d, paul b, dasgupta a, bandyopadhyay l, pal a, roy s. community perception and risk reduction practices toward malaria and dengue: a mixed-method study in slums of chetla, kolkata. indian j public health. 2019;63(3):178–85. 18. al-hanawi mk, angawi k, alshareef n, qattan amn, helmy hz, abudawood y, et al. knowledge, attitude, and practice toward covid-19 among the public in the kingdom of saudi arabia: a cross-sectional study. front public heal. 2020;8(may):1–10. 19. sinaga is., chairani i, armelia d. kerentanan covid-19 berdasarkan umur dan jenis kelamin di indonesia. pus penelit kependud [internet]. 2020; available from: https://kependudukan.lipi.go.id/id/berita/53-%0amencatatcovid19/1027-kerentanan covid-19-berdasarkan-umur-dan-jenis-%0akelamin-di-indonesia 20. hairunisa n, amalia h. review: penyakit virus corona baru 2019 (covid-19). j biomedika dan kesehat. 2020;3(2):90–100. 21. purba ipmh. implementasi undang-undang nomor 6 tahun 2018 tentang kekarantinaan kesehatan di jawa timur menghadapi pandemi covid-19. j pahlawan. 2021;4(1):1–11. 22. yanti nped, nugraha imadp, wisnawa ga, agustina npd, diantari npa. gambaran pengetahuan pasyarakat tentang covid-19 dan perilaku masyarakat di masa pandemi covid-19. j keperawatan jiwa. 2020;8(4):491–504. 23. hu p, ma m, jing q, ma y, gan l, chen y, et al. retrospective study identifies infection purnama et al. (association between close contact history and the risk of covid-19 in purwakarta district) vol. 5, no. 1, 2023, pp. 32-40 40 10.26555/eshr.v5i1.6216 related risk factors in close contacts during covid-19 epidemic. int j infect dis. 2021;103:395–401. 24. mao c, liu d, wang z, chen p, tang j, mao c. modes of contact and risk of transmission in covid-19 : a prospective cohort study 4950 close contact persons in guangzhou of china. j med. 2020;1(1):1–40. 25. world health organization. pertimbangan langkah-langkah kesehatan masyarakat dan sosial di tempat kerja dalam konteks covid-19. pernyataan keilmuan. 2020;1–7. 26. quyumi e, alimansur m. upaya pencegahan dengan kepatuhan dalam pencegahan penularan covid-19 pada relawan covid. j public health (bangkok). 2020;4(1):81–7. microsoft word fin-pub-5391-article text-27942-1-18-20230207-ss.edited.docx epidemiology and society health review| eshr vol. 5, no. 1, 2023, pp. 21-31 issn 2656-6052 (online) | 2656-1107 (print) http://journal2.uad.ac.id/index.php/eshr/index eshr@ikm.uad.ac.id 10.26555/eshr.v5i1.5391 21 research article behavior assessment for non-communicable disease prevention using the health belief model addellia yoma hastani1, helfi agustin1*, hary budiman2, ezza addini3 1 faculty of public health, universitas ahmad dahlan, yogyakarta, indonesia 2 faculty of public health, universitas baiturrahmah, padang, indonesia 3 faculty of medicine, ankara yildirim beyazit university, turkey * correspondence: helfi.agustin@ikm.uad.ac.id phone: +6285274554097 received 20 december 2021; accepted 03 february 2023; published 08 february 2023 abstract background: germacis is a community-based program educating and facilitating people to adopt a healthy lifestyle in jogokaryan hamlet, yogyakarta. it includes doing physical activities with groups, doing health checks, not smoking in the house or at community meetings, and replacing snacks with fruit. this study aims to evaluate whether the program positively impacts community behavior by assessing perceptions and practices of healthy lifestyles based on participation after the program has been implemented for two years. methods: this quantitative research with a cross-sectional approach uses the perception assessment of the health behavior model (hbm). the population was 165 people, and the sample was 54 from the hamlet number 36 at jogokariyan sub-district, yogyakarta. this research collected primary data using a 4-likert scale questionnaire. data were analyzed using the chi-square test. results: there is a relationship between active participation in activities and perceived susceptibility, perceived severity, perceived benefits, perceived barriers, cues to action, and prevention behavior. there is no relationship between participation and self-efficacy. our result shows the p-value of the 5 hbm constructs is 0.01; 0.00; 0.00; 0.03; 0.34, and 0.00 for perceived susceptibility, severity, benefits, barriers, self-efficacy, and cues to section; respectively. conclusion: program managers should consider sanctions to encourage self-efficacy in behavior, especially for active smokers; they must not smoke at home or in community meetings. keywords: health belief model; non-communicable disease; preventive behavior introduction centers for disease control and prevention reported that non-communicable diseases (ncds) are the leading cause of death and disability worldwide. this disease is the most significant burden in lowand middle-income countries, contributing to 85% of all premature hastani et al. (behavior assessment for non-communicable disease prevention using the health belief model) vol. 5, no. 1, 2023, pp. 21-31 10.26555/eshr.v5i1.5391 22 deaths.1 in indonesia, heart disease, cancer, chronic lung disease, and diabetes mellitus are among the top 5 causes of death that impact the quality of life and economic productivity. every year, the number of these cases continues to increase along with increased risk factors, such as high sugar/salt/fat consumption, smoking, and low physical activity. in 2020, health insurance spent 17.05 trillion rupiahs for the service of the disease.2 based on the data health profile of yogyakarta city in 2019, non-communicable diseases dominate the causes of death in this city.3 the integrated disease surveillance report (stp) at hospitals in yogyakarta province in 2020 obtained data on the top 10 diseases, eight non-communicable diseases. among the diseases in hospitals (outpatient) were hypertension (29,944 cases), type ii diabetes (14,090 cases), and heart disease (3,566 cases).4 non-communicable diseases have many risk factors; modifiable behavioral risk factors are tobacco and alcohol consumption, unhealthy diet, lack of physical activity, obesity, high blood pressure, and cholesterol. these risk factors remain a significant public health challenge in all countries, especially in low-income countries where more than three-quarters of deaths from non-communicable diseases occur.5 the government of indonesia developed a movement to change people's healthy lifestyles to control non-communicable diseases aimed to improve the health status of the community through promotive and preventive efforts through physical activity campaigns, consumption of vegetables and fruit, and regular health checks.6 a community-based health program in jogokaryan has adopted the national movement's healthy lifestyle due to the high prevalence of hypertension in the elderly group at jogokaryan, yogyakarta. the program is called “germacis." this program aims to change community behavior to familiar healthy life movements. the activities are smoke-free villages, health education, periodic health checks, physical activities, and advocacy to replace the snack menu at community meetings with fruit and vegetables.7 research using health belief model (hbm) is used to evaluate health behaviors and investigate possible hbm interventions to improve behaviors. hbm explains that individual values and beliefs about an activity drive their behavior.8,9 each person has a unique perception related to a particular object. these differences can be influenced by knowledge, experience, and point of view. both positive and negative perceptions are like files that have been stored carefully in one's subconscious mind. the file appears when a stimulus triggers it or an event opens it. in such a way, perception determines one's behavioral response.10 the findings of jorvand's research (2020), which evaluated the intervention's effects using the hbm model, revealed a decrease in hdl and cholesterol in the group that received exercise intervention while adhering to the same two diet groups.11 yazdanpanah's (2019) study found that one of the essential aspects when using the health belief model was the application of education on the community-based method, which helped regulate self-care behaviors.12 while imtichan (2019) said that people typically only try new things if they can do something. when someone perceives benefits from a new activity but feels unable to carry it through due to perceived barriers, likely, he will not engage in the action.13 the participant's experience after two years in this community-based health program should have increased their perception, willingness, and ability to practice a healthy lifestyle. this study aimed to determine the relationship between community participation in community-based programs and the perception or practice of preventing non-communicable diseases using the health belief model (hbm). this research provides material for consideration to develop the activities by program managers. hastani et al. (behavior assessment for non-communicable disease prevention using the health belief model) vol. 5, no. 1, 2023, pp. 21-31 10.26555/eshr.v5i1.5391 23 method this was a quantitative study used the health belief model framework to evaluate the perception and practice of healthy living in individuals based on the level of participation during community-based health programs. data were collected from february to march 2021 at mantrijeron sub-district, yogyakarta, indonesia. the total population was 165 participants, and the sample was 54 respondents at hamlet number 36, jogokariyan, mantrirejon sub-district, yogyakarta. variable and indicator were summarized in table 1. table 1. variables and indicators used in the research questionnaire variables indicators perceived susceptibility median = 15 ncd risk factor perceived severity median = 20 ncd’s danger ncd’s impact perceived benefits median = 29 regular exercise no smoking consume nutrient food healthy lifestyle routine health check manage weight perceived barriers median = 29 time barriers economic barriers environment barriers psychology barriers self-efficacy median =24 capability to manage a healthy lifestyle cues to action median =35 social support mass media health behavior scores of 4-6 health check (blood pressure, blood sugar, cholesterol) do not smoke exercise consume nutritious food manage stress membership status coding = 0 (inactive) 1 (active) community participation in the program we used the following criteria to recruit the participants: 1) only for participants of the program (active and non-active participants), 2) aged 45-75 years, and 3) suffering from hypertension and diabetes mellitus. while the exclusion criteria for the sample were 1) had moved from jogokariyan village, 2) not willing to be interviewed. the study used primary data obtained from questionnaires. a four-likert scale measures the variables since it is suitable to measure a person's perception or attitude. the answer scale was 1-4 (1 to disagree to 4 to agree) for favorable questions and vice versa for unfavorable questions. due to the small number of samples, the variables were categorized into two groups to avoid empty cells in the crosstable analysis. the scores for each variable was added and then grouped based on the: if the total hastani et al. (behavior assessment for non-communicable disease prevention using the health belief model) vol. 5, no. 1, 2023, pp. 21-31 10.26555/eshr.v5i1.5391 24 score on one variable was more than the median, then it was grouped to be positive or vice versa. the validity test results of community participation in community-based health programs were to be valid with an r-value of 1.00. the results of the validity test of the questionnaire on the perception of susceptibility perception, severity, benefits, obstacles, self-efficacy, and stimulus to act, it was known that there were two questionnaire items on the statement of susceptibility perception that were not valid with r values of 0.210 and 0.283. invalid questionnaire items were subsequently deleted from this research. the results of the reliability test using cronbach's alpha. for reliability results: for participation in the program with a value = 1; perceived susceptibility value = 0.613; perceived severity value = 0.635; perceived benefit value = 0.725; perceived obstacle value = 0.787. self-efficacy value = 0.709; the cues to action value = 0.756 and the implementation of behavior in the community value = 0.732, indicating the reliability of the questionnaire reliability test results. analysis was performed using the chisquare test. result respondent characteristic table 2 describes the distribution of the frequency and percentage of the characteristic of respondents. respondent’s ages are divided into three groups, represented most age groups were 55 – 65 years (48.1%), women (53.7%), and education level; high school or equivalent (35.2%). respondents with a positive susceptibility perception of 57.4% agreed that smoking could increase the risk of hypertension and diabetes mellitus by 75.9% and that unhealthy eating habits cause hypertension and diabetes mellitus by 81.5%. as much as 76% of respondents agree that routine health checks can help early detection of hypertension and diabetes mellitus. however, respondents agreed that there was no health impact if they reduced sugar, salt, and fat consumption by 25.9%. this data shows that their knowledge about managing hypertension and diabetes is still low. as many as 77.8% of respondents perceived that hypertension and diabetes mellitus could cause damage to internal organs to believe that this disease would change their view of a healthy life. however, 44.5% of respondents agree that hypertension and diabetes mellitus will not change their daily life. as many as 37% of respondents believe that having hypertension and diabetes mellitus will not have a significant impact on their lives and that of their families. more than forty percent (42%) believe hypertension and diabetes mellitus will not significantly affect their careers and believe this disease will change their view of a healthy life 54.8%. from the statement about perceived benefits, 66.7% of respondents who answered believed the behavior offered in the program was beneficial for preventing hypertension and diabetes mellitus. most 88.8% of respondents agree that practicing healthy living can improve their quality of life. respondents agree that managing body weight can prevent hypertension and diabetes mellitus, believing that avoiding smoking, limiting consumption of sugar and salt, and consuming lots of vegetables and fruit can reduce the risk of hypertension and diabetes mellitus. hastani et al. (behavior assessment for non-communicable disease prevention using the health belief model) vol. 5, no. 1, 2023, pp. 21-31 10.26555/eshr.v5i1.5391 25 table 2. distribution of respondent characteristics age, gender, and education level in jogokariyan village variable category n % age 45 – 54 years old 15 27.8 55 – 65 years old 26 48.1 66 – 74 years old 13 24.1 sex male 25 46.3 female 29 53.7 level of education elementary school 12 22.2 first, middle school 14 25.9 high middle school 19 35.2 university 9 16.7 more than half, 64.8% of the respondents, feel confident that there are no barriers to healthy behavior. the study found that 46.3% of respondents agreed that losing weight is a new habit challenging, and 55.7% of respondents agree that being busy at work is an obstacle to regular physical activity. 42.5% of respondents think it is too troublesome to make their food. from this study, 53.7% of respondents were unsure they could manage a healthy lifestyle to avoid the risk of disease, and 57.4% did not avoid consuming foods containing lots of salt and caffeine. this study found that the family has an essential role as a support system for healthy behavior, but 24.1% of family members will not reprimand if the respondent smokes. more than half (59.3%) of respondents think posters and banners do not provide enough information about hypertension and diabetes mellitus. the results show that the respondents who have good behavior are 61.1%. the respondents carried out health checks at least once when the program (59.3%); respondents do not smoke (61.1%) and avoid exposure to secondhand smoke. as many as 57.4% of respondents do not routinely do physical activity for at least 30 minutes daily. furthermore, and 44.4% of respondents have not been able to manage stress well. table 3 shows the variables that have been categorized. table 3. frequency distribution of variables based on category variable category n % perceived susceptibility negative 23 42.6 positive 31 57.4 perceived severity negative 27 50.0 positive 27 50.0 perception of benefits negative 18 33.3 positive 36 66.7 perception of barriers negative 19 35.2 positive 35 64.8 self-efficacy negative 25 46.3 positive 29 53.7 cues to action negative 23 42.6 positive 31 57.4 membership status active 38 70.4 non-active 16 29.6 ncd’s prevention behavior bad 21 38.9 good 33 61.1 hastani et al. (behavior assessment for non-communicable disease prevention using the health belief model) vol. 5, no. 1, 2023, pp. 21-31 10.26555/eshr.v5i1.5391 26 using a simple randomized technique, from 54 respondents, we found 38 active and 16 inactive participants. the activeness of the respondents was interpreted by participating in healthy gymnastics, participating in health checks held by the programmer team, or participating in declarations of commitment not to smoke at community meetings, in the house, and near mothers and children. the relationship between the involvement in communitybased health activities and the perception can be seen in table 4. table 4. relationship of participation in program community-based health with perceptions and behaviors of ncd prevention participation perception and behaviors of ncd prevention negative positive total p-value pr (95% ci) n % n % n % perceived susceptibility inactive 11 68.7 5 31.3 16 100 0.012 2.177 (1.228-3.861) active 12 31.6 26 68.4 38 100 perceived severity inactive 14 87.5 2 12.5 16 100 0.000 2.558 (1.585-4.126) active 13 34.2 25 65.8 38 100 perceived benefit inactive 10 62.5 6 37.5 16 100 0.003 2.969 (1.440-6.119) active 8 21.1 30 55.6 38 100 perceived barriers inactive 9 56.3 7 43.7 16 100 0.035 2.138 (1.077-4.242)) active 10 26.3 28 73.7 38 100 self efficacy inactive 9 56.3 7 43.7 16 100 0.341 1.336 (0.755-2.364) active 16 42.1 22 57.9 38 100 cues to action inactive 14 87.5 2 12.5 16 100 0.000 3.698 (2.027-6.732) active 9 23.7 29 76.3 38 100 ncd prevention behavior inactive 12 75.0 4 25.0 16 100 0.000 3.167 (1.675-5.988) active 9 23.7 29 76.3 38 100 the relationship between participation in community-based health and the perception the chi-square test results show that participation is significantly related to the perception of five components of the health belief model (hbm) in preventing hypertension and diabetes mellitus. for example, based on the results of the analysis of the relationship between participation in community-based health activities and the perception of susceptibility, there is a significant difference in the percentage of negative susceptibility perceptions (68.8%) of respondents who did not participate compared to respondents who participated (31.6%). the statistical test results obtained a p-value = 0.01, which means statistically, there is a relationship between active activity participation and perceptions of susceptibility. likewise, hastani et al. (behavior assessment for non-communicable disease prevention using the health belief model) vol. 5, no. 1, 2023, pp. 21-31 10.26555/eshr.v5i1.5391 27 with the results of the analysis of the relationship between the involvement and perceived severity, the results of the statistical test obtained a p-value = of 0.00; perceived benefit p value = 0.00; perceived barrier 0.03; cues to action p-value = 0.00 which means that statistically there is a relationship between participation and perceptions. the relationship between participation and the ncd prevention behavior the results show a relationship between community participation in community-based health activities and ncd prevention behavior. we found a significant percentage difference between respondents who participated and did not participate in the behavior to prevent ncd. the statistical test results obtained a p-value of 0.000 which means that statistically, there is a relationship between activity participation and ncd prevention behavior. the bivariate analysis describes the relationship between involvement in community-based health programs and ncd prevention behavior. discussion this study observed the association between community participation in community-based programs and the perception or practice of preventing non-communicable diseases. from the characteristic of participants, it was found that women were more than men. generally, indonesian women have autonomy in making decisions to practice healthy living. the findings of this study differ from habib’s research, which states that women in pakistan experience significant barriers to accessing tb health because of the lack of autonomy in making family decisions, problems with travel time, and lack of priority in health spending, and the lack of female health workers.14 the majority of our respondent was elderly, aged 55-65 years. increasing age will lead to the perception and awareness that aging affects their physical and psychological well-being. it makes the elderly susceptible to disease. perceived disease susceptibility can refer to individual judgments that encourage and motivate healthy behavior. the increasing age of the elderly makes their experience more mature to obtain information about health for themselves. the level of education also influences information and knowledge about the dangers of disease so that awareness grows to make efforts to prevent disease. 15 the chi-square statistical test results show a relationship between participation in this community-based program and all hbm constructs. this study is in line with previous studies that show a relationship between the effect of the construct health belief model and prevention behavior. 16–19 the perception of severity felt by respondents was influenced by the perceived threat perception. individual perceptions influence health behavior. if the individual feels vulnerable and thinks that the disease can threaten him, then the individual will take action to protect himself or seek treatment.20 the elderly, susceptible to hypertension and diabetes mellitus, will perceive the disease as threatening their lives. perceptions of susceptibility and severity are related to disease prevention behavior, and respondents think that they are vulnerable and think that hypertension and diabetes mellitus are severe diseases and can threaten their lives. some respondents actively participate in community-based health to carry out preventive practices through routine physical activities and health checks, are willing to replace cake snacks at community meetings by consuming fruit, and support residents not to smoke. efforts to form a positive susceptibility perception so that residents practice healthy living to prevent hastani et al. (behavior assessment for non-communicable disease prevention using the health belief model) vol. 5, no. 1, 2023, pp. 21-31 10.26555/eshr.v5i1.5391 28 hypertension and diabetes mellitus, one of which is by strengthening communication strategies.21 healthy living practices need to be carried out by all people. therefore it is necessary to have the cooperation of all parties to play a role in conducting socialization and habituation of healthy living practices to prevent disease. the health education strategy must touch vulnerable groups at high risk of developing hypertension and diabetes. rosenstock explains that a person's beliefs about perceived susceptibility will encourage him to take action to prevent and support healthy behavior change. change depends on the individual's belief in the effectiveness of actions to reduce the threat of disease or perceived benefits. individuals aware of the benefits of healthy living practices will continue to take health actions.22 one effort to increase the perception of the benefits of practicing healthy living is to align this health-based program with integrated health posts. this study's results indicate a relationship between perceived barriers and non-communicable disease prevention behavior. most respondents have a positive perception of the obstacles to healthy living practices. in line with the theory, that respondents feel that obstacles can affect the practice of healthy living. the more the individual feels obstacles in practicing healthy living, the less success he will have in practice. in line with obirikorang, research states that ghana's high perceived barrier is a significant predictor of non-adherence to hypertension therapy.23 the obstacles respondents feel to practicing healthy living are generally caused by personal barriers. the elderly face obstacles in practicing healthy living and need support, assistance, and supervision from their families or health workers to overcome the barriers so that they elderly can practice healthy living. these efforts can provide motivation and confidence for the elderly to face obstacles in practicing healthy living. another effort to reduce cigarette consumption is to have strict sanctions for active smokers who smoke in public places or at home. sanctions that are applied need to be regulated jointly, regulated openly, and designed to create fear of violations and provide a deterrent effect for violators. the results of the study show statistically result that there is no relationship between selfefficacy and disease prevention behavior. based on the data obtained from the respondents' answers, the number of lousy prevention behaviors with positive self-efficacy. this research is in line with imtichan’s research, which explains a relationship (b = 1.51;95% dan p = 0.015) between self-efficacy and clean behavior among the elderly with hypertension. sometimes individuals already feel confident about their ability to behave healthily, but the obstacles they face affect their efforts to behave healthily. due to the challenges faced, individuals with positive self-efficacy only sometimes have good healthy behavior.13 bandura explains that self-efficacy is always related and impacts the selection of one's behavior, motivation, and determination when facing problems. self-efficacy can affect stress and anxiety levels through behavior that can solve problems. individuals will feel anxious when faced with something beyond their control because of the threat that affects them. in line with research that there is a relationship between obstacles and healthy behavior, it affects individual self-efficacy. respondents think the obstacles encountered affect their efforts to behave healthily even though they have positive self-confidence.24 this study was in line with the research of larki (2021), which states that there is a stimulus relationship to act with self-care for hypertension sufferers. respondents with low literacy have low self-confidence. therefore they need to get stimulation from outside to practice healthy living in a supportive environment and health information through health education, mass and hastani et al. (behavior assessment for non-communicable disease prevention using the health belief model) vol. 5, no. 1, 2023, pp. 21-31 10.26555/eshr.v5i1.5391 29 electronic media, and medical regulations from health workers who provide motivation and support for practicing healthy.25 in line with the research findings, self-efficacy can be achieved by increasing germacis participants' knowledge, participating in some program activities, and ensuring the sustainability of healthy living practices through supervision and empowerment. germacis' programmer can act as a mentor, supporter, and motivator for participants, fostering selfconfidence and the ability to practice healthy living while overcoming obstacles. respondents received stimulation from outside through community-based health programs, health education through counseling and print media (posters and wall clocks), motivation, support, and reprimand from family and closest people to carry out healthy living practices to maintain their health. it is necessary to strengthen the cues to action by improving health services for the elderly. health services need to be provided early on at the pre-elderly age. home visits to the elderly can help them obtain regular health checks. strengthening support for the elderly is also needed; support has a significant role in the efforts of the elderly to maintain their health status by practicing healthy living. conclusion there is a relationship between the level of participation and perception (perceived susceptibility, perceived severity, perceived benefit, perceived barriers, and cues to action) and prevention behavior). there is no relationship between participation and self-efficacy. health empowerment must touch at-risk community groups regularly. for the program's sustainability, it is necessary to involve the cooperation of all parties to take on the habituation of healthy living practices and create sanctions for active smokers at community gatherings and homes. there is a need for regular monitoring, support, and assistance from health workers so that the elderly can optimally participate in activities and can encourage the community to be more active in practicing healthy living and maintaining the sustainability of the program. declarations authors' contribution ha contributed to the research design, analysis, and manuscript. ay contributed to data collection and analysis. ea and hb contributed to the manuscript editing. funding/acknowledgement this research has not received external funding. conflict of interest there is no conflict of interest in this research. hastani et al. (behavior assessment for non-communicable disease prevention using the health belief model) vol. 5, no. 1, 2023, pp. 21-31 10.26555/eshr.v5i1.5391 30 references 1. centers for disease control and prevention. global noncommunicable diseases fact sheet [internet]. web page. 2023 [cited 2022 feb 8]. available from: https://www.cdc.gov/globalhealth/healthprotection/resources/fact-sheets/global-ncd-factsheet.html 2. penyakit dp dan p. kick off bulan gerakan deteksi dini penyakit tidak menular. in: http://p2p.kemkes.go.id/kick-off-bulan-gerakan-deteksi-dini-penyakit-tidak-menular/. 2022. 3. dinas kesehatan kota yogyakarta. profil kesehatan kota yogyakarta 2019. 2019. 31– 45 p. 4. https://www.dinkes.jogjaprov.go.id/berita/detail/penyakit-tidak-menular-masihmendominasi-masalah-kesehatan-di-diy. penyakit tidak menular masih mendominasi masalah kesehatan di diy. in 2021. 5. who. noncommunicable diseases progress monitor 2020. switzerland; 2020. 6. kementerian kesehatan ri. panduan gerakan masyarakat sehat. jakarta: pusat promosi kesehatan kementerian kesehatan ri; 2016. 7. trisnowati h. gerakan masyarakat cinta sehat (germascis) sebagai strategi mengendalikan penyakit tidak menular : studi pada kampung di yogyakarta. yogyakarta: yayasan indonesia ramah lansia; 2018. 8. snelling a. introduction to health promotion. 1st ed. anastasia snelling, editor. usa: jossey bass a willey brand; 1385. 302 p. 9. karen glanz, barbara k. rimer kv. health behavior and health education : theory, research, and practice. fourth edi. rimer bk, viswanatah, editors. san fransisco, jossey-bass: jossey bass; 2008. 10. rahmat j. psikologi komunikasi. 13th ed. bandung: rosda karya; 1999. 51–98 p. 11. jorvand r, ghofranipour f, haerimehrizi a, tavousi m. evaluating the impact of hbmbased education on exercise among health care workers: the usage of mobile applications in iran. bmc public health. 2020;20(1):1–11. 12. yazdanpanah y, moghadam ars, mazlom sr, beigloo rha, mohajer s. effect of an educational program based on health belief model on medication adherence in elderly patients with hypertension. evid based care j. 2019;9(1):52–62. 13. imtichan sn, tamtomo d, sulaeman es. path analysis: application of health belief model on the determinants of clean and healthy behavior among elderly with hypertension. j heal promot behav. 2019;4(2):110–20. 14. habib ss, jamal wz, zaidi sma, siddiqui jur, khan hm, creswell j, et al. barriers to access of healthcare services for rural women— applying gender lens on tb in a rural district of sindh, pakistan. int j environ res public health. 2021;18(19). 15. onoruoiza si, ibrahim am, umar bd, kunle ys. using health beliefs model as an intervention to non-compliance with hypertension information among hypertensive patient. j humanit soc sci. 2018;20(9):10–6. 16. yousefi p, farmanbar r, omidi saeed4 s, farhadi hassankiadeh r. a study on the predictive power of the health belief model constructs in self-care behaviors of patients with hypertension. heal educ heal promot. 2015;3(3):5–13. 17. khorsandi m, fekrizadeh z, roozbahani n. investigation of the effect of education based on the health belief model on the adoption of hypertension-controlling behaviors in the elderly. clin interv aging. 2017;12:233–40. 18. dehghani-tafti a, mazloomy mahmoodabad ss aei., morowatisharifabad ma l., afkhami ardakani m, rezaeipandari h, lotfi mh assa. determinants of self-care in diabetic patients based on health belief model. glob j health sci. 2015;7(5):33–42. 19. sukohar a. health belief model and hypertension prevention. indian j forensic med toxicol. 2021;15(3):2054–9. 20. febriani wm. description of health seeking behavior among public health students airlangga university. indones j heal promot ad heal educ. 2019;7(2):193–203. 21. chukumnird s, boonyasopun u, sirisom k. factors influencing adherence to preventive hastani et al. (behavior assessment for non-communicable disease prevention using the health belief model) vol. 5, no. 1, 2023, pp. 21-31 10.26555/eshr.v5i1.5391 31 behaviors among thais with hypertension: a literature review. walailak j sci technol. 2019;16(8):509–21. 22. rosenstock im. the health belief model and preventive behaviour. heal educ behav. 1974;2(4):354. 23. obirikorang y, obirikorang c, acheampong e, odame anto e, gyamfi d, philip segbefia s, et al. predictors of noncompliance to antihypertensive therapy among hypertensive patients ghana: application of health belief model. int j hypertens. 2018;2018. 24. glanz k, rimer bk. theory at a glance. vol. 83, health san francisco. 2005. 52 p. 25. larki a, reisi m, tahmasebi r. factors predicting self-care behaviors among low health literacy hypertensive patients based on health belief model in bushehr district, south of iran. soc med. 2021;14(1):4–12. epidemiology and society health review| eshr vol. 3, no. 1, 2021, pp. 8-14 issn 2656-6052 (online) | 2656-1107 (print) 10.26555/eshr.v3i1.2295 8 research article low birth weight and immunizations status: risk factors of acute respiratory infection in children 2-5 years qonita rahmadiena 1,*, erika diana risanti 1, listiana masyita dewi 1, shinta riana setiawati 1 1 faculty of medicine, universitas muhammadiyah surakarta, surakarta, indonesia *correspondence: qonita.diena@gmail.com. phone: +6281288457460 received 15 june 2020; accepted 20 january 2020; published 21 february 2021 abstract background: acute respiratory infection (ari) is one of the most important causes of morbidity and mortality in children under five years old (toddlers) worldwide, especially in developing countries. ari is an acute upper or lower respiratory tract disease that occurs acutely, usually transmitted with mild to lethal symptoms. various risk factors cause a high incidence of ari cases in infants, including low birth weight (lbw) and incomplete immunization. children aged 2-5 years are expected to have received basic immunizations and complete tests according to age to have a stronger immunity to ari than children aged less than two years. objective: to determine the relationship of lbw and immunization history with ari events in children aged 2-5 years. method: this is an analytic observational study with a cross-sectional design using 31 samples of ari and non-ari pediatric patients treated at the pku muhammadiyah hospital surakarta. samples were determined using a purposive technique meaning that samples were taken according to specific criteria. the population was pediatric patients aged 2-5 years diagnosed with ari: common cold, nasopharyngitis, tonsillitis, laryngitis, bronchitis, bronchiolitis, pneumonia, and sars. this study's study populations are pediatric patients aged 2-5 years who were outpatient at pku muhammadiyah hospital surakarta in december 2019. therefore, the number of samples is calculated using the sample formula for study groups with different sample sizes, and data was taken employing a patient's parent interview. results: there were 31 patients with details of 17 ari and 14 non-ari. fisher's test showed there was no relationship between lbw and ari (p-value = 0.597, p> 0.05 and prevalence ratio = 1.286). and there was no significant relationship between the history of immunization with ari (p-value = 0.287, p> 0.05 and prevalence ratio = 2.5). conclusion: there is no significant relationship between lbw and immunization history with ari in children aged 2-5 years. keywords: low birth weight; history of immunization; acute respiratory infection; children introduction acute respiratory infection (ari) is one of the most important causes of morbidity and mortality in children worldwide, especially in developing countries (1). every year, ari kills https://doi.org/10.26555/eshr.v3i1.2295 http://creativecommons.org/licenses/by-sa/4.0/ http://crossmark.crossref.org/dialog/?doi=10.26555/eshr.v3i1.2295&domain=pdf rahmadiena et al. (low birth weight and immunizations status: risk factors of acute respiratory infection in children 2-5 years …) vol. 3, no. 1, 2021, pp. 8-14 9 10.26555/eshr.v3i1.2295 around 1.4 million children under five (toddlers), accounting for 18% of all deaths of children under five in the world (2). the prevalence of ari in central java province in 2017 was 9.7% or 10.551 cases of ari according to the diagnosis of health workers in some healthcare. while the prevalence of ari in surakarta in the same year, the highest number was found in the age group under five years (toddlers) (24-35 months) 19.112 cases, followed by 36-47 months, 18.821 cases (3). based on previous research, there was a significant correlation between the mr vaccine (p = 0.011) and the dpt vaccine (obtained p = 0.002) to reduce pneumonia in children aged ten months to 5 years. adequate mr immunization can prevent about 11% of pneumonia deaths under five, and with pertussis immunization (dpt), 6% of pneumonia deaths can be controlled (4). a research study conducted in stockholm, sweden in 2014 showed, in a research population of 6.014 single infants born between 35-42 weeks of gestation, low levels of t-cell receptor excision circles (trec) and κ-deleting recombination excision circles (krec) more often found in infants with a low birth weight with adequate gestational age (5) various risk factors cause high mortality rates of ari cases in infants, such as low birth weight (lbw), children who do not get complete immunization, do not get adequate breast feed, and exposed to cigarette smoke or pollution (6). besides, risk factors underlying the course of ari in children include host factors, disease agents, and the environment, including age, sex, nutritional status, breastfeeding, low birth weight (lbw), immunization, parents’ educational status, socio-economic status, air pollution, other diseases, natural disasters, and consideration of antibiotic use (7)(8). low birth weight is a risk factor of ari in infants due to the low number of immune cells in the body of infants with low birth weight, namely t lymphocytes and b lymphocytes (9). when viewed from the immunization schedule, children aged 2-5 years are expected to have received basic immunizations and complete tests according to age to have a stronger immunity to ari than children aged less than two years (10). immunization is one of the effective preventive measures to prevent infectious diseases by providing artificial active immunity (11). the vaccine that affects ari's case is pentavalent vaccine immunization, and it was articulated by research in india (12). pentavalent vaccine (dpt-hb-hib) and bcg, polio, and mr vaccines are originally only to prevent nine infectious diseases, namely diphtheria, pertussis, tetanus, hepatitis b, tuberculosis, polio, measles, and rubella have developed into eight diseases contagious. hib antigens can prevent pneumonia and meningitis, which are inflammatory diseases of the brain, and pneumonia, which account for 17.2 percent of infants' deaths (10). based on research conducted by sari and vitawati in 2015, there was a significant correlation between mr vaccine administration (p=0.011) and dpt vaccine (p=0.002) in reducing the incidence of pneumonia in children aged ten months to 5 years. adequate mr immunization can prevent about 11% of pneumonia deaths under five, and with pertussis immunization (dpt), 6% of pneumonia deaths can be controlled (4). a research study conducted in stockholm, sweden in 2014 showed, in a study population of 6,014 single infants born between 35-42 weeks of gestation, low levels of t-cell receptor excision circles (trec) and κ-deleting recombination excision circles (krec) more often found in infants with a low birth weight with sufficient gestational age (5). https://doi.org/10.26555/eshr.v3i1.2987 rahmadiena et al. (low birth weight and immunizations status: risk factors of acute respiratory infection in children 2-5 years …) vol. 3, no. 1, 2021, pp. 8-14 10 10.26555/eshr.v3i1.2295 the purpose of this study was to determine the relationship between lbw and history of immunization with ari in children aged 2-5 years. this research can provide information for clinicians and the community so that prevention can be done early and reduce ari incidence in children aged 2-5 years. method this research is an observational analytic study with a cross-sectional approach conducted at the children's polyclinic pku muhammadiyah surakarta hospital. we retrieve the data using interviews with parents of pediatric patients diagnosed with ari who underwent outpatient treatment at the paediatric clinic pku muhammadiyah surakarta hospital within novemberdecember 2019 that met the criteria of retention. this study used 31 samples of ari and non-ari patients following predetermined retention criteria. the age of the study subjects was 2-5 years. the sampling technique is using nonprobability purposive sampling. this study's independent variables were low birth weight (lbw) and immunization history, then the dependent variable of the study was the incidence of acute respiratory infections (ari). the data were analyzed using a statistical software program, then analyzed bivariate with the fisher's test with a significance level of p <0.05. this research has already been ethically approved by a human research ethics committee (hrec). results the data were analysed based on age and gender. based on gender, this study was dominated by males, with 19 patients (61.3%). based on age, most of the patients in this study 9 patients (29.0%) were 4 years old, and at least 6 patients (19.4%) were at the 3 years old (table 1). table 1. characteristics of subjects characteristics frequency percentage (%) gender male female age (y.o.) 2 3 4 5 19 12 8 6 9 8 61.3 38.7 25.8 19.4 29.0 25.8 table 2 shows that children aged 2-5 years who were treated at pku muhammadiyah hospital surakarta were born above the average body weight of 26 children (83.9%). most of the children have a history of the complete immunization status of 24 children (77.4%), and most of the ari diagnosed were 17 children (54.8%) (table 2). https://doi.org/10.26555/eshr.v3i1.2987 rahmadiena et al. (low birth weight and immunizations status: risk factors of acute respiratory infection in children 2-5 years …) vol. 3, no. 1, 2021, pp. 8-14 11 10.26555/eshr.v3i1.2295 table 2. univariate analysis result characteristic frequency percentage (%) low birth weight lbw non-lbw immunization status complete incomplete diagnosis ari not ari 5 26 24 7 17 14 16.1 83.9 77.4 22.6 54.8 45.1 statistical analysis to see the relationship of low birth weight (lbw) with ari using fisher's test obtained p = 0.597 (p> 0.05) meaning that there is no significant relationship between low birth weight (lbw) with the incidence of ari in children aged 2-5 years. the relationship between lbw and ari in children is presented in table 3, a prevalence ratio of 1.28 (95% ci: 0.183–9.021) there is no significant relationship between lbw and ari in children 2-5 years. table 3. multivariate analysis ari incidence total p-value rp 95% ci ari non-ari lbw history lbw 3 2 5 0.597 1.286 0.183-9.021 non-lbw 14 12 26 immunization status complete 5 2 7 0.287 2.5 0.403-15.501 incomplete 12 12 24 we found that here was no relationship between the history of immunization with ari in children aged 2-5 years in this study. statistical analysis to see the relationship between the history of immunization status and the incidence of ari using fisher's test, obtained the value of p = 0.287 (p> 0.05), it can be concluded that h0 is accepted and h1 is denied or there is no significant relationship between the history of immunization status with ari in children aged 2-5 years old (table 3). discussion low birth weight is a risk factor of ari in infants. based on the theory, birth weight determines physical growth and development in infancy. children with a history of low birth weight (lbw) have a greater risk of death than children with a history of adequate birth weight (bblc), especially in the first months of birth, due to imperfect immune formation making it more susceptible to infectious diseases especially pneumonia and other respiratory infections. https://doi.org/10.26555/eshr.v3i1.2987 rahmadiena et al. (low birth weight and immunizations status: risk factors of acute respiratory infection in children 2-5 years …) vol. 3, no. 1, 2021, pp. 8-14 12 10.26555/eshr.v3i1.2295 babies with lbw often experience respiratory problems. this is caused by the growth and development of imperfect lungs and weak respiratory muscles (13) however, in this study, no relationship was found between lbw and ari in children aged 25. this study was dominated by the number of children born with average birth weight compared to children who had a history of low birth weight, thereby affecting the unrelated outcome between lbw and ari in children aged 2-5 years. this result is in line with research conducted (lestari, 2017), which states that there is no significant relationship (p = 0.467) between lbw and ari (14) based on table 3, the relationship between the history of immunization status with ari in children, a prevalence ratio of 2.5 with confidence interval (95% ci: 0.403–15,501), it can be concluded that there is no meaningful relationship between historical status immunization with ari in children aged 2-5 years. this is different from research conducted by imelda (2017), which states that toddlers with incomplete immunization history have 8.6 times the chance of suffering from ari than toddlers who have a complete immunization history (15). however, other studies conducted also showed the same thing with this study: the absence of a relationship (p = 0.363) between immunization status and the incidence of ari in infants (14). following the results of research conducted by (tazinya, 2018) which states that age, sex, immunization status, breastfeeding, parental (father) education status, parental age, absenteeism in attendance, and population density are not significant factors related to ari in toddlers (6) the sample in this study was dominated by children who have a complete history of immunizations, that is, complete basic immunizations and tests according to the child's age because most of the patients follow the government's immunization program regularly by the government. however, based on interviews with parents of children, they often stated late or not given to children aged 2-5 years are measles / mr vaccine and pentavalent (dpt-hbhib) tests experiences illness or parents are busy at the time of the immunization schedule. besides, some parents of children also doubted the vaccine's halalness, so that they chose not to give or continue giving the vaccine to their children. ari that occurs in children can also be influenced by several other factors such as history of breastfeeding, nutritional status, environmental conditions, the child's immune condition when sick, and children's food / beverage habits that irritate the pharyngeal epithelium, thereby triggering the occurrence of pharyngitis and other aris (10). to reduce the factors that increase the ari mortality, complete immunization is essential, including full primary immunization and repetition. toddlers with an entire history of vaccination can be expected that the disease will not become more severe. the method that has proven to be the most effective is the administration of measles and pertussis immunization (dpt) aimed to reduce infant mortality (16). conclusion there was no relationship between low birth weight (lbw) and history of immunization in the incidence of acute respiratory infections (ari) in children aged 2-5 years. https://doi.org/10.26555/eshr.v3i1.2987 rahmadiena et al. (low birth weight and immunizations status: risk factors of acute respiratory infection in children 2-5 years …) vol. 3, no. 1, 2021, pp. 8-14 13 10.26555/eshr.v3i1.2295 authors’ contribution qr was responsible for the design, data collection, analysis, and drafting of the manuscript. ed, lm, and sr were responsible for design and analysis, and manuscript review. funding this research has not received external funding. conflict of interest there is no conflict of interest in this research. references 1. denny fw, loda fa. acute respiratory infections are the leading cause of death in children in developing countries. am j trop med hyg. 1986 [cited 2021 feb 18];35(1):1– 2. available from: https://pubmed.ncbi.nlm.nih.gov/3946732/ 2. who. who | pneumonia is the leading cause of death in children. who. world health organization; 2011 [cited 2021 feb 17]. available from: https://www.who.int/maternal_child_adolescent/news_events/news/2011/pneumonia/en/ 3. ministry of health ri research and development agency. main results of basic health research. kementrian kesehat republik indones. 2018; 4. sari p, vitawati. hubungan pemberian imunisasi dpt dan campak terhadap kejadian pneumonia pada anak usia 10 bulan 5 tahun di puskesmas sangurara kota palu tahun 2015. j ilm kedokt. 2019;3(1):42–51. 5. schlinzig t, johansson s, stephansson o, hammarström l, zetterström rh, von döbeln u, et al. surge of immune cell formation at birth differs by mode of delivery and infant characteristics a population-based cohort study. plos one. 2017;12(9):: e0184748. 6. tazinya aa, halle-ekane ge, mbuagbaw lt, abanda m, atashili j, obama mt. risk factors for acute respiratory infections in children under five years attending the bamenda regional hospital in cameroon. bmc pulm med. 2018;16(1):7. 7. said, mardjanis. pneumonia. in n.n. rahajoe bs& dbs. buku ajar respirologi anak. edisi pertama. edisi pert. jakarta: ikatan dokter anak indonesia (idai); 2012. 350–548 p. 8. efni y, machmud r, pertiwi d. faktor risiko yang berhubungan dengan kejadian pneumonia pada balita di kelurahan air tawar barat padang. j kesehat andalas. 2016 aug 11;5(2). 9. kai mw, tomayahu mb, syamsidar, anggraini r. the relationship of low birth weight with acute respiratory infection (ari) on toddlers in telaga health care clinic of gorontalo district. in: surabaya international health conference “empoweringg community for health status improvement”. surabaya: unusa; 2019. p. 1–9. available from: https://conferences.unusa.ac.id/index.php/sihc19/article/download/532/243 10. n.rahajoe n, supriyanto b, setyanto db. buku ajar respirologi anak. badan penerbit ikatan dokter anak indonesia. 2012. 11. clem as. fundamentals of vaccine immunology. in: journal of global infectious diseases. wolters kluwer -medknow publications; 2011 [cited 2021 feb 18]. p. 73–8. available from: /pmc/articles/pmc3068582/ 12. selvaraj k, chinnakali p, majumdar a, krishnan i. acute respiratory infections among under-5 children in india: a situational analysis. j nat sci biol med. 2014 jan [cited 2021 feb 18];5(1):15–20. available from: /pmc/articles/pmc3961922/ 13. febriana chandrawati p, ni alhabsyi f. hubungan berat badan lahir rendah terhadap frekuensi kejadian ispa pada balita usia 1-4 tahun. vol. 10, saintika medika. 2017. 14. lestari n. hubungan antara kondisi saat bayi, status gizi, dan lingkungan dengan https://doi.org/10.26555/eshr.v3i1.2987 rahmadiena et al. (low birth weight and immunizations status: risk factors of acute respiratory infection in children 2-5 years …) vol. 3, no. 1, 2021, pp. 8-14 14 10.26555/eshr.v3i1.2295 kejadian ispa faringitis pada balita di wilayah kerja puskesmas sangkrah surakarta. eprints.ums. universitas muhammadiyah surakarta; 2017. 15. imelda i. hubungan berat badan lahir rendah dan status imunisasi dengan kejadian infeksi saluran pernafasan akut pada balita di aceh besar. j ilmu keperawatan. 2017;5(2):90–6. 16. lestari d, tirta in, novidariyanti e, ikhsan fa. effect of balance immunization on infant mortality rate in indonesia. maj pembelajaran geogr. 2019;2(2):1–21. https://doi.org/10.26555/eshr.v3i1.2987 microsoft word **qura**.docx epidemiology and society health review| eshr vol 1 no1 2019 17 research article the determinants of cervical cancer early detection behaviour with via test method in visitors of policlinic “kia-kb” in kassi-kassi public health centre of kota makassar ummul qura*, jumriani ansar, dian sidik arsyad, indra dwinata, muh. ikhsan, suriah. faculty of public health, hasanuddin university, makassar, indonesia *correspondence: ummulqurahasan@gmail.com; telp.: +6281342953780 received 07 august 2019; accepted 09 september 2019; published 09 september 2019 abstract background: cervical cancer can be recognized at the pre-cancer stage by doing early detection test in married women. one of the cervical cancer early detection methods is visual inspection with acetic acid (via) test. the coverage of the early detection of cervical cancer through via test method in 2017 was still very low, i. e. 1.03% from the national target of 50%. the research aims to know the determinants of cervical cancer early detection behaviour by using iva test method in visitors of policlinic kia-kb (pediatric and family planning polyclinic) in kassi-kassi public health center. methods: the research was observational analytical research with cross sectional study design. the population of the study was all women of fertile couple that visited policlinic kia-kb in kassi-kassi public health center and lived within the coverage area of kassi-kassi public health center, which amounted to 135 women. the samples were 101 women that were collected by using accidental sampling technique. results: the results showed that there was a relation between knowledge (p=0.000), attitude (p=0.005), husband support (p=0.000), as well as health worker support (p=0.000) and early detection behaviour by using iva test method. conclusions: meanwhile, there was no relation between education and early detection behaviour by using iva test method. there should be proactive and creative actions from health workers in improving the knowledge of the targets and their husbands about early detection of cervical cancer. keywords: determinant, early detection, iva epidemiology and society health review| eshr vol 1 no1 2019 18 introduction cervical cancer is the occurrence of abnormal cell growth at the cervix that turns into cancer (1). based on the data obtained from world health organization (who) in 2016, the number of cervical cancer cases placed fourth after breast cancer, colorectal cancer, and endometrium cancer in women with a total number of 530,000 of new cases in 2012, whereas 7.5% of them caused death aside from all the cancer impacts on women (2). meanwhile, the incidence of cancer in indonesia estimated by globocan, international agency for research on cancer (iarc) in 2012 was 134 per 100,000 citizens. leading with the highest incidence in women was breast cancer with 40 per 100,000, followed by cervical cancer with 17 per 100,000 and colorectal cancer with 10 per 100,000 women (3). from the data obtained from riskesdas in 2013, the estimated number of cervical cancer patients in south sulawesi province placed 6th as the area with the highest number of patients with 3,400 cases (4). according to the data obtained from the health office of south sulawesi province, there were 460 cases of cervical cancer in 2015, while in 2016 there were 319 cases (5). on the other hand, the number of cervical cancer cases in kota makassar was 117 in 2015 and 64 in 2016 (6). the incidence of cervical cancer can be decreased by making primary efforts, such as conducting counselling activities more often for the citizens to lead a healthy life, avoiding risk factors of the cancer, having vaccination with human papillomavirus (hpv) vaccine and having early detection test (7). having early detection is an effort made to clinically identify diseases before getting diagnosed by having certain examination or test and identifying the disease as early as possible, which is in the early stage of the disease. thus, it is expected that the disease can be treated immediately. one of the screening and early detection methods for cervical cancer is visual inspection with acetic acid (via), which is an alternative screening choice in indonesia because it is easy, practical, and can be carried out in every maternity check-up centre. furthermore, the tools needed for the screening are quite simple (8). the total number of women who had an early detection of cervical cancer with iva test method in indonesia in 2017 was 2.2 million (5%) of the entire population with a total of 34 million women. meanwhile, the specified target for screening on the national level is 50% for women aged 30-50 within the period of 5 years or until the year of 2019 (9). from the health profile data of south sulawesi province in 2017, the coverage of the early detection with iva test method was only 2.6% (5). on the other hand, from the health profile data of kota makassar in 2017, the coverage of the early detection with iva test method was 2803 women (1.03%) from the total target of 450,395. from the same source, we found that rappocini sub-district was the area that had the lowest level of iva test coverage among 14 sub-districts in kota makassar with only 0.16% coverage. kassi-kassi public health center was one of the health centers located in rappocini sub-district with the highest number of target fertile women from 46 health centers that were located in kota makassar, amounting to 14,499 people. out of all epidemiology and society health review| eshr vol 1 no1 2019 19 the target fertile women, only 104 (0.72%) of them had iva test with iva positive amounting to 6 people (5.7%) in 2017 (6). from the data above, the researcher was interested in conducting a study on the determinants of cervical cancer early detection behaviour with via test method in visitors of policlinic kia-kb (pediatric and family planning polyclinic) in kassi-kassi public health center of kota makassar. the researcher was aware of the time and resource limitation. thus, the researcher only focused on examining five factors (education, knowledge, attitude, husband support, and health worker support) that were considered to be related to the coverage accomplishment of cervical cancer early detection with iva test method. methods study design the research method and design for the study was observational analytical with cross sectional design, which is a research design for examining correlation dynamics among risk factors or the effects caused with an approach, observation or data collection done at the same time or point time approach. setting the study was conducted in kassi-kassi public health center with the coverage area of rappocini sub-district of kota makassar from september 24th to october 20th of 2018. data source and data collection the data collection techniques used for the study were interview and literature analysis. the primary data was obtained from the interview with the respondents through questionnaire. meanwhile, the secondary data was obtained from the data of coverage area of early detection of cervical cancer with via test method from the health office of south sulawesi and kota makassar. from the same source, the data on the number of women of fertile couple in kassi-kassi health centre was also obtained. sample population the population of the research was all women of fertile couple who visited policlinic kia-kb in kassi-kassi health centre from august, with a total number of 135 people. with accidental sampling technique, a total of 101 respondents were selected. variables the study was conducted to find out the relation between the independent variables (education, knowledge, attitude, husband support, and health worker support) and the dependent variable (cervical cancer early detection behaviour with via test method). epidemiology and society health review| eshr vol 1 no1 2019 20 analysis the data analysis techniques used were univariate and bivariate analyses with chisquare test. ethical approval this research did not use ethical approval because on the field, the researchers only used informed consent which was the agreement to be a respondent in this research and no biological intervention was made to the respondent. in this study, the data collection was conducted by interviewing respondents based on each question prepared in the form of a research questionnaire. results result 1 table 1 the distribution of respondents based on the respondents’ characteristics in visitors of policlinic kia-kb in kassi-kassi health center kota makassar respondents’ characteristic frequency (n) percentage (%) age group (year) 15-19 20-24 25-29 30-34 35-39 40-44 45-49 5 13 26 25 16 13 3 5.0 12.9 25.7 24.8 15.8 12.9 3.0 education do not graduate elementary school elementary school graduate junior high school/equivalence graduate senior high school/equivalence graduate university graduate 1 4 11 36 49 1.0 4.0 10.9 35.6 48.5 occupation not working (housewife) civil servant entrepreneur private employee others (honorarium worker) 61 8 13 15 4 60.4 7.9 12.9 14.8 4.0 source: primary data, 2018 most respondents were in the age group of 25-29 with 26 respondents (25.7%). based on their latest education, most respondents graduated from university with 49 respondents (48.5%). meanwhile, from the respondents’ distribution based on their occupation, it was found that most respondents were not working/housewives with 61 respondents (60.4%). epidemiology and society health review| eshr vol 1 no1 2019 21 result 2 table 2 respondents distribution based on the research variables in visitors of policlinic kia-kb in kassi-kassi public health center kota makassar observed variable frequency (n) percentage (%) education high low 85 16 84.2 15.8 knowledge high low 63 38 62.4 37.6 attitude positive negative 86 15 85.1 14.9 husband support supportive unsupportive 59 42 58.4 41.6 health worker support supportive unsupportive 52 49 51.5 48.5 early detection behaviour with via test method yes no 30 71 29.7 70.3 source: primary data, 2018 from the education variable, it was found that 85 respondents (84.2%) had a high education, while 16 respondents (15.8%) had a low education background. from the knowledge variable, we found that 63 respondents (62.4%) had a high level of knowledge, while the other 38 (37.6%) had a low level of knowledge. meanwhile, from the attitude variable, 86 respondents (85.1%) had a positive attitude and the other 15 respondents (14.9%) had a negative attitude. the variable of husband support showed that 59 respondents (58.9%) got support from the husband, while the 42 respondents (41.6%) were lacking support. from the data obtained for health worker support, it was found that 52 respondents (51.5%) got support and 49 respondents (48.5%) did not get enough support. on the other hand, for the variable of cervical cancer early detection behaviour with via test method, 30 respondents (29.7%) had early detection examination with via test method and 71 respondents (70.3%) did not have early detection examination with via test method. epidemiology and society health review| eshr vol 1 no1 2019 22 result 3 table 3 the relationship between independent variable and dependent variable independent variable early detection behaviour with via test method total p yes no n % n % n % education high low 26 4 30.6 25.0 59 12 69.4 75.0 85 16 100.0 100.0 0.772* knowledge high low 27 3 42.9 7.9 36 35 57.1 92.1 63 38 100.0 100.0 0.000 attitude positive negative 30 0 34.9 0.0 56 15 65.1 100 86 15 100.0 100.0 0.005* husband support supportive unsupportive 28 2 47.5 4.8 31 40 52.5 95.2 59 42 100.0 100.0 0.000 health worker support supportive unsupportive 30 0 57.7 0.0 22 49 42.3 100 52 49 100.0 100.0 0.000 source: primary data, 2018 based on the data of the relationship between education and cervical cancer early detection behaviour with via test method, out of the 85 respondents who had a high education, there were 26 respondents (30.6%) who got early detection with via test method. on the other hand, out of all the 16 respondents who had a low education, 4 respondents (25%) got early detection with via test method. from the fisher exact test analysis result, a p value of 0. 772 was obtained, meaning that there was not any relationship between education and early detection behaviour with via test method. from the data on the relationship between knowledge and early detection behaviour with via test method, out of the 63 respondents who had a high level of knowledge, 27 respondents (42.9%) got early detection with via test method. on the other hand, out of the 38 respondents who had a low level of knowledge, 3 respondents (7.9%) got early detection or cervical cancer with via test method. from the analysis result of the chi-square test, p = 0.000 was obtained. therefore, it can be concluded that there was a relationship between knowledge and cervical cancer early detection behaviour with via test method. from the data on the relationship between attitude and early detection behaviour with via test method, out of the 86 respondents who had a positive attitude, 30 respondents (34.9%) got early detection behaviour with via test method. meanwhile, from the total 15 respondents who had a negative attitude, no one got early detection of cervical cancer with via test method. from the result of fisher exact test analysis, epidemiology and society health review| eshr vol 1 no1 2019 23 p = 0.005 was obtained. thus, it can be concluded that there was a relationship between attitude and cervical cancer early detection behaviour with via test method. based on the data obtained on the relationship between husband support and early detection behaviour with via test method, out of the 59 respondents who got support from their husbands, 28 respondents (47.5%) got early detection of cervical cancer with via test method. meanwhile, out of the 42 respondents who did not get enough husband support, 2 respondents (4.8%) got early detection of cervical cancer with via test method. from the result of the chi-square test analysis, p = 0.000 was obtained. therefore, it can be concluded that there was a relationship between husband support and early detection behaviour of cervical cancer with via test method. from the data on the relationship between health worker support and cervical cancer early detection behaviour with via test method, out of all 52 respondents who got support from the health worker, 30 respondents (57.7%) got early detection of cervical cancer with via test method. on the other hand, from all the respondents who did not get enough support from health worker, no one got early detection of cervical cancer with via test method. from the result of the chi-square test analysis, p = 0.000 was obtained. therefore, it can be concluded that there was a relationship between health worker support and early detection behaviour of cervical cancer with via test method. discussions generally, the results of the research showed that cervical cancer early detection behaviour with via test method was still low. the test results on the five determinant variables of early detection behaviour of cervical cancer with via test method showed that four variables had a relationship with cervical cancer early detection behaviour with via test method, while the other one did not have any relationship with cervical cancer early detection behaviour with via test method in visitors of policlinic kia-kb in kassi-kassi public health center, rappocini sub-district, kota makassar. education is one of the factors that influence someone, and one’s attitude on healthy lifestyle, in motivating oneself to contribute to development and, generally, the higher the education the easier it is for someone to accept new information (10). based on the result of the research, the majority of the respondents had high education (84.2%), and most of respondents who had got early detection of cervical cancer with via test method were highly-educated women. the result of the fisher exact test analysis showed that there was no any relationship between education and cervical cancer early detection behaviour with via test method. one’s preventive behaviour is not only influenced by the education he/she has, but is related to the information exposure he/she gets. consequently, the respondents who had high education background with a lack of awareness in healthy behaviour were a result of the lack of knowledge on cervical cancer early detection behaviour with via test method. therefore, their awareness and action in treating and preventing the disease were still lacking. the result of this study is in line with the study conducted by nordiani and wahyono, showing that there was no any relationship between education and via test visit (11). however, it was not in line with the findings made in epidemiology and society health review| eshr vol 1 no1 2019 24 a study conducted by lestari where there was a relationship between education and detection behaviour of cervical cancer (12). knowledge or cognitive is one domain that is very essential in shaping one’s behaviour. one’s knowledge on health may be an important factor preceding health behaviour. however, the expected health action may not be carried out, unless there is motivation to act upon the knowledge one possesses (13). based on the result of the research, the number of respondents who had a high level of knowledge on cervical cancer and via test was greater (62.4%). the analysis of chi-square test showed that there was a relationship between knowledge and cervical cancer early detection behaviour with via test method. the respondents who had a high level of knowledge also had good behaviour in conducting early detection of cervical cancer with via test method compared to the respondents who had a low level of knowledge. the respondents who had got early detection of cervical cancer with via test method found out about the information on cervical cancer and some preventive measures, as well as early detection of cervical cancer through electronic media. additionally, women of fertile couple got via test when they had symptoms or participated in an annual event, such as a free via test conducted by the government. on the other hand, the majority of the respondents who had a low level of knowledge never got via test, influenced by the lack of information exposure they received, either because of the non-existent explanation made by health workers related to early detection of cervical cancer with via test method or because of the lack of awareness of the respondents to find any information on the importance of early detection of cervical cancer. this finding is in line with the study conducted by siwi and trisnawati, claiming that knowledge influenced behaviour in having via test (14). however, it is not in line with the finding in a study conducted by sundari and setiawati, stating that there was no any relationship between knowledge on early detection of cervical cancer with via test method and via test behaviour (15). from the result of the statistical test, we found that there was a relationship between attitude and cervical cancer early detection behaviour with via test method. attitude is the tendency to carry out an action. by knowing one’s attitude, we can predict what response or action will be taken in response to a problem being faced. after one knows the stimulus or object, the next process is to observe and behave towards the stimulus or the health object (16). respondents who got early detection of cervical cancer with via test method were those who had a positive attitude towards cervical cancer and early detection, compared to those who had a negative attitude, where there was no any respondent with negative attitude who got early detection of cervical cancer with via test method. however, in this study it was also found that the majority of the respondents who had a positive attitude never got early detection of cervical cancer with via test method. this was a result of the lack of understanding on via test, hence it led to the lack of cervical cancer early detection behaviour with via test method. this finding is in line with that of the study conducted by sartiwi, indicating that there was a relationship between attitude and via test for early detection of cervical cancer (17). however, dewi found a different finding where there was no any significant relationship between attitude and via test method (18). based on the research result on husband support, it can be concluded that there was a relationship between husband support and cervical cancer early detection epidemiology and society health review| eshr vol 1 no1 2019 25 behaviour with via test method. the respondents who did not get enough husband support had less enthusiasm to behave well because of the lack of influence from their closest companion, which was their husband who had a big role in motivating the respondents to improve their health. this result is in line with the finding of the study by fauza, aprianti and azrimaidaliza where there was a significant relationship between husband support and via test participation (19). however, it is not in line with a study by febriani which indicated that there was no any relationship between husband support and early detection of cervical cancer (7). from the result of the study on health worker support, it can be concluded that there was a relationship between health worker support and cervical cancer early detection behaviour with via test method. some factors that caused respondents not to get early detection with via test method regardless of the high support from health workers were the time unavailability to do the test and unpreparedness for the possibility to be positively diagnosed with via test. this finding is in line with that of the study conducted by rasyid and afni which indicated that there was a relationship between health worker support and fertile woman behaviour (20). a similar finding was also stated in a study by sihombing and windiyaningsih, showing that there was a significant relationship between health worker support and via test behaviour in fertile women (21). conclusions the result of the study showed that the variables of knowledge, attitude, husband support, and health worker support had a relationship with cervical cancer early detection behaviour with via method in visitors of policlinic kia-kb in kassi-kassi public health center of rappocini sub-district, kota makassar. authors’ contribution the contributions from uq researchers in this study began from data collection, processing and data analysis. this research got a lot of inputs. the author of ja contributes addition information related to the background of the problem, dsa authors provide advice in terms of determining the variables that could have influenced a person's good behaviour, especially in women of fertile couple who want to do early detection of cervical cancer, one of them with the via examination method. from idn who provided direction in determining the criteria for the study sample, mi authors provided input in determining the appropriate sampling technique in this study and the last contribution from the author s in terms of addition in field discussion or discussion in this research. funding funding in this study was fully funded by the researcher. acknowledgements the researcher would like to thank universitas ahmad dahlan yogyakarta for providing support and funding for this research. epidemiology and society health review| eshr vol 1 no1 2019 26 conflict of interest there are no conflicts of interest references 1. parapat ft, setyawan h, saraswati ld. faktor faktor yang berhubungan dengan perilaku deteksi dini kanker leher rahim metode inspeksi visual asam asetat di puskesmas candiroto kabupaten temanggung. e-journal. 2016;4(4):363–70. 2. who. human papillomavirus (hpv) and cervical cancer [internet]. 2016 [cited 2018 feb 22] available from: http://www.who.int/mediacentre/factsheets/fs380/en/ 3. globocan. estimated cancer incidence, mortality and prevalence worldwide in 2012 [internet]. who. 2012 [cited 2018 feb 22]. available from: http://globocan.iarc.fr/pages/fact_sheets_population.aspx 4. kemenkes ri. buletin situasi penyakit kanker. jakarta: kementerian kesehatan; 2015. 5. dinkes provinsi sulawesi selatan. laporan kasus penyakit kanker di sulawesi selatan tahun 2017. makassar; 2017. 6. dinkes kota makassar. data cakupan pemeriksaan iva di kota makassar tahun 2017. makassar; 2017. 7. febriani ca. faktor-faktor yang berhubungan dengan deteksi dini kanker leher rahim di kecamatan gisting kabupaten tanggamus lampung. jurnal kesehatan. 2016;7(2):228–37. 8. kustiyati s, winarni. deteksi dini kanker leher rahim dengan metode iva di wilayah kerja puskesmas ngoresan surakarta. jurnal gaster. 2011;8(1):681–94. 9. kemenkes ri. seluruh pegawai kemenkes dihimbau lakukan tes iva dan sadanis [internet]. 2017 [cited 2018 mar 15]. available from: http://webcache.googleusercontent.com/search?q=cache:http://www.depkes.go.i d/article/view/17100300001/seluruh-pegawai-kemenkes-diimbau-lakukan-tesiva-dan-sadanis-.html 10. taufia d. faktor-faktor yang berhubungan dengan perilaku wanita pasangan usia subur (pus) dalam deteksi dini kanker leher rahim metode iva di wilayah kerja puskesmas nanggalo padang tahun 2017 [skripsi]. padang: politeknik kesehatan kemenkes; 2017. 11. nordianti me, wahyono b. determinan kunjungan inspeksi visual asam asetat di puskesmas kota semarang. jurnal higeia. 2018;2(1):33–44. 12. lestari s. hubungan tingkat pendidikan, pengetahuan dan sikap ibu rumah tangga dengan perilaku deteksi dini kanker serviks metode iva di puskesmas jaten ii kabupaten karanganyar [skripsi]. surakarta: universitas sebelas maret; 2012. epidemiology and society health review| eshr vol 1 no1 2019 27 13. notoatmodjo s. ilmu perilaku kesehatan. edisi 2. jakarta: rineka cipta; 2014. 14. siwi rpy, trisnawati y. faktor-faktor yang mempengaruhi perilaku pemeriksaan iva (inspeksi visual asam asetat) dalam deteksi dini kanker serviks pada pasangan usia subur. jurnal global health science. 2017;2(3):220–5. 15. sundari, setiawati e. pengetahuan dan dukungan sosial mempengaruhi perilaku deteksi dini kanker serviks metode iva. indonesian journal of midwivery. 2018;1(1):6–11. 16. notoatmodjo s. pendidikan dan perilaku kesehatan. jakarta: rineka cipta; 2003. 17. sartiwi w. faktor–faktor yang berhubungan dengan pemeriksaan inspeksi visual asam asetat (iva) terhadap deteksi kanker servik pada wus di wilayah kerja puskesmas paninggahan kabupaten solok. jurnal medika saintika. 2017;8(2):33–44. 18. dewi l. faktor-faktor yang berhubungan dengan perilaku wanita usia subur dalam deteksi dini kanker serviks dengan metode pemeriksaan inspeksi visual asam asetat (iva) di wilayah kerja puskesmas tanjung hulu pontianak timur tahun 2014. jurnal proners. 2014;1(1):1–10. 19. fauza m, aprianti, azrimaidaliza. faktor yang berhubungan dengan deteksi dini kanker serviks metode iva di puskesmas kota padang. jurnal promosi kesehatan indonesia. 2018;14(1):68–80. 20. rasyid n, afni n. faktor-faktor yang berhubungan dengan perilaku wus (wanita usia subur) tentang deteksi dini kanker leher rahim metode iva (inspeksi visual asam asetat) di puskesmas singgani. jurnal promotif. 2017;7(1):63–75. 21. sihombing m, windiyaningsih c. faktor penentu pemeriksaan iva pada wanita usia subur di puskesmas pademangan, suku dinas kesehatan jakarta utara 2015. jurnal bidang ilmu kesehatan. 2016;7(1):421–6. epidemiology and society health review| eshr vol 1 no1 2019 28 microsoft word ss_rr_5_5529-other-21329-1-18-20220521.edited_ok.docx epidemiology and society health review| eshr vol. 4, no. 2, 2022, pp. 54-60 issn 2656-6052 (online) | 2656-1107 (print) 10.26555/eshr.v4i2.5529 54 research article local wisdom fly trap effectiveness in the culinary area of bantul beach tourism, yogyakarta asep rustiawan* and muchamad rifai faculty of public health, universitas ahmad dahlan, yogyakarta, indonesia *correspondence: asep.rustiawan@ikm.uad.ac.id. phone: +6285743847969 received 06 january 2022; accepted 07 january 2022; published 2 august 2022 abstract background: flies are insects that can contaminate food with various harmful disease agents. it is not yet known which fly trap is the most effective at trapping flies. there are three types of fly traps as local wisdom for the culinary area of bantul beach, which is used to control fly populations: sticky paper, plastic bowls, and plastic bottles. this study aims to determine the effectiveness of sticky paper, plastic bowls, and plastic bottles in trapping flies. method: this research was an experimental study with three fly traps: sticky paper, plastic bowls, and plastic bottles. measurements were made by placing fly traps in 12 seafood stalls in the culinary area of bantul beach. the number of trapped flies was counted by hand counter. data were analyzed using the one-way anova test, significance level (α) = 0.05, and post hoc test multiple comparison advanced test. results: sticky paper could trap 297 flies (69.4%), followed by 121 plastic bowls (28.3%) and ten plastic bottles (2.3%). the analysis showed that sticky paper had significantly different effectiveness in trapping flies compared to plastic bowls (p = 0.032) and plastic bottles (p = 0.004). in contrast, the efficacy of plastic bowls and bottles was not significantly different (p = 0.130). conclusion: the effectiveness of sticky paper in trapping flies was significantly different from that of plastic bowls and plastic bottles, while the efficacy of plastic bowls and plastic bottles was not significantly different. keywords: coastal tourism culinary; effectiveness; fly; fly traps introduction the coast of bantul regency, special region of yogyakarta (diy), has become a popular culinary tourism destination for processed seafood. the number of tourists visiting this tourist location increases every year. in 2016, the number of tourists who visited was 2.2 million people, then in 2017, it grew to 2.8 million visits and rose again to 3.6 trips in 2018 (1,2). this rustiawan (local wisdom fly trap effectiveness in the culinary area of bantul beach tourism, yogyakarta) vol. 4, no. 2, 2022, pp. 54-60 55 10.26555/eshr.v4i2.5529 increase in the number of visits will impact the economic development of the surrounding community. according to a preliminary study at the end of 2020 (pandemic period), the number of seafood-processed culinary stalls operating on the beach of bantul amounted to 80 stalls. they spread over four central beach locations: parangtritis beach on the east side of bantul with a total of 21 stalls, depok beach with 26 stalls, goa cemara beach with 11 stalls and baru beach on the west side of bantul with a total of 22 stalls. the increase in people's income due to the development of culinary tourism is undeniable. however, seafood processed culinary also has problems for public health (3,4). many culinary managers have limited infrastructure and knowledge, and the habit of implementing a healthy lifestyle is still low. this situation is reflected in the sanitation of culinary stalls and an unsanitary environment. ultimately, this triggers the growth and proliferation of fly populations (5). several flies from the family syrphidae, calliphoridae, empididae, tachinidae, and muscidae, help pollinate plants and support the sustainability of natural ecosystems through the process of breaking down waste into other needed organic materials (6-8). however, flies that land on feces can transfer the dirt into the food and drink of the humans it infests (9,10). flies can be dangerous for consumers, such as diarrhea, dysentery, cholera, typhus, hepatitis, and myiasis in humans and animals (11-15). flies cause myiasis by laying eggs in wounds so that when they hatch, the larvae enter the damage and cause more extensive wounds (wound myiasis) (16,17). flies can also spread diphtheria-causing agents (18,19) and anthrax (20,21). flies transfer disease agents by contaminating the food they infest through vomit, feces, or transmitting disease agents attached to their bodies (22,23). according to the information of 12 culinary managers spread over four coastal locations, namely parangtritis beach, depok, goa cemara, and baru beach, they know that flies are dangerous to health and have controlled the fly population by using fly traps. there are three types of fly traps they know and circulate among the community as local wisdom fly traps: sticky paper, plastic bowls, and plastic bottles. the use of the three types of fly traps by the community has several reasons. sticky paper is a fly trap easily obtained by the public because it is widely sold at low prices in stalls around the culinary area. plastic bowls are used because of the tool's durability, which can be used many times in trapping flies. the community obtained this bowl as a fly trap for the assistance given by the government. plastic bottles are used to utilize used goods and reduce environmental pollution. the technique of making fly traps from used plastic bottles was obtained from training held by the government. the effectiveness of fly traps used to control fly populations has been measured in various locations (24-27). however, based on literature studies, no publications present the results of different tests of effectiveness in trapping flies from fly traps of local wisdom in the bantul beach tourism culinary area. this information is essential to know to provide input to the community on which type of fly trap should be used. this study aims to determine the differences in the effectiveness of sticky paper, plastic bowls, and plastic bottles in trapping flies. rustiawan (local wisdom fly trap effectiveness in the culinary area of bantul beach tourism, yogyakarta) vol. 4, no. 2, 2022, pp. 54-60 56 10.26555/eshr.v4i2.5529 method this research was carried out in 12 seafood stalls in the culinary area of bantul beach tourism, namely parangtritis beach, depok, goa cemara, and baru beach. the study used a quasiexperimental design with a post-test-only design (28), which allowed researchers to measure the number of flies trapped by each type of fly trap studied and then analyze the differences in their effectiveness. the research was carried out in the field, and the confounding variables cannot be fully controlled (29). the tools and instruments used were fly traps of local wisdom of the bantul beach tourism culinary community: sticky paper, plastic bowls, plastic bottles, stopwatches, hand counters, roll meters with a length of 5 meters, and filling sheets. the three fly traps were installed in culinary seafood stalls in the kitchen, dining room, and courtyard. the distance between fly traps were ± 2 meters. the bait followed the local community's custom: shrimp paste for plastic bowls and bottles. no additional bait was given for sticky paper because it already emits an aroma. measurements were taken during the day for 2 hours. after 2 hours, the number of trapped flies was counted, processed, and analyzed using the one-way anova statistical test because the results of the variance test were not different/homogeneous (p-value = 0.103). the level of significance used was at 0.05 (30). results the number of flies trapped by the fly trap shows the effectiveness of the fly trap in trapping flies. the number of trapped flies by type of fly trap is presented in table 1. sticky paper was a fly trap that can trap the most flies compared to plastic bowls and plastic bottles. sticky paper trapped as many as 297 flies with an average of 24.8. a plastic bowl trapped 121 flies with an average of 10.1 flies, while a plastic bottle only trapped as many as ten flies with an average of 0.8. furthermore, a homogeneity test results obtained p-value = 0.103 (α> 0.05), which means that the variance of the data was homogeneously distributed. accordingly, further statistical tests were should be carried out using one-way anova. table 1. number of flies trapped by fly trap type beach location seafood stall observed number of flies caught in the fly trap sticky paper plastic bowl plastic bottle parangtritis p1 1 0 0 p2 17 0 0 p3 19 3 0 depok d1 10 8 0 d2 28 25 0 d3 57 49 0 goa cemara g1 43 8 1 g2 42 12 0 g1 57 7 3 baru b1 11 1 4 b2 4 5 1 b3 8 3 1 amount 297 121 10 average 24.75 10.08 0.83 rustiawan (local wisdom fly trap effectiveness in the culinary area of bantul beach tourism, yogyakarta) vol. 4, no. 2, 2022, pp. 54-60 57 10.26555/eshr.v4i2.5529 table 2 shows the results of the one-way anova test shows the value of the sum of the squares in the variance between groups of 13962.88, and the variance value in the group is 4009.33. the degree of validity between groups is 2 with a mean square of 6981.44. the degree of validity in the group is 6, with a mean square of 668.22. in this study, the calculated f value was 10.44 and a significance value of 0.01 which means significant (0.01<0.05). this means there was a substantial difference between the number of flies trapped by sticky paper fly traps, plastic bowls, and plastic bottles. furthermore, further tests were carried out with the post hoc test multiple comparison to determine which type of fly trap had a significant difference in trapping flies. table 2. anova test results group sum of squares df mean square f sig between groups 13962.88 2 6981.44 10.448 0.01 within groups 4009.33 6 668.22 total 17972.22 8 table 3 shows a significant difference between sticky paper and plastic bowls in trapping flies with a p-value = 0.032 (0.032 <0.05). likewise, there was a significant difference between sticky paper and plastic bottles with a p-value = 0.004 (0.004 <0.05). in contrast, there was no significant difference between plastic bowls and plastic bottles with p-value = 0.130 (0.130> 0.05). the data meant that the effectiveness of trapping sticky paper fly traps differs from plastic bowls and plastic bottles. in contrast, the effectiveness of plastic bowls and plastic bottles was no different. table 3. the results of the different tests of flies trapped by fly traps treatment sticky paper plastic bowl plastic bottles sticky paper 0.032 0.004 plastic bowl 0.032 0.130 plastic bottles 0.004 0.130 discussion the results of the anova statistical test and the post hoc test multiple comparison followup tests showed that sticky paper fly traps had significantly different effectiveness in trapping flies than plastic bowl fly traps, even substantially different from plastic bottles. meanwhile, plastic bowl fly traps and bottles have the same or no different effectiveness. the results showed that the number of flies trapped by the sticky paper fly trap was 297 flies or 69.4%, followed by the bowl fly trap, as many as 121 flies or 28.3%, then the plastic bottles fly trap with the number of flies trapped as many as ten flies or 2.3 %. the sticky paper had the highest fly trapping effectiveness (64.9%) and was statistically significantly different from plastic bowls (28.3%) and plastic bottles (2.3%). this happens because the catch area of the sticky paper is much broader than the catch area of plastic bowls and plastic bottles. meanwhile, catching plastic bowls is wider than plastic bottles, so rustiawan (local wisdom fly trap effectiveness in the culinary area of bantul beach tourism, yogyakarta) vol. 4, no. 2, 2022, pp. 54-60 58 10.26555/eshr.v4i2.5529 trapping plastic bowl flies (28.3%) is more effective than plastic bottles (2.3%). however, the difference between the effectiveness of plastic bowls and plastic bottles is not statistically significant. the catchment area affects the catch of the target insect (31): the more comprehensive the fishing area, the more excellent the opportunity to trap flies. in addition, flies have a habit of perching and do not like to fly continuously (32). this habit allows the fly to land on the sticky paper surface and then get trapped. flies also have a habit of living in groups (33). therefore, flies attached to the sticky paper will invite other flies to land on the sticky paper. thus, the number of flies that stick to the sticky paper increases over time. the sticky paper has a more pungent and diffuse odor than plastic bowls and bottles. the smell of fish on sticky paper is evenly distributed over the entire surface of the paper and spreads freely into the environment. in contrast, the smell of shrimp paste on plastic bowls and plastic bottles is more concentrated in the space of the bowl and bottle where the bait is located, so that little is spread to the environment. thus, the odor stimulus produced by sticky paper becomes more robust and more diffuse to the environment than the odor stimulus from plastic bowls and bottles. that makes sticky paper can invite more flies to get trapped (34,35). research results nadeak et al. (25), who examined the effectiveness of fly traps with various baits, concluded that shrimp bait was more effective than tomato fermented bait because the aroma released by shrimp bait was more pungent than tomato fermented bait. fitriana and mulasari’s research results (36) also concluded that shrimp bait was most effective in attracting flies because it had a more pungent aroma than fish bait, jackfruit, shrimp paste, and mango. similarly, research conducted by savitriani and maftukhah (27) stated that flies preferred fish gill bait to wet shrimp and bagasse bait because fish gills emitted a more pungent odor than wet shrimp and bagasse. conclusion the effectiveness of trapping sticky paper fly traps differs from plastic bowls and plastic bottles. in contrast, the efficacy of plastic bowls is no different from that of plastic bottles. authors' contribution ar contributed to data collection, analysis, report writing, and manuscript publication. mr contributed to data collection, report writing, and licensing. funding statement this research has not received external funding. conflict of interest there is no conflict of interest in this research. references 1. poerwanto e. visited by 3.6 million tourists. bantul, yogyakarta; 2018. available from: https://bisniswisata.co.id/visited-36-juta-turis-achievement-pariwisata-bantul-lalui-target/ 2. visitingjogja. diy tourism statistics 2018. bantul, yogyakarta; 2019. available from: https://visitingjogja.com/download/statistik-pariwisata/ rustiawan (local wisdom fly trap effectiveness in the culinary area of bantul beach tourism, yogyakarta) vol. 4, no. 2, 2022, pp. 54-60 59 10.26555/eshr.v4i2.5529 3. de sousa c. the impact of food manufacturing practices on food-borne diseases. brazilian arch biol technol. 2008;51(4):815–23. available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=s1516-89132008000400020 4. ghosh m, wahi s, kumar m, ganguli a. prevalence of enterotoxigenic staphylococcus aureus and shigella spp. in some raw street vended indian foods. int j environ health res. 2007;17(2):151–6. available from: https://sci-hub.tw/10.1080/09603120701219204 5. chaiwong t, srivoramas t, sueabsamran p, sukontason k, sanford mr sk. the blow fly, chrysomya megacephala, and the house fly, musca domestica, as mechanical vectors of pathogenic bacteria in northeast thailand. trop biomed. 2014;31(2):336–46. 6. cickova h, newton gl, lacy rc km. the use of fly larvae for organic waste treatment. waste manag. 2015;35:65–80. 7. lalander c, diener s, magri me, zurbrügg c, lindström a vb. faecal sludge management with the larvae of the black soldier fly (hermetia illucens)-from a hygiene aspect. sci total env. 2013;458(460):312–8. 8. rader r, bartomeus i, garibaldi la, garratt mpd, howlett bg, winfree r et al. non-bee insects are important contributors to global crop pollination. proc natl acad sci. 2016;113(1):146–51. 9. andiarsa d, setianingsih i, fadilly a, hidayat s, setyaningtyas de hb. bacteriological description of flies and culicidae (ordo: diptera) in the research and development center p2b2 tanah bumbu. dis vector j. 2015;9(2):37–44. 10. barreiro c, albano h, silva j, teixeira p. role of flies as vectors of foodborne pathogens in rural areas. isrn microbiol. 2013;2013:1–7. available from: https://downloads.hindawi.com/archive/2013/718780.pdf 11. kassiri h, zarrin m, veys-behbahani r, faramarzi s, kasiri a. isolation and identification of pathogenic filamentous fungi and yeasts from adult house fly (diptera: muscidae) captured from the hospital environments in ahvaz city, southwestern iran. j med entomol. 2015;52(6):1351–6. 12. pava-ripoll m, pearson reg, miller ak, ziobro gc. detection of foodborne bacterial pathogens from individual filth flies. j vis exp. 2015;(96):1–9. available from: https://www.scienceopen.com/document_file/36431376-ac9b-473e-9d7ca8f850832208/pubmedcentral/36431376-ac9b-473e-9d7c-a8f850832208.pdf 13. bahrndorff s, de jonge n, skovgard h, nielsen jl. bacterial communities associated with houseflies (musca domestica l.) sampled within and between farms. plos one. 2017;12(1):1–15. available from: 10.1371/journal.pone.0169753. 14. hall mjr. screwworm flies as agents of wound myiasis. fao. 1992;8–17. available from: http://www.fao.org/docrep/u4220t/u4220t07.htm 15. guerra b, fischer j, helmuth r. an emerging public health problem: acquired carbapenemase-producing microorganisms are present in food-producing animals, their environment, companion animals and wild birds. vet microbiol. 2014;171(3–4):290–7. available from: http://dx.doi.org/10.1016/j.vetmic.2014.02.001 16. wardhana ah, muharsini s. myiasis cases caused by chrysomya bezziana in java island. in: proceeding of national seminar "teknologi peternakan dan veteriner 2005". 2005.p.1078-1084 17. yolanda n, winata sm. wound myasis pada anak. cdk-219. 2014;41(8):601–4. 18. hotez pj, remme jhf, buss p, alleyne g, morel c, breman jg. combating tropical infectious diseases: report of the disease control priorities in developing countries project. clin infect dis. 2004;38(6):871–8. available from: https://doi.org/10.1086/382077 19. soto-arias jp, groves rl, barak jd. transmission and retention of salmonella enterica by phytophagous hemipteran insects. appl environ microbiol. 2014;80(17):5447–56. available from: https://sci-hub.se/10.1128/aem.01444-14 20. blackburn jk, van ert m, mullins jc, hadfield tl, hugh-jones me. the necrophagous fly anthrax transmission pathway: empirical and genetic evidence from wildlife epizootics. vector-borne zoonotic dis. 2014;14(8):576–83. available from: https://sci rustiawan (local wisdom fly trap effectiveness in the culinary area of bantul beach tourism, yogyakarta) vol. 4, no. 2, 2022, pp. 54-60 60 10.26555/eshr.v4i2.5529 hub.se/10.1089/vbz.2013.1538 21. fasanella a, adone r h-jm. classification and management of animal anthrax outbreaks based on the source of infection. ann ist super sanit. 2014;50(2):192–5. available from: https://www.researchgate.net/publication/263513840_classification_and_management_ of_animal_anthrax_outbreaks_based_on_the_source_of_infection 22. onwugamba fc, fitzgerald jr, rochon k, guardabassi l, alabi a, kühne s, et al. the role of 'filth flies' in the spread of antimicrobial resistance. travel med infect dis. 2018;22(december 2017):8–17. available from: http://dx.doi.org/10.1016/j.tmaid.2018.02.007 23. sarwar m. insect borne diseases are transmitted by some important vectors of class insecta hurtling public health. int j bioinformata biomed eng. 2015;1(3):311–7. available from: http://www.aiscience.org/journal/paperinfo/ijbbe?paperid=2133 24. komariah, pratita s mt. vector control. bina husada heal j. 2016;6(1):34–43. available from: https://repository.dinus.ac.id/docs/ajar/pengtangan_veektor.pdf 25. nadeak esm, rwanda t, iskandar i. effectiveness of bait variations in the use of flytrap at the tanjungpinang city ganet final disposal site. j andalas masy health. 2017;10(1):82. available from: http://jurnal.fkm.unand.ac.id/index.php/jkma/ 26. andini t, siregar sd, siagian m. the effectiveness of modified fly grill technology to reduce flies density at meat sales places at sukaramai market, medan city. j health glob. 2019;2(2):54. 27. savitriani s, maftukhah na. the effectiveness of bait variations in fly traps in control of flies density. ruwa jurai j environmental health. 2021;15(1):16. available from: https://ejurnal.poltekkes-tjk.ac.id/index.php/jkesling/article/view/shela savitriani%2c nur afni maftukhah/1217 28. sugiyono. statistics for research. bandung: alphabeta; 2019. 29. creswell jw. research design: qualitative, quantitative and mixed approaches. yogyakarta: student library; 2017. 30. sarmanu. basic research methodology: quantitative, qualitative & statistical. surabaya: airlangga university press; 2019. 31. schowalter t. insect ecology an ecosystem approach 2nd edition. new york: elsevier inc; 2006. 32. directorate general of p2mplp. technical instructions on fly eradication. jakarta; 1992. 33. sucipto cd. tropical disease vectors. yogyakarta: gosyen publishing; 2011. 34. azwar a. introduction to environmental health science. jakarta: mutiara sumber widya; 1995. 35. puspitarani f sd. application of ultraviolet lights on fly trap equipment to the number of trapped house flies. j public heal res dev. 2017; available from: http://journal.unnes.ac.id/sju/index.php/higeia 36. fitriana e, mulasari sa. the effectiveness of bait variations in fly traps in controlling flies density at temporary disposal sites (tps) jalan andong yogyakarta. j indonesian environmental health. 2021;20(1):59–64. available from: https://ejournal.undip.ac.id/index.php/jkli/article/view/32411/18920 microsoft word 2160-6100-1-sm-rv-au.2-final.docx epidemiology and society health review| eshr vol 2, no2 (2020) 37 research article characteristics of mothers and stunting toddlers in pekuncen village, wiradesa, pekalongan, indonesia siti rofiqoh1*, imam hanifudin rizkian1, naila vandawi1, febri lianasari1 1 faculty of health science, universitas muhammadiyah pekajangan pekalongan, pekalongan, indonesia. *correspondence: rofiqoh.siti@yahoo.com. telp: +6281542030114 received 05 may, 2020; accepted 28 may, 2020; published 28 may, 2020 abstract background: stunting is the condition of short stature due to abnormal growth caused by a severe malnutrition problem that needs attention. stunting can cause health problems, decrease productivity, and trigger poverty in the future. this study aims to determine the characteristics of mothers and stunting toddlers in pekuncen village wiradesa pekalongan district, central java, indonesia. methods: the study was conducted in pekuncen village in the wiradesa subdistrict of the pekalongan district. the retrospective design was used in this study. respondent was recruited using total sampling techniques. a set of questionnaires was employed to collect the data among 35 respondents, which is the mothers of stunting toddler. results: the results showed most of the respondents (82.7%) hold basic education level. 77.1% of respondents have family income < regional minimum salary of pekalongan district. more than half of respondents (68.6%) have less nutrition knowledge. no mothers have good nutrition knowledge. less than half (42.9%) provide parenting democratic type of feeding, and there are still 14.3% of mothers giving the neglect parenting feeding type. while the characteristics of stunting toddlers are 68.6% female, 37.1% aged 3-4 years, 28.6% aged 1-3 years, 42.9% do not get exclusive breastfeeding, and 88.6% have a history of normal born weight. conclusions: stunting toddler in pekuncen village wiradesa, pekalongan was associated with a parent who has elementary education, family income less than the regional minimum salary. most of them have less nutrition knowledge level, and almost half of them provide parenting with the democratic type of feeding. while the characteristics of stunting toddlers were the majority of women, and nearly half do not get exclusive breastfeeding, and most have a normal birth weight history. we suggest that related parties should collaborate to reduce stunting prevalence based on the characteristics of mothers and stunting toddlers. keywords: mother, toddlers, stunting, pekalongan. introduction stunting is a condition of failure to thrive in toddlers due to chronic malnutrition so that the children become too short compared to their ages (1). stunting is based on body length index compared to age (pb/u) or height compared to age (tb/u) with a limit (z-score) of less than 2 sd (2). stunting in toddlers is one of the problems in the world, including indonesia. the incidence of stunting in the world in 2017 reached 22.2% or around 150.8 million children (3). epidemiology and society health review| eshr vol 2, no2 (2020) 38 the prevalence of stunting in indonesia ranks fifth largest in the world (1). in 2018, the prevalence of stunting in indonesia was quite high, reaching 30.8% and in central java province in the year 2014 amounted to 22.57% (4). based on the data from the pekalongan district health office in 2017, the wiradesa subdistrict of pekalongan district has the highest number of stunting cases. data from the wiradesa health center in pekalongan district shows that there are 3,556 children, and 386 are stunted. the highest number of stunting toddlers’ cases is at pekuncen village in wiradesa. pekalongan (5). stunting is caused by multidimensional factors such as poor parenting practices, limited quality health services, lack of family access to nutritious food, and access to clean water and sanitation (1). parenting practices include maternal knowledge about nutrition and children's food intake, including exclusive breastfeeding and infant treatment with low birth weight. the incorrect feeding behavior by the parent causing the lack of nutritional intake received by toddlers. a mother's education is also related to the ability to care for children properly. family income factors cause a lack of family access to nutritious food. family income closely related to the family's ability to provide nutritious food and access to health services required for the growth of toddlers. stunting is a problem that needs serious attention because if left untreated, it will cause an impact on adulthood. various issues arise in stunting children, including issues of stunted physical growth, mental development, health problems, poor school performance, low education, and low income as adults that have an impact on poverty (1). so, it is necessary to identify the factors that trigger off stunting, especially in areas with a high prevalence of stunting. it will be useful for decision-makers on providing appropriate intervention and policy to solve stunting. this study aims to describe the characteristics of mothers and stunting toddlers in pekuncen village wiradesa subdistrict of the pekalongan district. methods study design the research design is quantitative with a retrospective approach. mother and stunting toddlers data has obtained from wiradesa public health center, pekalongan. door to door visit was conducted to interview the respondent. setting the research took place in pekuncen village wiradesa subdistricts of the pekalongan district with the highest case of stunting toddlers in 2017. data source and data collection a questionnaire was used to collect the data. parenting questionnaire regarding infant feeding was adopted from astuti about the parenting feeding style (6). the questionnaire consisted of 24 questions divided into 17 questions of demandingness (d) and seven questions of responsiveness (r). questionnaire answers using a likert scale consisting of 5 alternative answers, namely, 0) never, 1) rarely, 2) sometimes, 3) often, 4) always. this questionnaire has been tested for validity and reliability with pearson's correlation point demandingness results of cronbach's alpha value of 0.85 and cronbach alpha of responsiveness of 0.82. thus this questionnaire was declared reliable (6). the nutritional knowledge questionnaire consisted of 18 questions. it had been tested for validity and reliability, with r count > 0.44 and cronbach alpha also > 0.44, so they were valid and reliable. parenting feeding, because of the abnormal data distribution, then categorized into democratic parenting, if the d and r ≥ median; authoritarian parenting, if d ≥ median and r < median; epidemiology and society health review| eshr vol 2, no2 (2020) 39 permissive parenting, if d < median and r ≥ median and neglect parenting, if d and r < median. while knowledge is categorized as good if the value is 76-100, enough, if 56-75 and less if 0-55. sample population this study's population was the mothers of stunting toddlers in pekuncen village wiradesa subdistrict of the pekalongan district. we applied total sampling to select the respondent. accordingly, this study involved 35 respondents. the criteria for the participant were mothers of stunting toddlers who were domiciled in the selected village and willing to participate in this study. in contrast, the exclusion criteria were toddlers who are not cared for by mothers. variables the variables of this study include the characteristics of mothers and stunting toddlers. maternal characteristics include the level of education, knowledge about nutrition, family income, and parenting feeding. toddler characteristics include age, sex, history of exclusive breastfeeding, and history of low birth weight. analysis the analysis was performed using descriptive and percentage analysis. results characteristics of mothers in stunting toddlers the characteristics of mothers in stunting toddlers, which include the mother's education, family income, mother's knowledge about nutrition, and parenting feeding for a toddler, are presented in tables 1. table 1. characteristics of mothers in stunting toddlers (n=35) characteristics n (%) mothers’ education level basic (primary and junior high school) 29 8.7 medium (senior high school) 6 17.1 family income <regional minimum salary of pekalongan district =< idr 1,721,637 27 77.1 ≥ regional minimum salary of pekalongan district = ≥ idr 1,721,637 8 22.9 nutrition knowledge low 24 68.6 sufficient 11 31.4 parenting feeding neglect 5 14.3 permissive 9 25.7 authoritarian 6 17.1 democratic 15 42.9 table 1 shows that most mothers' education level 29 (82.7%) hold basic education level, only 6 (17.1%) have middle education level, and none of the respondents have a high education epidemiology and society health review| eshr vol 2, no2 (2020) 40 level (university). most of the 27 (77.1%) have family income less than the regional minimum salary of pekalongan district. knowledge about nutrition is mostly less than 24 (68.6%), and none of them has sufficient knowledge, parenting feeding practices most of the 15 (42.9%) were democratic, 9 (25.7%) permissive, and there is still 5 (14.3%) neglect. characteristics of stunting toddlers the characteristics of stunting toddlers, which include gender, age, history of breastfeeding, and birth weight history, are illustrated in tables 2. table 2. characteristics of stunting toddlers (n = 35) characteristics n % gender male 11 31.4 female 24 68.6 age 1-2 year 10 28.6 2-3 year 9 25.7 3-4 year 13 37.1 4-5 year 3 8.6 breastfeed history exclusive breastfeed 20 57.1 in exclusive breastfeed 15 42.9 birthweight history normal 31 88.6 low 4 11.4 table 2 shows that most of the toddlers are female (24 (68.6%), more than one third 13 (37.1%) aged 3-4 years old, and 10 (28.6%) are 1-2 years old. almost half of the toddlers did not receive exclusive breastfeeding; there are about 15 (42.9%) and only four toddlers (11.4%) with a history of low birth weight. discussions the characteristics education of mothers with stunting toddlers shown the majority of them hold basic education level. highly educated people are more likely to adopt healthy lifestyles, maintain personal fitness, consume nutritious food, avoid things that damage health (7). likewise, mothers with higher education are more likely to take care of their children properly. high educated mothers are more capable of implementing a healthy lifestyle to their children, maintaining their children's fitness, providing and feeding nutritious food to their children. they are also capable of protecting their children from things that can interfere with health. these abilities are needed by children so that children can grow and develop properly. research conducted by setiawan, mahmud, and masrul (2018) in padang and anisa (2012) in depok, stated that mother's education was related to the incidence of stunting in children. mothers with higher education have a lower risk of stunting (8,9). mothers with higher education can formulate strategies to maintain the continuity of better child care, be able to solve problems properly, such as providing proper food to children, bringing children to health services, etc. therefore, increasing the mother's education level is important for reducing stunting (10). in epidemiology and society health review| eshr vol 2, no2 (2020) 41 contrast to mothers with lower education are at greater risk of the incidence of stunting. mothers with low education are less able to take good care of their children. as a result, the need for nutrition and health among children at risk is not sufficient. these conditions, if it prolonged, will cause stunting in children. income factor is also one of the causes of stunting. the results of the study in table 1 shows that most mothers of stunted toddler earn less than the regional minimum salary. research in padang shows that the level of family income is related to stunting toddlers (8). income relates to access to nutritious food, access to health services, and children's education that have a positive impact on the nutritional status of children (11). good family income supports the ability of families to provide nutritious food to their families, including toddlers. nutritious food is needed by children to maintain the health of the child's body, the child's growth, and the development process. likewise, good family income is needed for the fulfillment of health services that are needed to ensure the health status of families and children. a good family income is also needed to access good education services for children so that children are facilitated into a healthy and smart generation. conversely, low-income families cause the inability to meet family needs. families are unable to provide nutritious and varied food so that the child's nutrition intake is reduced. poor nutrition for a long time is one of the factors causing stunting. health services can also be inaccessible to low-income family members. poor nutrition is at risk of decreasing the child's immune system. children are more likely to get sick more often if access to health services still not proper. this condition worsens the nutritional status of children who can be more at risk of experiencing malnutrition and stunting. the results showed the majority of mothers about nutrition knowledge is very low. meanwhile, knowledge is a fundamental domain for the formation of one's actions (12). the lack of nutrition knowledge about mothers causes an inability to serve and feed good, nutritious food. thus, the nutrient intake in children will be disrupted. chronic disruption of nutrient intake in a toddler can be at risk of causing stunting. the characteristics of mothers regarding parenting for child feeding in table 1 show that most are democratic, some are permissive and authoritarian, but some are neglectful. 17.1% in this study, the mother gives parenting feeding authoritarian type. authoritarian parenting is parenting by parents who tend to force, rule, and punish children always to follow parental orders without reason. children with this parenting style tend to the trouble to express his wish and high levels of depression. permissive parenting is parenting as opposed to authoritarian parenting, in permissive parenting parents give freedom to children to do anything, parents are very concerned with the needs of children's feelings, but parents tend to spoil children. the risk of stunting can occur in the permissive type of parenting if the child chooses to consume less nutritious foods, while parents tend to fulfill the child's wishes. parenting neglect is the worst because it cannot provide control but cannot provide warmth to the children (13). in this type, food that enters the child’s body is controlled by the children because of a lack of control, demands, and direction from parents. less nutritious feeding food will inhibit the toddler's growth so that a risk of stunting (14). democratic parenting is ideal parenting among others because, in this parenting, children live within the provisions that must be met, but they also get attention and fulfillment of adequate needs (13). the results of this study indicate the characteristics of parenting feeding of mothers in stunting toddlers are mostly democratic type. however, if parents continue to apply the democratic type to the condition of children who behave to avoid certain foods for long periods, they can be at risk of malnutrition (stunting) epidemiology and society health review| eshr vol 2, no2 (2020) 42 (15,16). in the democratic parenting type, if the parent's knowledge about nutrition is less well, also risk causing nutritional problems in children (17). parents need to implement parenting feeding the most appropriate to the child's condition. in daily life, parents can provide appropriate parenting multidimensional child's condition. although parents parenting feeding implement democratic type, in certain situations, parents need to be authoritarian if the increasing demands of a child to eat are considered effective in maintaining normal nutrition. instead, permissive parenting is required if the child is considered to require a more pleasant dining atmosphere to maintain a normal nutritional status (6). the characteristics of stunting toddlers in the results of the study in table 2 show that almost half of the toddlers do not get exclusive breastfeeding. breast milk is the best for infants, and exclusive breastfeeding should be given in the first six months. this means that the baby is only given breast milk without other additional other than medicines, vitamins, and minerals according to the doctor's instructions. giving exclusive breastfeeding to infants up to six months old will increase the child's immunity and maintain the child (18). research by hindawati and rusdiati (2018) in jember and setiawan, et al. (2018) in padang shows that exclusive breastfeeding is not associated with stunting (8,19). this can occur because stunting is indeed caused by multi factors, not only exclusive breastfeeding but complementary feeding factors. after six months of infancy, adequate and varied nutritious feeding in children also greatly determines the nutritional status of children. the number of feeding problems occurs in children after six months, and even toddlers are at risk of reduced nutrient intake in children. if parents have less knowledge and are less concerned about the problem, then the children are at risk of a lack of additional food intake that can have an impact on the incidence of stunting in toddlers. likewise, the history of low birth weight in table 2 shows that only four toddlers (11.4%) reported low birth weight, while (78.6%) reported normal birth weight. this also shows that stunting is not only caused by a history of low birth weight, but there are still many other factors, including nutritional intake after birth, also affect the incidence. septira and anggraini's research results (2016) in lampung show that proper nutrition early on could help prevent growth disorders in infants with low birth weight (lbw) (20). providing adequate nutrition early on infants with low birth weight will pursue infant growth, so the infant experiences normal growth. conclusions this research concluded that the characteristics of mothers of stunting toddlers in pekuncen village wiradesa, pekalongan are 82.7% of basic education level, 77.1% of family income < regional minimum salary in pekalongan district, 68.6% have less nutrition knowledge level, 31.4% had sufficient nutrition knowledge. there are no mothers who have adequate nutrition knowledge, and 42.9% provided parenting with the democratic type of feeding. in comparison, 14.3% of mothers give neglect parenting type, 25.7% of mothers gave care pattern of permissive feeding, and 17.1 authoritarian type. while the characteristics of stunting toddlers are 68.6% female, 37.1% aged 3-4 years, 28.6% aged 1-3 years, 42.9% do not get exclusive breastfeeding, and 88.6% have a history of normal birth weight. epidemiology and society health review| eshr vol 2, no2 (2020) 43 authors’ contribution ihr, nv, and fl contributed to licensing and the data collection, sr contributed to the data analysis, report writing and manuscript publication. funding this research has not received external funding conflict of interest there is no conflict of interest in this research. references 1. tim nasional percepatan penanggulangan kemiskinan (tnppk). 100 kabupaten/kota prioritas untuk intervensi anak kerdil (stunting). jakartatnppk. 2017;1. 2. yudianti & rahmat haji saeni. pola asuh dengan kejadian stunting pada balita di kabupaten polewali mandar. j kesehat manarang jur gizi poltekes kemenkes mamuju. 2016;2(1):21–5. 3. kementrian kesehatan republik indonesia (kemenkes ri). bulletin jendela data dan informasi : situasi balita pendek (stunting) di indonesia. available from: httpp//www.pusdatin.kemenkes.go.id. 2018; 4. riskesdas. laporan riset kesehatan dasar. jakarta badan penelit dan pengemb kesehatan kementrian kesehat ri. 2018; 5. dinas kesehatan kabupaten pekalongan. profil kesehatan kabupaten pekalongan 2017. pekalongan dinas kesehatan kabupaten pekalongan. 2018; 6. yumni dz. perbedaan pola asuh pemberian makan dan perilaku makan antara balita obesitas dan balita tidak obesitas di kota semarang. skripsi sgz, univ diponegoro semarang nutr coll vol 6, nomor 1 tahun 2017 [internet]. 2016;43. available from: http://ejournal-s1.undip.ac.id/index.php/jnc 7. huang w. understanding the effects of education on health : evidence from china. 2015; available from: https://scholar.harvard.edu/ weihuang/publications/understandingeffectseducation-health-evidence-china 8. setiawan e, machmud r. artikel penelitian faktor-faktor yang berhubungan dengan kejadian stunting pada anak usia 24-59 bulan di wilayah kerja puskesmas andalas kecamatan padang timur kota padang tahun 2018. 2018;7(2):275–84. available from: http://jurnal.fk.unand.ac.id 9. anisa p. faktor-faktor yang berhubungan dengan kejadian stunting pada balita usia 25-60 bulan di kelurahan kalibiru depok tahun 2012. jakarta univ indones. 2012; 10. senbanjo io, oshikoya ka, odusanya oo, njokanma of. prevalence of and risk factors for stunting among school children and adolescents in abeokuta, southwest nigeria. j heal popul nutr [internet]. 2011;29(4):364–70. available from: www.bioline.org 11. bishwakarma r. spatial inequality in child nutritionin nepal: implications ofregional contextand individual household compotition (disertasi). univ maryland proquest informationand learn co. 2011; 12. notoatmodjo s. ilmu perilaku manusia. jakarta: rineka cipta; 2012. 13. baskoro d. menjadi lebih baik (parenting healing). jakarta: pt alex media; 2019. 14. rambu, n. pola asuh pemberian makan pada balita stunting usia 6-12 bulan di kabupaten sumba tengah nusa tenggara timur. journal of nutrition college, 2017;6(1):84-95 15. menzel, j. avoidant-restrictive food intake disorder (arfid). neda feeding hope.2016. epidemiology and society health review| eshr vol 2, no2 (2020) 44 available from: https://www.nationaleatingdisorders.org/avoidant-restrictive-food-intakedisorder-arfid 16. ehmke, r. more than picky eating. kids with a serious a version to many foods may need help to overcome avoidance. 2016. available from: http://childmind.org/article/more-than-picky-eating/ 17. manuaba. obesitas jangan dianggap remeh. 2004. available from: www.smallcrab.com 18. perry, s.e, hockenberry, m.j., loedermilk, d.l., wilson dl. maternal child nursing care. missouri: mosby elsevier. 2010; 19. hindrawati, n. & r. gambaran riwayat pemberian asi eksklusif dengan kejadian stunting pada anak usia 6-24 bulan di desa arjasa kecamatan arjasa kabupaten jember. jkakj. 2018;2(1):1–7. 20. septira, s. & angraini, d.i. nutrisi bagi bayi berat badan lahir rendah (bblr) untuk mengoptimalkan tumbuh kembang. 2016. available from: http://repository.lppm.unila.ac.id/2020/1/salsabila%26dian_september%202016.pdf microsoft word fin-6129-article text-22203-1-4-20220630-7 feb 2023.edited.docx epidemiology and society health review| eshr vol. 5, no. 2, 2023, pp. 60-68 issn 2656-6052 (online) | 2656-1107 (print) http://journal2.uad.ac.id/index.php/eshr/index eshr@ikm.uad.ac.id 10.26555/eshr.v5i2.6129 60 research article correlation between hba1c and lipid profile in diabetes: a primary health concern in aseer, saudi arabia fatima riaz1 and archana nimesh2* 1 department of family and community medicine, college of medicine, king khalid university, saudi arabia 2 department of clinical biochemistry, college of medicine, king khalid university, saudi arabia * correspondence: archana.akku.2010@gmail.com. phone: +966-594261524 received 04 june 2022; accepted 07 february 2023; published 30 july 2023 abstract background: type 2 diabetes mellitus (t2dm) presently affects 537 million adults globally. it has a high prevalence in the saudi population (31.6%), ranking 2nd highest in the middle east and 7th worldwide. t2dm is characterized by insulin resistance and hyperglycemia, causing the glycation of hemoglobin, plasma proteins, tissue proteins, and their receptors. the high insulinemic state leads to dyslipidemia. these biochemical alterations can cause complications like atherosclerosis, coronary artery disease, angina, myocardial infarctions, and hypertension. considering the high prevalence of diabetes in the saudi population and the lack of studies conducted at primary health care (phc) centers in saudi arabia, this study was done to investigate the status of diabetes control in t2dm patients and propose appropriate measures to prevent the development of future complications. method: this cross-sectional study recruited 191 known t2dm patients presenting at the phc center in the al qabil locality of aseer province of saudi arabia. the patient's demographic and glycemic and lipid profile data were recorded and statistically analyzed. results: t2dm was more prevalent in males. t2dm patients were found to be obese, and 52% had coexisting hypertension. patients had deranged glycemic profiles and dyslipidemia despite taking hypoglycemic agents. hyperglycemia and dyslipidemia were significantly higher in people with diabetes having hba1c > 7. hba1c is correlated with dyslipidemia, and dyslipidemia is linked considerably with obesity. conclusion: t2dm patients must be regularly followed up to ensure drug compliance, explained about foreseen medical complications, and motivated to adopt lifestyle modification measures to control their weight, bp, and blood glucose. keywords: correlation; hba1c; lipid profile; type 2 diabetes mellitus; saudi arabia riaz (correlation between hba1c and lipid profile in diabetes: a health concern in aseer, saudi arabia) vol. 5, no. 2, 2023, pp. 60-68 61 10.26555/eshr.v5i2.6129 introduction type 2 diabetes mellitus (t2dm) is one of the most commonly encountered metabolic disorders in clinical practice and communities worldwide. the prevalence of this chronic disorder is increasing at an alarming rate globally. presently 537 million adults are living with diabetes worldwide, accounting for about one diabetic person in every ten persons (according to the year 2021 data), and this number is predicted to rise to 643 million by 2030 and 783 million by 2045.1 the prevalence of diabetes in saudi population2 is 31.6% which is relatively high and saudi arabia is ranked as the 2nd highest country in the middle east zone and seventh in the world regarding the prevalence of diabetes mellitus.3 type 2 diabetes mellitus is characterized by insulin resistance leading to hyperglycemia which consequently leads to further biochemical derangements in the body leading to the development of a vast array of clinical complications in due course of time. insulin resistance leads to a hyperinsulinemia state in the body in an attempt to bring down the blood glucose levels by trying to facilitate the entry of plasma glucose into the tissue cells. this high insulin level leads to dyslipidemia in the body, thereby increasing the propensity to develop cardiovascular complications. besides this, hyperglycemia leads to the glycation of hemoglobin, plasma proteins, tissue proteins, and their receptors. these biochemical alterations over a chronic period have been known to cause several complications, especially atherosclerosis, coronary artery disease, angina, myocardial infarctions, hypertension, stroke, obesity, retinopathy, neuropathies, nephropathy, and xanthelasmas.4 moreover, it is not uncommon to see patients presenting to the medical emergency department having diabetic ketoacidosis or hyperosmolar coma due to poorly controlled diabetes mellitus. thus, it becomes essential that a patient, once diagnosed with diabetes, is strictly followed up clinically to prevent the development of these medical sequelae that leads to depreciation in their quality of life. this study has been carried out in the primary health care (phc) center of the aseer region on known cases of type 2 diabetes mellitus patients because primary health care serves as the first interface of interaction with patients to provide healthcare to the community. due to the increasing prevalence of diabetes among the saudi population and the lack of studies conducted at the primary healthcare level in saudi arabia, this study was conducted to investigate the status of diabetes control in t2dm patients and if they had dyslipidemia or not and to propose appropriate measures to be adopted at primary health care level that could help serve the community in a better way to battle this disease that silently affects almost all tissue of the body. method this cross-sectional study was carried out after taking ethical permission from our organization's scientific committee of research. informed consent was taken from the patients to recruit them for the study. the known cases of type 2 diabetes mellitus who presented to the primary health care center (situated at al-qabil locality of the aseer province of saudi arabia) for their follow-up were the subjects of this study. only patients with type 2 diabetes mellitus with at least one year of duration were included in the study. the study was conducted for ten months, from april 2019 to january 2020, and 191 t2dm patients were recruited in the riaz (correlation between hba1c and lipid profile in diabetes: a health concern in aseer, saudi arabia) vol. 5, no. 2, 2023, pp. 60-68 62 10.26555/eshr.v5i2.6129 study group. diabetic patients who were taking drugs causing hypolipidemia were excluded from the study. patients having a history of any other metabolic disorder were excluded from the study to avoid getting confounding results. type 1 diabetes patients and newly diagnosed type 2 diabetics were also excluded from the study. the patients' demographic data were recorded and then asked to undergo biochemistry lab investigations to check their glycemic and lipid profile status. the socio-demographic data included age, gender, body mass index (bmi), blood pressure (bp), and nationality. the glycemic profile of the patients was checked by measuring fasting blood glucose (fbs), random blood glucose (rbs), and glycated hemoglobin (hba1c) levels. the lipid profile assessment was done by measuring serum total cholesterol (tc), ldl cholesterol (ldl), triglycerides, hdl cholesterol (hdl), and vldl levels. vldl levels were determined using freidwald’s formula (vldl = tg/5). the hba1c data was used to further categorize the diabetes patients into well-controlled diabetes (hba1c ≤ 7) and inadequately controlled diabetes groups (hba1c ≥ 7) for further comparison of glycemic and lipid profiles. the data so obtained from the patients were compiled and statistically analyzed. statistical analysis the data related to age, bmi, fbs, rbs, hba1c, total cholesterol, ldl cholesterol, triglycerides, hdl cholesterol, and vldl was parametric and has been expressed as mean ± standard deviation. the glycemic and lipid profile comparison amongst the two groups (wellcontrolled diabetes group and inadequately controlled diabetes group) has been made using an independent student t-test. linear regression analysis was used to check the correlations between the biochemical parameters in diabetes patients. p value < 0.05 has been considered significant. the statistical analysis was done using spss software (version 20). results the demographic data and glycemic and lipid profiles of diabetes patients have been shown in table 1. in this study, it was found that the prevalence of type 2 diabetes mellitus was relatively higher in males in comparison to females. the mean age of the study subjects was 54.9 years. the mean bmi of these patients was 30.3 falling in class 1 obese category. out of 191 diabetes patients, 100 (52%) also had hypertension. the nationality of these patients was saudi. the diabetic patients showed a hyperglycemic and dyslipidemia blood picture (n=191, table 1). table 2 compares glycemic and lipid profiles amongst patients with adequately controlled diabetes and inadequately controlled diabetes. it was found that the patients whose hba1c was > 7 had significantly higher fbs, rbs, hba1c, total cholesterol, ldl cholesterol, triglycerides, and vldl cholesterol level compared to diabetes patients with hba1c ≤ 7. in linear regression analysis (table 3, figure 1), the hba1c groups of the diabetes patients showed a significant positive correlation with total cholesterol and ldl levels. linear regression analysis (table 3, figure 2) also revealed that total cholesterol and triglyceride levels of diabetic patients showed a significant positive correlation with bmi. riaz (correlation between hba1c and lipid profile in diabetes: a health concern in aseer, saudi arabia) vol. 5, no. 2, 2023, pp. 60-68 63 10.26555/eshr.v5i2.6129 table 1. demographic data, glycemic and lipid profile of diabetes patients (n=191) demographic and biochemical variables data gender male 111(58%) female 80 (42%) nationality saudi 191 (100%) age (years) (mean ± sd) 54.9 ± 12.7 bmi (mean ± sd) 30.3 ± 5.6 blood pressure hypertensive (bp ≥140/90mmhg) 100 (52%) normotensive (bp < 130/85) 91 (48%) glycemic and lipid profile parameters mean ± sd fasting blood sugar (fbs)(mg/dl) 201.3 ± 69.8 random blood sugar (rbs)(mg/dl) 313.9 ± 84.6 hba1c (%) 10.3 ± 2.9 total cholesterol (mg/dl) 210.4 ± 51.4 ldl (mg/dl) 121.7 ± 42.0 hdl (mg/dl) 33.9 ± 6.3 triglycerides (mg/dl) 201.7 ± 120.3 vldl (mg/dl) 40.3 ± 24.1 table 2. comparison of glycemic and lipid profile amongst patients with adequately controlled diabetes and inadequately controlled diabetes. variables patients with adequately controlled diabetes patients with inadequately controlled diabetes p-value (hba1c ≤ 7) (hba1c > 7) (n=40) (n=151) mean ± sd mean ± sd fasting blood sugar (fbs) (mg/dl) 137.3 ± 29.1 218.3 ± 67.6 0.000* random blood sugar (rbs) (mg/dl) 223.0 ± 36.9 337.9 ± 76.9 0.000* hba1c (%) 6.5 ± 0.7 11.3 ± 2.4 0.000* total cholesterol (tc) (mg/dl) 184.4 ± 40.7 217.3 ± 51.9 0.000* ldl (mg/dl) 106.8 ± 15.8 125.6 ± 45.8 0.000* hdl (mg/dl) 33.2 ± 2.1 34.1 ± 6.8 0.39 triglyceride (mg/dl) 132.8 ± 85.4 216.8 ± 121.9 0.001* vldl (mg/dl) 26.6 (17.1) 43.4 (24.4) 0.001* *p value < 0.05 is considered significant riaz (correlation between hba1c and lipid profile in diabetes: a health concern in aseer, saudi arabia) vol. 5, no. 2, 2023, pp. 60-68 64 10.26555/eshr.v5i2.6129 table 3. linear regression analysis to check the correlation between the biochemical parameters in diabetes patients variables correlation coefficient (beta) p-value hba1c and tc 0.3 0.001* hba1c and ldl 0.3 0.000* hba1c and triglyceride 0.2 0.053 hba1c and hdl 0.1 0.533 hba1c and vldl 0.2 0.053 total cholesterol and bmi 0.2 0.037* triglyceride and bmi 0.4 0.001* *p value < 0.05 is considered significant (a) (b) figure 1. correlation of hba1c with total cholesterol (a) and hba1c with ldl (b) discussion this study shows that type 2 diabetes mellitus was more prevalent in males, and the average age of the patients was 54.9 years. these patients were found to be falling in the obesity class 1 category. these patients were of saudi nationality. saudi arabian diet predominantly contains food items of non-vegetarian origin. the non-vegetarian diets are considered high in cholesterol and triacylglycerol content, which might have been a contributing factor to obesity. a study by wang et al. has shown that meat consumption is associated with increased bmi and obesity.5 the study also found that 52% of diabetes patients also had hypertension. the glycemic profile of the study subjects (n = 191) showed the mean with a standard deviation of fasting blood glucose (201.3 ± 69.8), random blood glucose (313.9 ± 84.6, and hba1c (10.3 riaz (correlation between hba1c and lipid profile in diabetes: a health concern in aseer, saudi arabia) vol. 5, no. 2, 2023, pp. 60-68 65 10.26555/eshr.v5i2.6129 ± 2.9) were all out of the normal reference range indicating that these patients' despite of taking oral hypoglycemic drugs and insulin were not able to maintain an average glycemic profile. the lipid profile analysis also revealed that these patients had dyslipidemia. their mean with a standard deviation of total cholesterol (210.4 ± 51.4), ldl cholesterol (121.7 ± 42.0), triglycerides (201.7 ± 120.3), hdl cholesterol (33.9 ± 6.3), and vldl (40.3 ± 24.1) were found to be out of normal reference range. according to the ncep atp iii criteria, the total cholesterol level in the range of 200-239 is considered to be borderline high, ldl cholesterol in the range of 100-129 is considered above the optimal range, hdl cholesterol < 40 is considered to be low and fasting triglyceride level > 150 mg/dl is considered to be high. this study confirmed through linear regression analysis that hba1c, a glycemic profile indicator, significantly correlated with total serum cholesterol and ldl cholesterol, indicating that hyperglycemia leads to dyslipidemia in diabetic patients. (a) (b) figure 2. correlation of total cholesterol with bmi (a) and triglycerides with bmi (b) the linear regression also confirmed that serum total cholesterol and triglyceride levels were significantly correlated with bmi, indicating that dyslipidemia leads to increased bmi. the mean bmi of the diabetic subjects enrolled in this study was found to be in the obesity category, implying that dyslipidemia could have led to obesity. a study in the literature has shown that approximately 60-70% of patients who are obese are dyslipidemia.6 dyslipidemia and obesity7 are associated with increased risk for cardiovascular complications. besides this, the presence of hypertension is also considered to be a risk factor for the development of cardiovascular disease.8 the adequately controlled diabetic group and inadequately controlled diabetic group, when compared for their glycemic and dyslipidemia profile, showed a significantly deranged glycemic and dyslipidemia picture in the poorly controlled diabetic group (table 2). this implies that if tight glycemic control is not maintained in diabetes patients, then the pathophysiology of diabetes progresses in an uncontrolled manner leading to the worsening of the lipid profile. riaz (correlation between hba1c and lipid profile in diabetes: a health concern in aseer, saudi arabia) vol. 5, no. 2, 2023, pp. 60-68 66 10.26555/eshr.v5i2.6129 dyslipidemia increases the risk for cardiovascular complications mainly because dyslipidemia promotes atherosclerosis. 9,10 high levels of low-density lipoprotein (ldl)11 and low levels of high-density lipoprotein (hdl)12 are associated with myocardial infarction (mi) and stroke.13,14 a study by tasneem et al. also found that hba1c can be used as a marker for dyslipidemia and to screen patients with a high risk for cardiovascular complications.15 a study by anderson et al. also showed that dyslipidemia is a strong predictor of cardiovascular disease.16 dyslipidemia causes endothelial damage17 and subsequent loss of physiological vasomotor activity that may manifest as increased blood pressure (bp).18,19 many studies have recommended treating dyslipidemia to decrease the risk of cardiovascular diseases. 20,21 besides cardiovascular complications, hyperglycemia and dyslipidemia in diabetes are also found to be associated with other complications such as diabetic retinopathy, cataract, diabetic nephropathy, diabetic foot, urinary tract infections, skin infections, and xanthomas. thus, it is of great concern to control diabetes by administering oral hypoglycemic drugs, insulin, and lifestyle modification and maintaining a regular follow-up of diabetic patients.22 it is our observation that diabetes patients are not very compliant in taking pharmacological treatment regularly, which might be a probable reason in our study that 151 out of 191 diabetes patients (79%) had inadequately controlled diabetes. diabetic patients must be thoroughly counseled regarding the importance of taking drugs regularly in appropriate doses. though drugs play an indispensable role in controlling the blood sugar level, the role of lifestyle modification should not be overlooked in type 2 diabetes mellitus.23 since type 2 diabetes mellitus is characterized by insulin resistance, these patients must be counseled and encouraged by healthcare practitioners to adopt measures related to lifestyle modification, such as engaging in daily physical exercise to upregulate the peripheral insulin receptors on the cells to decrease the insulin resistance in the body which would eventually help in controlling the blood glucose levels.24 these patients must be explained about the medical complications associated with diabetes mellitus that they are likely to develop in the future. besides this, the patients should be advised to consume a smaller number of meats, eggs, and oily foods to improve their lipid profile further and that they should avoid eating foods with high glycemic index and must include complex carbohydrate-rich foods and dietary fibers (salads) in their meals which would further decrease the absorption of cholesterol from intestine into the blood. the patients of t2dm must also be motivated to keep their body weight in control and self-monitor their blood pressure and blood glucose levels continuously by using user-friendly point-of-care testing devices such as digital bp apparatus and glucometers.25 since studies conducted at a primary health care center in saudi arabia are minimal, our research data has substantial value in formulating health policies for the local population to ensure reasonable control over diabetes mellitus. conclusion type 2 diabetes mellitus patients presenting at the primary health care center of the aseer region were found to be obese, with 52% of cases having concomitant hypertension. despite taking oral hypoglycemic drugs and insulin, these patients showed a deranged glycemic and lipid profile. patients of t2dm in the aseer region of saudi arabia must be regularly followed up to review the ongoing drug therapy and its compliance so that glycemic and lipid profiles can be adequately controlled, given the impending risk of complications associated with riaz (correlation between hba1c and lipid profile in diabetes: a health concern in aseer, saudi arabia) vol. 5, no. 2, 2023, pp. 60-68 67 10.26555/eshr.v5i2.6129 t2dm. the authors also recommend that thorough counseling of these patients regarding lifestyle management measures might be helpful. acknowledgment the authors thank the nursing staff working at a primary health care center for assisting in data collection for this study. declarations authors' contribution fr designed the study, collected the data, and reviewed and edited the manuscript. an statistically analyzed the data, prepared the result, and wrote the manuscript. funding statement this research has not received external funding. conflict of interest there is no conflict of interest in this research. references 1. international diabetes federation. idf diabetes atlas, 10th edition. 2021. 2. meo sa, usmani am, qalbani e. prevalence of type 2 diabetes in the arab world: impact of gdp and energy consumption. eur rev med pharmacol sci. 2017;21(6):1303–12. 3. al dawish m, robert a, braham r, al hayek a, al saeed a, ahmed r, et al. diabetes mellitus in saudi arabia: a review of the recent literature. curr diabetes rev. 2016;12(4):359–68. 4. faselis c, katsimardou a, imprialos k, deligkaris p, kallistratos m, dimitriadis k. microvascular complications of type 2 diabetes mellitus. curr vasc pharmacol. 2020;18(2):117–24. 5. wang y, beydoun m. meat consumption is associated with obesity and central obesity among us adults. int j obes. 2009;33(6):621–8. 6. bays he, toth pp, kris-etherton pm, abate n, aronne lj, brown wv, et al. obesity, adiposity, and dyslipidemia: a consensus statement from the national lipid association. j clin lipidol. 2013;7(4):304–83. 7. cercato c, fonseca fa. cardiovascular risk and obesity. diabetol metab syndr. 2019;11(1):1–15. 8. fuchs fd, whelton pk. high blood pressure and cardiovascular disease. hypertension. 2020;(cvd):285–92. 9. pedersen t, kjekshus j, berg k, haghfelt t, faergeman o, faergeman g, et al. scandinavian simvastatin survival study group. randomised trial of cholesterol lowering in 4444 patients with coronary heart disease: the scandinavian simvastatin survival study (4s). j atheroscler. 1994;5(3):81–7. 10. wong nd. epidemiological studies of chd and the evolution of preventive cardiology. nat rev cardiol. 2014;11(5):276–89. 11. berliner j, navab m, fogelman a, frank j, demer l, edwards p, et al. atherosclerosis: basic mechanisms oxidation, inflammation, and genetics. circulation. 1995;91(9):2488– 96. riaz (correlation between hba1c and lipid profile in diabetes: a health concern in aseer, saudi arabia) vol. 5, no. 2, 2023, pp. 60-68 68 10.26555/eshr.v5i2.6129 12. gordon t, castelli w, hjortland m, kannel w, dawber t. high density lipoprotein as a protective factor against coronary heart disease. the framingham study. am j med. 1977;62(5):707–14. 13. ference ba, ginsberg hn, graham i, ray kk, packard cj, bruckert e, et al. low-density lipoproteins cause atherosclerotic cardiovascular disease. 1. evidence from genetic, epidemiologic, and clinical studies. a consensus statement fromthe european atherosclerosis society consensus panel. eur heart j. 2017;38(32):2459–72. 14. yaghi s, elkind msv. lipids and cerebrovascular disease: research and practice. stroke. 2015;46(11):3322–8. 15. tasneem a, vemuri h, shaik m, khan m. correlation between glycosylated haemoglobin and dyslipidaemia in patients with type 2 diabetes mellitus. int j health sci (qassim). 2021;4(24):1–3. 16. anderson km. cholesterol and mortality. 30 years of follow-up from the framingham study. jama j am med assoc. 1987;257(16):2176–80. 17. nickenig g. central role of the at(1)-receptor in atherosclerosis. j hum hypertens. 2002;16:26–33. 18. nickenig g, harrison d. current perspective the at1 -type angiotensin receptor in oxidative stress and atherogenesis part ii: at1 receptor regulation. circulation. 2002;530–6. 19. nickenig g, harrison d. current perspective current perspective the at1 -type angiotensin receptor in oxidative stress and atherogenesis part i: oxidative stress and atherogenesis. circulation. 2002;393–6. 20. khavandi m, duarte f, ginsberg hn, reyes-soffer g. treatment of dyslipidemias to prevent cardiovascular disease in patients with type 2 diabetes. curr cardiol rep. 2017;19(1):1–16. 21. dolzhenko m, barnett o, grassos c, dragomiretska n, goloborodko b, ilashchuk t, et al. management of dyslipidemia in individuals with low-to-moderate cardiovascular risk: role of nutraceuticals. adv ther. 2020;37(11):4549–67. 22. papatheodorou k, banach m, bekiari e, rizzo m, edmonds m. complications of diabetes 2017 konstantinos. j diabetes res. 2018;2018, arti:4. 23. khaltaev n, axelrod s. global trends in diabetes-related mortality with regard to lifestyle modifications, risk factors, and affordable management: a preliminary analysis. chronic dis transl med. 2021;7(3):182–9. 24. bird s, hawley j. update on the effects of physical activity on insulin sensitivity in humans. bmj open sport exerc med. 2017;2(1):1–26. 25. mellergård e, johnsson p, eek f. developing a web-based support using self-affirmation to motivate lifestyle changes in type 2 diabetes: a qualitative study assessing patient perspectives on self-management and views on a digital lifestyle intervention. internet interv. 2021;24(march):100384. microsoft word ss5_4728-article text-19432-1-18-20220220.docx epidemiology and society health review| eshr vol. 4, no. 1, 2022, pp. 29-35 issn 2656-6052 (online) | 2656-1107 (print) 10.26555/eshr.v4i1.4728 29 research article blood sugar levels and lipid profiles of t2dm among hypertension patients in bambanglipuro health centre qothrunnadaa fajr rooiqoh1*, didik gunawan tamtomo2, risya cilmiaty3 1 department of postgraduate nutrition science, sebelas maret university, surakarta, indonesia 2 department of anatomy, faculty of medicine, sebelas maret university, surakarta, indonesia 3 department of dental and mouth, faculty of medicine, sebelas maret university, surakarta, indonesia * correspondence: qothrunnadaa111@gmail.com. phone: +628998418947 received 23 august 2021; accepted 09 february 2022; published 21 february 2022 abstract background: type 2 diabetes mellitus is a common chronic disease with multiple complications contributing to the global healthcare burden. untreated t2dm causes multiple organs and systemic injury, including heart, kidney, nerve, and blood vessels, which impairs quality of life and increases mortality rates caused by complications of diabetes. some of these complications play a clear role in increasing diabetes mortality. the objective of this study was to determine the differences in blood glucose level and lipid profile among t2dm patients with hypertension and without hypertension. method: this research was a cross-sectional analytic study. research subjects were taken using a purposive sampling technique with inclusion and exclusion criteria among the 40 t2dm patients in the chronic disease management program called prolanis at bambanglipuro health centre. the inclusion criteria were t2dm patients who were members of prolanis. the exclusion criteria were patients with a history of complications such as heart disease, stroke, and cancer. accordingly, in total, 32 t2dm patients were joining this study. we collected the total cholesterol, hdl, and ldl data and analyzed it with an independent t-test. the fasting blood glucose level, hba1c, and triglyceride data were analyzed using the mann-whitney u test. results: there were differences in ldl levels (p=0.005) in t2dm patients with hypertension and without hypertension. meanwhile, there was no difference in fasting blood glucose among t2dm patients with hypertension and without hypertension. conclusion: there was a significant difference in ldl, and there were no significant differences in fasting blood glucose levels in t2dm patients with hypertension and without hypertension. keywords: diabetes mellitus; hypertension; blood glucose level; lipid profile qothrunnadaa (blood sugar levels and lipid profiles of t2dm among hypertension patients in bambanglipuro health centre) vol. 4, no. 1, 2022, pp. 29-35 10.26555/eshr.v4i1.4728 30 introduction diabetes mellitus is a long-term metabolic condition marked by an abnormally high blood glucose level. according to the international diabetes federation (idf), diabetes mellitus patients in 2019 are estimated to be 463 million people aged 20-79 years. patients with uncontrolled diabetes mellitus (dm) will experience blindness, heart disease, and kidney failure (1). the prevalence of dm is estimated to increase as the population grows, reaching 578 million people in 2030 and 700 million globally in 2045. indonesia is the 7th country globally, with the most dm patients of 10.7 million (2). the prevalence of dm in indonesia is 2%, and yogyakarta province has the second-highest prevalence of 3.1% in indonesia (3). diabetes mellitus type 2 is the most common type of diabetes mellitus in indonesia. type 2 diabetes mellitus will increase the prevalence of lipids, resulting in cardiovascular disease (cvd). in type 2 diabetes mellitus (t2dm), cholesterol levels are around 28% to 34%, triglyceride level 5% to 14%, and lower high-density lipoprotein (hdl) level (4). high carbohydrate consumption in t2dm patients can interfere with carbohydrate metabolism, which results in increased fatty acid synthesis in the liver, and converts fat into cholesterol (5). atherosclerosis, or the appearance of fat in blood arteries, is caused by high cholesterol levels. atherosclerosis can cause cardiovascular disease by clogging the blood arteries of the heart. (6,7). hypertension is significant comorbidity of diabetes, with around 67% of individuals with diabetes having a blood pressure of 140/90 mmhg or higher and using antihypertensive medications (8). about 66% of diabetics had excessive blood pressure in 2017 (9). insulin delivery and weight gain produce hypertension in t2dm patients, resulting in reduced arterial distensibility, leading to a rise in systolic blood pressure (10). according to epidemiological studies, cardiovascular mortality is 2-3 times higher in a diabetic with hypertension than a diabetic without hypertension (11). low-density lipoprotein cholesterol is an atherogenic component that has a clinically significant influence on cardiovascular disease development. low-density lipoprotein cholesterol is an independent predictor of cardiovascular events in people with t2dm (12). a meta-analysis of 102 prospective studies including 698,782 people indicated that dm is linked to a two-fold increased risk of coronary heart disease, stroke, and mortality from cardiovascular causes such as heart failure, cardiac arrhythmia, sudden death, hypertension, and aortic aneurysms (13). this research aimed to determine the differences in blood glucose level and lipid profile in t2dm patients with hypertension and those without hypertension. the results of this study contribute as input for making policies to control t2dm at the bambanglipuro health center and other regions that have similar characteristics. method this study was employed a cross-sectional analytic survey to determine the differences in blood glucose level and lipid profiles in t2dm patients with hypertension and without hypertension at bambanglipuro public health center, bantul, yogyakarta. the population in this study was 40 t2dm patients. research subjects were taken using a purposive sampling technique with inclusion and exclusion criteria. the inclusion criteria were t2dm patients who were members of the chronic disease management program (prolanis). exclusion criteria were patients with a history of complications such as heart disease, stroke, and cancer. qothrunnadaa (blood sugar levels and lipid profiles of t2dm among hypertension patients in bambanglipuro health centre) vol. 4, no. 1, 2022, pp. 29-35 10.26555/eshr.v4i1.4728 31 type 2 diabetes mellitus with hypertension using criteria having a blood pressure of >140/90 mmhg. we used medical records at bambanglipuro health centre taken in december 2020. we collected 32 samples that fulfilled our criteria during the data collection, consisting of 16 t2dm patients with hypertension and 16 t2dm patients without hypertension (normal blood pressure). the shapiro wilk test was used to test the data normality distribution. the independent t-test was used to calculate total cholesterol, hdl, and ldl data. at the same time, the mann-whitney test was employed to analyze fasting blood glucose levels, hba1c, and triglyceride data. for each analysis, we used a 0.05 significant p-value. results a. characteristics of the respondent table 1 shows the sociodemographic of respondents for this study (sex, age, and educational background). females were dominating this respondent in this research. the age group of 5665 years was the most populated (56.25%). the majority of the respondent were farmers (56.25%). we found the p-value was >0.05 on each characteristic, indicating that both groups' sex, age, and profession are homogeneous. table 1. characteristics of the respondent b. the differences in blood glucose level and lipid profile our analysis results indicated that only t2dm patients with hypertension had higher ldl levels than those without hypertension (p <0.05). table 2 presents the differences in blood glucose level and lipid profiles in this study, including fasting glucose level, hba1c, total cholesterol, ldl, hdl, and triglyceride presented. table 2. the differences in blood glucose level and lipid profile variable t2dm with hypertension t2dm without hypertension p-value characteristics of subjects t2dm with hypertension t2dm without hypertension total p-value n (%) n (%) n (%) sex female 12 (75.0) 7 (43.75) 19 (59.37) 0.074 male 4 (25.0) 9 (56.25) 13 (40.63) age 36-45 years old. 0 (0.0) 1 (6.25) 1 (2.12) 0.774 46-55 years old 2 (12.5) 2 (12.5) 4 (12.5) 56-65 years old 9 (56.25) 9 (56.25) 18 (56.25) >66 years old. 5 (31.25) 4 (0.25) 9 (28.13) occupation civil servant 1 (6.25) 2 (12.5) 3 (9.38) 0.310 private 0 (0.0) 2 (12.5) 2 (6.25) entrepreneur 3 (18.75) 2 (12.5) 5 (15.63) farmer 9 (56.25) 5 (31.25) 13 (40.63) laborer 1 (6.25) 0 (0.0) 1 (3.13) unemployed 3 (12.5) 5 (31.25) 8 (25.0) qothrunnadaa (blood sugar levels and lipid profiles of t2dm among hypertension patients in bambanglipuro health centre) vol. 4, no. 1, 2022, pp. 29-35 10.26555/eshr.v4i1.4728 32 mean ± sd mean ± sd fasting blood glucose level 100.25 ± 32.70 138.06 ± 83.08 0.356** hba1c 7.59 ± 1.79 8.58 ± 3.01 0.534** total cholesterol 191.12 ± 46.86 190.69 ± 32.48 0.730* hdl 46.44 ± 7.28 46.19 ± 8.30 0.996* ldl 126.38 ± 38.00 123.00 ± 26.9 0.005* triglyceride 176.88 ± 116.64 165.31 ± 56.434 0.749** *) independent t-test **) mann whtney u test on the examination of fasting blood glucose level, the result was 100.25 ± 32.70 mg/dl in t2dm with hypertension and a mean fasting blood glucose level of 138.0 ± 83.08 mg/dl without hypertension. there was no significant difference between fasting blood glucose levels in the t2dm group with hypertension and without hypertension (p> 0.05). the mean hba1c level in the blood was 7.59 ± 1.79% for t2dm with hypertension and the mean of 8.58 ± 3.01% without hypertension. there was no significant difference between hba1c levels in t2dm with hypertension and without hypertension (p> 0.05). the mean for total cholesterol was 191.12 ± 46.86 and 190.69 ± 32.48 mg/dl for t2dm with hypertension, respectively. there was no significant difference between total cholesterol levels in the t2dm group with hypertension and without hypertension (p> 0.05). the hdl level among the two groups showed that the mean hdl level was 46.44 ± 7.28 mg/dl for the t2dm with hypertension and a mean of 46.19 ± 8.30 mg/dl for those without hypertension. there was no significant difference between hdl levels in the t2dm with hypertension and those without hypertension (p> 0.05). the mean of ldl examination was 126.38 ± 38.00 mg/dl in the t2dm group with hypertension and 123.00 ± 26.9 mg/dl without hypertension. the result was a significant difference in ldl on t2dm with hypertension and without hypertension (p <0.05). the triglyceride test for t2dm with hypertension means 176.88 ± 116.64 mg/dl and 165.31 ± 56.434 mg/dl without hypertension. the result was no significant triglyceride level among the two groups (p-value > 0.05). discussion in this study, there were significant differences in ldl level, and the mean ldl levels in t2dm with hypertension (sd 126.38 ± 38.88) were higher than those without hypertension (123.00 ± 26.90). the fasting blood glucose level, total cholesterol, hdl, and triglycerides in t2dm without hypertension had a lower mean than in t2dm with hypertension, but there was no significant difference. according to siregar (12), there is a substantial positive link between increased total cholesterol, triglycerides, hdl, and ldl with hypertension in the t2dm population. however, only the lipid profile (no blood sugar levels) was compared with hypertension in this study. in contrast to kumar's research that compared fasting blood sugar hba1c and lipid profile (14). a rise in ldl cholesterol levels has been linked to an increased risk of cardiovascular disease in some studies (12,15). the incidence of hypertension will result in atherosclerosis. atherosclerosis involves endothelial dysfunction, impaired lipid metabolism, oxidative stress, activation of vascular smooth muscle, genetic factors, and recently, it is also widely known that there is a role for inflammation at each stage of atherosclerosis formation. atherosclerosis, characterized by endothelial dysfunction, is linked to metabolic syndrome and cardiovascular disease risk factors. blood pressure factors, central obesity, hyperinsulinemia, and dyslipidemia occur before insulin resistance (16). qothrunnadaa (blood sugar levels and lipid profiles of t2dm among hypertension patients in bambanglipuro health centre) vol. 4, no. 1, 2022, pp. 29-35 10.26555/eshr.v4i1.4728 33 there is also a considerable reduction in ldl catabolism in t2dm patients, resulting in a prolonged duration of ldl in plasma, enhancing fat deposition into the artery wall (15). lowdensity lipoprotein cholesterol has become a significant focus on managing lipid profiles in patients with coronary artery disease or risk factors equivalent to coronary artery disease, such as diabetes, who must have cholesterol control. according to the european society of cardiology's (esc) recommendations for treating dyslipidemia. low-density lipoprotein is tight if it is less than 70 mg/dl (17). it demonstrates the importance of a lipid profile in cardiovascular disease risk and diabetes prognosis. in addition to an increase in ldl, high blood glucose levels potentially make the initiation of atherosclerosis by stimulating the proliferation of endothelial cells and blood vessel muscle cells (18). hyperglycemia is frequently linked to hyperinsulinemia, dyslipidemia, and hypertension in individuals with t2dm. this situation could be resulting cardiovascular disease and stroke. for example, among studies of t2dm patients, hypertension increased by 42%44% the risk of death and cardiovascular events, whereas t2dm without hypertension only 7%-9% the risk of death and cardiovascular disease (19). this study shows that most patients with t2dm with hypertension were female. this research was in line with previous research that stated the most t2dm with hypertension was female, 63.9% (12). most t2dm patients are aged 56-65 years old. this follows a study that found that people over 45 had a greater risk of developing type 2 diabetes than people under 45 (20). this is because as we age, our tissues' capacity to absorb glucose from the blood declines (21). in this study, the mean fasting blood glucose levels in t2dm with hypertension (sd 138.06 ± 83.08) were higher than those without hypertension (100.25 ± 32.70). it shows that the relationship between t2dm and hypertension is complex. hypertension makes insulin sensitivity decrease (22). even though insulin plays a role in increasing glucose uptake in many cells and carbohydrate metabolism, insulin resistance will occur. therefore, blood glucose levels can also be disrupted (23). autonomic dysfunction, activation of the renin-angiotensinaldosterone (raas) system, insulin resistance, sympathetic nerve activation, endothelial dysfunction, and arterial stiffness are some factors known to contribute to hypertension in diabetes (2). excess insulin levels can also cause increased sodium retention by the kidney tubules, leading to hypertension. the results of this study were influenced by external variables such as food consumption, cigarettes, glycemic control, and fat (24). although treating linked risk factors is considerably more likely to be cardioprotective than merely maintaining glucose levels. effective glycemic control is required to reduce the risk of nephropathy, retinopathy, and neuropathy (1). the american diabetes association's decision to lower the glucose threshold for "impaired fasting glucose" from 110 mg/dl to 100 mg/dl highlights the importance of better glycemic control (25). therefore, a proper diet is needed to deal with t2dm with hypertension to control blood glucose levels, blood pressure, and lipid profiles. some non-pharmacological therapies include weight loss programs for the obese, increasing a potassium-based diet, the dietary approach to stop hypertension (dash), and regular exercise. although it did not evaluate the benefits of the dash diet in diabetic patients, their implementation seems reasonable in people with diabetes since they may positively affect glycemic and lipid profiles. therefore, current ada standards recommend adopting all diabetic patients with blood pressure values of > 120/80 mmhg (26). conclusion qothrunnadaa (blood sugar levels and lipid profiles of t2dm among hypertension patients in bambanglipuro health centre) vol. 4, no. 1, 2022, pp. 29-35 10.26555/eshr.v4i1.4728 34 this study found a significant difference in ldl, and there were no significant differences in fasting blood glucose level, hba1c, cholesterol, hdl, or triglyceride in patients with t2dm hypertension and without hypertension. authors' contribution qfr, dgt contributed to the research design and developed the first draft of the manuscript. qfr contributed to the data collection and statistical analysis. dgt and rc contributed to reviewing and evaluating this manuscript for publication. acknowledgment we thank bambanglipuro public health center for the support of data of prolanis in facilitating this research. the author was responsible independently for funding this research. conflict of interest there is no conflict of interest in this research. references 1. perkumpulan endokrinologi indonesia (perkeni). consensus and prevention of type 2 diabetes mellitus in indonesia. jakarta; 2019 (in indonesian). [update2019; cited 2021 mei 1]. available from: https://pbperkeni.or.id/unduhan 2. international diabetes federation. diabetes atlas. ninth. uk: international diabetes federation; 2019. [update 2019; cited 2021 mei 1]. available from: https://idf.org/elibrary/epidemiology-research/diabetes-atlas.html 3. indonesia ministry of health. main results of basic health research (riskesdas). 2018 (in indonesian). [update 2018; cited 2021 mei 1]. available from: https://www.litbang.kemkes.go.id/laporan-riset-kesehatan-dasar-riskesdas/ 4. franz mj, ever ab. medical nutrition therapy for diabetes mellitus and hypoglycemia of nondiabetic origin. in: mahan lk, raymond jl, editors. krause’s food and the nutrition care process, four teenthedition. fourteenth. st. louis, missouri: elsevier inc; 2017. p. 586–618. 5. tadesse k, amare h, hailemariam t, gebremariam t. prevalence of hypertension among patients with type 2 diabetes mellitus and its socio demographic factors in nigist ellen mohamed memorial hospital hosanna, southern ethiopia. j diabetes metab. 2018;09(04):4–10. 6. kahn se, hull rl, utzschneider km. mechanisms linking obesity to insulin resistance and type 2 diabetes. nature. 2006;444:840–846. 7. stapleton pa, goodwill ag, james me, brock rw, frisbee jc. hypercholesterolemia and microvascular dysfunction : interventional strategies. 2010;1–10. 8. centers for disease control (cdc). national chronic kidney disease fact sheet. 2014. 9. de boer ih, bangalore s, benetos a, davis am, michos ed, muntner p, et al. diabetes and hypertension: a position statement by the american diabetes association. diabetes care. 2017;40(9):1273–84. 10. cruickshank k, riste l, anderson sg, wright js, dunn g, gosling rg. aortic pulsewave velocity and its relationship to mortality in diabetes and glucose intolerance an integrated index of vascular function ? 2002; 11. rivellese aa, riccardi g, vaccaro o. cardiovascular risk in women with diabetes. nutr metab cardiovasc dis. 2010;20(6):474–80. 12. siregar j. comparison of lipid profile with hypertension in type 2 diabetes mellitus with or without hypertension at h. adam malik hospital, medan, indonesia. intisari sains medis. 2019;10(2):354–8 (in indonesia). qothrunnadaa (blood sugar levels and lipid profiles of t2dm among hypertension patients in bambanglipuro health centre) vol. 4, no. 1, 2022, pp. 29-35 10.26555/eshr.v4i1.4728 35 13. the emerging risk factors collaboration. diabetes mellitus, fasting blood glucose concentration, and risk of vascular disease: a collaborative meta-analysis of 102 prospective studies. lancet. 2010;(375):2215–22. 14. kumar sp, sandhya am. a study on the glycemic, lipid and blood pressure control among the type 2 diabetes patients of north kerala, india. indian heart j. 2018;70(4):482–5. 15. yudha nsd, arsana pm, rosandi r. comparison of lipid profiles in patients with type 2 diabetes mellitus with good glycemic control and poor glycemic control in rsud dr. saiful anwar malang. j penyakit dalam indones. 2022;8(4):172–8 (in indonesia). 16. ference ba, ginsberg hn, graham i, ray kk, packard cj, bruckert e, et al. low-density lipoproteins cause atherosclerotic cardiovascular disease. 1. evidence from genetic, epidemiologic, and clinical studies. a consensus statement from the european atherosclerosis society consensus panel. eur heart j. 2017;38(32):2459–72. 17. catapano al, graham i, backer g de, wiklund o, chapman mj, drexel h. 2016 esc/eas guidelines for the management of dyslipidaemias. eur hear j. 2016;37(39):2999–3058. 18. putra intk, dharma iks, wibhuti ibr. the relationship between the decrease in glomerulus filtration rate (gfr) and the increase in amount of coronary artery lesions on coronary heart disease patients in sanglah general hospital, denpasar-indonesia. intisari sains medis. 2018;9(2):113–7. 19. emdin ca, rahimi k, neal b, callender t, perkovic v, patel a. blood pressure lowering in type 2 diabetes : a systematic review and meta-analysis. jama j am med assoc. 2015;313(6):603–15. 20. palimbuga, trivena, ratag, kaunang. factors associated with the incidence of type 2 diabetes mellitus at rsu gmim pancaran kasih manado. media kesehatan. 2016; 9(3) (in indonesia). 21. suiroka. penyakit degeneratif: mengenal, mencegah dan mengurangi faktor risiko 9 penyakit degeneratif (pertama). yogyakarta: nuha medika; 2012. 22. mihardja. factors associated with blood sugar control in diabetes mellitus patients. jakarta: majalah kedokteran indonesia. 2009; 23. sari mi, wijaya dw. relationship between calorie intake, physical activity, and dopamine d2 receptor taq1a gene polymorphism in normal-weight, overweight, and obese students of the faculty of medicine of university of sumatera utara. bali med j. 2017;6(1):125. 24. hasneli, kasmiyetti, umar. relationship between fat intake, fiber intake and blood lipid levels and their relationship to waist-to-hip circumference ratio.[skripsi]. poltekkes kemenkes padang. 2012; (in indonesia). 25. american diabetes association. diagnosis and classification of diabetes mellitus. diabetes care. 2014;37((supplement 1)):s81–s90. [update 2014; cited 2021 mei 1]. available from: https://pubmed.ncbi.nlm.nih.gov/24357215/ 26. wong nathan d, zhao y, patel r, patao c, malik s, bertoni ag, correa a, et al. cardiovascular risk factor targets and cardiovascular disease event risk in diabetes: a pooling project of the atherosclerosis risk in communities study, multi-ethnic study of atherosclerosis, and jackson heart study. diabetes care. 2016;39( may):668–676. microsoft word fin-6313-article text-26837-1-18-20230109-v2 (1).docx epidemiology and society health review| eshr vol. 5, no. 1, 2023, pp. 1-10 issn 2656-6052 (online) | 2656-1107 (print) http://journal2.uad.ac.id/index.php/eshr/index eshr@ikm.uad.ac.id 10.26555/eshr.v5i1.6313 1 research article a qualitative study on the effectiveness of displayed health education materials (hems) in an immunization clinic of a tertiary care hospital in west bengal, india maumita de1, saikat bhattacharya1*, soumitra mondal2 1 department of community medicine, nil ratan sircar medical college, kolkata, west bengal, india 2 department of biochemistry, shri vasantrao nalik government medical college, yavatmal, maharashtra, india * correspondence: ressaikat@gmail.com. phone: +919038279672 received 21 july 2022; accepted 13 december 2022; published 02 february 2023 abstract background: health education materials are intended to percolate certain messages to the general population in order to influence their knowledge and attitude toward health issues. the current study aims to determine the effectiveness of health education materials in terms of visibility, attractiveness and clarity of message perceived by the study participants. method: a cross-sectional qualitative study was conducted in the immunization clinic of a tertiary care hospital in west bengal, india, upon 32 caregivers accompanying the children for immunization. their explanation of the posters was recorded, transcribed, and translated into english. results were obtained by analyzing data in both ms excel and visual anthropac. results: out of 20 displayed posters, 12 were mostly situated around the vaccination table and had a pictorial presentation with child images. those posters were first noticed by the participants while waiting. after the pile sorting of 10 attractive posters, four were related to child health, four were about nutrition and breastfeeding, and 2 were included under the personal hygiene group. only a single poster associated with vitamin a oil was fully understood by all respondents. a total of 6 posters were fully or partially understood by more than 80% of the respondents, whereas 3 posters related to personal hygiene were wrongly interpreted. conclusion: the health education materials in the immunization clinic may be planned in clear pictorial presentation with less text, so those could be noticed easily and accompanied with audiovisual aids for understanding correctly. keywords: effectiveness; health education material; immunization clinic maumita de et al. (a qualitative study on effectiveness of displayed health education materials…) vol. 5, no. 1, 2023, pp. 1-10 2 10.26555/eshr.v5i1.6313 introduction health education is a vital component of the primary prevention of disease. it is an intentional activity carried out to inform the population about different ways to prevent communicable and non-communicable diseases, as well as make the mass aware of presentations of a disease, its complications, and good treatment practices.1 prevention is always superior and less expensive than treatment, so it has become a quintessential part of any health program. india is the second largest populous country in the world, with a doctorpatient ratio of only 1: 834, much less than the developed countries.2 hence it depends more on health education for the control of different diseases. health education can be conveyed in different ways like miking, mass media, folk media, posters, pamphlets, etc. but in institutional settings, displayed health education materials in the form of posters and banners remain the better choice for health promotion of a more significant proportion of the population.3 these banners and posters are displayed in different sizes, sites of a health institution, both pictorial and text forms. the written language may again be either english or the local language. these posters also intended to percolate messages on various health-related topics like maternal and child health, immunization, breastfeeding; nutrition; family planning; infectious diseases and non-communicable diseases; personal hygienic measures etc. this way, displayed health education materials can incorporate diverse selection by the viewers due to their attractiveness, as interpreted in front of the eyes of the patients, patient parties, and people in general. a study in manchester city by ward k et al. reported that about 82% of patients in the waiting room noticed the poster, 98% of them remembered the subject of the display, and 53% of patients were interested in getting more information about a topic.4 effective health education thus brings about positive changes in knowledge, attitude, and behavioral practices in some regions of concern.1 there is a shortage of similar studies in developing countries like india, where the literacy rate is poor compared to countries like the usa and the uk. moreover, most studies3-4 were conducted in general outdoor or indoor settings where patients or patient parties are presumably more stressed than immunization clinic attendees. so, we don’t know how these hems are perceived in relatively less stressed conditions in the indian scenario. different types of health education material (hem) are displayed all over the room of the immunization clinic in our study setting. mothers and caregivers spend at least 35-40 minutes in the clinic, as it is mandatory for the child to wait at the vaccination site for at least 30 minutes after vaccination. this gives caregivers ample time to look around. again, they are not accompanying any patient with active disease, so presumably, they will be facing less stress than the others with patients. hence this study aims to determine the effectiveness of health education materials displayed in an immunization clinic of a medical college in west bengal, india, in terms of visibility, attractiveness and clarity of message as per the study participants' understanding. this research will further contribute to design more attractive maumita de et al. (a qualitative study on effectiveness of displayed health education materials…) vol. 5, no. 1, 2023, pp. 1-10 3 10.26555/eshr.v5i1.6313 and clear hems for the propagation of health-related information to the beneficiaries and to bring about desired changes in their health behavior. method the study was a cross-sectional institution-based qualitative study. this study was carried out in the routine immunization clinic of a tertiary care medical college of kolkata, west bengal in india, for six months upon the mothers and caregivers accompanying the children for immunization. kolkata is a metro city in the state of west bengal in eastern india. the population from rural areas and nearby urban areas visit medical colleges for different purposes, including immunization of children. the sampling technique applied was maximum variation sampling, where variation was based on the literacy status of study participants in terms of four groups viz. illiterate, educated up to primary school, educated up to higher secondary, graduated and above. from each group of 8 participants, thus a total of 32 caregivers were interviewed, two caregivers each week. caregivers of children of different age groups from birth to 16 years were taken. both male and female caregivers were interviewed wherever applicable. the interview was on a one-toone basis so that others’ opinions did not influence one’s answer. at the time of exit from the clinic, the interviews were carried out with written informed consent. all the points related to the study were described in the local language to the illiterate participants in the presence of a witness. thumb impressions of illiterate subjects were taken in the informed consent sheet. first, they were asked which posters they could remember noticing while waiting in the immunization clinic and where they were located. after showing the researcher all the health education materials and their positions in the immunization clinic, they were asked to list ten posters/banners according to attractiveness. those posters or banners may or may not be similar to those they first observed during waiting. the listed attractive posters were shown separately to five interns (posted in the immunization clinic). they were asked to sort them into different piles per commonality regarding topic and presentation. lastly, study participants were asked whether they understood messages given by the health education materials they first noticed while waiting there and the ten most attractive posters/banners as per their choice. their explanation of the posters was recorded with prior permission and then transcribed and translated into english from a local language. had they understood the theme or area of health education message but not the exact message itself, it was termed as partial ‘understanding’. results were obtained by analyzing data in both ms excel and visual anthropac. ethical approval was taken from the institutional ethics committee (memo no: nrsmc/iec/34/2022), and then permission was sought to obtain informed consent from the maumita de et al. (a qualitative study on effectiveness of displayed health education materials…) vol. 5, no. 1, 2023, pp. 1-10 4 10.26555/eshr.v5i1.6313 participants. the study could confer minimal risk to the participants, particularly on privacy and confidentiality issues maintained throughout the study. results as per the demographics (table 1), most participants, i.e., 26 respondents were mothers of children, and 6 of them were fathers. the participants ranged from 17 to 40 years, with the median being 25, while the age of the children they were accompanying ranged from 6 weeks to 12 years. most of the mothers had two children. 20 of the 32 subjects were from urban areas. according to literacy status, the lowest educational qualification is illiterate, and the highest is graduate. most of the caregivers were mothers & most of them were homemakers. according to the modified b.g. prasad socio-economic scale 2021,5 most belonged to class iii. the mean waiting time for caregivers was 40 minutes, with 30 minutes minimum and 45 minutes maximum waiting time. table 1. sociodemographic profile of the study participant (n =32) variables characters no (%) gender female male 26 (81.3) 6 (18.7) age group (years) < 20 20 – 30 >30 2 (8.4) 24 (73.9) 6 (17.7) age of child <6 months 6 months -1 year 1year2 years 2years5 years >5 years 6 (18.8) 10 (31.3) 9 (28.1) 2 (6.3) 5 (15.5) residence urban rural 20 (62.5) 12 (37.5) occupation homemaker working 22 (68.7) 10 (31.3) education illiterate up to primary school up to higher secondary graduation & above 8 (25.0) 8 (25.0) 8 (25.0) 8 (25.0) socio-economic class i (upper) ii (upper middle) iii (middle) iv (lower middle) v (lower) 2 (6.3) 3 (9.3) 20(62.5) 4 (12.6) 3 (9.3) waiting time 30 minutes 30-40 minutes >40minutes 10 (31.3) 19 (59.3) 3 (9.4) maumita de et al. (a qualitative study on effectiveness of displayed health education materials…) vol. 5, no. 1, 2023, pp. 1-10 5 10.26555/eshr.v5i1.6313 in the immunization clinic, a total of 20 different health education materials were displayed in other places and of various sizes. in interviewing, subjects, on average, recalled seeing three posters/banners. after interviewing 32 participants, a total of 12 different posters were found to be noticed by the participants while waiting. this result shows that most of the displayed education materials the subjects saw were similar. 2 of the materials, one displayed behind the public health nurse administering immunization and one on the left side of the inner wall of the exit door, were noticed by all the 32 participants. other places where displayed posters were noticed were the top of the window, beside the window, on the corridor just after the final staircase, etc. when the subjects were asked to find out the five most attractive posters, they identified those posters/banners 1st noticed by them. the 32 participants identified a total of 10 different posters to be the most attractive. all 32 participants mentioned three among them, the topic of those three being two on vaccination and one on breastfeeding, and all three contained a single big image as a central theme. after pile sorting by five interns, all the posters/banners were divided into three groups per topic: child health, including immunization; nutrition, including breastfeeding; miscellaneous, including personal hygiene & family planning. 4 out of 10 posters were related to child health, including immunization, four about nutrition & breastfeeding, and two about hand washing and personal hygiene (figure 1). figure 1. piles showing health education posters according to the topic discussed = cluster 1 contains posters on child health, including immunization = cluster 2 contains posters on nutrition and breastfeeding = cluster 3 contains miscellaneous posters like hygiene & family planning while sorting those as per the presentation of display material, three piles were found. the first pile contains those posters with single or very few big pictures with one or two lines of written message. this pile had 5 of 10 posters. the second pile contained more than three pictures with some writing in tabular or grid patterns. this group included four posters. a maumita de et al. (a qualitative study on effectiveness of displayed health education materials…) vol. 5, no. 1, 2023, pp. 1-10 6 10.26555/eshr.v5i1.6313 single poster was on the 3rd pile, which contained posters with only written messages with logos or graphics (figure 2). though in the first pile, people chose posters with english messages to be attractive, none of the posters in piles 2 or 3 contained any english messages, and all of the posters selected in these two piles were written in the local language. when the transcribed and translated interviews of the respondents were analyzed, it was found that only one poster was fully understood by 100 %. it is intended to teach the importance of vitamin a oil doses under the national immunization schedule (nis). a total of 6 posters were fully or partially understood by more than 80% of the respondents. there were three posters which, though found to be attractive but misunderstood by the participants. 2 of those posters were on hygiene, and one was thought to be talking about girl education. another poster on hand washing was interpreted as the supply of drinking water from the pipeline. the poster with no picture was correctly interpreted by those who could read bengali, but others did not understand anything about it. figure 2. piles showing health education posters according to the type of presentation = cluster 1 contains posters having a single big picture = cluster 2 contains posters having multiple small pictures with a message in the local language = cluster 3 includesa poster with no pictures and writing inthe local language discussion this study focused qualitatively on the perception of a specific group population about hems. previously some studies were conducted in developed countries like the uk, singapore, and france,6-8 but all of them took the general population as study subjects. they were either admitted or morbid patients waiting for doctor’s consultation in the general emergency room. on the other hand, we took a particular group of study subjects who were healthy mothers/caregivers of children attending routine immunization at a government medical college in west bengal, india. as they are apparently disease free, they may have ample stress-free time to look around the immunization room and check out the hems. but they hardly did so actively. maumita de et al. (a qualitative study on effectiveness of displayed health education materials…) vol. 5, no. 1, 2023, pp. 1-10 7 10.26555/eshr.v5i1.6313 when after the waiting time of 30 minutes, they were asked about three posters they had noticed during that period. they were primarily non-responsive. with extensive probing, most of them could only remember one poster precisely. only 5 (16.7%) respondents could remember three posters vaguely. this is much less than the previous studies conducted in the uk.6,9 whereas previous studies just enquired whether they had noticed a hem, we tried to pinpoint the placement of noticed posters to ensure whether they had noticed the posters or just gave a socially acceptable response. our study indicates that noticeability depends on the place of display of that poster. those posters displayed in and around the vaccination area are more noticeable than those in the corridor or waiting area. this, in turn, shows subjects noticed more posters in a relatively greater stressed environment when the child was getting vaccinated. maybe the mothers looked away from the child to avoid observing the injection procedure and noticed the hems nearby. all the other times, they were too preoccupied with their children to notice posters around. so, for immunization clinics, posters with the most important messages must be displayed around the vaccination area. to the best of our knowledge, no previous studies tried to pinpoint the importance of display position on the noticeability of posters elsewhere. then the subjects were passively exposed to all the posters and asked about their attractiveness of them. it is seen that most of the posters with child pictures or anything associated with children, like pictures of food-item, injections, and vaccine vials, were more attractive to them. this finding goes hand in hand with the study done in manchester uk,4 where adolescents found posters on smoking cessation and hiv-aids more attractive. so, it can be said that attractiveness depends on the subject’s mental state and priority areas at that time. when the designs of the posters were pile sorted, it was found that the most attractive posters had big single or two pictures with very minimal writing. posters with multiple small pictures followed this. so, all of these indicate that pictorial presentation of health education materials was more acceptable to subjects in our scenario. it differs from the uk study.9 here, researchers found that posters with a written message were more attractive. no foreign language poster was found in most uk study settings.6on the other hand, most of the posters were in english, followed by bengali, the local language. for many indians, especially from lower socio-economic strata, english is a foreign language they can’t read. some of our study subjects were hindi-speaking, too, as kolkata is a cosmopolitan metro city where people from different parts of india with varying tongues of mother reside temporarily. the language barrier may be one reason for choosing pictorial posters as attractive. whether the intended message was perceived by the subjects properly is another novel approach for this study. previous studies (uk, manchester)4,6 explored whether subjects read or remembered the message but whether they understood the actual meaning was not elicited. here it is seen the subjects correctly interpreted that very few posters, and in many cases, their understanding was vastly different from the actual message. language barriers, maumita de et al. (a qualitative study on effectiveness of displayed health education materials…) vol. 5, no. 1, 2023, pp. 1-10 8 10.26555/eshr.v5i1.6313 a relatively lower level of literacy status, and less attentiveness towards the hems may be the reasons behind this faulty understanding. a study conducted in louisiana, usa, concluded that comprehension of health education materials depends on the comprehension power of the subjects, and at least 6th-grade education is essential for understanding.10 the situation is more complicated in india as, unlike in the usa, here local language varies from state to state, and many literate persons are not very comfortable with english, let alone illiterate ones. unsurprisingly, our study found that posters with only the english language are the least attractive. so, the chance of comprehension of those posters is relatively less even for those with a lower formal education level. as the attendees of immunization clinic in the government setting of a developing country finds pictorial presentations more attractive, those pictures must be designed so that no alternate meaning is conveyed to that. otherwise, it may jeopardize the whole purpose of the display of hems. a malaysian study found that health education materials are more perceived when doctors discuss them.11 in our setting, it is difficult for the health care providers to explain the hems due to workload and scarcity of time. this may be another reason for the present study's poor perception of the posters. a recent study in the netherlands opined that there should be a strategy to ensure patients' understanding of diseases and more active use of hems, as many patients are still health illiterate.12 similar studies were conducted all over the world. all have opined that patients hardly want to be health literate, and their participation in health-related active decision-making is very low unless facilitated by healthcare providers, preferably doctors.13-16 health literacy is a major challenge in a developing country like india, and only displaying hems is not the solution. though difficult, the active participation of health care providers is essential in this regard. it should also be noted that in this era of audiovisual entertainment, visual hems have far less appeal than audiovisual media.17-19 previous studies have pointed out that health education in waiting rooms through television or projected animations or movies has better noticeability and comprehension than pamphlets and posters.20-21 so it is recommended that along with posters, there should be some provision for audiovisual teaching in the immunization clinic. it will breech the literacy barrier, and if given in the local language, it may have a far-reaching impact on subjects' health literacy. the limitation of the study was that it was carried out only among healthy caregivers of children attending immunization clinics. their relative stress-free condition may give us a better noticeability & understanding of hems. it may differ if conducted upon patients visiting outdoors or indoor hospital areas portraying hems. conclusion caregivers of children attending immunization clinics hardly notice hems actively. when they do, they notice posters behind or beside the vaccination table. mothers of vaccinated children found pictorial posters related to child pictures more attractive, and very few of them maumita de et al. (a qualitative study on effectiveness of displayed health education materials…) vol. 5, no. 1, 2023, pp. 1-10 9 10.26555/eshr.v5i1.6313 correctly understood the message conveyed through the posters. a more extensive study with a likert scale for both poster design and topic may give us further knowledge, which will help us to design and display more effective posters of health education materials in the future. acknowledgement we would like to express our heartfelt gratitude to the hospital authorities for their kind support during the research. we thank the participants for their patience and cooperation in completing the interview. declarations authors' contribution research design: sb, sm. data collection: md, sb, analysis: sb, manuscript preparation: md, sb funding statement this research has not received external funding. conflict of interest there is no conflict of interest in this research. references 1. tones k. health education: evidence of effectiveness. arch dis child. 1997 sep 1;77(3):189–91. 2. deo m. doctor population ratio for india the reality. indian j med res. 2013 apr 1;137:632–5. 3. preston ma, baranowski t, higginbotham jc. orchestrating the points of community intervention: enhancing the diffusion process. int q community health educ 1988 jan 1;9(1):11–34. 4. ward k, hawthorne k. do patients read health promotion posters in the waiting room? a study in one general practice. br j gen pract 1994 dec;44(389):583–5. 5. majhi m, bhatnagar n. updated b.g prasad’s classification for the year 2021: consideration for new base year 2016. j fam med prim care 2021;10(11):4318. 6. maskell k, mcdonald p, paudyal p. effectiveness of health education materials in general practice waiting rooms: a cross-sectional study. br j gen pract 2018 dec;68(677):e869–76. 7. see mta, chan wcs, huggan pj, tay yk, liaw sy. effectiveness of a patient education intervention in enhancing the self-efficacy of hospitalized patients to recognize and report acute deteriorating conditions. patient educ couns 2014 oct;97(1):122–7. maumita de et al. (a qualitative study on effectiveness of displayed health education materials…) vol. 5, no. 1, 2023, pp. 1-10 10 10.26555/eshr.v5i1.6313 8. gignon m, idris h, manaouil c, ganry o. the waiting room: vector for health education? the general practitioner’s point of view. bmc res notes [internet]. 2012 dec;5(1). available from: https://bmcresnotes.biomedcentral.com/articles/10.1186/1756-0500-5511 9. montazeri a, sajadian a. do women read poster displays on breast cancer in waiting rooms? j public health[internet]. 2004 dec 1[cited 2022 july 24];26(4):355–8. 10. davis tc, crouch ma, wills g, miller s, abdehou dm. the gap between patient reading comprehension and the readability of patient education materials. j fam pract 1990 nov;31(5):533-8. pmid: 2230677. 11. jaafar n, perialathan k, zulkepli mz, mohd zin z, jonoi pe, johari mz. patients’ perception towards health education services received at the enhanced primary healthcare facilities: a qualitative exploration. j prim care community health 2020 jan;11:215013272098062. 12. murugesu l, heijmans m, rademakers j, fransen mp. challenges and solutions in communication with patients with low health literacy: perspectives of healthcare providers. plos one 2022 may 4;17(5): e0267782. doi: 10.1371/journal.pone.0267782. pmid: 35507632; pmcid: pmc9067671. 13. ousseine ym, durand ma, bouhnik ad, smith ab, mancini j. multiple health literacy dimensions are associated with physicians’ efforts to achieve shared decision-making. patient education and counseling. 2019. doi: 10.1016/j.pec.2019.05.015 . 14. elwyn g, frosch d, thomson r, joseph-williams n, lloyd a, kinnersley p, et al. shared decision making: a model for clinical practice. j gen intern med. 2012;27(10):1361–7. 15. légaré f, witteman ho. shared decision making: examining key elements and barriers to adoption into routine clinical practice. health affairs 2013;32(2):276–84. doi: 10.1377/hlthaff.2012.1078 16. vennedey v, hower ki, hillen h, ansmann l, kuntz l, stock s. patients’ perspectives of facilitators and barriers to patient-centred care: insights from qualitative patient interviews. bmj open 2020;10(5), e033449. doi: 10.1136/bmjopen-2019-033449 17. wicke dm, lorge re, coppin rj, jones kp. the effectiveness of waiting room noticeboards as a vehicle for health education. fam pract 1994; 11(3): 292–295. 18. shah a, scogin f, pierpaoli cm. older adults’ attitudes toward depression screening in primary care settings and exploring a brief educational pamphlet. int j geriatr psychiatry 2018; 33(1): e40–e48. 19. jawad m, ingram s, choudhury i, et al. television-based health promotion in general practice waiting rooms in london: a cross-sectional study evaluating patients’ knowledge and intentions to access dental services. bmc oral health 2016; 17(1): 24. 20. eubelen c, brendel f, belche jl, et al. effect of an audiovisual message for tetanus booster vaccination broadcast in the waiting room. bmc fam pract 2011; 12: 104. 21. koperski m. health education using video recordings in a general practice waiting area: an evaluation. j r coll gen pract 1989; 39(325): 328–330. epidemiology and society health review| eshr vol. 3, no. 1, 2021, pp. 28-35 issn 2656-6052 (online) | 2656-1107 (print) 10.26555/eshr.v3i1.3629 28 research article spatial analysis of tuberculosis, population and housing density in yogyakarta muthia ardiyanti 1,*, sulistyawati 1, yudha puratmaja 2 1 faculty of public health, universitas ahmad dahlan, yogyakarta, indonesia 2 master of public health, faculty of public health, khon kaen university, khon kaen, thailand * correspondence: muthia1600029089@webmail.uad.ac.id. phone: +6282328817403 received 05 february 2021; accepted 04 march 2021; published 05 march 2021 abstract background: tuberculosis (tb) is an infectious disease that becomes a health problem globally, including in indonesia. yogyakarta city is a district that struggle with tb; from 20172018, there was an increase of tb case in this city. there was limited evidence concerning tb and its possible risk factors among tb case 2017-2018, mainly using gis in yogyakarta. method: this study used an ecological study design to determine the correlation between population and housing density with tb incidence in yogyakarta city in 2017-2018. secondary data was obtained from the yogyakarta city health profile 2018-2019. spearman rank correlation test and spatial analysis using quantum gis software were employed to analyse the data. results: there was a relationship between tb and population density variables (p-value = 0.034; r = -0.568) and housing density (p-value = 0.012; r = -0.625) in yogyakarta, 20172018. conclusion: this study indicates that the density of housings and population affect the prevalence of tuberculosis. keywords: population density; housing density; spatial analysis; tuberculosis introduction tuberculosis (tb) is one of the top 10 infectious diseases a significant health problem globally. most tb bacteria attack the lungs but can also attack other organs. the transmission occurred through the air when a person with pulmonary tb coughs, sneezes, talks, or spits up. most of the tb cases occurred in southeast asia (44%), africa (24%), and the western pacific (18%). globally, indonesia is the third rank of tb case after india and china (1). yogyakarta special region (diy) is one of the provinces that still have tb problems. in 2017, diy reported the total number of tb cases as many as 2,785 cases and increased in 2018; there were 3,237 tb cases in 2018 (2). yogyakarta city is part of the diy province, which still struggles to combat tb. in 2017, the number of tb cases in yogyakarta city was 551 cases, https://doi.org/10.26555/eshr.v3i1.3629 http://creativecommons.org/licenses/by-sa/4.0/ http://crossmark.crossref.org/dialog/?doi=10.26555/eshr.v3i1.3629&domain=pdf ardiyanti (spatial analysis of tuberculosis, population and housing density in yogyakarta) vol. 3, no. 1, 2021, pp. 28-35 29 10.26555/eshr.v3i1.3629 29 of which 253 were confirmed as new cases (3). in 2018, the number of tb cases in yogyakarta city had increased. according to the yogyakarta city health profile in 2019, the highest number of tb cases was in the umbulharjo i health center with 74 cases of all tb cases, while those confirmed with positive smear tb were 41 cases (4). with an area of 32.50 km2, the city of yogyakarta's population density in 2018 was 12,703 people / km2. the densest area is in the gondomanan sub-district, 37,866 people / km2, and the lowest population density is in the kotagede sub-district with 6,038 people / km2. the housing density in yogyakarta city in 2018 was 3,113 units/km2. the densest housing is in the gedongtengen sub-district with 5,757 units/km², and the lowest housing density is in the umbulharjo sub-district with 1,868 units / km² (4). population density affects tb incidence because it increases the possibility of contact with tb sufferers (5). apart from population density, housing density can also affect the spread of tb disease because it is related to poor sanitation, slum places, lots of garbage if it not well maintained. home is a place to grow and develop both physically, spiritually, and socially. the situation of the housing environment affects the health environment (6). according to nafsi, who overviewed the spatial analysis of tb incidence based on housing density, all pulmonary tb cases were found in high housing density areas (7). every region has a different risk factor for tb disease. a spatial analysis approach is needed to help analyse risk factors, especially those related to geographic conditions, to develop the control measures (8). in the health sector, gis can produce a spatial picture of health events, analyse the relationship between locations and the environment and disease incidence. based on the existing environmental conditions, gis can also stratify risk factors for disease (9). this research aimed to perform spatial analysis with the geographic information system (gis) and risk factor analysis of population and housing density versus tuberculosis (tb) in yogyakarta city in 2017-2018. method we used a quantitative study using an ecological study design with a geographic information system (gis) approach. this research was conducted in yogyakarta july 2020 by including independent variables: population and housing density; the dependent variable is tb incidence. this study's population and the sample had an aggregate number of tb cases in yogyakarta city in 2017-2018 per sub-district. data were collected from yogyakarta city health profile 2018-2019: tb cases, population density, housing density. the analysis was performed in three steps: (1) univariate analysis, to determine the statistical distribution of each variable, including the independent variables (population density and housing density) and the dependent variable (tb incidence); (2) bivariate analysis, used to see the correlation of the independent variables (population density, housing density) with the dependent variable (tb incidence) by using an alternative test of pearson's correlation, namely the spearman rank test (3) spatial analysis using quantum gis to produce map depicting the spatial relationship of the independent variables (population density and housing density) with the dependent variable (tb incidence). https://doi.org/10.26555/eshr.v3i1.3629 ardiyanti (spatial analysis of tuberculosis, population and housing density in yogyakarta) vol. 3, no. 1, 2021, pp. 28-35 30 10.26555/eshr.v3i1.3629 30 results there were 551 and 564 tb cases in yogyakarta city during 2017 and 2018, respectively, that spread into 14 sub-districts. in 2017, the highest tb incidence was in the umbulharjo subdistrict with 89 cases and the lowest in pakualaman sub-district with 4 cases. in 2018, the highest tb incidence occurred in the umbulharjo sub-district with 110 cases and the lowest in pakualaman sub-district with 11 cases (table 1). table 1. number of tuberculosis incidents in yogyakarta city in 2017-2018 sub-district number of cases (person) population density (people / km2) housing density (units / km²) 2017 2018 2017 2018 2017 2018 n % n % n % n % n % n % danurejan 35 6 31 5 19255 9 33703 14 3661 8 3661 8 gondokusuman 55 10 59 10 10598 5 6785 3 1917 4 1917 4 gondomanan 22 4 30 5 13437 6 37866 16 2809 6 2811 6 gedongtengen 32 6 34 6 21289 10 22340 9 5757 13 5757 13 jetis 47 9 43 8 16068 8 11692 5 3270 8 3270 8 kotagede 27 5 34 6 10978 5 6036 3 2364 5 2364 5 kraton 34 6 40 7 15749 7 19940 8 2604 6 2604 6 stimulating 41 7 38 7 13897 7 15284 6 2583 6 2583 6 mantrijeron 45 8 31 5 13541 6 8408 4 3129 7 3129 7 look 34 6 25 4 22704 11 18295 8 4173 10 4173 10 nails 4 1 11 2 17121 8 17130 7 4806 11 4806 11 tegalrejo 45 8 43 8 12709 6 11022 5 2155 5 2155 5 umbulharjo 89 16 110 20 8542 4 8565 4 1868 4 1868 4 wirobrajan 41 7 35 6 15861 7 19297 8 2489 6 2489 6 in 2017, the highest population density was in the ngampilan sub-district with 22,704 people / km², and the lowest was in umbulharjo sub-district with 8,542 people / km². in 2018, the highest population density was in the gondomanan sub-district of 37,866 people / km², and the lowest was in the kotagede sub-district of 6,036 people / km² (table 1). gedontengen subdistrict was ranked as the highest housing density of 5,757 units / km², and the lowest was in the gondokusuman sub-district of 1,917 units / km² (table 1). bivariate analysis of population density and tb incidence in yogyakarta city in 2017-2018, obtained r = 0.568 and p-value = 0.034. there was a significant relationship between population density and tb with a p-value ˂ 0.05. the statistical test showed that the relationship between population density and tb incidence has a strong relationship (r = 0.510.75) and has a negative direction where the lower the population density, the higher the tb incidence. there was a significant relationship between housing density and tb incidence in yogyakarta city in 2017-2018 (p ˂ 0.05) r = 0.652. the statistical tests showed that the relationship between housing density and tb incidence had a strong relationship (r = 0.510.75) and had a negative pattern where the lower the housing density, the higher the tb incidence (table 2). https://doi.org/10.26555/eshr.v3i1.3629 ardiyanti (spatial analysis of tuberculosis, population and housing density in yogyakarta) vol. 3, no. 1, 2021, pp. 28-35 31 10.26555/eshr.v3i1.3629 31 table 2. bivariate analysis between tb risk factors for tb incidence variable r p-value population density 0.568 0.034 housing density 0.652 0.012 figure 1 shows the distribution of tb incidence tends to the distribution of population density inversely. the high incidence of tb tends in areas with low to moderate population densities. areas with low population density have a higher incidence of tb than regions with high population densities; for example, the umbulharjo sub-district has a low population density but has a high tb incidence. figure 1. map of population density vs the number of tb incidence in yogyakarta city 2017-2018 per sub-district based on figure 2, the distribution of tb incidence tends not to follow housing density distribution. the high incidence of tb tends to be in areas with low to moderate housing https://doi.org/10.26555/eshr.v3i1.3629 ardiyanti (spatial analysis of tuberculosis, population and housing density in yogyakarta) vol. 3, no. 1, 2021, pp. 28-35 32 10.26555/eshr.v3i1.3629 32 densities. areas with low housing densities have a higher incidence of tb than regions with high housing densities, such as umbulharjo sub-district has a low housing density but has a high incidence of tb. figure 2. housing density map vs the number of tb incidence in yogyakarta city 2017-2018 per sub-district discussion there was a statistically significant relationship between population density and tb incidence in yogyakarta city in 2017-2018 (p-value ˂ 0.05). the spatial analysis shows that the https://doi.org/10.26555/eshr.v3i1.3629 ardiyanti (spatial analysis of tuberculosis, population and housing density in yogyakarta) vol. 3, no. 1, 2021, pp. 28-35 33 10.26555/eshr.v3i1.3629 33 distribution of tb incidence in yogyakarta city tends to distribute population density inversely. wulandari, in her research, shows different results from this study there is a significant relationship between population density and new cases of pulmonary tb afb (+) in south jakarta in 2006-2010 with p = 0.000, where an increase in population density is followed by the rise in tb cases (5). our result is different from achmad's research, which found no correlation between population density and the number of smear-positive pulmonary tb cases in south jakarta in 2007-2009 with a p-value = 0.116 (10). the same finding found in other parts of indonesia, which stated that there is no significant relationship between population density and the proportion of positive smear pulmonary tb in kota pariaman (p-value = 0.551), bukittinggi (p-value = 0.140) and dumai (p-value = 0.993) (11). some factors trigger a disease occurrence (12). following the research conducted by hastuti, ahmad and ibrahim in kendari city, there was no significant difference between high population density and low population density and tb positive smear in kendari city (13). we found a relationship between population density and tb incidence, where the lower the population density, the higher the tb incidence. spatially, the population density is not related to the tb incidence because the tb incidence does not follow the population density distribution. this finding can be seen in the umbulharjo sub-district with the lowest population density among 14 sub-districts, namely 8,565 people / km², but has the highest tb incidents. accordingly, the spatial pattern of population density does not affect the incidence of tb. therefore, predicted other factors influence the increase in the number of tb cases in the umbulharjo sub-district, such as nutritional status, socioeconomic conditions, housing’s occupancy, the housing floor's condition, and ventilation, lighting, humidity, and altitude. according to utami, ventilation is a risk factor for tb in the working area of the umbulharjo i health centre; respondents who live in housing with poor ventilation are estimated to be 7.563 times more at risk of tb incidence compared to those who live in a large housing with proper ventilation (14). another thing that proves that population density is not the only risk factor contributing to tb incidence is that gedongtengen and danurejan sub-districts have relatively high population densities. still, an increase does not follow this in the number of tb incidents. according to dotulong, sapulete and kandou (15), age and sex are also risk factors for tb; a productive age and male are more susceptible to pulmonary tb. however, this study is not following the existing theory, where a densely populated area will undoubtedly cause disease transmission with a more complex chain of spread, especially in airborne diseases such as tuberculosis. regarding the housing density, there is a statistically significant relationship between housing density and tb incidence in yogyakarta city in 2017-2018 (p-value ˂ 0.05). spatial analysis shows that the distribution of tb incidence in yogyakarta city tends the housing density distribution inversely. umbulharjo sub-district has a low housing density but with high tb cases. the study results in wonosobo, central java, showed the same results as this study: there was a significant relationship between housing density and tb incidence. pratiwi, pramono and junaedi mentioned that someone who lives in an area with a high density of housings has 5 times higher risk of being exposed to tb than those who live in a low density (16). this shows that the density of housings affects tb incidence because dense environments may also have poor sanitation, slum areas, lots of garbage, and poorly maintained grounds, especially in developing countries (6). https://doi.org/10.26555/eshr.v3i1.3629 ardiyanti (spatial analysis of tuberculosis, population and housing density in yogyakarta) vol. 3, no. 1, 2021, pp. 28-35 34 10.26555/eshr.v3i1.3629 34 we found that there was a statistically significant relationship between housing density and tb incidence but in a negative direction the lower the housing density, the higher the tb incidence, and spatially the tb incidence did not follow the distribution of housing density the lowest housing density had the highest number of cases. umbulharjo sub-district has the lowest housing density (1,868 units / km²) but has a high tb incidence. this shows that the density of housings does not have a direct effect on the incidence of tb. the needs for housing in the city of yogyakarta is increasing in recent years. in yogyakarta city, it was reported there were 3,304 housing is not habitable, unhealthy for habitation, spread unevenly in all sub-districts and villages. housing not feasible for a living is considered slum areas caused by high-density settlements' environmental factors and the buildings' physical condition (17). the condition of the home environment has a close relationship with disease transmission, including tb. one of the housing conditions that can allow tb transmission is the density of occupancy. according to utami, the housing density is a risk factor for tb incidence in the umbulharjo community health center's working area. respondents who live in high occupancy homes that do not meet the as healthy housing are estimated to be 4.375 times more likely to be at risk of tb incidence than those who live in homes with low occupancy that meet healthy housing (14). thus, it is necessary to increase environmental-based tb control programs and healthy living behaviours. the role of sanitarians or environmental health workers is needed to prevent and eradicate tb disease by creating a healthy environment and healthy living habits, especially improvements in the sufferer and people living in areas with high housing densities and an increased number of tb cases. increase education about healthy homes. besides, tb control can be done by immunisation to boost immunity. immunisation coverage is essential because it can prevent disease. conclusion the spatial analysis results show no relationship between population density and housing density on the incidence of tb in yogyakarta city in 2017-2018. in contrast, the statistical analysis results show a significant relationship between population density and housing density on the incidence of tb with p <0.05 during 2017-2018 in yogyakarta city. authors' contribution ma was responsible for the design, data collection, analysis, and drafting of the manuscript. ss and yp were responsible for the design and analysis, and review of the manuscript. funding this research has not received external funding. conflict of interest there is no conflict of interest in this research. references 1. who. global tuberkulosis report. 2019. https://doi.org/10.26555/eshr.v3i1.3629 ardiyanti (spatial analysis of tuberculosis, population and housing density in yogyakarta) vol. 3, no. 1, 2021, pp. 28-35 35 10.26555/eshr.v3i1.3629 35 2. dinkes provinsi diy. profil kesehatan provinsi daerah istimewa yogyakarta tahun 2018. yogyakarta: dinas kesehatan provinsi diy; 2019. 3. dinkes kota yogyakarta. profil kesehatan tahun 2018 kota yogyakarta (data tahun 2017). yogyakarta: dinas kesehatan kota yogyakarta; 2018. 4. dinkes kota yogyakarta. profil kesehatan tahun 2019 kota yogyakarta (data tahun 2018). vol. 107. yogyakarta: dinas kesehatan kota yogyakarta; 2019. 107–126 p. 5. wulandari f. analisis spasial tuberkulosis paru bta (+) di jakarta selatan tahun 20062010. universitas indonesia; 2012. 6. aditama rt, suharyo. analisis distribusi dan faktor risiko tuberkulosis paru melalui pemetaan berdasarkan wilayah di puskesmas candilama semarang triwulan terakhir tahun 2012. j dunia kesehat. 2012;7(6):1–25. 7. nafsi ay. analisis spasial tuberkulosis paru ditinjau dari faktor demografi dan tingkat kesejahteraan keluarga di wilayah pesisir. universitas negeri semarang; 2019. 8. nurbeti m, kusnanto h, nugroho ws. analisis spasial kasus leptospirosis di perbatasan kabupaten bantul, sleman, dan kulon progo. j kesehat masy. 2016;10(1):1–10. 9. wulandari sa. analisis spasial aspek kesehatan lingkungan dengan kejadian filariasis di kota pekalongan. universitas negeri semarang; 2009. 10. achmad f. analisis spasial penyakit tuberkulosis paru bta positif di kota administrasi jakarta selatan tahun 2007-2009. universitas indonesia; 2010. 11. haq a, achmadi uf, susanna d. analisis spasial (topografi) tuberkulosis paru di kota pariaman, bukittinggi, dan dumai tahun 2010-2016. j ekol kesehat. 2019;18(3):149–58. 12. hadisaputro s, nizar m, suwandono a. epidemiologi manajerial teori dan aplikasi. semarang: badan penerbit universitas diponegoro; 2011. 13. hastuti t, ahmad lo, ibrahim k. analisis spasial, korelasi dan tren kasus tb paru bta positif menggunakan web sistem informasi geografis di kota kendari tahun 2013-2015. j chem inf model. 2013;53(9):1689–99. 14. utami r. hubungan kondisi fisik rumah dan riwayat penyakit penyerta dengan kejadian tuberkulosis (tb) bta positif di wilayah kerja puskesmas umbulharjo i, kota yogyakarta. unoversitas ahmad dahlan; 2018. 15. dotulong jfj, sapulete mr, kandou gd. hubungan faktor risiko umur, jenis kelamin dan kepadatan hunian dengan kejadian penyakit tb paru di desa wori kecamatan wori. j kedokt komunitas dan trop. 2015;3(2):57–65. 16. pratiwi rd, pramono d, junaedi j. socio-economic and environmental risk factors of tuberculosis in wonosobo, central java, indonesia. j kesehat masy. 2020;16(1):61–70. 17. ritohardoyo s, sadali i. kesesuaian keberadaan rumah tidak layak huni (rtlh) terhadap tata ruang wilayah kota yogyakarta. tata loka. 2017;19(4):291–305. https://doi.org/10.26555/eshr.v3i1.3629 microsoft word desi mendeley.docx epidemiology and society health review| eshr vol 1 no1 2019 41 research article evaluation of smoke-free area declaration program to establish a healthy city desi nurfita1*, rokhmayanti rokhmayanti1, helfi agustin1, sandheep sugathan2 1department of public health, universitas ahmad dahlan, yogyakarta, indonesia 2faculty of medicine, quest international university perak, malaysia *correspondence: desi.nurfita@ikm.uad.ac.id. telp,: +6282191350472 received 07 august 2019; accepted 09 september 2019; published 09 september 2019 abstract background: indonesia is experiencing a major health challenge, that is triple burden diseases (communicable diseases, non-communicable diseases, and reemerging diseases). one of the programs established by the government to face the threat is healthy lifestyle community movement (gerakan masyarakat hidup sehat or germas). the declaration of the smoke-free area is one of the efforts of the government on this movement aimed to have smoke-free homes to create a healthy city. however, the monitoring and evaluation of the program do not run well. the goal of this research is to provide a description and analysis of the implementation of the smoke-free area declaration program. methods: this was a qualitative research. the subjects or main informants of this study were the people in charge of smoke-free area declaration program and the head of the clinic at puskesmas gondokusuman 2. the supporting informants in this study were the community declaring the program as well as the elite figures of the community involved in the declaration. the method of primary data collection was through in-depth interviews, observation, and review documentation. the implemented analysis technique was content analysis. results: the inputs of the smoke-free area declaration program were measured from the human resources, fund, facilities, organization, information, and guidelines. further, the process of the smoke-free area declaration was viewed from the community roles, community responses, and reports. however, there was a shortcoming of the process variable, i.e. the in-existence of written reports done by the head of the program. furthermore, the output variables were observed from the commitments, impacts on society, and the comprehensiveness of the reports. conclusions: based on the analysis, the inputs of the program were considered as well. the outputs of the program were considered to be positive. keywords: evaluation, smoke-free area, healthy city epidemiology and society health review| eshr vol 1 no1 2019 42 introduction indonesia is in the middle of a major health challenge known as triple burden of disease (infectious diseases, non-communicable diseases, and controlled diseases making a comeback). in 1990, contagious diseases, such as infeksi saluran pernapasan akut (ispa), tuberculosis, and diarrhea, were the most common ones found in health facilities. however, the change of lifestyle caused the changing pattern of disease (epidemiological transition). in 2015, non-communicable diseases, such as stroke, coronary heart diseases (chd), cancer, and diabetes, ranked highest(1). there have been efforts to control and prevent the diseases to reduce the number of cases and mortality rate. the goal is to create an optimum healthy community. one of the programs established by the government is healthy lifestyle community movement (gerakan masyarakat hidup sehat (germas))(2). germas is a planned and systematic effort involving all members of community with awareness, willingness, and ability to live healthily and improve their quality of life. it starts at families since family is the smallest part of a community which helps to form one’s personality. the program involves having regular physical exercises, consuming fruit and vegetables, not smoking, not consuming alcohol, having regular health check-ups, participating in environment cleaning activities, and using toilets(1). the city government of yogyakarta supports germas by establishing mayor regulation no 373 year 2017 on the empowerment system of alert kelurahan in relation to healthy lifestyle community movement. one of the ways to support the movement is through the declaration of smoke-free area. the aim is to have freesmoke houses so that a healthy city is created (3). at first, the smoke-free area declaration program was conducted by the district health office of yogyakarta and gadjah mada university (ugm). however, later ugm decided not to be involved in the program, therefore, afterwards, the yogyakarta district health office handled the program alone. the written declaration was done at the level of neighbourhood groups (rt). however, up to the present moment, the monitoring and evaluation of the program did not run well. based on an interview with the person in charge of smoke-free area declaration program at puskesmas gondokusuman 2, it was found that there were not any appropriate instruments to monitor and evaluate the program. through the course of time, the program ran, and the report was done through direct report from each cadre to the health clinic staff. based on those descriptions, the researchers were interested to conduct a research on the evaluation of smoke-free area declaration program at puskesmas gondokusuman 2. epidemiology and society health review| eshr vol 1 no1 2019 43 methods study design this research used qualitative methods. setting the study was conducted in puskesmas gondokusuman 2. data source and data collection the method of primary data collection was through in-depth interviews, observation, and review documentation. sample population the key informant of this study was the person in charge of the smoke-free area declaration program at puskesmas gondokusuman 2. meanwhile, the triangulation informants were the elite figures of the community involved in the declaration, as well as community representatives directly involved in the programs of puskesmas gondokusuman 2. analysis the researcher evaluates the implementation of smoke-free programs using an evaluation system, discusses management programs through analysis of inputs, processes, and outputs. the input component discusses the main and core resources such as labor, funds, facilities, organizations, information and guidance. the process component is seen from the management program carefully monitored from how the community in gondokusuman 2 health center formulates the performance seen from the planning process, implement and support programs by selecting indicators and targets, collecting data, analysing the data and giving feedback. the output component illustrates the performance of the quality achievement program in accordance with the achievement of the program targets against the indicator. findings and discussions the city of yogyakarhas declared smoke-free area. puskemas gondokusuman 2 is one among many community health clinics in yogyakarta committed to conducting smoke-free area program. the smoke-free area program was formed based on city of yogyakarta regulation number 2 year 2017. the commitment was set forth in the declaration of smoke-free areas. contents of the declaration of smoke-free areas in gondokusuman ii health center are 1) no smoking in the house, 2) do not provide ashtrays in the house 3) no smoking in community meetings, 4) do not throw cigarette butts in any place, 5) do not smoke in front of babies, toddlers and pregnant women, 6) may not order small children to buy cigarettes. epidemiology and society health review| eshr vol 1 no1 2019 44 the researchers in this study conducted an evaluation of the program by using system approach. the approach consisted of three parts, namely input, process, and output. the components of the input were the availability of main and fundamental resources, i.e. human resources, fund, facilities, organization, information, and guidelines. 1. input a. human resources based on interviews to informants, the information on human resources involved in smoke-free area was obtained, i.e. the district health office of yogyakarta (health promotion programmer), head of pkk (family welfare establishment program), heads of sub-districts, heads of villages, community groups (rw), neighbourhood groups (rt) and community members. the program was regulated by the mayor regulation no 2 year 2017. it regulateed the parties required to be involved in the program in relation to the field of health, regional work units, and community participation(4). the regional work unit conducting health matters was the district health office of yogyakarta and community health clinics. in addition, the involved regional work units were head of pkk, heads of sub-districts, heads of villages, community groups (rw), and neighbourhood groups (rt). all parties worked together in the program. meanwhile, community participation means the direct involvement of the community members in the program. the participation was observed through the implementation of smoke-free area declaration in kelurahan (village) terban and kotabaru. all parties have their own responsibilities and duties. regional work units focusing on health matters have the responsibility to determine the smokefree area(5) the health units are the district health office of yogyakarta and puskesmas gondomanan 2. both act as the founder and organizer of smokefree area arrangement. it is in line with the mayor regulation no 2 year 2017. regional work units were responsible to do a follow-up on the determination of smoke-free area. the work units were the head of pkk, heads of subdistricts, heads of villages, community groups (rw), and neighborhood groups (rt). head of the pkk, heads of sub-districts, and heads of villages supported the program through their participation in the signing of an agreement on smoke-free area. community groups (rw) and neighborhood groups (rt) had the roles in program implementation. the head of community groups was assigned as the leader of the program in the area and therefore holds responsibilities for the program. it is in line with the mayor regulation no 2 year 2017. however, the evaluation of each community group has not been done yet. regional work units conducted follow-ups on the arrangement of smoke-free area by collecting data and information on the smoke-free area, providing education on the dangers of cigarette to the community, conducting awareness programs on the laws and regulations related to smoke-free area, epidemiology and society health review| eshr vol 1 no1 2019 45 observing and evaluating the smoke-free area program implementation, and conducting assistance and observation in the smoke-free area(4). b. funding the declaration of smoke-free area relies on three main sources of funding, i.e. the fund of the district health office of yogyakarta, puskesmas gondokusuman, and community donation. the fund from the health district office was rp. 960,000 (rp. 8,000 x 120). it was aimed to pay for the refreshments during the declaration. the fund from the health clinic was taken from the operational aid for health program (bantuan operasional kesehatan (bok)). it was given once to community groups. the total amount was rp. 1,800,000 (rp. 18,000 x 100 persons). it was expected that after the two funds were given, the community was willing to donate if the given fund was insufficient. such donation was commonly taken from the treasury of the community. the first step that the district health office as the initiator of smoke-free area program has to do was developing the conceptual framework and technical materials of smoke-free area. afterwards, the office advocated the decision makers, either the internal parties of health sector or legislative parties, to obtain support on policies, fund, and facilities(6). the results of this study are in accordance with the non-smoking regional guidelines of the ministry of health. non-smoking areas at the rw level are not only provided with funds, but the community also demands self-financing. the findings of this study are also in line with the guidelines of smoke-free area of the ministry of health. the smoke-free area at community groups is supported with some fund as well as some donation from the community. it encourages the community to independently fund this smoke-free area program. the results of nizwardi's study (2013) suggested that the funds available for the implementation of non-smoking areas in the city of padang panjang and payakumbuh were sufficient and was not a problem in the implementation of non-smoking areas. the source of the funds came from the regional budget and cigarette excise. even though it is not comparable to a puskesmas, in three regencies/cities, the funds provided were quite large, namely in the city of padang, amounting to rp.85,000,000.00 from cigarette excise for socialization activities, dialogues on smoking-free areas on television and increasing banners and leaflets. in city of padang panjang, the availability of funds for the implementation of smoking-free areas were as much as rp. 75,000,000.00 from cigarette excise and rp. 24,000,000 which were used for monitoring and evaluation, supervision of government institutions such as hospitals, the district health office, puskesmas, government education institutions, and offices as well as socialization. while in payakumbuh the funds available for the implementation of the non-smoking area amounted to rp341,278,129.00 (7). c. facilities epidemiology and society health review| eshr vol 1 no1 2019 46 based on the indonesian ministry of health guidebook related to smoke-free area facilities which are indicators, among others, there are media promotions about smoking bans / smoke-free areas(6). the district health office of yogyakarta and puskesmas gondokusuman 2 provide facilities to support the declaration of smoke-free area program. some of the facilities are the media to publicize and urge the community on the program. a petition on the declaration of smoke-free area is also provided for all the involved community members to sign. based on the guidelines provided by the indonesian ministry of health on smoke-free area, the required facilities are the promotion media on smoking restrictions/smoke-free area(6). it is provided and facilitated by puskesmas gondokusuman 2 and the district health office of yogyakarta. the role of the district health office of yogyakarta as the provider of facilities for this promotion is to spend substantial funds, as stated by nizwardi (2013) that the use of television promotion media for socialization, increasing banners and printed leaflets. thus, the production of promotional facilities is not the responsibility of the puskesmas. the role of the puskesmas is only as a mediator in the distribution to the community(7). other than promotion media on health, smoking rooms should also be provided(6). it was found that puskesmas gondokusuman 2 has not provided such rooms yet. based on interviews with some community members, it was revealed that they commonly smoke in certain designated-areas, such as river banks or cemetery area. it indicates that although smoking rooms are not provided yet, the community members are aware to smoke only in the designated-areas. the research is slightly different from wati's (2014) research on the application of non-smoking areas in metro city, at the metro city health office and the city planning and environment agency, specifically for smokers to encourage the operation of smoke-free areas quite well(8). d. organization the declaration of smoke-free area was conducted at each community group (rw). each would have its own committee involving the head of the community group, the secretary, the treasurer, and any other parties (adapted to the need of each rw and community). the committee is responsible to conduct the smoke-free area program and educate community members. the guideline book of ministry of health on smoke-free area does not specify and require the community to form an organization in smoke-free areas(6). nevertheless, the community had the initiative to form the committee. in addition, community members are expected to actively participate in succeeding the program of smoke-free area. furthermore, the committee helped to coordinate all activities related to smoke-free area program. e. information some awareness raising programs were conducted by the district health office of yogyakarta and puskesmas gondokusuman 2. furthermore, the information media was in the written form. the distribution of information on epidemiology and society health review| eshr vol 1 no1 2019 47 smoke-free area was done by using many different methods and media in many different opportunities. the aim was to make all members of the community aware of this program and willing to actively participate, either as the observer or supervisor of smokers and non-smokers by giving necessary punishment as required(6). f. guidelines the guideline of the smoke-free area is mayor regulation no 2 year 2017. it was issued by the mayor of yogyakarta. it regulates smoke-free area. according to juanita (2012), the attraction of interest in setting cigarette policies at the central level needs to be addressed by the government by making local policies. the ban on smoking in public space at the local level can affect people's perceptions of the norm of smoking in the community. the guidelines issued by the mayor of yogyakarta answered the results of research conducted by juanita(9). 2. process the indicator of smoke-free area is seen from the existence of staff obliged to observe smoke-free area in all vicinities. the vicinities are such as public health facilities, schools, playgrounds, places of worship, public transportations, offices, and public places(6). in this study, it was found that the program was conducted in each community group (rw). however, only some vicinity was involved in the smoke-free area of puskesmas gondokusuman 2. in relation to this regulation, community members’ participation is needed. such participation can be done by: a. sharing suggestions, opinions, and considerations related to the observation and implementation of smoke-free area policy. b. providing guidance and assistance as well as sharing information on smokefree area. c. declaring smoke-free area at home and the living environment. d. reminding everyone not to break the restrictions of smoking, producing, selling, advertising, or promoting cigarettes at smoke-free areas. e. reporting every incident of infringements on smoking, producing, selling, advertising, and promoting cigarette restriction at smoke-free areas to the administrator, head, the person in charge of the smoke-free area program, as well as related regional work units. according to the ministry of health ri, smoke-free area process is as follows: a. meeting of initiator team initiator team regularly conducts meeting to discuss many different things related to smoke-free area arrangement, such as the plans and regulations. b. establishment of smoke-free area it is done by the high-ranking officials and attended by all involved parties on the determination of smoke-free area. the team prepares implementation and technical guidelines as well as the publication materials so that the program can be started. c. post-establishment publication epidemiology and society health review| eshr vol 1 no1 2019 48 distribution of information on smoke-free area is done using many different methods and media in many different opportunities. thus, all parties are able to implement the program; either as the observer or supervisor of smokers and non-smokers by giving necessary punishment as required. the socialization was carried out by the district health office and puskesmas gondokusuman 2. media information includes printed media. and residents are used as education for other residents. dissemination of information and dissemination of non-smoking areas are carried out by using various methods and media on various opportunities that exist so that the implementation of non-smoking areas can be known and implemented by all parties, both observer andsupervisors of smokers and non-smokers by applying sanctions according to the law applied. 3. evaluation assessment of the implementation of smoke-free area includes observing and erecting regulations on smoke-free area. the evaluation is done using determined indicators. when compared with mayor regulation no 2 year 2017, some things have not been implemented, among others, have not yet been evaluated in each community group (rw). ideally, the assessment is not only the responsibility of the community group (rw), but is the responsibility of all regional offices, such as the involved regional work units which was head of pkk, the village head and the sub-district head. 4. output and outcome the output of the non-smoking area program is in the form of commitment documents signed by community members and all parties involved. commitment to the declaration of smoke-free areas was held at the community group (rw) level. the puskesmas had reported the number of community groups (rw) that had carried out the declaration to the district health office in yogyakarta, accompanied by proof of declaration. there were 10 community groups (rw) that had carried out the declaration of smoke-free areas in terban village and 2 community groups (rw) in kota baru village. there were 4 community groups (rw) in terban and kota baru that had not implemented the declaration of smoke-free areas. in addition, the community benefits from the declaration of smoke-free areas. the benefits felt by the community include: people became aware of the dangers of smoking, people became more ethical when smoking, and some people also stopped smoking. opposing this research which focuses more on smoke-free offerings at the household level, the findings of hamdan, et al. (2015) recommended that children in schools need to be vigilant even though the area is free cigarette smoke has been running, because it turns out that children are quite easily affected when exposed to cigarette advertisements by the media, especially television. according to hamdan, the regulation of non-smoking areas is still weak, and there is no clear sanction regulation regarding the restrictions on the age of cigarette buyers. the community needs to pay attention to cigarette seller stalls that make it easier for people to get cigarettes, especially for children and adolescents(10). in addition, affordable prices with strong media exposure to children are things that need to be observed by the government. in terms of a social environment, adolescents tend to be more easily affected than other age epidemiology and society health review| eshr vol 1 no1 2019 49 groups. the community group (rw) residents in the gondokusuman health center area must focus on fostering a youth playing environment that supports teenagers to stay away from smoking behavior. sutha’s (2016) study in pangarengan subdistrict, sampang regency suggests that an area which consists of family environment, school environment, and the playing environment has a very important role to play in the formation of smoking behavior in adolescents today(11). conclusions the implementation of smoke-free area declaration ran well. it was found that the input was in line with the guidelines provided by the indonesian ministry of health as well as the mayor regulation of yogyakarta with the availability of committed energy resources, organization, the existence of guidelines, and funding from both the government and community self-help. however, some aspects did not run well. among them was the availability of the smoking room. in terms of facilities, a special smoking corner had already available, even though they still used makeshift places such as patrol posts, youth posts, and tombs. residents had no longer smoke inside the house. on the other hand, the process of the program was also considered to run well. furthermore, there have been some outputs. there were only four community groups (rw) which did not conduct the declaration of smoke-free area. authors’ contribution dn designed the study, collected, analysed, interpreted the data, and wrote the manuscript. rr designed the study and conducted a literature review. ha wrote the manuscript and conducted a literature review. ss wrote the manuscript. funding this work was supported by universitas ahmad dahlan under grant pdp033/sp3/lpp-uad/iv/2018 conflict of interest there are no conflicts of interest. references 1. kementerian kesehatan ri. germas wujudkan indonesia sehat. germas. 2016;1–9. 2. kementerian kesehatan republik indonesia. warta kesmas. gerak masy hidup sehat. 2017;01. 3. sistem informasi promosi dan pemberdayaan masyarakat-dinas kesehatan kota yogyakarta. wilayah kita mau sehat? ayo ikuti program si kesi gemes. gerak masy hidup sehat. 2018; 4. pemerintah kota yogyakarta. peraturan daerah kota yogyakarta nomor 2 tahun 2017 tentang kawasan tanpa rokok. 2017;1–18. 5. pemerintah kota yogyakarta. peraturan daerah kota yogyakarta nomor 7 tahun 2017 tentang penataan dan pengendalian menara telekomunikasi dan epidemiology and society health review| eshr vol 1 no1 2019 50 fiber optik. 2017; 6. indonesia kkr. pedoman pengembangan kawasan tanpa rokok. 2011; 7. nizwadi azkha. studi efektivitas penerapan kebijakan perda kota tentang kawasan tanpa rokok ( ktr ) dalam upaya menurunkan perokok aktif di sumatera barat tahun 2013. j kebijak kesehat indones. 2013;02(04):171–9. 8. ade retsy ambar wati. penerapan kawasan tanpa rokok berdasarkan peraturan daerah kota metro nomor 4 tahun 2014. j huk. 2014; 9. juanita. kebijakan kawasan tanpa rokok : peluang dan hambatan. j kebijak kesehat iidonesia. 2012;01(02):112–9. 10. hamdan sr, putri w. faktor kontrol perilaku merokok pada anak sekolah dasar. pros semin nas penelit dan pkm kesehat. 2015;9–14. 11. diah wijayanti sutha. analisis lingkungan sosial terhadap perilaku merokok remaja di kecamatan pangarengan kabupaten sampang madura. manaj kesehat stikes yayasan rs dr soetomo. 2016;2(1):43–59. microsoft word 3801-14755-1-ed-final3.docx epidemiology and society health review| eshr vol. 3, no. 2, 2021, pp. 10-16 issn 2656-6052 (online) | 2656-1107 (print) 10.26555/eshr.v3i2.3801 10 research article factors associated with hypertension among postmenopausal women in parangtritis coastal area in bantul, yogyakarta, indonesia yanasta yudo pratama1* 1 faculty of public health, universitas ahmad dahlan, yogyakarta, indonesia * correspondence: yanastayudo@gmail.com. phone: +6282223635566 received 09 march 2021; accepted 30 july 2021; published 31 july 2021 abstract background: blood pressure tends to increase in women associated with menopause. thus, post-menopausal women more often had hypertension than pre-menopausal. one of the risk factors for hypertension is high blood cholesterol levels (hypercholesterolemia). meanwhile, people who live in coastal areas can suffer from hypertension, which is higher than in rural or mountain areas. objective: to study the factors associated with hypertension among post-menopausal women in parangtritis coastal area. method: we used an observational study using the case-control design conducted in parangtritis village, kretek subdistrict, bantul district, in june-july 2013. amount 62 respondents were recruited using consecutive sampling consist of 31 people for each case and control—data obtained from primary data (measurements and interviews). analysis war performs using descriptive and the chi-square test. results: among the three risk factors we assessed, age and bmi significantly affect postmenopausal women's hypertension. at the same time, total cholesterol is not a risk factor for post-menopausal women to get hypertension. conclusion: there was an association between age, bmi, and hypertension among postmenopausal women in parangtritis coastal area. in contrast, total cholesterol was not a risk factor for post-menopausal women to get hypertension. keywords: hypertension; post menopause; woman; coastal pratama (factors associated with hypertension among postmenopausal women in parangtritis coastal area….) 11 vol. 3, no. 2, 2021, pp. 10-16 10.26555/eshr.v3i2.3801 introduction nowadays, hypertension received serious attention globally as it rolled as a silent killer disease in society. poor management of hypertension can damage human organs and develop several complications such as heart attacks, strokes, kidney disorders, and blindness (1). based on the indonesia ministry of health, there were increases in hypertension during 2013-2018 from 25.8 to 34.11 (2). almost 90% of people with hypertension have a common understanding of the cause. the hypertension risk factor can be grouped into two. the first is uncontrollable factors, including heredity, gender, and age. second is controllable factors related to behavior, lifestyle, and diets, such as obesity, lack of exercise, smoking and alcohol consumption, and excessive salt consumption (3). in the young to middle-aged, hypertension and cardiovascular disease are more common in men than women (4,5). hypertension in women is often not diagnosed or treated inadequately, especially after menopause when cardiovascular risk increases. in pre-menopausal women, endogenous estrogens maintain vasodilation, thereby playing a role in blood pressure regulation. the aging process, the loss of endogenous estrogen production after menopause, and increased blood pressure play a role in the high prevalence of hypertension in older women. in the united states, 75 percent of post-menopausal women experience hypertension. the high prevalence of obesity reduced regular physical exercise, salt intake as essential factors that play a role and worsen postmenopausal hypertension (6,7). hypercholesterolemia is associated with hypertension. high cholesterol in the blood will form deposits on the walls of blood vessels, causing a narrowing called atherosclerosis (8,9). hypertension can occur due to atherosclerosis that has lasted a long time. as a result of thrombus formation, scar tissue, and proliferation of smooth muscle cells, the arterial lumen is reduced, and resistance to blood flow across the arteries increases. the left ventricle must pump more strongly to generate sufficient force to flow blood through the atherosclerotic vascular system (10). it triggers an increase in systolic and diastolic blood pressure, leading to hypertension (10,11). the parangtritis beach area is at bantul district. this area is coastal, meaning that people living in this place have a higher chance of suffering from hypertension than inland or mountainous areas (12). in addition, people with predominantly salty eating habits have a higher risk of suffering from hypertension because salt can retain water osmotically, increasing blood volume and playing a role in the long-term control of blood pressure (13). evidence about this problem in this area is lacking. accordingly, we are interested in studying the relationship between total cholesterol levels and hypertension in post-menopausal women in the coastal area of parangtritis. this study contributes to the hypertension prevention program, mainly for prevention addressing gender aspects. method this research was an observational analytic study (non-experimental) with a case-control method design conducted june to july 2013. the population was post-menopausal women who suffer from hypertension, and they lived in the parangtritis beach area, especially in parangtritis village, kretek sub-district, bantul district, diy province. pratama (factors associated with hypertension among postmenopausal women in parangtritis coastal area….) 12 vol. 3, no. 2, 2021, pp. 10-16 10.26555/eshr.v3i2.3801 the sample was divided into two groups: case and control. the case group was postmenopausal women with hypertension according to jnc vii (systolic pressure ≥140 mmhg or diastolic pressure ≥90 mmhg). meanwhile, the control group was post-menopausal women who did not suffer from hypertension according to jnc vii. (systolic pressure <140 mmhg and diastolic pressure <90 mmhg). we used inclusion and exclusion criteria to recruit the sample. the inclusion criteria of this study include post-menopausal women, experiencing menopause naturally, residing in the parangtritis coastal area, and willing to participate in this research. at the same time, they experience surgical menopause, smoking, drinking alcoholic beverages, suffering from liver, kidney, and endocrine diseases, and consuming hormone replacement therapy (hrt). according to our calculation, 31 samples should be recruited for each arm. we selected the sample through consecutive sampling techniques. the data was collected via direct measurement and interviews with the respondent. blood pressure measurement used a mercury tensimeter and a stethoscope while measuring total cholesterol levels using an easy touch gcu (glucose, cholesterol, uric acid). analysis was performed using descriptive and bivariate analysis using the chi-square test. results characteristics of research subjects table 1. characteristics of research participants in this study characteristic total (n = 62) % age <65-year-old ≥65-year-old body mass index <25 kg/m2 ≥25 kg/m2 cholesterol total <200 mg/dl ≥200 mg/dl blood pressure non-hypertension hypertension 31 31 49 13 43 19 31 31 50.0 50.0 79.0 21.0 69.4 30.6 50.0 50.0 in total, 62 people participated in this study consist of 31 cases and 31 control. table 1 shows the characteristics of the respondent. most of the respondents (79%) had a bmi of less than 25 kg/m. more than half of the total respondents (69.4%) had less the 200 mg/dl cholesterol. table 2 presents the characteristic respondents between case and control. it means that there was no different mean between case and control. we found three characteristics (p-value <0.05): age, systolic, and diastolic blood pressure. pratama (factors associated with hypertension among postmenopausal women in parangtritis coastal area….) 13 vol. 3, no. 2, 2021, pp. 10-16 10.26555/eshr.v3i2.3801 table 2. characteristics of case and control groups characteristic case group (mean) control group (mean) p-value age (year old, sd) 67.42 ± 7.49 61.45 ± 7.67 0.00 systolic blood pressure (mmhg, sd) 160.90 ± 24.26 120.81 ± 876 0.00 diastolic blood pressure (mmhg, sd) 100 ± 14.83 80.16 ± 3.95 0.00 body heigh (cm, sd) 147.37 ± 7.73 148.80 ± 5.60 0.40 body weight (kg, sd) 47.53 ± 11.05 48.54 ± 7.24 0.67 body mass index (kg/m2, sd) 22.24 ± 5.01 21.93 ± 3.15 0.76 cholesterol total (mg/dl, sd) 181.39 ± 32.51 183.84 ± 32.07 0.86 relationship between age, bmi, total cholesterol and hypertension the relationship between age and hypertension is presented in table 3. we found a statistically significant p-value <0.05 between age and hypertension in the parangtritis beach area post-menopausal women. the woman who is ≥65 years has higher odds (4.41 times) of getting from hypertension than post-menopausal women. table 3. relationship between age, bmi, and hypertension variable hypertension p-value crude or (95% ci) case (hypertension) control (non-hypertension) n % n % age ≥65-year-old 21 67.7 10 32.3 0.00 4.41 (1.52-12.79) <65-year-old 10 32.3 21 67.7 bmi ≥25 kg/m2 10 32.3 3 9.7 0.02 4.44 (1.08-18.18) <25 kg/m2 21 67.7 28 90.3 cholesterol total ≥200 mg/dl 10 32.3 9 29 0.78 1.16 (0.39-3.43) <200 mg/dl 21 67.7 22 71 the relationship between bmi and hypertension is found significant, p <0.05. postmenopausal women in the parangtritis beach area with a bmi of ≥25 kg /m have higher odds (4.44 times) than post-menopausal women with a bmi <25 kg/m. it seems there is no different risk between control and group related to total cholesterol, meaning total cholesterol is not a risk factor for getting hypertension among post-menopausal women. discussion this research assessed the association between several potential risk factors for getting hypertension among post-menopausal women. age is identified as a possible risk factor for a post-menopausal woman to have hypertension. our finding was confirmed by another previous research (14). the aging process is associated with changes in the anatomy and physiology of the cardiovascular system, which affect blood pressure regulation (15,16). systemic hypertension that occurs in old age arises as a consequence of structural changes in the cardiovascular system. decreased vascular compliance and increased resistance are associated with narrowing the vascular radius and increased vessel wall-lumen ratio (17). pratama (factors associated with hypertension among postmenopausal women in parangtritis coastal area….) 14 vol. 3, no. 2, 2021, pp. 10-16 10.26555/eshr.v3i2.3801 histologically, these changes are seen in the subendothelial layer and the media of the blood vessels. when people getting older, there is thickening and increased infiltration of connective tissue in calcification and lipid deposition. this process results in improved stiffness of the walls of the aorta and large arteries (18). body mass index (bmi) also had a statistically significant relationship with hypertension in post-menopausal women in the coastal area of parangtritis. the results of this study are in line with several previous studies which concluded that body mass index has a positive relationship with hypertension (19). in addition, other studies have also revealed that obesity is a risk factor for the incidence of hypertension (20). a study of three populations in africa and asia, one of which was indonesian, stated that the mean blood pressure would increase with bmi (21). the risk of hypertension is higher in the overweight and obese population (bmi ≥25 kg / m2) (22). an increase in body weight (body mass index) triggers an overactivity of the sympathetic nerves, increasing blood pressure. hyperinsulinemia and hyperleptinemia are also additional factors that contribute to sympathetic nerve stimulation due to this weight gain (23,24). the analysis of total cholesterol levels and hypertension showed that this variable did not have a statistically significant relationship with hypertension in post-menopausal women. in addition, whole cholesterol level was not a risk factor for hypertension in post-menopausal women in this study. the same finding was stated by previous research (15,16,17). the previous research shows a statistically not significant relationship between hypertension and total cholesterol levels (p = 0.093) (25). the different results among the study are probably due to other factors that influence hypertension in post-menopausal women in the parangtritis beach area. cholesterol is one factor that plays a role in the incidence of hypertension in postmenopausal women, but other factors are still related. environmental factors that play an essential role in hypertension in post-menopausal women are age, body mass index, oxidative stress, and insulin (26). meanwhile, two other factors also play a role in hypertension in postmenopausal women, namely genetic factors and changes in sex hormones in postmenopausal women (27). in this study, total cholesterol level was not a risk factor for hypertension in post-menopausal women. changes in sex hormones are one of the factors that influence the incidence of hypertension in post-menopausal women. the production of the endogenous hormone estrogen begins to disappear. in pre-menopausal women, endogenous estrogens maintain vasodilation and thus play a role in blood pressure regulation. the aging process and the loss of endogenous estrogen production play an essential role in the high prevalence of hypertension in older women (28). in post-menopausal women, a decrease in estradiol levels and a reduced ratio of estrogen to testosterone have several effects that lead to increased blood pressure (29). it triggers an increase in body mass index (bmi), resulting in increased sympathetic nerve activation, followed by the release of renin and angiotensin ii (23). a decrease in estradiol and a decrease in the ratio of estrogen to testosterone also results in endothelial dysfunction followed by a decline in nitrite oxide (no) and an increase in endothelin, both of which play a role in salt sensitivity to blood pressure, which is common in post-menopausal women (30,31). the pratama (factors associated with hypertension among postmenopausal women in parangtritis coastal area….) 15 vol. 3, no. 2, 2021, pp. 10-16 10.26555/eshr.v3i2.3801 escalation of angiotensin ii and endothelin produces vasoconstriction on the kidney blood vessels, which will lead to kidney hypertension (32). this study may have a limitation in terms of the sample number that could affect the result of this study. accordingly, interpret and generalize this research need to be careful. conclusion in summary, there is no statistically significant relationship between total cholesterol levels and hypertension in post-menopausal women in the coastal area of parangtritis. age and bmi are potential risk factors for getting hypertension among post-menopausal women in coastal settings. this research has been conducted for more than seven years. it is necessary to reexamine at this time whether there is a shift in facts about hypertension on the coast of parangtritis authors' contribution yyp is the single author for this work; he is responsible thorough the content. acknowledgment we thank to all respondents who participated in this study. conflict of interest there is no conflict of interest in this research. references 1. simbolon d, yorita e, talib ra. the risk of hypertension in adulthood as a consequence of adolescent obesity. kesmas. 2019;14(1):28–36. 2. the ministry of health of indonesia. hypertension is a silent killer [internet]. jakarta: indonesia ministry of health; 2019 [cited 2021 aug 7]. available from: www.p2ptm.kemkes.go.id. [in bahasa] 3. nuraini b. risk factors of hypertension. j major. 2015;4(5):10–9. 4. kusumawaty j, hidayat n, ginanjar e. relationship between sex and hypertension intensity in the elderly in the working area of the lakbok public health center, ciamis district. j mutiara med. 2016;16(2):46–51. [in bahasa] 5. song jj, ma z, wang j, chen lx, zhong jc. gender differences in hypertension. j cardiovasc transl res. 2020;13(1):47–54. 6. barton m, meyer mr. post-menopausal hypertension: mechanisms and therapy. hypertension. 2009;54(1):11–8. 7. wenger nk, arnold a, bairey merz cn, cooper-dehoff rm, ferdinand kc, fleg jl, et al. hypertension across a woman’s life cycle. j am coll cardiol. 2018;71(16):1797–813. 8. hurtubise j, mclellan k, durr k, onasanya o, nwabuko d, ndisang jf. the different facets of dyslipidemia and hypertension in atherosclerosis. curr atheroscler rep. 2016;18(12). 9. ivanovic b, tadic m. hypercholesterolemia and hypertension: two sides of the same coin. am j cardiovasc drugs. 2015;15(6):403–14. 10. daniati, erawati. correlation of blood pressure with ldl (low-density lipoprotein) cholesterol levels in coronary heart disease patients in rsup.dr.m.djamil padang. j kesehat perintis. 2018;5(2):153–8. [in bahasa] pratama (factors associated with hypertension among postmenopausal women in parangtritis coastal area….) 16 vol. 3, no. 2, 2021, pp. 10-16 10.26555/eshr.v3i2.3801 11. gimbrone ma, garcía-cardeña g. endothelial cell dysfunction and the pathobiology of atherosclerosis. circ res. 2016;118(4):620–36. 12. saparina.l t. identification of individual characteristics of hypertension incidence in communities in the mountains and coastal areas of kendari city. miracle j public heal. 2019;2(2):169–80. [in bahasa] 13. saputra o, anam k. lifestyle as a risk factor for hypertension in coastal communities. j major. 2016;5(3):118–23. [in bahasa] 14. song l, shen l, li h, liu b, zheng x, zhang l, et al. age at natural menopause and hypertension among middle-aged and older chinese women. j hypertens. 2018;36(3):594–600. 15. buford tw. hypertension and aging. ageing res rev. 2016; 26:96–111. 16. cheitlin md. cardiovascular physiology changes with aging. am j geriatr cardiol. 2003;12(1):9–13. 17. laurent s, boutouyrie p. the structural factor of hypertension: large and small artery alterations. circ res. 2015;116(6):1007–21. 18. bentzon jf, otsuka f, virmani r, falk e. mechanisms of plaque formation and rupture. circ res. 2014;114(12):1852–66. 19. addo oy, stein ad, fall ch, gigante dp, guntupalli am, horta bl, et al. maternal height and child growth patterns. j pediatr [internet]. 2013;163(2):549-554.e1. available from: http://dx.doi.org/10.1016/j.jpeds.2013.02.002. 20. landi f, calvani r, picca a, tosato m, martone am, ortolani e, et al. body mass index is strongly associated with hypertension: results from the longevity check-up 7+ study. nutrients. 2018;10(12):1–12. 21. tesfaye f, nawi ng, van minh h, byass p, berhane y, bonita r, et al. association between body mass index and blood pressure across three populations in africa and asia. j hum hypertens. 2007;21(1):28–37. 22. hruby a, hu fb. the epidemiology of obesity: a big picture. pharmacoeconomics. 2015;33(7):673–89. 23. brooks vl, shi z, holwerda sw, fadel pj. obesity-induced increases in sympathetic nerve activity: sex matters. auton neurosci basic clin. 2015; 187:18–26. 24. da silva aa, do carmo jm, li x, wang z, mouton aj, hall je. role of hyperinsulinemia and insulin resistance in hypertension: metabolic syndrome revisited. can j cardiol. 2020;36(5):671–82. 25. sopiah p, haryeti p, ningrum d. correlation of bmi and cholesterol levels with hypertension in the elderly. 2020;6539(january):6533–9. 26. demarco vg, aroor ar, sowers jr. the pathophysiology of hypertension in patients with obesity. nat rev endocrinol. 2014;10(6):364–76. 27. zilberman jm, cerezo gh, sueldo m del, fernandez-perez c, martell-claros n, vicario a. association between hypertension, menopause, and cognitionin women. j clin hypertens. 2015;17(12):1–7. 28. sabbatini ar, kararigas g. estrogen-related mechanisms in sex differences of hypertension and target organ damage. biol sex differ. 2020;11(1):1–17. 29. zhao d, guallar e, ouyang p, subramanya v, vaidya d, ndumele ce, et al. endogenous sex hormones and incident cardiovascular disease in post-menopausal women. j am coll cardiol. 2018;71(22):2555–66. 30. malik aubead n. role of sex hormones in human body. reprod horm. 2021;1–25. 31. suandi la. different effect of general exercise and progressive muscle relaxation on reducing hypertension in the elderly. universitas ’aisyiyah, yogyakarta; 2018. [in bahasa] 32. raina r, chauvin a, chakraborty r, nair n, shah h, krishnappa v, et al. the role of endothelin and endothelin antagonists in chronic kidney disease. kidney dis. 2020;6(1):22–34. microsoft word 2205 pb.docx epidemiology and society health review| eshr vol 2, no 2 (2020) 61 research article health education to improve the compliance of low salt diets in patients with hypertension beti kristinawati1*, siti rahmawati2, riska nurul khasanah3 1 medical-surgical nursing, school of nursing, faculty of health sciences, universitas muhammadiyah surakarta, indonesia 2,3 professional program education, school of nursing, faculty of health sciences, universitas muhammadiyah surakarta, indonesia. *correspondence: bk115@ums.ac.id. phone: +6282137266023 abstract background: the level of knowledge of hypertensive people can influence obedience in running a low-salt diet. low levels of public awareness about low-salt diets can be at risk of complications due to hypertension and death. health education activities in this community aim to increase the understanding of patients with hypertension on the importance of low-salt diets to improve adherence to the exercise of the diet methods: educational methods used in the form of teaches and demonstrations in groups of people with hypertension in drono village, ngawen sub-district, klaten regency. results: knowledge of the hypertension diet increased between before and after educational activities. success demonstrated with increased knowledge scores before educational activities of 3.46 and after education score rose to 85.02. conclusions: devotion to the community in health education provides increased knowledge in the group of hypertension sufferers. this activity is expected to continue, programmatic, and developed with specialized training in cadres to improve the degree of public health. keywords: health education, low salt diet, hypertension introduction hypertension is one of the non-infectious diseases with high mortality and morbidity figures. hypertension is a condition in which there is an increase in systolic blood pressure above 149 mmhg and diastolic pressure above 90 mmhg. it causes heart work to become increasingly severe in fulfilling oxygen and nutrients throughout the body (1). the world health organisation (who) in 2015 states that around 1,13 billion people in the world suffer from hypertension, with 9,4 million deaths annually (2). southeast asia is an area with a hypertensive sufferer of 36% and predicted to continue to increase to 65% in 2025 (3). the prevalence of indonesian national hypertension was 34, 1%(4). in central java province in the year 2016, the highest case of the non-infectious disease was hypertension, which is 61% (5). the health profile of klaten district shows that the first sequence of the five significant not contagious diseases is hypertension. in 2018 there epidemiology and society health review| eshr vol 2, no 2 (2020) 62 was an increase in the number of hypertension sufferers in klaten district as many as 53.362 people (6). hypertension treatment can be conducted through two approaches: pharmacological and nonpharmacological therapy (6). the pharmacological approach through antihypertensive drugs. non-pharmacological can be done by behavioral action: stopping smoking, avoiding alcoholic beverages, limiting salt intake, avoiding preserved and preserved food, exercising and physical activity, or doing proper self-management (7) such as restrict of salt intake (6). low salt diet compliance in hypertensive sufferers is indispensable to achieve success in their diet therapy, thus helping to lower blood pressure and prevent complications (8). a low-salt diet in daily foods was sufficient to reduce blood pressure in patients with hypertension (9). a lowsalt diet and dietary compliance can lower systolic and diastolic blood pressure and help maintain the blood pressure of patients with hypertension (10). one factor that affects the ability to restrict salt intake is the knowledge of hypertension among the sufferers. health education activities can enhance an individual's level of expertise. health education in the community is one capital to empower people and the community. the activity is not only able to improve knowledge but also can change the attitude and practice of an individual in maintaining its health independently (11). continuing health education can lead people to participate in managing their health actively. data from ngawen health center in drono village in 2018 recorded as many as 190 people suffering from essential hypertension (12). our preliminary assessment of patients with hypertension in drono village obtained 9 out of 10 sufferers have not known about the importance of low-salt diets, and the restriction of salt intake in diets consumed was also not routine. besides, patients with hypertension still often consume instant foods high rated and foods preserved with preservatives derived from salt. other data was found only some 40 hypertension that actively follows routine health screening activities in an integrated service post for the elderly. research conducted by sulistiorini about the compliance of low-salt diets in hypertensive sufferers' research locations found that people with hypertension were not obedient in choosing low-salt foods, sodiumbased herbs, and foods containing sodium preservatives (12). this study aims to understand the level of knowledge on low salt-diet compliance in hypertensive sufferers in drono village after education. expected with increased awareness and adherence to the exercise of the diet can help shape the positive attitude of society and improve the quality of their life. methods study design and intervention course the experimental, one-group pre-post-test design was applied in this study. health education in the communities was conducted by lecture and demonstration techniques. the implementation of the activities consists of several phases: pre-test, intervention, and posttest. three team members held the education and a demonstration on how to quantify salt consumption daily. the activity also involves a village midwife who serves as the head of health care and as a key person who provides information about the public health status of drono village, ngawen sub-district, klaten regency. settings and participant this research was conducted in drono village, ngawen sub-district, klaten regency. the population was people with hypertension in drono village. data were obtained from ngawen public health center in 2018 as many as 190 patients. we took 40 samples for this research by considering purposive sampling using criteria, including people with hypertension who actively participated in the integrated service center for the elderly (posyandu lansia). epidemiology and society health review| eshr vol 2, no 2 (2020) 63 data collection and pre and post-assessment data collection was conducted in the monthly meeting of the integrated service center for the elderly (posyandu lansia). pre and post-tests were delivered before and after the intervention, respectively, using similar questionnaires consisting of seven questions to measure the change of hypertension knowledge before and after the intervention (table 2). table 2. inquiry list pre and post-test education analysis pre and post data were administered and presented descriptively using table and chart. ethical approval the implementation of this research activity is done after the activity proposal. memorandum of understanding (mou) is approved and signed by the head of ngawen public health center and researchers. the research team also asks for approval to respondents after being explained the intent, purpose, and permit to photograph process activities for documentation purposes by signing informed consent. results respondents were involved in this study as much as 40 people, with characteristics shown in table 1. table 1. characteristics of the study subjects (n = 40) variable frequency number proportion (%) gender male 11 27.5 female 29 72.5 age (years) 45-59 22 55 60-74 16 40 75-90 2 5 education elementary school 29 72.5 junior high school 7 17.5 senior high school 2 5 college 2 5 no questions 1 what is the purpose of the restriction of salt consumption for patients with hypertension? 2 mention a variety of low-salt diets! 3 are instant foods and foods preserved mostly high in salt content? 4 what is the safe limit of salt content in instant foods and foods preserved for people with hypertension? 5 how many sizes of salt consumption recommended for people with hypertension? 6 how do i limit salt intake if the hypertension is eating at the restaurant? 7 what is the risk if people with hypertension do not limit salt consumption? epidemiology and society health review| eshr vol 2, no 2 (2020) 64 participants' total score pre-post-test presents in figure 1. in the pre-test, the lowest and the highest score of respondents were 28.58 and 42.87, respectively. subsequently, in the posttest, the respondent got a better score with the lowest score of 71.45 and the highest score of 85.74. figure 1. total score pre and post-test for each participant discussions non-infectious disease risk factors (ncds) such as hypertension are categorized in a risk factor that can be modified and cannot be modified. unmodifiable risk factors are individual characteristics that cannot be altered and cannot be controlled. these factors include age, gender, race, family history, genetics, etc. besides, the risk factors that can be controlled are characteristics of individuals that can be adjusted or can be changed to prevent disease progression. risk factors that can be modified included; obesity, high intake of salt, inactive or lack of exercise, a diet high in fat, smoking, alcohol consumption, etc. (13,14). the results of the study gained that patients with hypertension were dominated by women (72.5%). most sufferers (55%) are in the 45-59 age group. in young women, hypertension is rarely found; this condition is associated with endogenous estrogen content. hypertension is common in women when entering the age of the elderly (65 years or more) than women (15,16). women who have entered the age of menopause are more susceptible to having 0 10 20 30 40 50 60 70 80 90 100 score score pre test score post test epidemiology and society health review| eshr vol 2, no 2 (2020) 65 problems with cardiovascular one of them is hypertension because the levels of hdl patients have decreased, thereby causing atherosclerosis. hypertension experienced by women is associated with a unique condition that is only experienced, namely related to pregnancy, menopause, and the use of oral contraceptive drugs (16,17) our result shows, based on the pre and post assessment, we found the change of knowledge among participants after the intervention. education is part of non-pharmacological action to control blood pressure and prevent the risk of complications from hypertension (15). the possible complications for hypertension are stroke, heart attack, and kidney disease. accordingly, proper management is required to avoid complications (14). education level, most elementary schools are 72.5%. low level of education affects the level of knowledge of sufferers on compliance with medication, conducting medical examinations, and maintaining a proper diet in hypertensive patients (18). previous research obtained data that self-management by limiting salt intake to one way to control blood pressure (19). low salt diet compliance in hypertensive sufferers is indispensable to achieve success in therapy. the knowledge assessment of a diet low in salt on research includes a variety of low-salt diets, sodium levels in the instant foods that are safe for people with hypertension, and the amount of daily sodium consumption. we also included the strategy of reducing sodium intake when eating at the restaurant as well as the purpose of limiting sodium consumption and risks that can arise when not adhered to the hypertension diet. the results of the evaluation showed that there was a significant change in educational pre-post knowledge levels. the results of previous studies were found that there was a close connection between increasing blood pressure for hypertension and sodium intake. high sodium intake will increased blood pressure associated with the occurrence of water retention, increased peripheral resistance, changes in endothelial function, changes in structures and features of the elasticity of large blood vessels, modifications in sympathetic activity, and autonomic nerve modulation of the cardiovascular system (20). besides limiting salt intake, hypertensive diets limit the consumption of saturated fats and high cholesterol foods. hypertension sufferers can use the dietary approaches to stop hypertension/dash method in regulating food intake. dash focuses on structuring the patient's diet with the restriction of sodium, fat, and cholesterol intake. patients are recommended to consume a lot of foods that contain a lot of protein, calcium, potassium, and fiber to encounter the daily needs of the body (21). the study showed that the respondents' level of knowledge about the high content of sodium in low food. healthy subjects consume fast food 3 to 4 times a week, while the fact 74% sodium content is in prepared food or fast food (22). patients with hypertension need to reduce salt per day to a maximum of 6 grams and not more than 2400 milligrams. patients with adherent hypertension who maintain a diet low in salt proved to lower blood pressure at 3.4 systole mmhg and diastolic blood pressure 1.5 mmhg (23). conclusions education with the method of lectures and demonstrations can improve society's knowledge, especially patients with hypertension. furthermore, increasing awareness is expected to increase adherence to low salt diets that impact the quality of life and lower the risk of complications and deaths from hypertension. health care personnel are expected to make education a promotive and preventive effort to prevent hypertension complications. for the stakeholder, such results can be primary data to be followed up with behavioral change assessment activities in running a low-salt diet. besides, it is expected to motivate patients epidemiology and society health review| eshr vol 2, no 2 (2020) 66 with hypertension who have not been actively involved in activities in the integrated service center for the elderly (posyandu lansia) to be active. for further researchers, these results are expected to be primary data for subsequent studies. authors' contribution each author has contributions to the process of research and the preparation of this article. bk, as the head of the team and the speaker in education activities, rn assists in the process of research activities, and sr roled in the process of evaluating and compiling the reports of events that have conducted. funding this research was funded by universitas muhammadiyah surakarta, indonesia. conflict of interest the is no conflict of interest. references 1. the ministry of health of indonesia. indonesian health profile data and information 2018. jakarta: the ministry of health of indonesia; 2019. available from: https://pusdatin.kemkes.go.id/resources/download/pusdatin/profil-kesehatanindonesia/data-dan-informasi_profil-kesehatan-indonesia-2018.pdf. (in indonesian) 2. who. world health statistic report 2015. geneva; 2015. https://apps.who.int/iris/bitstream/handle/10665/170250/9789240694439_eng.pdf;jsessi onid=4d55f1759cb2b1311b6315914ac5a560?sequence=1 3. banik kk. save lives: make hospitals safe for emergencies. j indian med assoc. 2009;107(4):206–7. 4. the ministry of health of indonesia. main finding of basic heath research of indonesia (riskesdas) 2018. jakarta: the ministry of health of indonesia; 2019. http://kesmas.kemkes.go.id/assets/upload/dir_519d41d8cd98f00/files/hasil-riskesdas2018_1274.pdf. (in indonesian) 5. klaten district health office. health profile 2018. klaten: klaten district health office. https://www.kemkes.go.id/resources/download/profil/profil_kab_kota_2018/3310_j ateng_kab_klaten_2018.pdf. (in indonesian) 6. ainurrafiq a, risnah r, ulfa azhar m. non-pharmacological therapy in controlling blood pressure in hypertensive patients: systematic review. mppki (media publ promosi kesehat indones indones j heal promot. 2019;2(3):192–9. (in indonesian) 7. burnier m, vuignier y, wuerzner g. state-of-the-art treatment of hypertension: established and new drugs. eur heart j. 2014;35(9):557–62. 8. tarigan ar, lubis z, syarifah s. the influence of knowledge, attitudes and family support for hypertension diets in hulu village, pancur batu sub-district in 2016. j kesehat. 2018;11(1):9–17. (in indonesian) 9. kiha rr, palimbong s, kurniasari md. the effectiveness of a low-salt diet in ordinary and soft foods for the duration of recovery of hypertensive patients. j keperawatan muhammadiyah. 2018;3(1). (in indonesian) epidemiology and society health review| eshr vol 2, no 2 (2020) 67 10. hayati a. evaluation of treatment compliance among patients with lung tuberculosis year 2010-2011 in pancoran mas health center, depok. universitas indonesia; 2011. (in indonesian) 11. bisallah ci, rampal l, lye ms, sidik sm, ibrahim n, iliyasu z, et al. effectiveness of health education intervention in improving knowledge, attitude, and practices regarding tuberculosis among hiv patients in general hospital minna, nigeria – a randomized control trial. plos one. 2018;13(2):1–14. 12. sulistiorini h. kepatuhan diet rendah garam pada penderita. universitas muhammadiyah surakarta; 2019. (in indonesian) 13. mayega rw, makumbi f, rutebemberwa e, peterson s, östenson cg, tomson g, et al. modifiable socio-behavioural factors associated with overweight and hypertension among persons aged 35 to 60 years in eastern uganda. plos one. 2012;7(10). 14. ahmed n, rahman m, islam m, ali s, hossain a, fatema k, et al. socio-demographic, clinical characteristics and status of hypertension control among rural hypertensive patients. faridpur med coll j. 1970;6(1):5–9. 15. nuraini b. risk factors of hypertension. j major. 2015;4(5):10–9. 16. ahmad a, oparil s. hypertension in women: recent advances and lingering questions. hypertension. 2017;70(1):19–26. 17. rahmatika d. the relationship between emotional support and adherence to the diet of elderly people with hypertension. the indonesian journal of public health. 2019; 14(2):252-262. (in indonesian) 18. pramestutie hr, silviana n. the knowledge level of hypertension patients for drug therapy in the primary health care of malang. indones j clin pharm. 2016;5(1):26–34. 19. welviana i, waliyo e. general description of food scraps and nutritional status in hypertensive patients who receive a low salt diet at sultan syarif mohamad alkadrie hospital pontianak. pontianak nutr j. 2018;1(1):40. (in indonesian) 20. grillo a, salvi l, coruzzi p, salvi p, parati g. sodium intake and hypertension. nutrients. 2019;11(9):1–16. 21. apriana r, rohana n, simorangkir y. the relationship between the application of the dash (dietary approach to stop hypertension) method with the level of hypertension. medisains. 2017;15(3):179–84. (in indonesian) 22. prihatini s, permaesih d, julianti ed. sodium intake of indonesians: analysis of 2014 individual food consumption survey (skmi) data. gizi indones. 2017;39(1):15. (in indonesian) 23. fauziah ny, bintanah s, handarsari e. the pattern of consumption of sodium food ingredients in outpatient hypertension patients at tugurejo hospital semarang. j gizi univ muhammadiyah semarang. 2013;2(1):1-9. (in indonesian) epidemiology and society health review| eshr vol 2, no 2 (2020) 68 microsoft word 4039-12749-ed-21 jan 2022-ss.edited ref edit.docx epidemiology and society health review| eshr vol. 4, no. 1, 2022, pp. 12-20 issn 2656-6052 (online) | 2656-1107 (print) 10.26555/eshr.v4i1.4039 12 research article stunting determinants in kulonprogo district, yogyakarta year 2019 desi nurfita1* annisa parisudha1, sugiarto sugiarto2 1 public health faculty, universitas ahmad dahlan, yogyakarta, indonesia 2 kulonprogo health office, yogyakarta, indonesia * correspondence:desi.nurfita@ikm.uad.ac.id. phone: 62821-9135-0472 received 30 april 2021; accepted 02 august 2021; published 23 january 2022 abstract background: unicef stated that in 2014, about 66% of children aged less than five years in lower-middle-income countries were stunted. stunting is a predictor of poor quality of human resources and reduces a nation's productivity in the future. stunting control in the kulonprogo district is one of the priority districts in indonesia. this study aimed to analyze the determinants of stunting in the kulonprogo district. methods: this research was conducted in kuponprogo district. the population was children under five in kulonprogo district. analysis was done through a descriptive approach. descriptive quantitative research was used by employing secondary data from the year 2013. results: the prevalence of stunting among children under five in the kulonprogo district was 11.12%, spread across all primary health centers (puskesmas) in the kulonprogo district. the three puskesmas with the highest prevalence rate were puskesmas girimulyo 2, puskesmas samigaluh 2, and puskesmas kalibawang. the analysis found that lowincome families, maternal education, age at pregnancy, chronic energy deficiency during pregnancy, anemia during pregnancy, early initiation of breastfeeding, exclusive breastfeeding, and parenting mode are the determinant factors of stunting in the kulonprogo district in 2019. conclusion: several determinants of stunting were found, namely low-income families, maternal education, age at pregnancy, chronic energy deficiency during pregnancy, anemia during pregnancy, early initiation of breastfeeding, exclusive breastfeeding, and parenting mode. keywords: stunting; determinants; malnutrition; under-five children introduction stunting is a chronic undernutrition status during growth and development since early life. this situation is indicated by the z-score of height for age (height-for-age) less than-2 standard deviations (sd) based on growth standards according to who (1). (2)nutritional problems, nurfita (stunting determinants in kulonprogo district, yogyakarta year 2019) vol. 4, no. 1, 2022, pp. 12-20 10.26555/eshr.v4i1.4039 13 especially stunting in toddlers, can hinder child development, with negative impacts in the next life, such as intellectual decline, vulnerability to non-communicable diseases, decreased productivity that causes poverty, and risk factors for delivering low birth weight baby (3). stunting is the point of the six global nutrition targets in 2025 and one indicator of the post2015 development agenda (2). family socioeconomic status such as family income, parental education, mother's knowledge of nutrition, and the number of family members can indirectly relate to stunting (4). research in south ethiopia states that the number of family members is a risk factor for stunting in toddlers aged 24-36 months (6). the incidence of stunting in children under five is influenced by low income and parental education (5). families with high incomes will have easier access to education and health to improve children's nutritional status (6).(7) the direct causes of stunting are infectious diseases and nutrient intake (8)(9). the intake of nutrients that significantly affect the linear growth of children is a protein (10), zinc (11), iron (12) as well as vitamin a (13). theoretically, differences in topography and geographical location give their characteristics to people's eating patterns and impact food availability in certain areas (14). the selection of 100 priority districts/cities for stunting interventions in indonesia is based on the criteria for the number and prevalence of stunted under-fives, taking into account the district/city poverty level (14). kulon progo is the only district in the special region of yogyakarta that is included in the 100 priority districts for stunting intervention in indonesia. the prevalence of stunting under five in kulon progo in 2013 was 26,31%. the incidence of stunting decreased in 2018 to 12,66%. (15)stunting in kulon progo is almost spread in every village. based on data from the kuloprogo district health office in 2019, kulonprogo district has 10 stunting prevention priority villages. priority villages consist of nomporejo, tuksono, karangsari, mediumsari, donomulyo, sidoharjo, gerbosari, ngargosari, pagerharjo, and kebonharjo. stunting is an exciting topic to study, considering that stunting has a profound impact in shortem and long-term. the short-term impact would be closely connected with morbidity and mortality on the baby or under five-year-old children, the midterm effect relating to low cognitive skills, and the long term relating to human resource quality and degenerative illness in the adult period (16). accordingly, the researcher is attracted to analyze the determinants of stunting in the kulonprogo district. this research contributes to informing policymaker about the factors associated with stunting in this region. it is essential to explore because the covid19 pandemic that occurred at the beginning of 2020 could exacerbate the situation of nutritional fulfillment in the marginal group. method the design of this study was descriptive quantitative research that attempts to collect quantifiable information for statistical analysis of the population sample. we used secondary data from the kulonprogo health office data for stunting toddlers in kulonprogo district year 2019. those data-based on community data surveys with the population of children under five in this area. we analyzed using frequency distribution. nurfita (stunting determinants in kulonprogo district, yogyakarta year 2019) vol. 4, no. 1, 2022, pp. 12-20 10.26555/eshr.v4i1.4039 14 results based on the data from the kulonprogo district office, in 2019, there were 2.740 toddlers out of a total of 24,644 toddlers. we figure out the number of toddlers based on the number of toddlers of their body weight in posyandu. this measurement is one indicator of posyandu achievement in each health center. figure 1 shows the comparison between the number of children under five and the number under five that measure their body weight in kulonprogo during 2019. figure 1. comparative analysis of toddlers who came and weighed in kulonprogo district in 2019 based on figure 2, it is known that most of the puskesmas in kulonprogo district are not achieving 100% of toddlers coming and being weighed yet. the highest achievement was reached by puskesmas kalibawang with more than 95%, and the lowest achievement was puskesmas temon 2 with about 83%. stunting in kulonprogo district figure 3 shows the proportion of stunted children under five by puskesmas in the kulonprogo district. it is known that the highest proportion of stunting toddlers under five is in puskesmas girimulyo 2, followed by puskesmas samigaluh 2 and kalibawang health center. while the lowest stunting toddler under five is in puskesmas nanggulan. nurfita (stunting determinants in kulonprogo district, yogyakarta year 2019) vol. 4, no. 1, 2022, pp. 12-20 10.26555/eshr.v4i1.4039 15 figure 2. the proportion of toddlers who come and weighed by health center in kulonprogo district in 2019 figure 3. the proportion of stunting toddlers per health center in kulonprogo district in 2019 nurfita (stunting determinants in kulonprogo district, yogyakarta year 2019) vol. 4, no. 1, 2022, pp. 12-20 10.26555/eshr.v4i1.4039 16 regarding the gender of the toddler who was getting stunting, it was known that mostly stunting children were dominated by a male toddler (53%). however, it seems the proportion was not significant (figure 4). figure 4. stunting toddlers by gender in kulonprogo district in 2019 determinants of stunting in kulonprogo district table 1. frequency distribution analysis the determinants of stunting in kulonprogo district indicator number percentage (%) family status poor 1475 56 wealthy 1146 44 mother's education primary school 123 6 junior high school 406 22 senior high school 1250 52 diploma/university 105 6 age when pregnant (year) 15 – 20 96 5 20 – 30 938 47 30 – 35 727 37 >35 216 11 chronic energy deficiency during pregnancy yes 767 30 no 1817 70 anemia status yes 370 25 no 1108 75 early initiation of breastfeeding status yes 1750 70 no 743 30 exclusive breastfeeding status yes 1710 66 no 893 34 parenting mode by themselves 1757 77 helped by others 106 5 mix 418 18 53% 47% malefemale nurfita (stunting determinants in kulonprogo district, yogyakarta year 2019) vol. 4, no. 1, 2022, pp. 12-20 10.26555/eshr.v4i1.4039 17 based on table 1, as many as 44% of children under five with stunting come from low-income families. about 52% of mothers with stunting toddlers have a high school education. there are still mothers who give birth at an age that has a high risk, namely 5% at the age of 15-20 years and 11% at the age of >35 years. there are still risk factors for insufficient total energy intake, which is 30% of pregnant women. there are still risk factors for anemia, which is 25% of pregnant women. the majority of mothers with toddler stunting have done early breastfeeding initiation (70%). most mothers with stunting children conducted exclusive breastfeeding (66%). most toddlers are cared for by their mothers (77%). according to our data, the determinants of stunting in kulonprogo during 2019 were lowincome families, mother's education, age during pregnancy, chronic energy deficiency during pregnancy, anemia during pregnancy, early initiation of breastfeeding, exclusive breastfeeding, and parenting mode. discussion kulonprogo district is an area that is included in the 100 priority districts/cities for stunting intervention and is also the only district in the special region of yogyakarta that is suffering from stunting problems. unbalanced nutrient intake or inadequate complementary feeding is one factor that directly affects stunting. nutrient intake is influenced by the quality of the food, especially macronutrient and micronutrients, and the eating behavior of the families, especially mothers and children, which will impact the rule of feeding practice. changes in behavior can occur when mothers have sufficient knowledge about balanced nutrition and understand nutritional problems at risk for stunting in children (17). the quality and quantity of a person's food depend on the nutritional content of the food, the presence or absence of other food in the family, the purchasing power of the family, and the mother's characteristics regarding food and health. nutritional status is determined by two aspects: the food eaten and the state of health. the state of health is also related to the mother's characteristics of food and health, the family's purchasing power, the presence or absence of infectious diseases, and the reach of health services. stunting is caused by multi-dimensional factors and not only caused by poor nutrition experienced by pregnant women and children under five (18). therefore, interventions that will be very decisive in reducing stunting prevalence need to be carried out in the first 1,000 days of life. poor maternal education is related to the incidence of stunting in children. lack of maternal education and knowledge about nutrition is associated with stunting in toddlers aged 6-59 months (19). stunting is also related to food and animal source food expenditure in families of children under five (household-level food security) (20). family income is also reported as one of the determinants of stunting. several studies have stated that children from low economic levels tend to be at risk of stunting(19,21–23). research reports that toddlers living in families with low incomes are at 6.24 times greater risk of experiencing stunting than toddlers with families with sufficient income, which is the main factor of stunting in toddlers (23). another determinant factor of stunting in indonesia is related to gender. the male sex is the dominant gender that suffers stunting than the female sex. nurfita (stunting determinants in kulonprogo district, yogyakarta year 2019) vol. 4, no. 1, 2022, pp. 12-20 10.26555/eshr.v4i1.4039 18 many studies related to the history of insufficiency total energy intake in pregnant women with stunting have been carried out. the research conducted by dewi et al. (2020) found that mothers with a history of chronic energy deficiency were associated with stunting (24). however, another study conducted by prabandari et al. (2016) obtained an inversely proportional result. there was no significant relationship between the history of poor nutrition during pregnancy and the incidence of stunting in toddlers (25). based on research conducted by febrina (2017), it was found that there is a significant relationship between anemia in pregnant women and the incidence of stunting (26). however, another study conducted by warsini et al. (2016) obtained different results (27). another study conducted by prabandari et al. (2016) in boyolali district also showed that a history of maternal anemia did not significantly correlate with the incidence of stunting in children under five. toddlers under two years who experience stunting will have a lower level of intelligence, making children more susceptible to disease and, in the future, maybe at risk of decreasing productivity levels. in the end, stunting will broadly inhibit economic growth, increase poverty, and widen inequality (15). therefore, stunting prevention needs to be carried out to develop a healthier generation. conclusion in conclusion, several determinants of stunting under-five children were identified in kulonprogo district: low-income families, mother's education, age during pregnancy, chronic energy deficiency during pregnancy, anemia during pregnancy, early initiation of breastfeeding status, exclusive breastfeeding for six months, and parenting mode. authors' contribution dn contributed to data collection, analysis, report writing, and manuscript publication. ap contributed to the data collection and report writing. ss contributed to the data collection and licensing. funding this research has not received external funding conflict of interest there is no conflict of interest in this research. references 1. world health organization. nutrition landscape information system (nlis) country profile indicators: interpretation guide. geneva: who; 2010. 2. de onis m, branca f. childhood stunting: a global perspective. vol. 12, maternal & child nutrition. wiley-blackwell; 2016 [cited 2022 jan 23]. p. 12. available from: /pmc/articles/pmc5084763/ nurfita (stunting determinants in kulonprogo district, yogyakarta year 2019) vol. 4, no. 1, 2022, pp. 12-20 10.26555/eshr.v4i1.4039 19 3. unicef india. stop stunting. web. 2021 [cited 2022 jan 23]. available from: https://www.unicef.org/india/what-we-do/stop-stunting 4. karsa ns, mappaware na, latief s, irwan aa, andi u, pangnguriseng. analysis of medicosocial determinant factors in mothers with stunted. green med j. 2021;3(2):101–9. 5. soekatri mye, sandjaja s, syauqy a. stunting was associated with reported morbidity, parental education and socioeconomic status in 0.5–12-year-old indonesian children. int j environ res public health. 2020;17(17):1–9. 6. bishwakarma r. spatial inequality in children nutrition in nepal: implications of regional context and individual/household composition. university of maryland; 2011. available from: https://drum.lib.umd.edu/bitstream/handle/1903/11683/bishwakarma_umd_0117e_1208 1.pdf?sequence=1&isallowed=y 7. fikadu t, assegid s, dube l. factors associated with stunting among children of age 24 to 59 months in meskan district, gurage zone, south ethiopia: a case-control study. bmc public health. 2014;14(1):1–7. 8. raiten dj, bremer aa. exploring the nutritional ecology of stunting: new approaches to an old problem. nutrients. 2020;12(2). 9. who. stunting in a nutshell. web. 2015 [cited 2021 aug 13]. available from: https://www.who.int/news/item/19-11-2015-stunting-in-a-nutshell 10. tessema m, gunaratna ns, brouwer id, donato k, cohen jl, mcconnell m, et al. associations among high-quality protein and energy intake, serum transthyretin, serum amino acids and linear growth of children in ethiopia. nutrients. 2018;10(11):1–17. 11. stammers al, lowe nm, medina mw, patel s, dykes f, pérez-rodrigo c, et al. the relationship between zinc intake and growth in children aged 1-8 years: a systematic review and meta-analysis. eur j clin nutr. 2015;69(2):147–53. 12. stoltzfus rj. iron deficiency: global prevalence and consequences. food and nutrition bulletin supplement. food nutr bull. 2003;24(4 suppl):s99-103. 13. mikhail wza, sobhy hm, el-sayed hh, khairy sa, salem hyha, samy ma. effect of nutritional status on growth pattern of stunted preschool children in egypt. acad j nutr. 2013;2(1):1–9. 14. kearney j. food consumption trends and drivers. philos trans r soc b biol sci. 2010;365(1554):2793–807. 15. national team for the acceleration of poverty reduction. summary of 100 priority districts/cities for interventions for stunting. jakarta pusat: sekretariat wakil presiden republik indonesia; 2017. [in bahasa indonesia] 16. budiastutik i, nugraheni a. determinants of stunting in indonesia: a review article. int j heal res. 2018;1(1):2620–5580. 17. dhital r, silwal rc, simkhada p, van teijlingen e, jimba m. assessing knowledge and behavioural changes on maternal and newborn health among mothers following postearthquake health promotion in nepal. plos one. 2019;14(7):1–15. 18. prasetyanti dk, fitriasnani me. the influence of calendar of health as a prevention of stunting in pre-marriage couples. str j ilm kesehat. 2020;9(2):1300–8. 19. semba rd, de pee s, sun k, sari m, akhter n, bloem mw. effect of parental formal education on risk of child stunting in indonesia and bangladesh: a cross-sectional study. lancet. 2008;371(9609):322–8. 20. fernald lch, kariger p, hidrobo m, gertler pj. socioeconomic gradients in child development in very young children : evidence from india , indonesia , peru ,. 2012;109:17273–80. 21. lee j, houser rf, must a, de fulladolsa pp, bermudez oi. socioeconomic disparities and the familial coexistence of child stunting and maternal overweight in guatemala. nurfita (stunting determinants in kulonprogo district, yogyakarta year 2019) vol. 4, no. 1, 2022, pp. 12-20 10.26555/eshr.v4i1.4039 20 econ hum biol. 2012;10(3):232–41. 22. schrijner s, smits j. grandparents and children’s stunting in sub-saharan africa. soc sci med. 2018;205(october 2017):90–8. 23. rahman n, napirah mr, nadila d, bohari. determinants of stunting among children in urban families in palu , indonesia. pakistan j nutr. 2017;16(november):750–6. 24. dewi r, evrianasari n, yuviska ia. hb levels, arm circumference and mother’s weight during pregnancy are at risk for stunting incidents in 1-3 years old children. j kebidanan malahayati. 2020;6(1):57–64. available from: http://ejurnalmalahayati.ac.id/index.php/kebidanan/article/view/1769. [in bahasa indonesia] 25. prabandari y, hanim d, ar rc, indarto d. correlation chronic energy deficiency and anemia during pregnancy with nutritional status of infant 6 – 12 months in boyolali regency. penelit dizi dan makanan. 2016;39(1):1–8. available from: https://media.neliti.com/media/publications/223581-hubungan-kurang-energi-kronik-dananemia.pdf. [in bahasa indonesia] 26. febrina y, santoso s, kurniati a. risk factors for stunting in newborns at wonosari hospital, gunungkidul regency in 2016. poltekes kemenkes yogyakarta. poltekes kemenkes yogyakarta; 2019. [in bahasa indonesia] 27. warsini kt, hadi h, nurdiati ds. history of kek and anemia in pregnant women is not associated with stunting in children aged 6-23 months in sedayu subdistrict, bantul, yogyakarta. j gizi dan diet indones. 2016;4(1):29–40. [in bahasa indonesia] microsoft word final pub 7237-article text.docx epidemiology and society health review| eshr vol. 5, no. 1, 2023, pp. 11-20 issn 2656-6052 (online) | 2656-1107 (print) http://journal2.uad.ac.id/index.php/eshr/index eshr@ikm.uad.ac.id 10.26555/eshr. v5i1.7237 11 research article study of adolescent health behavior towards noncommunicable disease risk factors in special region of yogyakarta luthfi nur rochman sudarko1, sitti nur djannah1*, lina handayani1, m. syamsu hidayat1, intan wahyuni tukiyo1 1 faculty of public health, universitas ahmad dahlan, yogyakarta, indonesia * correspondence: sitti.nurdjannah@ikm.uad.ac.id. phone: +6285868180863 correspondence: sitti.nurdjannah@ikm.uad.ac.idcom. phone: +62858-6818-0863 received 04 january 2023; accepted 02 february 2023; published 08 february 2023 abstract backgrounds: non-communicable diseases (ncds) are still one of the causes of high incidence and death rates in people of various age groups, especially adolescents with poor lifestyles and health behaviors due to a lack of awareness to prevent ncds from an early age. this study aimed to analyze adolescents health behavior of adolescents aged 15-24 years toward risk factors for non-communicable diseases based on the riskesdas results of the special region of yogyakarta. methods: this research is a quantitative descriptive study using secondary data to analyze the health behavior of adolescents aged 15-24 towards risk factors for non-communicable disease behavior based on data collected from riskesdas data for the special region of yogyakarta in 2007, 2013, and 2018. data analysis was carried out descriptively for each risk factor and presented as a percentage chart. results: the research shows that the risk factors for smoking every day and occasionally have decreased from 2007 to 2018. there has been an increase in the awareness of consuming fruits and vegetables. meanwhile, there was an increase in alcohol consumption in 2018 and a decrease in doing sufficient physical activity for one week in adolescents aged 15-24 years in the special region of yogyakarta. conclusion: it can be concluded that risk factors for health behavior related to noncommunicable diseases in adolescents are still caused by a lack of physical activity and the large number of adolescents who consume alcohol. keywords: adolescent, health behavior, non-communicable disease, riskesdas, risk factors sudarko et al. (study of adolescent health behavior towards non-communicable disease risk factors in special region of yogyakarta) vol. 5, no. 1, 2023, pp. 11-20 12 10.26555/eshr. v5i1.7237 introduction non-communicable diseases (ncds) kill 41 million people yearly, equivalent to 74% of all deaths globally. each year, 17 million people die from ncd before age 70; 86% of these premature deaths occur in lowand middle-income countries. of all ncd deaths, 77% are in lowand middle-income countries. cardiovascular disease is the most common cause of ncd death, or 17.9 million people each year, followed by cancer (9.3 million), chronic respiratory disease (4.1 million), and diabetes (2.0 million including deaths from chronic kidney disease). tobacco use, physical activity, harmful alcohol use, and unhealthy eating patterns all increase the risk of death from ncds. over 80% of ncd deaths occur from these four disease groups. detection, screening, and treatment of ncds and palliative care are critical components of the prevention and treatment of ncds.1 people with degenerative diseases (diseases caused by decreased organ function) are increasing due to modern lifestyles, including eating patterns, smoking, drinking, and using drugs.2 an unhealthy diet, lack of physical activity, exposure to tobacco smoke, or harmful alcohol use are all risk factors that contribute to ncds in children, adults, and the elderly.1 basic health research (riskesdas) 2013 shows the trend of non-communicable diseases as a cause of death is increasing, from 49.9% (2001) to 59.5% (2007). these non-communicable diseases include hypertension (25.8%), obesity (15.4%), stroke (12.1‰), diabetes mellitus (6.9%), coronary heart disease (1.5%), and chronic kidney failure (0.2%).3 the disease is driven by unplanned rapid urbanization, globalization of unhealthy lifestyles, and population aging. unhealthy eating patterns and lack of physical activity can appear in people as increased blood pressure, increased blood glucose, increased blood lipids, and obesity. regarding premature mortality, cardiovascular disease is the most common ncd caused by metabolic risk factors.1 the prevalence of hypertension in the special region of yogyakarta, according to the 2018 riskesdas, is 11.01% or higher compared to the national figure (8.8%). the yogyakarta special region is in 4th place as a province with high cases of hypertension. hypertension has been included in the top 10 diseases and the top 10 causes of death in the special region of yogyakarta for the last few years based on the integrated disease surveillance health center and integrated disease surveillance hospital. in 2020, based on the integrated hospital disease surveillance report in di yogyakarta, 6,171 new cases of hypertension and 33,507 were recorded. the total estimated number of hypertension sufferers aged ≥ 15 years is 210,112 cases. in 2020, the estimated number of hypertension sufferers aged ≥ 15 years have received health services is 69.6%. several diabetes mellitus cases in the special region of yogyakarta.4 non-communicable diseases are diseases that are not caused by bacterial or viral infections. non-communicable diseases often encountered include hypertension, diabetes mellitus, asthma, cardiovascular disease, mental disorders, and accidents. modernization, improved economic status, and lifestyle changes have increased the prevalence of non-communicable diseases. in the special region of yogyakarta in 2021, it is estimated that there will be 251,100 cases of hypertension sufferers aged ≥ 15 years. those who have received health services are 129,420 cases or 51.5%. cases of diabetes mellitus in 2021 are 83,568 cases, and those who receive standard health services are 50,530 cases (60.5%).2,5 sudarko et al. (study of adolescent health behavior towards non-communicable disease risk factors in special region of yogyakarta) vol. 5, no. 1, 2023, pp. 11-20 13 10.26555/eshr. v5i1.7237 looking at increasingly modern lifestyles and the impact of diseases caused both internationally and nationally, it can also be described in the behavior of adolescents that leads to risk factors for non-communicable conditions in the current era. changes in lifestyle which are risk factors for ncds, can also be described in the behavior of adolescents at this time. the prevalence of risk factors is the characteristics, signs, and symptoms of individuals statistically associated with an increased incidence of disease in the future. an unhealthy lifestyle is often associated with teenagers because of their numerous activities and bad eating habits.6–8 in another study, risky alcohol use, drug use, smoking, poor sleep, overweight/underweight, sedentary behavior, high media use, and truancy were linked to a range of poor mental health outcomes, including depression, anxiety and suicide among them. adolescents (mean age 14.9 years). risky alcohol use, drug use, smoking, unprotected sex, and sleep were all highly clustered lifestyle risk factors, while bmi was not. a risk index of risky alcohol use, drug use, unprotected sex, and sleep duration predicted the disease burden outcomes with the most incredible precision. more than thirty percent (31.9%) of the sample reported one or more of these behaviors. the risk index does not include energy balance risk behaviors, but bmi is used as a proxy for these behaviors. physical inactivity, eating patterns, and sedentary behavior was found to coexist in adolescents.9–11 previous studies have shown that risk factors for ncd that are at risk in adolescents are less consumption of vegetables and fruit and consumption of fast food.12 in addition, adolescents are also prone to risky behavior that has not been routinely carried out, namely blood pressure checks, physical activity, exercise, lack of consumption of fruits and vegetables, fast food, and smoking habits. early smoking is a risk factor for ncds, such as hypertension, heart disease, stroke, and cancer.6 non-communicable diseases occur due to various factors, such as smoking habits, unhealthy diets or eating patterns, minimal physical activity, and alcoholic beverages. in addition, family health history can also be a trigger for non-communicable diseases. many productive age groups are now experiencing disorders usually experienced by this elderly group. this condition is a threat that cannot be ignored. how could it not be? the productive age group is expected to become the next generation that will bring indonesia to face global competition.13,14 according to previous studies, the signs and symptoms generally do not appear during childhood and adolescence, making it difficult to detect during this period. nonetheless, the prevalence shows that most hypertension is lower in children or adolescents.15 based on this description, the purpose of this study was to analyze the health behavior of adolescents aged 15-24 years towards the risk factors for non-communicable disease behavior based on the riskesdas results from the special region of yogyakarta. methods this research is a quantitative descriptive study using secondary data to analyze the health behavior of adolescents aged 15-24 years toward risk factors for non-communicable disease behavior. data was generated from riskesdas data for the special region of yogyakarta in 2007, 2013, and 2018. the sample criteria for this study were adolescents aged 15-24 years old and having behaviors/habits: smoking habits (passive and active) both daily and occasionally, consuming less than five servings of fruit and vegetables, and having a history sudarko et al. (study of adolescent health behavior towards non-communicable disease risk factors in special region of yogyakarta) vol. 5, no. 1, 2023, pp. 11-20 14 10.26555/eshr. v5i1.7237 of drinking alcohol in the last month, history of physical activity for less than one week. data analysis was carried out descriptively for each risk factor and presented as a percentage chart. results figure 1 shows the health behavior risk factors in adolescents aged 15-24 years related to smoking habits, alcohol consumption habits, daily fruit and vegetable consumption, and a history of physical activity for at least 30 minutes daily. the history of smoking habits in adolescents aged 15-24 years was dominated by non-smoking adolescents in 2007, 2013, and 2018 but experienced a significant decrease every year. the daily history of smoking in adolescents decreased in 2007 from 19.2% to 17.26% in 2018. likewise, smokers sometimes also reduced to 7.47% in 2018 compared to 2007 (8.8%) and 2013 (8.35%). this is also supported by an increase in ex-smokers in 2018 of 12.78%, a far increase compared to 2007 of only 2.3%. figure 1. percentage of smoking history behavior in adolescents aged 15-24 years in the special region of yogyakarta the history of consuming alcohol in adolescents aged 15-24 years in the last month increased by 7.5% in 2018 compared to 2007, only 3.7% in 2013 (figure 2). figure 2. percentage of alcohol consumption in the last month at the age of 15-24 years in the special region of yogyakarta figure e shows that the lack of fruit and vegetable consumption in adolescents aged 1524 years, as much as five portions in 7 days, has decreased significantly from 2007 at 86.3% to 2018 at 31.23%. this shows that awareness of consuming fruits and vegetables among adolescents in the special region of yogyakarta has increased regarding one of the risk factors that trigger the emergence of non-communicable diseases in adolescents. 19 ,2 8, 8 2, 3 95 ,9 19 ,1 8, 35 7, 8 64 ,7 5 17 ,2 6 7, 47 12 ,7 8 61 ,6 s m o k e e v e r y d a y s m o k e s s o m e t i m e s e x s m o k e r n o n s m o k e r pe rc en ta g e history of smoking behavior 2007 2013 2018 3, 7 0 7, 5 2 0 0 7 2 0 1 3 2 0 1 8p er ce n ta g e alcohol consumption sudarko et al. (study of adolescent health behavior towards non-communicable disease risk factors in special region of yogyakarta) vol. 5, no. 1, 2023, pp. 11-20 15 10.26555/eshr. v5i1.7237 figure 3. percentage of lack of fruits and vegetable consumption (<5 servings/week) in 1524 years old figure 4 shows the behavioral risk factors in adolescents on physical activity. it shows that the physical activity carried out by adolescents is still inconsistent; adolescents who did the less physical activity for at least 30 minutes per day decreased in 2013 by 31.05%, while adolescents who did enough physical activity decreased from 2013 by 63, 95% to 54.26% in 2018. figure 4. percentage of physical activity (30 minutes/day) in people aged 15-24 years in the special region of yogyakarta discussion healthy living behaviors are actions related to a person's efforts or activities to maintain and improve their health or a healthy lifestyle. these behaviors include, among others: 1) eating a balanced menu (containing nutrients the body needs), and the amount is sufficient to meet the body's needs; 2) having regular exercise also includes quality (movement) and quantity in terms of the frequency and time used for sports or physical activities other than sports; 3) no smoking; 4) avoid drink alcohol or drugs.16 this study indicated that adolescents aged 15-24 still lack the awareness to consume fruits and vegetables and exercise for at least 30 minutes daily. on the other hand, the declining number of non-smokers is one of the focus factors for non-communicable diseases. smoking is one of the risk factors for non-communicable diseases that are common in society. still, according to riskesdas results, smoking is decreasing among people aged 15-24 years. health impacts that can arise from smoking behavior in adolescents include high blood pressure and heart problems caused by the influence of chemicals in cigarettes, such as nicotine and tar. in addition, it causes a decrease in the sensitivity of the sense of smell and taste for smokers.17 86 ,3 31 ,5 31 ,2 3 2 0 0 7 2 0 1 3 2 0 1 8 pe rc en ta g e lack of fruit and vegetables consumption 0 63 ,9 5 54 ,2 6 52 ,2 5 31 ,0 5 45 ,7 5 2 0 0 7 2 0 1 3 2 0 1 8 pe rc en ta g e history of physical activity moderately active less active sudarko et al. (study of adolescent health behavior towards non-communicable disease risk factors in special region of yogyakarta) vol. 5, no. 1, 2023, pp. 11-20 16 10.26555/eshr. v5i1.7237 the research results in developing countries show that smoking habits and diet quality, such as low fruit and vegetable consumption, are significantly higher in groups with low socioeconomic status, which directly relate to low education. residents with low education are associated with low awareness of healthy living behaviors and inadequate access to healthcare facilities, thereby increasing the risk of unhealthy lifestyles.18,19 based on previous studies, it was found that smoking behavior has a significant relationship with hypertension in adolescents and severe stress in adolescents.20–22 smoking by adolescents is a risk factor for dietary mistakes, poor oral health, and more dynamic damage to teeth, which may result in pain and tooth loss.23 our study indicates an increase in alcohol consumption in 2018 compared to 2007, but a history of alcohol consumption in 2013 was not recorded. the most significant factor for people consuming alcohol is environmental factors and friendships that influence a person's behavior. therefore self-awareness and self-principles are highly prioritized to make oneself avoid a particular risk factor.24 alcohol consumption, smoking habits, and excessive stress levels will impact health in the long term, one of which is an increase in blood pressure because alcohol has the same effect as carbon monoxide, which causes blood acidity to increase and blood pressure to rise.25 previous research on high school adolescents showed consistent results, namely that there were risk factors for high school students to experience infectious diseases due to smoking, consuming alcohol regularly, eating fewer vegetables and fruit, less physical activity, and blood pressure above normal and bmi above the normal standard.26 similar to research conducted at the anak dalam tribe in nyogan village, dietary patterns include fruit and vegetable consumption and risky foods such as sweets and foods containing seasonings. physical activity is a risk factor for hypertension and type ii diabetes mellitus (dm). the anak dalam society, which has a poor diet, has a risk of suffering 11.23 times from dm compared to suku anak dalam (sad), who have a good diet; it was seen from the lack of diversity and energy intake in one week.22 in contrast to alcohol consumption, adolescent awareness of consuming fruit and vegetables has increased; this is indicated by the decrease in the number of adolescents who consume fewer fruits and vegetables, at least five servings per week. this is in line with the previous research, which said that residents with poor diets and lack of fruit and vegetable consumption increase the incidence of non-communicable diseases and even death. the habit of consuming foods that are high in calories can cause obesity.2,27 the lack of fruit and vegetables is caused by the fact that fruits and vegetables are still considered complementary food, not a priority to consume. mothers' and parents' lack of understanding and skills in getting children to consume fruits and vegetables from an early age and a lack of variety in serving fruit is considered the primary cause of this behavior. besides, people have the perception that fruit is expensive.28,29 awareness of consuming fruits and vegetables can be increased with regular and continuous education to prevent non-communicable diseases.30 in line with the consumption of fruits and vegetables as a risk factor for non-communicable diseases, the risk factors for non-communicable diseases also experience a decrease in physical activity for 30 minutes per day. adolescents' awareness of physical activities to prevent non-communicable diseases still needs to improve. lack of physical activity, namely all body movements that burn calories, can be a risk factor for non-communicable diseases, including cardiovascular disease, obesity, and even diabetes mellitus.2,13,14,26 according to the sudarko et al. (study of adolescent health behavior towards non-communicable disease risk factors in special region of yogyakarta) vol. 5, no. 1, 2023, pp. 11-20 17 10.26555/eshr. v5i1.7237 ministry of the health republic of indonesia, tncd is caused by an unhealthy lifestyle, one of which is a lack of physical activity. intense activities and high mobility make people allocate less time to exercise. in addition, advanced technology makes it easier for people to meet their needs, so activities that require body movement are decreasing. lack of physical activity has also caused the trend of ncd to change; which initially only affected the elderly age group, but now it has been found in the young age group (0-15 years) and the productive age group (15-65 years ).31 previous research conducted at the school of hper at indiana university found that out of four risky behavior patterns, it was found that as many as 22% of women and 34% of men were included in a high-risk class characterized by poor eating patterns, lack of physical activity, and levels of substance use. female students in the "low substance use but other poor health behaviors" class were associated with racial/ethnic minority status and lower parental education levels.32 research by richardo et al. showed that the accumulation of noncommunicable disease risk factors was higher in girls, older adolescents, those who did not live with both parents, children of less-educated mothers, students attending public schools, and residents of cities in more developed urban areas of the country.33 it has been supported by other studies which state that being a boy, increasing age, and the presence of parental support reduce the likelihood of having risk factors for non-communicable disease behaviour.34 based on research conducted by yuningrum (2021) explains that the lifestyle of today's youth is at risk of non-communicable diseases as indicated by the consumption of vegetables and fruit, most of which are in the wrong category.12 research conducted by other studies also showed an unhealthy lifestyle, such as consumption of soft drinks, smoking, alcohol, and lack of physical activity, which causes a high risk of non-communicable diseases.35,36 the number of teenagers who rarely do physical activity and have a low level of physical activity to maintain body fitness is quite a lot. as a result, teenagers' health will be at risk because their body's metabolism is not adequately stimulated as they age. this condition is very worrying because the lack of physical activity will put you at risk for various degenerative diseases and even accelerate the onset of these diseases.7 non-communicable diseases that result from poor health behavior are also based on supporting factors, namely socio-economic status, income, and gender, to body mass index, which has an impact on adolescent obesity, especially in rural areas.37 supported by other studies which also state that heart disease globally contributes to 7.2-7.6% of deaths due to lack of physical activity, especially in developing countries depending on the population in the country.38 the vulnerability of non-communicable diseases in adolescents needs to be controlled and prevented related to healthy behavior and a healthier lifestyle. one of them is by conducting non-communicable disease screening through the integrated development post or posbindu ncd for adolescents, which is very useful for early detection of symptoms of noncommunicable diseases, monitoring and providing health education to increase youth understanding and knowledge regarding risk factors for non-communicable diseases among adolescents who are assisted by cadres or health center staff, also several strategies with policy-level implications which could be used to reduce smoking, improve nutrition, and increase physical activity.29,30,39,40 sudarko et al. (study of adolescent health behavior towards non-communicable disease risk factors in special region of yogyakarta) vol. 5, no. 1, 2023, pp. 11-20 18 10.26555/eshr. v5i1.7237 the germas program must continue to be encouraged to increase public awareness of adopting a healthy lifestyle. prevention efforts are far better than treatment when you have contracted the disease. with the increasing incidence of ncd, it is necessary to provide education and assistance to the community to carry out early detection or screening of ncd, especially in at-risk groups. besides that program, the beneficial effects of physical activity and cardiorespiratory fitness for the prevention of chronic non-communicable diseases. society should always be invited to recognize the disease. it is important to carry out community services regarding screening and assistance to prevent non-communicable diseases in the community.2,41 conclusion based on the results and discussion above, it can be concluded that there was a fluctuation of health behavior risk factors of riskesdas in 2007, 2013, and 2018 related to noncommunicable diseases. it can be caused by a poor lifestyle and unhealthy behavior such as smoking, alcohol consumption, lack of fruit and vegetables, and less physical activity. a related stakeholder is necessary to prevent and control non-communicable disease risk factors. one is conducting routine screening with health center cadres/officers through the integrated development post (posbindu) ncd for adolescents. acknowledgments we want to thank the riskesdas special region of yogyakarta team for the data and survey in yogyakarta and the ministry of health research and development center of the health republic of indonesia. declarations author's contribution lnr, snd, & iwt contained the presented idea of this study. snd and iwt developed the theory and designed the method. lnr collected the data, and snd & iwt verified the analytical methods. lh and msh reviewed and revised, and edited the manuscripts and publications. all authors have agreed on the manuscript's final draft before submitting it for publication. funding statement this research has not received external funding conflict of interests there is no conflict of interest in this research. references 1. who. fact sheets non communicable disease. https://www.who.int/news-room/factsheets/detail/noncommunicable-diseases. 2022. 2. warganegara e, nur nida nabilah. faktor risiko perilaku penyakit tidak menular. sudarko et al. (study of adolescent health behavior towards non-communicable disease risk factors in special region of yogyakarta) vol. 5, no. 1, 2023, pp. 11-20 19 10.26555/eshr. v5i1.7237 majority. 2016;5(2):88–94. 3. kemenkes. riskesdas 2013. badan penelitian dan pengembangan kesehatan kementerian kesehatan ri. 2013. 4. dinas kesehatan diy. profil kesehatan d.i yogyakarta tahun 2018. profil kesehat drh istimewa yogyakarta tahun 2018 [internet]. 2019;32. available from: http://www.dinkes.jogjaprov.go.id/download/download/27. 5. dinas kesehatan diy. profil kesehatan d.i yogyakarta tahun 2021. d.i. yogyakarta; 2022. 6. siswanto y, lestari ip. pengetahuan penyakit tidak menular dan faktor risiko perilaku pada remaja. pro heal j ilm kesehat. 2020;2(1):1–6. 7. permatasari a. pola makan dan aktivitas fisik sebagai faktor risiko ptm hipertensi, dm, stroke dan jantung pada siswa di smk n 6 sukoharjo : studi deskriptif. naskah publ. 2022;november. 8. irwan. epidemiologi penyakit tidak menular. yogyakarta: deepublish; 2016. 9. mewton l, champion k, kay-lambkin f, sunderland m, thornton l, teesson m. lifestyle risk indices in adolescence and their relationships to adolescent disease burden: findings from an australian national survey. bmc public health. 2019;19(1):1–11. 10. carli v, hoven cw, wasserman c, chiesa f, guffanti g, sarchiapone m, et al. a newly identified group of adolescents at “invisible” risk for psychopathology and suicidal behavior: findings from the seyle study. world psychiatry. 2014;13(1):78–86. 11. pearson n, biddle sjh, griffiths p, johnston jp, haycraft e. clustering and correlates of screen-time and eating behaviours among young children. bmc public health. 2018;18(1):1–9. 12. yuningrum h, trisnowati h, rosdewi nn. faktor risiko penyakit tidak menular (ptm) pada remaja: studi kasus pada sma negeri dan swasta di kota yogyakarta. j formil (forum ilmiah) kesmas respati. 2021;6(1):41. 13. widyasari n. relationship of respondent ’ s characteristic with the risk of diabetes mellitus and dislipidemia at tanah kalikedinding. j berk epidemiol. 2017;5(1):130–41. 14. amelia r, taiyeb am, idris is. hubungan pola makan dan aktivitas fisik terhadap kadar glukosa darah penderita diabetes melitus di wilayah kerja puskesmas sabbangparu kabupaten wajo relationship between diet and physical activity on blood glucose levels of diabetes mellitus patients in. pros semin nas biol vi. 2019;620–30. 15. kumar p, kumar d, ranjan a, singh cm, pandey s, agarwal n. prevalence of hypertension and its risk factors among school going adolescents of patna, india. j clin diagnostic res. 2017;11(1):sc01–4. 16. notoatmodjo s. promosi kesehatan dan ilmu perilaku. i. jakarta: rineka cipta; 2007. 17. khairunniza, susanto e, nugraha a. hubungan kebiasaan merokok terhadap penyakit tidak menular. pros semin nas. 2019;105–8. 18. musfirah m, masriadi. analysis of risk factor relation with hypertension occurrence at work area of takalala. j kesehat glob. 2019;2(2):93–102. 19. diffa putra surya, anindita a, fahrudina c, amalia r, renny. faktor risiko kejadian hipertensi pada remaja. j kesehat masy. 2022;3(2):10–5. 20. bawuna n, rottie j, onibala f. hubungan antara tingkat stres dengan perilaku merokok pada mahasiswa fakultas teknik universitas sam ratulangi. j keperawatan unsrat. 2017;5(2):107578. 21. saing jh. hipertensi pada remaja. sari pediatr. 2016;6(4):159. 22. kalsum u, lesmana o, pertiwi dr. pola penyakit tidak menular dan faktor risikonya pada suku anak dalam di desa nyogan provinsi jambi. media kesehat masy indones. 2019;15(4):338. 23. olczak-kowalczyk d, tomczyk j, gozdowski d, kaczmarek u. cigarette smoking as an oral health risk behavior in adolescents: a cross-sectional study among polish youths. anthropol rev. 2020;83(1):53–64. 24. sekarrini r, kurniawan re, makrifatullah na, rosar n, triana y, kunci k. gambaran sudarko et al. (study of adolescent health behavior towards non-communicable disease risk factors in special region of yogyakarta) vol. 5, no. 1, 2023, pp. 11-20 20 10.26555/eshr. v5i1.7237 faktor risiko penyakit tidak menular di kelurahan umban sari kecamatan rumbai pekanbaru menggunakan pendekatan stepwise who. j ilm multi disiplin indones. 2022;1(8):163–73. 25. sukma ep, yuliawati s, hestiningsih r, ginandjar p. hubungan konsumsi alkohol, kebiasaan merokok, dan tingkat stres dengan kejadian hipertensi usia produktif. j kesehat masy. 2019;7(3):122–8. 26. girsang vi, purba ie, harianja es. pemeriksaan faktor resiko penyakit tidak menular pada siswa menengah atas (sma). j adimas mutiara. 2021;2(1):128–32. 27. kurniati am, tamzil ns, dalilah d, prasasty gd, suciati t, muhammad f, et al. konsumsi sayur dan buah dalam upaya mencegah penyakit tidak menular. j pengabdi masy humanit med. 2022;3(2):105–15. 28. p2ptm ri. cegah penyakit tidak menular dengan rajin makan buah dan sayur dalam rangka memperingati hari buah sedunia 2017. https://p2ptm.kemkes.go.id/kegiatanp2ptm/subbagian-tata-usaha/cegah-penyakit-tidak-menular-dengan-rajin-makan-buahdan-sayur-dalam-rangka-memperingati-hari-buah-sedunia-2017. 2017. 29. rostinah r, nelly n. pengaruh peran orang tua dan aksesibilitas buah dan sayuran terhadap rendahnya konsumsi buah dan sayur pada anak pra sekolah di kota bima nusa tenggara barat. j manaj kesehat indones. 2022;10(1):1–6. 30. mahmudah u, yuliati e. edukasi konsumsi buah dan sayur sebagai strategi dalam pencegahan penyakit tidak menular pada anak sekolah dasar. war lpm. 2021;24(1):11–9. 31. p2ptm ri. rutin aktivitas fisik, keluarga terhindar ptm. https://p2ptm.kemkes.go.id/kegiatan-p2ptm/subbagian-tata-usaha/rutin-aktivitas-fisikkeluarga-terhindar-ptm. 2017. 32. luo j, agley j, hendryx m, gassman r, lohrmann d. risk patterns among college youth: identification and implications for prevention and treatment. health promot pract. 2015;16(1):132–41. 33. ricardo cz, azeredo cm, de rezende lfm, levy rb. co-occurrence and clustering of the four major non-communicable disease risk factors in brazilian adolescents: analysis of a national school-based survey. plos one. 2019;14(7):1–14. 34. pengpid s, peltzer k. behavioral risk factors of non-communicable diseases among a nationally representative sample of school-going adolescents in indonesia. int j gen med. 2019;12:387–94. 35. chakma, gupta s. lifestyle practice and associated risk factors of noncommunicable diseases among the students of delhi university. int j heal allied sci. 2017;6(1):20. 36. olawuyi at, adeoye ia. the prevalence and associated factors of noncommunicable disease risk factors among civil servants in ibadan, nigeria. plos one. 2018;13(9):1–20. 37. ahmad a, zulaily n, shahril mr, syed abdullah efh, ahmed a. association between socioeconomic status and obesity among 12-year-old malaysian adolescents. plos one. 2018;13(7):1–12. 38. katzmarzyk pt, friedenreich c, shiroma ej, lee im. physical inactivity and noncommunicable disease burden in low-income, middle-income and high-income countries. br j sports med. 2022;56(2):101–6. 39. blaga om, vasilescu l, chereches rm. use and effectiveness of behavioural economics in interventions for lifestyle risk factors of non-communicable diseases: a systematic review with policy implications. perspect public health. 2018;138(2):100–10. 40. trisnowati h. pemberdayaan masyarakat untuk pencegahan faktor risiko penyakit tidak menular (studi pada pedesaan di yogyakarta). j mkmi. 2018;14(1):17–25. 41. lavie cj, ozemek c, carbone s, katzmarzyk pt, blair sn. sedentary behavior, exercise, and cardiovascular health. circ res. 2019;124(5):799–815. microsoft word 3_5341_triyani_7 agustus.docx epidemiology and society health review| eshr vol. 4, no. 2, 2022, pp. 76-86 issn 2656-6052 (online) | 2656-1107 (print) 10.26555/eshr.v4i2.5341 76 research article quality of life among diabetes mellitus patients in indonesian chronic disease management program (prolanis) tri ani marwati1*, nur aini kusmayanti 2, rosyidah rosyidah1 1 faculty of public health, university of ahmad dahlan, yogyakarta, indonesia 2 department of nutrition, faculty of public health, university of ahmad dahlan, yogyakarta, indonesia *correspondence: triyani.marwati@ikm.uad.ac.id. phone: +628122942538 received 13 december 2021; accepted 07 august 2022; published 7 august 2022 abstract background: international diabetes federation (idf) data shows that the increasing prevalence of diabetes mellitus worldwide is still happening and is a significant global health challenge. patients with diabetes mellitus tend to have a poorer quality of life than those without a chronic disease. this study aims to obtain an overview of the quality of life of patients with diabetes mellitus. method: this research was a quantitative descriptive study with a cross-sectional approach, conducted in july–october 2021 at one of the chronic disease management program communities (prolanis) in bantul district, yogyakarta. the total participants of this study were 63 patients with diabetes mellitus who were registered in the prolanis community; they did not show mental disorders and were willing to participate in the study. we used purposive sampling to recruit the participants. researchers used the whoqol-brief questionnaire that has been standardized and created by who. other variables recorded in this study include eating patterns and socio-demographic characteristics. a descriptive analysis was conducted to present the results in tables and graphs. results: most participants were elderly (over 50 years old), had a high level of education, had good religious spirituality, were in marital status, and had no comorbidity. patients with diabetes mellitus in the prolanis group had a good quality of life and level of life satisfaction. the description of the participants' eating patterns was also good, where none of them consumed instant food anymore, and all consumed a variety of fruits and vegetables regularly. conclusion: this study showed the quality and satisfaction of life and a good diet in patients with diabetes mellitus in the prolanis community. therefore, it is necessary to advance the prolanis community to maintain the quality of life, life satisfaction, and lifestyle of patients with diabetes mellitus. keywords: quality of life; diabetes mellitus; prolanis community marwati (quality of life among diabetes mellitus patients in the indonesian chronic disease management program (prolanis)) 77 vol. 4, no. 2, 2022, pp. 76-86 10.26555/eshr.v4i2.5341 introduction the international diabetes federation (idf) reports an escalating prevalence of diabetes mellitus globally. this number will continue to increase and become a significant global health challenge for individuals, families, and communities. in 2021, the idf reported a total of 537 million or similar, with 1 in 10 adults living with diabetes. cases will increase to 643 million in 2030 and 784 million in 2045. the idf also states that because of diabetes, one person in the world dies every five seconds, and it causes a total loss of usd 966 billion (1). in indonesia, who and idf predict diabetes cases will increase by 2-3 times in 2030 (1-2). quality of life has an essential role in human health outcomes. it is the ultimate goal of all health interventions (3,4) who states that the definition of "health" is not only the absence of disease in a person but a state of complete physical, mental and social well-being (5). a person's quality of life can be measured by looking at physical and social functioning aspects and feelings towards their physical and mental condition (6). recently, interest in quality-oflife issues has increased significantly, especially in health-related issues. compared to persons who do not have a chronic disease, people with diabetes mellitus have a lower quality of life (7-9). people with diabetes mellitus have challenges accepting and adapting to the disease throughout their lives. therefore, improving or maintaining a good quality of life is part of the main goal in treating diabetes mellitus. studies identified factors related to the quality of life of people with diabetes mellitus, including blood sugar levels, complications with other diseases, and psychological, social, and demographic characteristics (3). the chronic disease management program (prolanis) is a health care system with a proactive approach implemented in an integrated manner involving participants, health facilities, and bpjs kesehatan. this program provided effective and efficient health care services, including medical education and consultations, home visits, reminders, club activities, and health status monitoring. prolanis aims to support participants who suffer from chronic diseases to achieve their optimal quality of life. prolanis' targets are all bpjs kesehatan participants with chronic conditions (diabetes mellitus type 2 and hypertension) (10). previous studies have reported positive public acceptance of prolanis, as evidenced by an increase in the number of participants, which has tripled since 2014 (11). however, some barriers related to support from policymakers were still found – i.e., limited funding, infrastructure, and human resources, as well as unclear standard operation procedure (sop) (12). this poor support, possibly caused by limited evidence, directly reported the advantages of prolanis for their participants. previous evaluation programs mainly focused on their impact on health costs and the health services system (11,12). thus, this study is intended to provide the descriptive impact of prolanis on its participants, particularly on their quality of life, to encourage policymakers to give maximum support to this program. marwati (quality of life among diabetes mellitus patients in the indonesian chronic disease management program (prolanis)) 78 vol. 4, no. 2, 2022, pp. 76-86 10.26555/eshr.v4i2.5341 method the research design and setting this research was a quantitative descriptive study with a cross-sectional method conducted from july-october 2021 in one of the prolanis communities in bantul regency, di yogyakarta. the reason for choosing this location was based on data showing 610 diabetes mellitus patients joined the prolanis community in bantul regency. research participants this study involved 61 patients with diabetes mellitus registered in the prolanis community, who did not show mental disorders, could communicate well and were willing to participate. the sample was selected by using purposive sampling. the sample calculation was based on a 90% confidence level and a 10% margin error. research variables and instruments the primary variable in this study was the quality of life of patients with diabetes mellitus. researchers used the standardized whoqol-brief questionnaire (6) and created by who. this questionnaire has good reliability, as indicated by an alpha coefficient of 0.76 and external validity of 93%. in this study, researchers included four aspects (physical, psychological, social, and environmental) in the whoqol-brief questionnaire. social factors: personal relationships, social relationships, and sexual activities. ecological aspects: have financial resources, freedom, security, physical safety, health and social care, home environment, sharing of information and skills, and engaging in fun activities. all questions were assessed using a likert scale of 1-5, including intensity, capacity, frequency, and evaluation. other variables recorded in this study: eating patterns and socio-demographic characteristics. dietary data were taken using a questionnaire containing the grouping of foodstuffs based on macro and micro nutrition sources and the frequency of eating weekly. data analysis data analysis was done descriptively through cleaning, editing, and coding before further analysis. the analysis was presented in graphical form to make it more informative. ethical consideration researchers respect participant confidentiality and only use research data for scientific purposes. researchers had explained the entire research process to the participants before the study was conducted. the research started when the participants had signed the informed consent. marwati (quality of life among diabetes mellitus patients in the indonesian chronic disease management program (prolanis)) 79 vol. 4, no. 2, 2022, pp. 76-86 10.26555/eshr.v4i2.5341 results general characteristics the total participants of this study were 61 patients with diabetes mellitus. most of the research participants were male, aged over 50 years (elderly), moslem, not working formally (housewife, retired, not working), highly educated (at least a bachelor's degree), and were in marital status. the comorbidities found in this study: are cholesterol, high blood pressure, gout, stomach acid, heart disease, and tuberculosis. however, for the most part, the study participants had no comorbidities. most of the participants in this study had a good quality of life and were satisfied with their current living conditions (table 1). table 1. characteristics of diabetes mellitus patients in the prolanis group variables frequency percentage (%) gender female male 33 28 54 46 age <50 >50 17 44 28 72 religion moslem not moslem 57 4 93 7 employment status employed unemployed 36 25 59 41 education senior high school or less university 23 38 37 63 marital status married not married 57 4 93 7 comorbidities no comorbidities hypertension lung disease gout cholesterol heart disease 37 14 4 3 3 1 61 23 7 5 5 2 quality of life very good good fair worse 9 32 13 7 15 53 21 12 self-condition satisfaction very satisfied satisfied moderately satisfied not satisfied 8 33 19 1 13 54 31 12 the quality of life physically, psychologically, socially, and environmentally. based on physical categories, most study participants did not need medical therapy, had an adequate sleep, and did not feel pain or discomfort. for the most part, participants thought they could work and carry out mobility daily, although they felt pretty tired and entirely dependent on drugs (figure 1). marwati (quality of life among diabetes mellitus patients in the indonesian chronic disease management program (prolanis)) 80 vol. 4, no. 2, 2022, pp. 76-86 10.26555/eshr.v4i2.5341 figure 1. the quality of life of diabetes mellitus patients by physical category psychologically, some of the research participants felt they could keep thinking, had good spirituality or belief in religion, were confident, had positive feelings, and were able to provide a self-image (figure 2). figure 2. the quality of life of diabetes mellitus patients by psychological category the results of this study indicated that most participants have a level of satisfaction that is not high enough for social quality, including satisfaction with support from friends and other social support, satisfaction with relationships and personal relationships, satisfaction with living 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% need medical therapy need rest feel unwell and discomfort perform mobility in daily life being able to work feeling tired very often drug addiction performing daily activities very high high moderate low very low 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% try to keep thinking and studying has religious believe self-confidence has positive thinking has negative thinking self-recognition very high high moderate low very low marwati (quality of life among diabetes mellitus patients in the indonesian chronic disease management program (prolanis)) 81 vol. 4, no. 2, 2022, pp. 76-86 10.26555/eshr.v4i2.5341 conditions, satisfaction with sexual life, and satisfaction to access information. however, most participants were satisfied with their health services (figure 3). figure 3. the quality of life of diabetes mellitus patients by social category the study's results related to the description of the quality of life based on environmental factors showed that most participants were in a relatively healthy and safe environment and quite able to enjoy their lives. most of them can do recreation and fun activities with moderate frequency. however, most also experience mild frequency disturbances from pollution, noise, climate, and traffic (figure 4). figure 4. experience of disturbances from pollution, noise, climate, and traffic the diet of patients with diabetes mellitus the results showed that the most consumed carbohydrate source by the participants was white rice. meanwhile, many participants have never again consumed instant noodles. participants in this study consumed a variety of sources of protein and vegetables. the type of fruit most consumed by participants in this study was banana. meanwhile, dragon fruit and melon were the most never consumed fruits by participants in this study. participants in the study were a group that rarely consumed milk and yoghurt, and many never consumed both (figures 5-9). 0% 20% 40% 60% 80% 100% sexual satisfaction support from friends satisfaction towards place of live satisfaction towards health facility sociability information access for daily life very satisfied satisfied moderate dissatisfied very dissatisfied 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% po lut ion , n ois e, cli ma te tra ns po rta tio n s ati sfa cti on he alt hy en vir on me nt sa fet y e nv iro nm en t su pp or t t o c on ce nt ra te life is m ea nin gfu l en joy lif e ne ed m ed ica l s up po rt lei su re op po rtu nit ies too many many moderate low never marwati (quality of life among diabetes mellitus patients in the indonesian chronic disease management program (prolanis)) 82 vol. 4, no. 2, 2022, pp. 76-86 10.26555/eshr.v4i2.5341 figure 5. diet of diabetes mellitus patients based on carbohydrate sources figure 6. diet of diabetes mellitus patients based on protein source figure 7. diet of diabetes mellitus patients by vegetable group 0% 20% 40% 60% 80% 100% white rice yellow rice bread instant noodle casava never 1-3 times a month 1-3 times a week 1-3 times a day 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% ch ick en me at du ck ch ick en eg gs du ck eg gs ta hu /to fu te mp eh ca t f ish ba nd en g f ish mu jai r f ish to ng ko l fi sh sh rim p sq uid ch ick en gi zza rd ch ick en liv er never 1-3 times a month 1-3 times a week 1-3 times a day 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% sp ina ch wa te r s pin ac h so up so ur so up ca p c ay lon g b ea ns mu sh ro om ur ap pe ce l never 1-3 times a month 1-3 times a week 1-3 times a day marwati (quality of life among diabetes mellitus patients in the indonesian chronic disease management program (prolanis)) 83 vol. 4, no. 2, 2022, pp. 76-86 10.26555/eshr.v4i2.5341 figure 8. diet of diabetes mellitus patients by fruits group figure 9. diet of diabetes mellitus patients by milk and yoghurt group discussion this study showed that diabetes mellitus patients in the prolanis group had a good quality of life and level of life satisfaction. however, most of them were elderly (over 50 years of age). prolanis is a health care system and a proactive approach implemented in an integrated manner involving participants, health facilities, and bpjs kesehatan. in this context of health care for bpjs kesehatan participants who suffer from chronic diseases achieve optimal quality of life with effective and efficient health care costs (10). the results of this study are similar to previous studies in the age group over 65 years, which showed that communitybased programs such as prolanis, which encourage activity and involvement of patients in maintaining health, can improve the quality of life of patients with diabetes mellitus (13-14). this study's results differ from a study conducted in mexico, which reported a low quality of life for people with diabetes mellitus (15). this result is probably because the participants in mexico were patients in the hospital, while the participants in this study were prolanis participants in the community. the assessment results in the physical, psychological, social, and environmental categories indicate good quality and life satisfaction. participants gave "fair" to "high" scores on all aspects of the assessment. the level of good quality and life satisfaction in this study was influenced by socio-demographic characteristics and clinical status of diabetes mellitus 0% 20% 40% 60% 80% 100% ba na na me lon wa te rm elo n ma ng o ap ple or an ge dr ag on fr uit sn ak e f ru it never 1-3 times a month 1-3 times a week 1-3 times a day 0% 20% 40% 60% 80% 100% never 1-3 times a month 1-3 times a week 1-3 times a day yoghurt fresh milk marwati (quality of life among diabetes mellitus patients in the indonesian chronic disease management program (prolanis)) 84 vol. 4, no. 2, 2022, pp. 76-86 10.26555/eshr.v4i2.5341 patients who participated in this study. including higher education level, good religious spirituality, marital status, and not having comorbidities. the participants in this study also had a picture of a good diet, where none consumed instant food, and all consumed various fruits and vegetables regularly. the resulting study is also in line with the previous research. although many are retired or no longer actively working formally, higher education levels symbolize good economic conditions that can improve their mood so that their perceptions of quality and life satisfaction are high (16). at the same time, research also proves that low levels of education are associated with low quality of life in patients with diabetes mellitus (17). the results of previous studies also showed that belief in religion significantly increased the patient's strength in dealing with difficult situations due to the diagnosis of his illness (18). marital status, which shows family support, is also a factor that significantly affects the quality of life of people with chronic diseases, even more than support from friends or other social environments (19). another thing that is very important in influencing the quality of life of patients with diabetes mellitus is a comorbid disease (20,21) because its presence can increase psychological stress and or reduce the patient's activity and mobility. this research is one of the studies on the quality of life and life satisfaction that is rarely carried out in the prolanis community in yogyakarta. therefore, this research is expected to become scientific evidence regarding the importance of conducting similar studies in more numbers so that health workers have good sources to pay more attention to patients' quality and life satisfaction with diabetes mellitus. the researcher admits that this research is limited by an explanatory study approach where all research results are analyzed and presented descriptively without analyzing the relationship on each variable. conclusion this study showed the quality and satisfaction of life and a good diet in patients with diabetes mellitus in the prolanis community. although most study participants did not have comorbidities, many still had hypertension and cholesterol. therefore, the researchers recommend that the prolanis member be more active in the prolanis community to maintain the quality of life, life satisfaction, and lifestyle of patients with diabetes mellitus, including by providing a pocketbook, "healthy living guide for diabetes mellitus patients." acknowledgement we are grateful to the university of ahmad dahlan for funding this research. we thank the prolanis community in bantul district for participating in this study. authors' contribution tam did the chapters introduction, method and result, nak did the data analysis, and r did language editing and generated the abstract funding statement this research has not received external funding. marwati (quality of life among diabetes mellitus patients in the indonesian chronic disease management program (prolanis)) 85 vol. 4, no. 2, 2022, pp. 76-86 10.26555/eshr.v4i2.5341 conflict of interest there is no conflict of interest in this research. references 1. international diabetes federation. idf diabetes atlas | tenth edition. international diabetes federation. 2011. 2. world health organization. diabetes in indonesia. world health organization. 2011. 3. rubin rr, peyrot m. quality of life and diabetes. diabetes mellitus research and reviews. 1999;15:205–2018. 4. haraldstad k, wahl a, andenæs r, andersen jr, andersen mh, beisland e, et al. a systematic review of quality of life research in medicine and health sciences. vol. 28, quality of life research. springer international publishing; 2019. p. 2641–50. 5. world health organization. constitution of the world health organization. world health organization. 2011. 6. the whoqol group. development of the world health organization whoqol-bref quality of life assessment. the whoqol grou. social science and medicine. 1998;46(12):1569–85. 7. nunes-silva jg, nunes vs, schwartz rp, mlss trecco s, evazian d, correa-giannella ml, et al. impact of type 1 diabetes mellitus and celiac disease on nutrition and quality of life. nutrition and diabetes. 2017 jan 9;7(1). 8. tonetto if de a, baptista mhb, gomides d dos s, pace ae. quality of life of people with diabetes mellitus. revista da escola de enfermagem. 2019;53. 9. zhuang y, ma qh, pan cw, lu j. health-related quality of life in older chinese patients with diabetes. plos one. 2020;15(2). 10. bpjs kesehatan. prolanis (program pengelolaan penyakit kronis). bpjs kesehatan, editor. indonesia; 2014. 11. khoe lc, wangge g, soewondo p, tahapary dl, widyahening is. the implementation of community-based diabetes and hypertension management care program in indonesia. plos one. 2020 jan 1;15(1). 12. rachmawati s, prihhastuti-puspitasari h, zairina e. the implementation of a chronic disease management program (prolanis) in indonesia: a literature review. in: journal of basic and clinical physiology and pharmacology. de gruyter; 2020. 13. markle-reid m, ploeg j, fraser kd, fisher ka, bartholomew a, griffith le, et al. community program improves quality of life and self-management in older adults with diabetes mellitus and comorbidity. j am geriatr soc. 2018 feb 1;66(2):263–73. 14. karamanakos g, costa-pinel b, gilis-januszewska a, velickiene d, barrio-torrell f, cosclaramunt x, et al. the effectiveness of a community-based, type 2 diabetes prevention programme on healthrelated quality of life. the de-plan study. plos one. 2019 oct 1;14(10). 15. zurita-cruz jn, manuel-apolinar l, arellano-flores ml, gutierrez-gonzalez a, najeraahumada ag, cisneros-gonzález n. health and quality of life outcomes impairment of quality of life in type 2 diabetes mellitus: a cross-sectional study. health and quality of life outcomes. 2018 may 15;16(1). 16. stojanović m, cvetanović g, anđelković-apostolović m, stojanović d, rančić n. impact of socio-demographic characteristics and long-term complications on quality of life in patients with diabetes mellitus. central european journal of public health. 2018 jun 1;26(2):104–10. 17. de souza ma, de freitas rwjf, de lima ls, dos santos ma, zanetti ml, damasceno mmc. health-related quality of life of adolescents with type 1 diabetes mellitus. revista latino-americana de enfermagem. 2019;27. marwati (quality of life among diabetes mellitus patients in the indonesian chronic disease management program (prolanis)) 86 vol. 4, no. 2, 2022, pp. 76-86 10.26555/eshr.v4i2.5341 18. matos td de s, meneguin s, ferreira m de l da s, miot ha. calidad de vida y coping religioso-espiritual en pacientes bajo cuidados paliativos oncológicos. revista latinoamericana de enfermagem. 2017;25. 19. jalali-farahani s, amiri p, karimi m, vahedi-notash g, amirshekari g, azizi f. perceived social support and health-related quality of life (hrqol) in tehranian adults: tehran lipid and glucose study. health and quality of life outcomes. 2018 may 10;16(1). 20. naranjo c, ortega-jimenez p, del reguero l, moratalla g, failde i. relationship between diabetic neuropathic pain and comorbidity. their impact on pain intensity, diab. diabetes research and clinical practice. 2020;165. 21. aschalew ay, yitayal m, minyihun a. health-related quality of life and associated factors among patients with diabetes mellitus at the university of gondar referral hospital. health and quality of life outcomes. 2020 mar 10;18(1). microsoft word ^7229-revisi13 maret 2023-edited 2-ss.docx epidemiology and society health review| eshr vol. 5, no. 1, 2023, pp. 51-59 issn 2656-6052 (online) | 2656-1107 (print) http://journal2.uad.ac.id/index.php/eshr/index eshr@ikm.uad.ac.id 10.26555/eshr.v5i1.7229 51 review article the relationship between household good security and incidence of stunting in toddlers during the new normal: a systematic review dwi syaputri yanti1*, sumardiyono2, kusnandar3 1 department of human nutrition, universitas sebelas maret, surakarta, indonesia 2 department of occupational safety and health vocational school, universitas sebelas maret, surakarta, indonesia 3 department of agribusiness, faculty of agriculture, universitas sebelas maret, surakarta, indonesia * correspondence: dwisyaputriy@gmail.com. phone: +6282387047115 received 09 january 2023; accepted 13 march 2023; published 13 march 2023 abstract background: stunting is a growth disorder and malnutrition problem experienced by toddlers worldwide and affects the quality of human resources that have an essential role in developing a nation. households experiencing food insecurity led to a lack of nutritional intake and stunting. this work aimed to analyze the relationship between household food security with the incidence of stunting in toddlers during the new normal era. method: this was a systematic review design conducted by searching relevant articles from some databases: google scholar, pubmed, and science direct using the keywords (“household food security” or “food security families”) and (“stunting” or “stunted” “nutritional status”) and (“toddlers” or “children”) and (“new normal” or “adaptation of “new habits”) in bahasa indonesia and english. this work was performed following prisma guidelines. articles were selected based on inclusion criteria: publication date from 2017 to 2022, food security with stunting incidence and factors affecting stunting, full text, open access, and academic journals. articles were analyzed using a matrix table. results: based on the search results for articles that match the keywords, there are 333 articles. of these, ten articles come from indonesia, iran, and rwanda. the analyzed articles were selected from 10 articles. conclusion: this study concludes that there is a relationship between household food security and the incidence of stunting in toddlers during the new normal. keywords: household food security; stunting; toddlers; new normal yanti et al. (the relationship between household good security and incidence of stunting in toddlers during …) vol. 5, no. 1, 2021, pp. 51-59 52 10.26555/eshr.v5i1.7229 introduction human resources (hr) quality is critical to a country's development. indonesia 2020 has a human resources index of 0.54 and is ranked 87th out of 174 countries.1 as a developing country, indonesia's low human resource index is a serious issue, with stunted children being one of the causes. this situation demonstrates that indonesia is likely to lose its future economic potential. new normal is a term that refers to a new situation or condition that arises after significant changes occur in society during the covid-19 pandemic. in the context of the covid-19 pandemic, stunting can become a severe problem due to the pandemic's impact on food and nutrition available for the population, primarily related to the ability to provide sufficient nutrients. for some low-income families who are affected economically and struggle to meet their children's nutritional needs, thus pandemic could be a horrible situation. accordingly, efforts are needed to address the potential increase of stunting in the new normal condition. this must be a collective concern and the responsibility of the entire community to prevent young children from stunting. stunting is one of the effects of hunger on toddlers worldwide. in 2017, approximately 150.8 million (22.2 %) children under five were stunted. according to the world health organization, indonesia ranks third in the southeast asia/south-east asia regional (sear) region for stunting prevalence, with 36.4 percent (who).2 furthermore, according to the riskesdas findings from 2018, indonesia has a stunting rate of 30.8 percent.3 in 2019, the prevalence of stunting in children under five years old, based on the studi status gizi indonesia (ssgi) results, was 27.67 percent4 and decreased to 24.4 percent in 2021.5 although the prevalence of stunting has decreased, the prevalence is still very high. it is considered a public health problem because the target for reducing the prevalence of stunting is less than 20%.2 one of the public health issues associated with stunting is an increased risk of disease, death, and cognitive and motor development challenges that will limit their productivity as adults.6 problems with food security, education, access to clean water, poverty, social issues, and other issues, in addition to health issues, influence the high stunting rate.7 the covid-19 pandemic has significantly impacted people's lives in the health and economic sectors, particularly on the elements that affect stunting. children's nutritional status will undoubtedly be influenced by the fact that approximately 3 million people have lost their jobs or means of support, children no longer have access to programs that deliver nutritious food to schools, and some families are struggling to buy the food they usually eat.8 previous research has found that households with low socioeconomic status are 1.67 times more likely to experience stunting than households with higher socioeconomic status.9 this study aims to determine whether household food security and the prevalence of stunting in toddlers during the new normal era are related based on the information provided. according to unicef (2013), one factor that influences stunting is household food security.10 food insecurity in households can be caused by insufficient availability and access, resulting in inadequate food intake or nutrition.11 according to safitri, children under five from foodinsecure families have a 21.4 percent higher risk of stunting.12 adelina claimed that children under five from non-food insecure homes are 3,059 times more likely to suffer from stunting.13 yanti et al. (the relationship between household good security and incidence of stunting in toddlers during …) vol. 5, no. 1, 2021, pp. 51-59 53 10.26555/eshr.v5i1.7229 in the new normal era, it is necessary to make adjustments and adaptations to the new way of life after experiencing many changes in social and economic aspects during the covid-19 pandemic that have affected or worsened the stunting condition. in the new normal era, it is essential to continue consuming healthy and nutritious foods and maintaining hygiene and health by adhering to health protocols. therefore, this research contributes to determining policies for preventing and reducing the stunting rate. method strategies for searching for relevant articles in indonesian and english, the age of the children who are respondents under five years old, and research articles published online between 2017 and 2022 using three databases: google scholar databases, pubmed and science direct. in the research, the authors used the boolean operators “and” and “or,” wildcards, and truncation to expand the search for various tenses. the keyword used for the search were (“household food security” or “food security families”) and (“stunting” or “stunted” “nutritional status”) and (“toddlers” or children”) and (“new normal” or “adaptation of new habits”). a matrix table was used to analyze the literature review. this review included studies with cross-sectional designs. studies were excluded if they were not linked to stunting, the child was not under five, and the subject was drawn from an unhealthy population. the inclusion criteria for this study were articles with titles and content relevant to the objectives that were published in full text in english or indonesian. articles found were screened by title and abstract according to the inclusion and exclusion criteria—literature search strategies using the pico approach (table 1). table 1. pico approach used in this research pico search terms patient or problem stunting and toddler intervention new normal, household food security comparison outcome household food security is good, so there are no stunting toddlers the flow of the article review using the prisma guideline is presented in figure 1. based on search results on google scholar, pubmed, and science direct, we found 6,101 articles that match those keywords. as many as 2,232 report found according to the research title are then screened, namely looking at the article list that matches the inclusion criteria; after being traced there, are:1,899 articles were excluded because they did not meet the inclusion criteria. by going back and re-excluding up to 324 articles that were duplicated and did not fulfill the inclusion criteria, 10 articles that did meet the inclusion criteria were obtained for evaluation, allowing for the assessment of eligibility against 333 full-text articles. yanti et al. (the relationship between household good security and incidence of stunting in toddlers during …) vol. 5, no. 1, 2021, pp. 51-59 54 10.26555/eshr.v5i1.7229 figure 1. flowchart of the study course results the reviewed articles have shown a correlation between household food security and the occurrence of stunting in toddlers. to examine this relationship, relevant and recent studies were tracked and compiled in table 3. each study presented in the table includes information on the author, title, purpose, methodology, and results of the research google scholar: 1,310 pubmed: 3,669 science direct: 1,122 total: 6,101 id en tif ic at io n s cr ee ni ng e lig ib ili ty r ev ie w 2,232 screening articles 3,869 articles were excluded due to did not match the keyword 1,899 full text articles were excluded due to duplication and did not match the inclusion criteria 333articles open access and full text were eligible for analysis 10 articles were reviewed • subjects age >5 years • subjects were recruited from an unhealthy population • article has no relation yanti et al. (the relationship between household good security and incidence of stunting in toddlers during …) vol. 5, no. 1, 2021, pp. 51-59 55 10.26555/eshr.v5i1.7229 table 3. article review result no title, author study aims method result 1. relationship between food security and diarrhea disease with stunting in toddlers 13-48 months in manyar sabrangan village, surabaya safitri et al., (2020)12 to analyze the relationship between household food security and diarrheal diseases with stunting in children under five. crosssectional study there is a relationship between household food security and stunting with a p-value<0.050. 2. the relationship between household food security with toddler nutritional status (study in palasari village and community health center in legok district, tangerang regency) arlius a et al., (2017) 14 this study aims to examine the relationship between food security and the nutritional status of children under five and various efforts to improve food security in preventing under-five malnutrition in the working area of the legok health center, legok district, tangerang regency. crosssectional study there is a relationship between household food security and the nutritional status of children under five 3. household food insecurity as a predictor of stunted children dan overweight/ obese mothers (scowt) in urban indonesia mahmudionot et al., (2018) 15 to determine the relationship between household food security with the incidence of stunting and obesity (scowt) crosssectional study there is a relationship between household food insecurity with stunting children and scowt 4. household food security with stunting and nonstunting in children aged 623 months in wilangan sub-district, nganjuk regency fadzila d et al., (2019)11 analyzing the condition of household food security with stunting and nonstunting in children aged 623 months in wilangan sub-district, nganjuk regency. casecontrol there is a relationship between the age of children under two years (p = 0.02) and food security (p = 0.041) with stunting. 5. analysis of factors affecting the prevalence of stunting in children under five years rahayuwati l et al., (2020)16 to analyze the factors that affect the prevalence of stunting in children in the west java region, including sociodemographics of mothers, children, and children's health status. crosssectional there is a relationship between mother's work, childbirth complications, completeness of immunization distribution, schedule of immunizations, exclusive breastfeeding, and medical records of children with stunting. 6. a community-based survey of household food insecurity and associated socio demographic factors among 2-6 years old children in the southeast of iran sotoudeh m et al., (2021)17 to find out the status of household food insecurity and influencing sociodemographic factors in children aged in urban areas of iran crosssectional there is an influence of household food insecurity and sociodemographic factors, including weight and height, mother's education level, and sanitation in children 2-6 years old. yanti et al. (the relationship between household good security and incidence of stunting in toddlers during …) vol. 5, no. 1, 2021, pp. 51-59 56 10.26555/eshr.v5i1.7229 no title, author study aims method result 7. analysis of household food security and household characteristics with the incidence of stunting sihite n et al., (2021)18 to analyze the relationship between household food security and household social factors with the incidence of stunting. crosssectional a significant relationship exists between household food security (p= 0.031) and stunting incidence. household food security is directly related to the incidence of stunting; families in households who are not food insecure tend to have children under five who are classified as stunting; this is due to the lack of nutritional intake received both in terms of quantity and quality and did not meet the nutritional adequacy standard for stunting toddlers. 8. food insecurity in household level with stunting during the covid19 pandemic imansari a et al., (2022)19 to analyze the relationship between food insecurity at the household level and stunting during the covid-19 pandemic crosssectional there is no significant relationship between the level of household food insecurity with the incidence of stunting in toddlers 9. analysis of food expenditure, food security, and nutrient intake of under two years old as stunting risk factors aritonang e et al., (2020)20 to analyze the proportion of food expenditure, household food security, and food intake as a risk factor for stunting children aged 6-24 month casecontrol there is a relationship between household food security and the incidence of stunting (p = 0.018), and household food insecurity has a 6.9 times greater risk of experiencing stunting. 10. moderate and severe household food insecurity predicts stunting and severe stunting among rwanda children 6-59 months residing in gicumbi district agho et al., (2018)21 to examine the association between household food insecurity and stunting and severe stunting among rwandan children aged 659 months residing in the gicumbi district. crosssectional there is a correlation between moderate and severe household food insecurity with stunting and severe stunting. the odds of moderate and severe hfi were significantly higher among stunted children aged 6-59 months than those not. children from households with moderate food insecurity were 2.47 times more likely to be severely stunted. those from families with severe food insecurity were more likely to be severely stunted (aor = 1.82) compared with children aged 6-59 months from households with food security. discussion the high prevalence of stunting is not only related to health problems but also influenced by other issues that indirectly affect health, such as food security, education, availability of clean water, poverty, social factors, and others.2 according to unicef (united nations children's fund), household food security is one-factor affecting stunting.10 food insecurity in households can be caused by insufficient availability and access to food, resulting in inadequate food or nutrient intake.11 toddlers classified as stunted are more common in families with inadequate access to nutritious food. children in households tend to experience a lack of nutritional intake needed for optimal growth and development. this can cause stunting in children, impacting physical yanti et al. (the relationship between household good security and incidence of stunting in toddlers during …) vol. 5, no. 1, 2021, pp. 51-59 57 10.26555/eshr.v5i1.7229 and mental health, and a high risk of developing chronic diseases in the future.18 a lack of food supply and poor nutrition, especially in terms of providing a balanced diet for the household, are further variables that contribute to food insecurity in families.12 in addition, food security is impacted by socioeconomic status, which affects children who experience stunting.23 food security is when all households have physical and economic access to sufficient and nutritious food for all family members. poverty and lack of income can lead to a lack of ability for families to provide adequate and healthy food for all family members, resulting in food insecurity, which can impact the nutritional status of children.20 based on ten reviewed studies, household food security is directly related to the incidence of stunting. in a study by sihite et al.,18 there was a significant association between household food security and the incidence of stunting in children. adelina et al.13 also stated that there is a relationship between household food security and the incidence of stunting, with an or value of 3.059. this is further supported by the study by aritonang,20 which found that the risk of stunting is 6.9 times higher in children from households that are not food-secure, as stunting results from the long-term effects of nutrient deficiencies. therefore, children who live in foodinsecure homes for years will experience stunting.24 household food security and stunting are related because the household's inability to meet sufficient and balanced food needs can affect the child's nutritional intake. insufficient nutrient intake during early growth and development can lead to stunting. children who experience stunting tend to have a higher risk of ongoing health problems. therefore, efforts to improve household food security and ensure sufficient and balanced nutrient intake for children are crucial in preventing and addressing stunting. in the new normal era, household food security still closely correlates with the incidence of stunting in children. although there have been changes in eating habits and dietary patterns in the new normal era, the risk of inadequate nutrient intake in children still exists, especially in families experiencing economic difficulties or being affected by the covid-19 pandemic.25 the new normal era can also worsen household food security due to economic and social restrictions affecting access to nutritious food.26 therefore, efforts to improve household food security must continue to be increased in the new normal era by providing access to quality food, increasing education on healthy and nutritious eating patterns, and providing support and assistance to families experiencing economic difficulties. this can help prevent stunting in children and improve the quality of life for communities in the new normal era. conclusion this review concludes that stunting was still a global health issue that needs to be addressed in the new normal era. there was a relationship between household food security and the incidence of stunting in toddlers. toddlers from food-insecure households have a higher risk of experiencing stunting compared to toddlers from food-secure families. using backyard gardens can be an alternative solution for household food security. therefore, the community needs to be informed about the importance of nutrition and health, educated on how to utilize backyard land effectively, and receive support from the local government to increase access to food or meet the needs of simple gardening activities in their backyard land. yanti et al. (the relationship between household good security and incidence of stunting in toddlers during …) vol. 5, no. 1, 2021, pp. 51-59 58 10.26555/eshr.v5i1.7229 declarations authors' contribution s and k designed the study. dsy writing the manuscript and conducted a literature search. dsy was writing the result. s and k contributed to reviewing and evaluating this manuscript for publication. funding statement this research has not received external funding. conflict of interest there is no conflict of interest in this research. references 1. world bank. the human capital index 2020 update: human capital in the time of covid-19. washington, dc: world bank group; 2021. 1-229 p. 2. kementerian kesehatan ri. situasi balita stunting. jakarta: pusat data dan informasi, kementerian kesehatan ri; 2018. 3. riskesdas. laporan nasional riskesdas 2018. jakarta: badan penelitian dan pengembangan kesehatan, kementerian kesehatan ri; 2018. 4. kemenkes ri. laporan pelaksanaan integrasi susenas maret 2019 dan ssgbi tahun 2019. jakarta: kementrian kesehatan ri; 2019. 69 p. 5. kemenkes ri. buku saku hasil studi status gizi indonesia (ssgi) tingkat nasional, provinsi, dan kabupaten/kota tahun 2021. jakarta: kementrian kesehatan ri; 2021. 6. rahmadhita k. permasalahan stunting dan pencegahannya. j ilm kesehat sandi husada. 2020;11(1):225–9. 7. kementerian kesehatan ri. situasi balita pendek. jakarta: pusat data dan informasi, kementerian kesehatan ri; 2016. 8. united nations indonesia. pernyatan bersama tentang ketahanan pangan dan gizi dalam konteks pandemi covid-19 di indonesia. vol. 1, kesmas: national public health journal. 2020. 1-13 p. 9. emamian mh, fateh m, gorgani n, fotouhi a. mother’s education is the most important factor in socio-economic inequality of child stunting in iran. public health nutr. 2013;17(9):2010–5. 10. unicef. improving child nutrition, the achievable imperative for global progress. united nations. new york: 3 united national plaza; 2013. 11. fadzila dn, tertiyus ep. ketahanan pangan rumah tangga anak stunting usia 6-23 bulan di wilangan, nganjuk. amerta nutr. 2019;3(1):18. 12. safitri am, pangestu dr, aruben r. hubungan ketahanan pangan keluarga dan pola konsumsi dengan status gizi balita keluarga petani. kesehat masy. 2017;5(3):120–8. 13. adelina fa, widajanti l, nugraheni sa. hubungan pengetahuan gizi ibu, tingkat konsumsi gizi, status ketahanan pangan keluarga dengan balita stunting (studi pada balita usia 24-59 bulan di wilayah kerja puskesmas duren kabupaten semarang). j kesehat masy. 2018;6(5):361–9. 14. arlius a, sudargo t, subejo s. hubungan ketahanan pangan keluarga dengan status gizi balita (studi di desa palasari dan puskesmas kecamatan legok, kabupaten tangerang). j ketahanan nas. 2017;23(3):359. 15. mahmudiono t, nindya ts, andrias dr, megatsari h, rosenkranz rr. household food yanti et al. (the relationship between household good security and incidence of stunting in toddlers during …) vol. 5, no. 1, 2021, pp. 51-59 59 10.26555/eshr.v5i1.7229 insecurity as a predictor of stunted children and overweight/obese mothers (scowt) in urban indonesia. nutrients. 2018;10(5). 16. rahayuwati l, nurhidayah i, hidayati no, hendrawati s, agustina hs, ekawati r, et al. analysis of factors affecting the prevalence of stunting on children under five years. j biosci. 2020;14(december):6565–75. 17. sotoudeh m, amaniyan s, jonoush m, vaismoradi m. a community-based survey of household food insecurity and associated sociodemographic factors among 2–6 years old children in the southeast of iran. nutrients. 2021;13(2):1–12. 18. sihite nw, nazarena y, ariska f, terati t. analisis ketahanan pangan dan karakteristik rumah tangga dengan kejadian stunting. j kesehat manarang. 2021;7(khusus):59. 19. imansari a, wulandari ar, sunista d, jafika h, tomeys r, sekolah s, et al. food insecurity in housefold level with stunting during the covid-19 pandemic. j sci heal [internet]. 2022;2(2):73–7. available from: https://journal.pkpm.ac.id/index.php/jsh/article/view/94 20. aritonang ea, margawati a, fithra dieny f. analisis pengeluaran pangan, ketahanan pangan dan asupan zat gizi anak bawah dua tahun (baduta) sebagai faktor risiko stunting. j nutr coll [internet]. 2020;9(1):71–80. available from: http://ejournal3.undip.ac.id/index.php/jnc/ 21. agho ke, mukabutera c, mukazi m, ntambara m, mbugua i, dowling m, et al. moderate and severe household food insecurity predicts stunting and severe stunting among rwanda children aged 6–59 months residing in gicumbi district. matern child nutr. 2018;15(3):1–10. 22. de onis m, branca f. childhood stunting: a global perspective. matern child nutr. 2016;12:12–26. 23. aini n, hera agm, anindita ai, malangkay ks, amalia r. hubungan rendahnya tingkat ekonomi terhadap risiko terjadinya stunting: a systematic review. j kesehat tambusai [internet]. 2022;3:127–35. available from: http://journal.universitaspahlawan.ac.id/index.php/jkt/article/view/4457%0ahttp://journal. universitaspahlawan.ac.id/index.php/jkt/article/download/4457/3069 24. betebo b, ejajo t, alemseged f, massa d. household food insecurity and its association with nutritional status of children 6-59 months of age in east badawacho district, south ethiopia. j environ public health. 2017;2017. 25. fao. the impact of covid-19 on food security and nutrition [internet]. 2020. available from: https://www.fao.org/2019-ncov/q-and-a/impact-on-food-and-agriculture/en/ 26. unicef. covid-19 and food security: what families need to know. [internet]. 2021. available from: https://www.fao.org/2019-ncov/q-and-a/impact-on-food-andagriculture/en/ microsoft word 3761-12323-6-editing 2.docx epidemiology and society health review| eshr vol. 3, no. 2, 2021, pp. 17-22 issn 2656-6052 (online) | 2656-1107 (print) 10.26555/eshr.v3i2.3761 17 research article factors related to stunting incidence in children underfive years in argodadi, sedayu, bantul yanasta yudo pratama1*, tri ani marwati1, muhammad syamsu hidayat1 1 master’s program in public health, universitas ahmad dahlan, yogyakarta, indonesia * correspondence: yanasta2007053008@webmail.uad.ac.id phone: +6282224008009 received 27 february 2021; accepted 05 mei 2021; published 14 august 2021 abstract background: stunting is a chronic nutritional problem due to insufficient food intake with the standard nutritional needs starting from pregnancy to 2 years of age. stunting could be raising a lousy impact on children's health, inhibited brain development, motor development, and physical growth obstruction. stunting is also harmful to national development because stunted children have low productivity and intelligence. this study aimed to determine the relationship between mother body height and the incidence of stunting in children aged 0-59 months in argodadi, sedayu, bantul. methods: this research was an observational analytic with a case-control design. this study population was all mothers who have toddlers aged 0-59 months. the population was 690 respondents. we recruited 154 samples using random sampling consisting of 77 cases and 77 controls. microtoise, infatometer, questionnaire, and who anthro were used to collect the data. data were analyzed using descriptive and chi-square tests. results: the chi-square test shows that mother body height was associated with the incidence of stunting p-value 0.005 (p <0.05); or: 3.2 ci (1.377.52). conclusions: mother body height is a risk factor for stunting in children aged 0-59 months. keywords: stunting; toddler; mother characteristic introduction stunting is a chronic nutritional problem due to food intake that does not follow standard nutritional needs, starting from pregnancy to the age of 2 years (1). in indonesia, the prevalence of stunting is around 30.8%, with 6.7% very short and 16.9% short (2). the world bank group (2018) stated that 37% of children under five in indonesia were stunted (3). while in daerah istimewa yogyakarta (diy) in 2019 the prevalence of stunting is 19.8%. the bantul district in 2019 has 22.89% of stunting prevalence, making bantul one of the 160 priority cities for tackling stunting in indonesia (4). the mother's health condition and nutritional status during pregnancy significantly affect the growth and development of the fetus. mothers who experience anemia during pregnancy will give birth to low birth weight (lbw) babies closely related to stunting. the high incidence of stunting influences several factors such as parity, birth spacing, maternal height, dietary care, pratama (factors related to stunting incidence in children under-five years in argodadi, sedayu, bantul) vol. 3, no. 2, 2021, pp. 17-22 10.26555/eshr.v3i2.3761 18 and maternal age (5). stunting can be severe for children's health, both in the short and long term—short-term adverse effects such as inhibited brain development, motor development, physical growth, and impaired metabolism. in a long time, stunting influences decreased learning achievement, cognitive decline, reduced productivity in adulthood and is very vulnerable to infection (6,7). maternal height describes the previous nutritional and socioeconomic status of the mother. ; short posture could be caused by heredity due to pathological conditions due to hormone deficiency so that it has the opportunity to reduce the tendency of short genes. short posture could also be due to maternal health factors due to nutritional deficiencies or disease. mother's height is a body size measured using a microtoise from the toe to the head. people are categorized as short if they <150 cm and normal if they > 150 (8). according to previous research, children born from too short mothers are at three times greater risk of stunting (9). since childhood, women who have experienced stunting will experience growth problems, including reproductive disorders and complications during pregnancy. mothers who are stunted have a more significant potential to have stunted children. it is called the intergenerational nutrition cycle (10). based on the background in mind, this research aimed to determine the association between mother body height and the incidence of stunting in children aged 0-59 months. this research will provide potential risk factors associated with stunting and then enhance the policymaker's intervention to prevent stunting incidence in society. methods this research was conducted at the posyandu for the argodadi sedayu village area, bantul, in february-march 2020. we employed analytic observational with a case-control study design. the study's population was all toddlers aged 0-59 months in argodadi sedayu bantul, as many as 690. according to our calculation, the minimum sample size was 63; then, we recruited 77 samples for each arm selected using simple random sampling to anticipated sample dropout. the inclusion criteria for the sample was a mother with children aged 0-59 months that participate in the posyandu, and they were able to participate in this study. the exclusion criteria were mothers and toddlers who had moved from the village of argodadi and children under five with incomplete immunization history. the research instruments were a questionnaire and microtoise. stunting was measured with microtoise and entered into the who anthro application. the chi-square test was used to analyze the result. this research has been approved by the ethics committee institute of alma ata university yogyakarta with the number ke/aa/iii/10121/ec/2020. pratama (factors related to stunting incidence in children under-five years in argodadi, sedayu, bantul) vol. 3, no. 2, 2021, pp. 17-22 10.26555/eshr.v3i2.3761 19 results a total of 154 respondents who was the mother of children under five have participated in this study. all of them were female. table 1 shows the association between variables and stunting. one variable was statistically significantly associated with stunting at p ≤0.05 level: mother height. the test results using fisher's exact or chi-square test showed that the value of the odds ratio (or) for the mother height with the incidence of stunting was 3.218. it means that children who had short mothers had higher odds (3.218 times) of stunting than tall mothers. table 1. characteristics distribution of parent and toddler respondents discussions short posture can indicate genetic disorders because the exact height is often unknown, increasing as a woman ages. according to liselle, women with a height of less than 150 cm can be suspected of pelvic narrowing, which will impact fetal growth (11,12). the factors that affect growth and development are divided into internal factors and external factors. internal factors include genetic factors and hormonal factors. both parents of children inherit the ability to be high. so tall children usually come from tall parents as well. hormonal factors influence the development of bone cells. one of them is thyroid hormone which will affect the growth and maturation of bone cells themselves. while other hormones, namely sex hormones and hormones in the suprarenal glands, can also affect the maturation of bone cells, especially during puberty. external factors include the prenatal environment, such as lack of food intake during pregnancy, viral infections, and other diseases that can cause mental deterioration, body notes, and heart defects. the post-birth environment includes a lack of body-building variable case control p-value or (95%ci) n % n % children sex male female 45 32 29.2 20.8 32 45 29.2 20.8 0.024 1.406 children age 0-24 month 25-59 month 38 39 24.7 25.3 33 44 21.4 28.4 0.419 1.139 children birth weight low birth weight not low birth weight 5 72 3.2 46.8 3 74 1.9 96.1 0.468 0.686 children length birth short normal 5 72 3.2 46.8 4 73 2.6 47.4 0.713 1.118 mother education low (junior high school or below) hight (high school education or above) 28 49 18.1 31.8 23 54 14.9 35.1 0.392 1.115 mother occupation employed unemployed/housewive 36 41 23.3 26.6 30 47 19.4 30.5 0.516 1.170 father education low (junior high school or below) hight (high school education or above) 39 39 25.3 24.7 29 48 18.8 31.1 0.144 1.278 father occupation formal non-formal 29 48 18.8 31.1 32 45 20.7 29.1 0.621 0.921 lila (maternal arm circumference) kek non-kek 10 67 6.5 43.5 9 68 6.0 44.0 0.806 1.561 mother’s height short (<150 cm) standard (>150 cm) 23 54 14.9 35.1 10 67 6.5 43.5 0.011 3.218 pratama (factors related to stunting incidence in children under-five years in argodadi, sedayu, bantul) vol. 3, no. 2, 2021, pp. 17-22 10.26555/eshr.v3i2.3761 20 foods, especially protein, which can interfere with growth. in addition, socioeconomic conditions play an essential role in people's development. other factors that also affect growth are improved sanitation, education, and psychological factors (13). this study indicates that males and females have the same risk for getting stunting. according to larasati, research in 2018 revealed that the male sex is more susceptible to stunting in early life because the male body is more extensive and requires more nutritional intake if, at this time, it is not sufficient. nutrition will result in the incidence of stunting. but in the second year of life, women are more at risk of experiencing stunting because it is related to parenting and nutrition in good conditions and environments; male growth is better than women (14). based on the characteristics of the parents, it shows that mothers with low education are more in the stunting group, namely as much as 18.1%. while in the father's education, the percentage of stunting is higher in the group of fathers with low education, namely 25.3%. this is in line with previous research that shows that maternal education is related to stunting and influences the incidence of stunting. mothers with tertiary education have broader knowledge about child care practices and can maintain and care for their environment to keep them clean. low maternal education can lead to stunting due to the lack of information obtained (15). parents' job characteristics show that respondents with mothers who do not work / irt are more in the control group, namely, as many as 47 people (30.5%) than the case group (23.3%). the mother who does not work / irt has a lot of time to take care of her child so that the pattern of care, hygiene, diet is well maintained, which affects the improvement of the nutritional status of children under five (16). respondents of their father's occupation mostly work non-formal 31.1% compared to the control group (29.1%). according to nadhiyah's research in 2014, parents' work affects the incidence of stunting because parental work affects income, affecting behavior, habits, and living norms in the family that are getting better. and this will encourage the improvement of the nutritional status of children under five (16). the maternal arm circumference (lila) showed an equal proportion between the case group, namely ten people (6.5%), and the control group as many as nine people (6.5%). according to warsini's research, it was revealed that the history of kek during pregnancy was not related to the incidence of stunting. it was associated with the awareness of pregnant women to have their pregnancy checked, as for the pmt supplementary feeding program for pregnant women who suffer from chronic energy deficiency. accordingly, the baby in the womb can continue to grow correctly (17). based on the child's birth weight, the percentage of lbw in the case group was (3.2%), compared to the control group (1.9%). previous research reported that low birth weight affects the incidence of stunting with a p-value of 0.00. birth weight is an indicator of a child's survival, growth, and long-term health. bodyweight is an indicator of the health of newborns, babies with low body weight will be vulnerable to adverse environmental influences in the future. so that growth and development will be slower, marked by suboptimal weight gain and height (18). relationship between maternal height and the incidence of stunting the pelvic skeleton in a woman is related to reproductive functions. the size of a woman's pelvis is influenced by nutrition, environment, or other factors that cause the pelvis to be smaller than normal standards. at the same time, the shape of the female pelvis has a wider pratama (factors related to stunting incidence in children under-five years in argodadi, sedayu, bantul) vol. 3, no. 2, 2021, pp. 17-22 10.26555/eshr.v3i2.3761 21 lower part for pregnancy purposes. regardless of the vaginal birth of a normal-weight fetus, the pelvis with normal size will not experience difficulties during delivery. it potentially is difficult in vaginal delivery (19). the results of this study indicate that maternal height is associated with the incidence of stunting. mothers with short stature tend to have stunted children and vice versa. mothers with standard height, the child will grow normally. the results of this study were in line with a previous study that said parents' height had a relationship with the incidence of stunting. also supported by wahdah, he stated that the mother's height was a risk factor for stunting (10). genetic, environmental, and nutritional factors influence human growth. one form of gene expression is the mother's height. parents who have short posture due to environmental and nutritional conditions can still grow into normal height as long as the child is not exposed to other risk factors. however, if the mother is short due to genetic conditions, the child will likely inherit the gene, growing up to be stunted (20). in this condition, the children need nutritional attention during the life span of 1000 days starting from pregnancy or the equivalent of a 2-year-old toddler. (19,20). genetic characters that carry short also affect the performance of hormones that play a role in growth. the presence of growth hormone affects cortical bone build-up and may stimulate growth and height gain. this must be balanced with adequate nutritional intake to support growth so that the next generation will not be affected by growth failure or stunting (19). conclusions mother's height is significant as a risk factor for children grows stunted. woman with short posture [<150 cm], they have three times greater odds to have stunting children than mothers with tall posture [>150 cm]. to health workers, especially health workers in the village of argodadi sedayu, bantul, it is suggested that they would monitor a woman's nutritional status during pregnancy. this can be done by conducting home visits to pregnant women and providing counseling to maintain the fetus's health. authors’ contribution yyp, fb contributed to the research design and developed the first draft of the manuscript. yyp & fb contributed to the data collection and statistical analysis. msh and tam contributed to evaluating this manuscript for publication. acknowledgement we thank futihatul baidho who assisted the data collection for this research. conflict of interest there are no conflicts of interest. references 1. who. stunting in a nutshell [internet]. web. 2015 [cited 2021 aug 13]. available from: https://www.who.int/news/item/19-11-2015-stunting-in-a-nutshell 2. kementerian desa pembangunan daerah tertinggal dan transmigrasi. buku saku desa dalam penanganan stunting. sandjojo ep, editor. buku saku desa dalam penanganan stunting. jakarta: kementerian desa, pembangunan daerah tertinggal, dan pratama (factors related to stunting incidence in children under-five years in argodadi, sedayu, bantul) vol. 3, no. 2, 2021, pp. 17-22 10.26555/eshr.v3i2.3761 22 transmigrasi; 2017. 42 p. available from: https://stunting.go.id/kemendesa-buku-sakustunting-desa-2017/ 3. the world bank group. indonesia accelerates fight against childhood stunting [internet]. world bank group. 2018 [cited 2021 aug 14]. available from: https://www.worldbank.org/en/news/feature/2018/06/26/indonesia-fights-stuntingcommitment-convergence-and-communities 4. luthfansa z. overview of birth body length and exclusive breastfeeding and breastfeeding in stunting children age 6-59 months in patalan village. j healthc technol med [internet]. 2020;5(2):2615–109. 5. aridiyah fo, rohmawati n, ririanty m. the factors affecting stunting on toddlers in rural and urban areas). pustaka kesehat. 2015;3(1). [in bahasa] 6. dasman h. four impacts of stunting for children and indonesian. the conversation [internet]. 2019 jan; available from: http://repo.unand.ac.id/21312/1/empat dampak stunting bagi anak dan negara indonesia.pdf [in bahasa] 7. leksananingsih h. the relationship between stunting and intelligence of 36-59 months old children in sedayu district, bantul regency, yogyakarta. universitas alma ata yogyakarta; 2017. [in bahasa] 8. addo oy, stein ad, fall ch, gigante dp, guntupalli am, horta bl, et al. maternal height and child growth patterns. j pediatr. 2013;163(2):1–14. 9. amin n a jm. sociodemographic factors and height of parents and their relationship with stunting incidence in toddlers age 6-23 months. j gizi dan diet etik indones. 2016;2(3):170–7. [in bahasa] 10. wahdah s, m j. risk factors for stunting in children aged 6-36 months in rural areas of silat hulu subdistrict, west borneo. j gizi dan diet etik indones. 2015;3(2):119–30. [in bahasa] 11. liselele hb, boulvan m, tshibangu kc, s m. maternal height and external pelvimetry to predict cephalopelvic disproportion in nulliparous african women: a cohort study. bjog int j obstet gynecol. 2005;107:947–52. 12. wheeler l. prenatal and postpartum care. jakarta: penerbit buku kedokteran egc; 2003. 182 p. [in bahasa] 13. deswaty f. factors affecting human growth and development. bandung: penerbit yudhistira; 2007. 36–37 p. [in bahasa] 14. larasati nn. factors associated with stunting incidence in toddlers age 25-59 months at posyandu in wonosari ii health center in 2017. politeknik kesehatan yogyakarta; 2018. [in bahasa] 15. uliyanti, tamtomo d. as. factors associated with stunting incidence in toddlers age 2459 months. j vokasi kesehat. 2017;3(2):1–11. [in bahasa] 16. nadiyah, briawan d, mastianto d. risk factors for stunting in children aged 0 — 23 months in the provinces of bali, west java, and east nusa tenggara. j gizi dan pangan. 2014;9(2):125–32. [in bahasa] 17. kristiana tri warsini, hadi h, nurdiati ds. history of kek and anemia in pregnant women is not related to the incidence of stunting in children aged 6-23 months in sedayu subdistrict, bantul, yogyakarta. j gizi dan dietetik indones. 2016;4(1):29–40. [in bahasa] 18. mustika h. dominant factors causing stunting incidents in children age 24-35 months in west nusa tenggara province. j sangkareang mataram. 2016;2(1):51–8. [in bahasa] 19. wiknjosastro h. midwifery. 4th ed. jakarta: yayasan bina pustaka sarwono prawirohardjo; 2009. 1–2 p. [in bahasa] 20. utami ra. the relationship between nutritional provision and stunting incidence in toddlers in karang anyar village. j kesehat holist. 2017;1(2):22–31. [in bahasa] microsoft word sulis-fafa_edit01.edited.docx epidemiology and society health review| eshr vol 1 no1 2019 29 review article climate change and dengue in indonesia: a systematic review fajar fatmawati 1 and sulistyawati sulistyawati 1* 1 faculty of public health, universitas ahmad dahlan, yogyakarta, indonesia * correspondence: email: sulistyawatisuyanto@gmail.com. tel: +628170402693 received 07 august 2019; accepted 09 september 2019; published 09 september 2019 abstract background: climate change is a global issue because of its impact on environmental and human health. no exception for indonesia, an archipelago state with a tropical climate. climate change potentially influences the mosquitos borne disease, including dengue fever, which poses a vulnerability to the indonesian populations. this article aims to review the association and the impact of climate change to dengue fever, particularly in indonesia and to inform the policymaker on directing the adaptation option. methods: of thirteen peer review articles were included in this review sourced from google scholar database. results: climate change affects dengue incidence in indonesia due to climate variability. conclusions: it is essential to strengthen the surveillance system and provide an early warning system (ews) based on climate information. keywords: climate change, dengue, indonesia introduction climate change which is a global phenomenon received attention from many countries due to its impact on human and environment. global temperature surface during the decade of 2006-2015 was 0.870c, and between 2030 and 2052 it has been predicted that temperature will be 1.5°c. consequently, the risk of climate change to health is expected to be growing (1). temperature plays a vital role in the development, longevity, reproduction and virus transmission of mosquito (2). climate change is suspected to aggravate the risk of mosquito-borne disease, including dengue fever. this situation is a global threat, particularly for countries in south asia and sub-sahara africa (3). epidemiology and society health review| eshr vol 1 no1 2019 30 indonesia is a tropical climate country and archipelagic state. accordingly, this country is easily affected by climate change such as temperature rising and climate shifting that carries some impacts such as drought and failure of harvesting. climate change in indonesia can be seen from the increasing of the temperature above average every year and the decreasing of annual rainfall in some regions. the south part of indonesia tends to have less rain while the north has more rainfall, even it is always increasing (4). the temperature average in indonesia during 1981-2010 was 27oc. however, in may 2019, it was detected that it was increasing up to 0,9oc (5). dengue is a disease that is closely associated with the environmental condition. as a result, the changing of environment will lead to a dengue transmission pattern. dengue case in indonesia in the last 45 years is increasing dramatically with intermitted hyperendemic pattern (6) which affected the health of the large population. this occurrence predicted the interplay between the disease and climate variable. for example, the changing of temperature, humidity and wind speed affects the changing of the number of vector population not only for dengue but also for some other diseases such as malaria, leptospirosis and filariasis (7). in 2017, the number of dengue case in indonesia was decreasing significantly from the previous period by having 204.171 cases (8). however, this situation could be different in the next coming year due to the changing the environment, such as climate changes. accordingly, a study to summarise the indonesian situation regarding dengue and climate change is essential as a part to prepare adaptation strategy to anticipate the worst situation. this review aims to summarize the previous research that elaborate on the relationship between climate change phenomenon and dengue incidence in indonesia. the goal of this review is to develop an idea on an adaptation strategy to reduce dengue disease in the future. methods search strategy google and google scholar were used as the main source of database accessed in june-july 2019 to extract studies published both in english and bahasa indonesia that discussed indonesia context. a set of combination keywords: “dengue haemorrhagic fever”, “dengue fever & climate”, “weather”, “climate change”, “climate variability”, “climatic factors”, “temperature”, “rainfall”, “humidity”, “indonesia" were used to search the article. we observed research paper published during 2014-2019. title, keyword and abstracts were screened for the first step for the relevant article and the full paper that met our criteria inclusion, were included in our analysis. inclusion criteria 1. articles must appraise the impact of climate change on dengue transmission and spread by discussing climate variables such as temperature, rainfall and humidity and disease variables such as incidence and case. 2. the article should employ epidemiology design such as actual analysis, spatio-temporal and descriptive study for identifying the relationship between climate variable versus dengue transmission and spreading 3. the article should discuss indonesia and published in 2014-2019 epidemiology and society health review| eshr vol 1 no1 2019 31 figure 1. flow chart of article review results literature search two hundred and sixty-one articles were collected from google scholar in the first step. among them, 240 articles were excluded since they did not meet the title and keyword, while 21 articles were included. in terms of the full paper, 16 articles were included, and at the final stage, 13 articles met our inclusion criteria. methodology and main finding of the 13 articles are summarised in table 1. the study took place in sleman (n=2), north minahasa district, ternate city, limboto subdistrict, jakarta city, sulawesi tenggara province, surabaya city, medan city, banjarmasin city, cirebon district, kolaka district and indonesia. all of the included articles were studying the association between climate variable and dengue incidence. some methods were used to determine the relationship between the climate variable and dengue incidence. three of them employed a descriptive study through ecologic approach (9),(13),(18). correlation and multiple regressions (poisson), path analysis which is an extension from linear regression also used as an approach 18. three articles used time series (12),(16),(21), one article employed time series decomposition analysis with loess (stl) model and one article used smoothing (19). only one article used ecology proxy indicators such as normalized difference vegetation index (ndvi), moran's i analysis, and lisa studies were selected for more detailed evaluation (fulltext articles were retrieved, and abstracts were read) (n=16) 3 articles did not meet inclusion criteria: discussing climate change and dengue fever discussing indonesia research paper published in 2014-2019 240 articles were excluded because the title and keywords were not relevant potentially relevant studies were identified by searching in google scholar database (n=261). studies were selected by title and keywords (n=21) potentially relevant studies (n=13) epidemiology and society health review| eshr vol 1 no1 2019 32 analysis (19). some research elaborated the determinants such as attitude and behaviour, environmental, land cover type, and altitude (11), (14), (15). gam model was used to express the non-linear relationship and non-monotonic between the response variable and predictor (17). four articles reviewed the use of geographic information system (gis) to create a risk map based on vector distribution (12),(17),(19),(21). discussion association between climate variable and dengue incidence in most of the endemic research location studied, climate variable was significantly correlated to dengue cases. temperature, humidity, and rainfall were the standard variables associated with dengue incidence. to identify climate risk factor to dengue incidence in indonesia, research had been done to seek the relationship between meteorological variable and dengue (9-21). according to the analysis, almost all of the article reported that temperature had a correlation to dengue transmission from low to medium power. in ternate, monthly temperature average is 24.8oc-29.0oc. the highest temperature occurred in 2009 (29oc). at that moment, dengue incidence was increasing from january, and the peak occurred in march (10). this occurrence was probably associated with mosquito longevity which is at 27oc, so the increase of the temperature influences the dengue virus. in other areas, the temperature did not have a correlation with dengue incidence, possibly due to the low temperature in that location. such as in sleman-yogyakarta, the monthly temperature average is 22,8oc-27,2oc, meaning that it tends to be cold for the maturation of mosquito egg. low temperature shortens the incubation period and prolongs the mosquito reproduction cycle as well as reduces mosquito biting (22). large differentiating temperature influences the number of female mosquitos, meaning that the number of blood-sucking mosquitoes for transmitting the virus is decreasing (11). meanwhile, in gamping subdistrict-godean-sleman district, medan city and kolaka district, the differences of maximum-minimum of the temperature were associated with dengue incidence (11), (17), (20). the high disparity of minimum and maximum temperature impacts on the low of dengue incidence (11). epidemiology and society health review| eshr vol 1 no1 2019 33 table 1. studies characteristic discussed the association between climatic variables and dengue study & language study area & period data collection statistical methods main findings comments risk factors disease/ vector lasut et al. (2017) indonesian (9) north minasaha district 20142016 temperature, humidity, wind speed, rainfall and number of days with rain case counts quantitative by using an ecology study design correlation test linear regression a positive correlation was found between temperature, humidity, wind speed and dengue incidence rainfall and number of day rain were not associated with dengue incidence a three-year short study period tomia et al. (2016) bahasa indonesian (10) ternate city 2007-2014 rainfall, temperature and humidity the monthly incidenc e of dengue -pearson correlation temperature and dengue incidence were found correlate rainfall and humidity were not associated with dengue incidence employed correlation added other variables such as habitat characteristic, larvae free number and community participation on breeding site habitat cleaning movement (psn) lag times of climatic factors were analysed kesetyanin gsih et al. (2017) english (11) sleman district 2008-2013 monthly minimummaximum temperature monthly incidenc e of dengue -linear regression temperature variability was found to be associated with dengue incidence the only temperature included explaining other factor such as host factors and the environmental factors pakaya, ririn (2015) english (12) limboto, gorontalo 20122015 precipitation, temperature, humidity and wind speed case counts -cross sectional -spearman correlation poisson regression -gis the association between humidity and dengue incidence was found to be significantly negative a four-years short study period hasannah jakarta 2008temperature, case descriptive with strong correlation was found relative long study period epidemiology and society health review| eshr vol 1 no1 2019 34 & dewi susanna (2019) english (13) 2016 rainfall, and humidity counts ecology study design -correlation test between humidity and dengue incidence -medium correlation was found between temperature and dengue incidence rainfall had weak correlation to dengue incidence kesetyanin gsih et al. (2018) english (14) sleman district 2008-2013 humidity, land cover, altitude, rainfall and temperature monthly incidenc e of dengue -spatial test -spearmen correlation test -pearson correlation humidity has medium correlation to dengue incidence land cover, altitude, rainfall had weak correlation with dengue incidence temperature was not associated with dengue incidence all climate parameter did not influence dengue incidence in sporadic area case number per month was absence tosepu et al. (2018) english (15) kendari, southeast sulawesi 20102015 temperature, rainfall and humidity monthly incidenc e of dengue -spearmen test -time-series poisson regression multivariate temperature has positive association with dengue incidence rainfall did not associated with dengue incidence humidity did not associated with dengue incidence geographical conditions and behaviour were explained tang et al. (2019) english (16) surabaya city 2009-2017 temperature average, rainfall and humidity monthly incidenc e of dengue -one-sample kolmogorov smirnov test spearman correlation rainfall and humidity were associated to dengue incidence temperature average did not associate with dengue incidence one city was included difficult to observe the influence of temperature because of the lack of seasonal variation of temperature in surabaya lack of mosquito data setiawati, et al. (2017) medan 20022016 average temperature, max-min case counts -compile data base -gam model rainfall, humidity, rainfall, maximum temperature influenced dengue incidence several statistical methods were applied epidemiology and society health review| eshr vol 1 no1 2019 35 english (17) temperature, relative humidity, precipitation -design vulnerability index & generate in gis climate variability influenced 74.8% of dengue incidence ishak et al. (2018) english (18) banjarmasin, south kalimantan 2012-2016 temperature, humidity, wind speed, rainfall monthly incidenc e of dengue quantitative descriptive with ecological time trend path analysis the only variable that shown positive correlation between dengue incidence and rainfall relative short study period astuti et al. (2019) english (19) cirebon, west java 2011-2017 rainfall, temperature, humidity and ndvi monthly incidenc e of dengue -spearman correlation -poisson (glm) -spatial analysis -time series (decomposition analysis with stl) moran’s i analysis lisa analysis rainfall, temperature and humidity were associated to dengue incidence one city was included several statistical methods were applied ssocioeconomic factors were considered spatial-temporal analysis tosepu et al. (2018) english (20) kolaka, southeast celebes 20102015 rainfall, humidity, temperature average, minimummaximum temperature monthly incidenc e of dengue -regression linear -spearman correlation -poisson distribution all climate variables investigated were associated with dengue incidence various meteorological variables were considered epidemiology and society health review| eshr vol 1 no1 2019 haryanto. budi (2016) english (21) indonesia 19802010 temperature and rainfall case counts -ecological time-series study design -vulnerability analysis of the ipcc 2001 -correlation and regression analysis -gis high intensity of rainfall had weak association in 11 districts in indonesia rainfall and temperature in other city were not associated with dengue incidence long-term data from a thirty years period epidemiology and society health review| eshr vol 1 no1 2019 37 the impact of rainfall to dengue incidence was recognised in most of the analysed research (13-21). research in jakarta by using 9 years of data set (2008-2016) shows dengue incidence was significantly associated with rainfall about 254-667mm then followed by high dengue incidence in 0-3 month in the beginning of the year (13). temporal relationship between rainfall and dengue incidence was identified as linear between the increase of 10mm of the rainfall and 1% increase of dengue incidence in three months (23). in another research, it was mentioned that the increase of the rainfall led to the increase of the mosquito breeding place (9). while in north minahasa and ternate city, rainfall and dengue were not associated (9),(10). according to plum model aimed to evaluate the high rainfall intensity and larva flush from the breeding place, it shows that rainfall and dengue were not associated (24). high of precipitation makes larvae transported and sometimes dies due to continues water stream and the absence of puddle for the mosquito breeding site (9). humidity sometimes caused by high intensity of rainfall, make the environment suitable for aedes life (11),(13). the relationship between humidity and dengue incidence occurred in some areas of indonesia was reported by some researches (9),(12),(13),(14),(16),(17),(19),(20) , while the rest of the research did not involve humidity as research variable. a research in jakarta shows that humidity was a meteorological variable that is strongly associated with dengue incidence compared to temperature and rainfall (13). likewise, a research in singapore reported that humidity was the most climate variable that influenced dengue incidence (25). humidity is a suitable condition for mosquito reproduction. high humidity affects the high dengue incidence as occurred in north minahasa. in that place, dengue incidence was high in january 2015 in 89% of humidity (9). when humidity is lower than 60% it will shorten the mosquito age; consequently, mosquito cannot continue its reproduction cycle (18). in north minahasa, the relationship between wind speed and dengue transmission was identified. it could be seen from the increase of dengue case along with the decrease of wind speed 1 knot in may 2015. wind speed influences the mosquitos flight range; accordingly, the decrease in wind speed is followed by the dengue incidence (9). however, research in limboto sub-district and banjarmasin city reported that there was no relationship between wind speed and dengue incidence (12),(18). conclusions the impact of climate change and dengue incidence have been discussed on this review. protection and adaptation to this situation are critical to overcoming dengue risk in society. early warning system (ews) development based on climate information can be one alternative solution to inform the community that when climate variables are changing it would potentially influence the dengue transmission. holistic work by involving the associated office such as meteorological, climatological and geophysical agency (bmkg) is recommended. ews based on climatic information has been done in jakarta province and expected to be extended epidemiology and society health review| eshr vol 1 no1 2019 38 in other regions in indonesia. this effort aimed to give information to the population according to the present climate situation. accordingly, there would be follow up actions such as epidemiological assessment, counselling, environment refinement, selective and mass larvaciding, and fogging (26). other efforts such as mosquito’s breeding site elimination or called psn and health services should be improved and scaled up authors’ contribution ss designed the study, writing the manuscript. ff conducted a literature search and writing the result. funding this research did not receive external funding conflict of interest there are no conflicts of interest references 1. ipcc. summary for policymakers. in: global warming of 1.5°c. an ipcc special report on the impacts of global warming [internet]. 2018. 32 p. available from: https://www.ipcc.ch/ 2. mordecai ea, cohen jm, evans m v., gudapati p, johnson lr, lippi ca, et al. detecting the impact of temperature on transmission of zika, dengue, and chikungunya using mechanistic models. plos negl trop dis. 2017;11(4):1– 18. 3. ryan sj, carlson cj, mordecai ea, johnson lr. global expansion and redistribution of aedes-borne virus transmission risk with climate change. plos negl trop dis. 2018;13(3):1–20. 4. hairiah k, rahayu s, suprayogo d, prayogo c. perubahan iklim: sebab dan dampaknya terhadap kehidupan. 2016. 1–40 p. 5. badan meteorologi dan geofisika (bmkg). ekstrem perubahan iklim [internet]. bmkg. 2019. available from: https://www.bmkg.go.id/iklim/?p=ekstremperubahan-iklim 6. karyanti mr, uiterwaal cspm, kusriastuti r, hadinegoro sr, rovers mm, heesterbeek h, et al. the changing incidence of dengue haemorrhagic fever in indonesia: a 45-year registry-based analysis. bmc infect dis. 2014;14(1):1–7. 7. haryanto b. climate change and human health scenario in south and southeast asia. 2016;(november). 8. kementrian kesehatan ri. infodatin situas demam berdarah dengue. 2018. 9. lasut ra, kaunang wpj, kalesaran afc. hubungan variabilitas iklim dengan kejadian demam berdarah dengue (dbd) di kabupaten minahasa utara tahun 2014-2016. fak kesehat masy univ sam ratulangi manad. 2016;9(3):1–12. epidemiology and society health review| eshr vol 1 no1 2019 39 10. tomia a, hadi u, soviani s, retnani e. kejadian demam berdarah dengue (dbd) berdasarkan faktor iklim di kota ternate. media kesehat masy indones univ hasanuddin. 2016;12(4):241–9. 11. kesetyaningsih tw, andarini s, sudarto s, pramoedyo h. the minimummaximum weather temperature difference effect on dengue incidence in sleman regency of yogyakarta, indonesia. walailak j sci technol. 2018;15(5):387–96. 12. pakaya r. spatial analysis and environmental factors associated against case of dengue hemorrhagic fever ( dhf ) in limboto district , gorontalo. public heal gorontalo univ. 2015;45–55. 13. hasanah, susanna d. weather implication for dengue fever in jakarta, indonesia 2008-2016. kne life sci. 2019;4(10):184. 14. kesetyaningsih tw, andarini s, sudarto, pramoedyo h. determination of environmental factors affecting dengue incidence in sleman district, yogyakarta, indonesia. african j infect dis. 2018;12(special issue 1):13–25. 15. tosepu r, tantrakarnapa k, nakhapakorn k, worakhunpiset s. climate variability and dengue hemorrhagic fever in southeast sulawesi province, indonesia. environ sci pollut res. 2018;25(15):14944–52. 16. tang scn, rusli m, lestari p. climate variability and dengue hemorrhagic fever in surabaya, east java, indonesia. arlangga unversity [internet]. 2018;(december). available from: https://www.preprints.org/manuscript/201812.0206/v1 17. setiawati mdkf. the influence of climate variables on dengue in singapore. int j environ health res [internet]. 2011;21(6):415–26. available from: http://ovidsp.ovid.com/ovidweb.cgi?t=js&page=reference&d=emed10&new s=n&an=2012050378 18. ishak nik. the effect of climate factors for dengue hemorrhagic fever in banjarmasin city, south kalimantan province, indonesia, 2012-2016. public heal indones. 2018;4(3):121–8. 19. astuti ep, dhewantara pw, prasetyowati h, ipa m, herawati c, hendrayana k. paediatric dengue infection in cirebon, indonesia: a temporal and spatial analysis of notified dengue incidence to inform surveillance. parasites and vectors [internet]. 2019;12(1):1–12. available from: https://doi.org/10.1186/s13071-019-3446-3 20. tosepu r, tantrakarnapa k, worakhunpiset s, nakhapakorn k. climatic factors influencing dengue hemorrhagic fever in kolaka district, indonesia. environ nat resour j. 2018;16(2):1–10. 21. haryanto b. dengue hemorrhagic fever vulnerability to climate in indonesia : assessment, projection, and mapping. univ indones. 2018;(october 2014). 22. goindin d, delannay c, ramdini c, gustave j, fouque f. parity and longevity of aedes aegypti according to temperatures in controlled conditions and consequences on dengue transmission risks. plos one. 2015;10(8):1–21. 23. silva fd, santos am dos, corrêa r da gcf, caldas a de jm. temporal epidemiology and society health review| eshr vol 1 no1 2019 40 relationship between rainfall, temperature and occurrence of dengue cases in são luís, maranhão, brazil. cien saude colet. 2016;21(2):641–6. 24. benedum cm, seidahmed ome, eltahir eab, markuzon n. statistical modeling of the effect of rainfall flushing on dengue transmission in singapore. plos negl trop dis. 2018;12(12):1–18. 25. xu hy, fu x, lee lkh, ma s, goh kt, wong j, et al. statistical modeling reveals the effect of absolute humidity on dengue in singapore. plos negl trop dis. 2014;8(5). 26. dewi mk. informasi peringatan dini dbd berbasis iklim. www.bmkg.go.id. 2018. microsoft word [4301]-14902-1-editing 4.docx epidemiology and society health review| eshr vol. 3, no. 2, 2021, pp. 23-30 issn 2656-6052 (online) | 2656-1107 (print) 10.26555/eshr.v3i2.4301 23 review article pre-operative education to reduce anxiety: literature review rissa widyasworo hartanti1,* and lina handayani1 1 faculty of public health, universitas ahmad dahlan, yogyakarta, indonesia * correspondence: widyaswororissa@gmail.com phone: +628562554570 received 26 june 2021; accepted 9 august 2021; published 10 august 2021 abstract background: surgical procedure is one of the stressors that can end up with psychological disorders such as anxiety. anxiety can lead to increased blood pressure and the risk of bleeding. receiving detailed information on the surgical procedure is a patient's right. the information provided is expected to reduce patient anxiety and foster good relations between health workers and patients. considering the importance of this step, we study the effect of pre-operative information before surgical procedures based on the published literature. this study aimed to summarize the previous research that elaborates on the relationship between education pre-operative and anxiety. method: a literature review was used in this study. google scholar, pubmed, and proquest databases were chosen as data sources. we sough article published during 2016-2021. in total, 450 articles were screened using inclusion and exclusion criteria for analysis. results: eight articles reported that there was an effect of education on patient anxiety. conclusion: providing education is an effective approach to reduce patient anxiety. keywords: education; patient; anxiety; information introduction surgery is an invasive treatment action that displays body parts, makes an incision, then repairs and closes the wound with suturing (1). surgery is a high-risk action that requires an operating room to minimize infection during surgery (2). the stages of surgery start from preoperative, intraoperative, and post-operative. pre-operative preparation is one of the phases that determines the success of the surgery. pre-operative preparation starts from the patient entering the treatment room until the patient arrives in the operating room (3). the readiness of the patient includes physical and mental readiness. physical readiness examines physical health, nutritional, fluid, and electrolyte balance, gastric and colonic hygiene, personal hygiene, and bladder emptying. mental/psychic pre-operation readiness is psychological readiness in dealing with surgery. patients who do not have mental readiness will experience anxiety before surgery (4). anxiety also has medical risks such as increased hartanti (pre-operation education to reduce anxiety: literature review) vol. 3, no. 2, 2021, pp. 23-30 10.26555/eshr.v3i2.4301 24 breathing, vasoconstriction of blood vessels, increased blood pressure which causes surgical bleeding. several reasons can cause pre-operative anxiety, including fear of physical changes, uncertainty, surgery pain, death risk (5). the prevalence of anxiety disorder worldwide varies 2.5 to 7 percent by country (6). it is estimated that globally 284 million people experienced an anxiety disorder in 2017. about 63 percent (179 million) are women, and 105 million are men. according to a survey in the united states, 18.1% or about 42 million people live with anxiety (7). in indonesia, the results of basic health research 2018 show that 6,2% of people aged 15-24 years and 15.941-157.695 people in indonesia experience anxiety (8). causes of anxiety such as potential stressors, knowledge, social support, environmental adaptation process, and operating experience influence patient anxiety (9). to make s surgical procedure successful need psychology preparations cover the patients. patients need to be educated, and all treatment alternatives should be explained (10). mental or psychological support is required for patients who experience anxiety by providing information about the surgery to be conducted. providing details on operating time, information on the operation site's situation or things experienced during the surgical procedure can reduce anxiety and make the patient more prepared to undergo surgical procedures. the role of the nurse as an advisor is vital to perform these actions (4). accordingly, we want to know the effect of pre-surgery education on patient anxiety patients. this paper aims to summarize the previous research that elaborates on the relationship between education pre-operative and anxiety. method search strategy this literature study searched research articles in reputable databases such as pubmed, proquest, and google scholar. a set of keywords, namely "education pre-surgery," "patient anxiety," "effect of education," and "effect of pre-surgery education," were used to search for articles. title, keywords, abstracts, language, year of published and method were screened for the first step for relevant articles. in the second step, we screened the article according to the relevant variable, and last we selected the article based on the full-text availability. figure 1 shows the flow chart of the article review employed in this paper. inclusion and exclusion criteria in our analysis, the article should fulfill the following inclusion criteria: article published in english or indonesian, the article discussed indonesia or globally, published 2016-2021, abstract and the full text is freely accessible, the research sample was elective surgery patient (planned surgery). while the exclusion criteria were qualitative research, the article did not mention the instrument used for measuring anxiety, study in the emergency setting, full text not freely available. results based on the results of a literature search, eight articles were found that matched the criteria. the research article identifies patient education and anxiety in various hospitals in indonesia and outside indonesia. eight articles were published as review articles, five from indonesia, and three journals were published outside indonesia (polandia, iran, and hartanti (pre-operation education to reduce anxiety: literature review) vol. 3, no. 2, 2021, pp. 23-30 10.26555/eshr.v3i2.4301 25 taiwan). the most significant number of samples used was 213, and the smallest number of samples was 15. a research instrument is a tool used to collect or obtain data in conducting research. a total of 3 articles used state-trait anxiety inventory (stai) anxiety instrument, three articles used the hars (hamilton anxiety rating scale) instrument, 1 article used zung self-rating anxiety scale (sas/zras), and 1 article used t-mas. figure 1. the flow chart of the article review there are differences in the research design used, 6 studies using quasi-experiments and 2 studies using pre-experiments. all articles explain that educating and providing information to patients can reduce patient anxiety. we found that five articles using wilcoxon signedrank test, and three studies using the t-test for analysis purposes. all articles explained that educating and providing information to patients before getting an operation can reduce patient anxiety. table 1. literature search synthesis no title, author method sample instrument and analysis used. result 1 the effect of health education on changes in anxiety of pre elective surgery patients in 3rd class of rsud city of madiun widyaningrum. (2017) preexperiment the number of samples was 35 respondents, one group without control by consecutive sampling. data collection used zung selfrating anxiety scale (zsas) data were analyzed using a t-test before being given health education, the average anxiety level of respondents was in the moderate anxiety category, 24 respondents (68.6%). after being given health education, most of the respondents' anxiety levels were in the non-anxious category were 19 respondents (54.3%). statistical test results show p-value = 0.000 (p-value< = 0.05), there is an effect of education in patients with potentially relevant studies were identified by searching in google scholar (n=241), pubmed (n=62), proquest (n=147) total n=450 studies were selected by title and keyword (n=105) 245 articles were excluded because published in other than english and indonesian, not mentioned the instrument used for anxiety measure, published before 2016, using a qualitative approach studies were selected for more detailed evaluation (full-text articles were retrieved, and abstracts were read) (n=25) 17 articles were excluded because the full text was not freely available potentially relevant studies (n=8) 80 articles were excluded due to variables not relevant to the research purpose hartanti (pre-operation education to reduce anxiety: literature review) vol. 3, no. 2, 2021, pp. 23-30 10.26555/eshr.v3i2.4301 26 no title, author method sample instrument and analysis used. result pre-elective surgery in 3rd class of general hospital of madiun district. 2 effect of an orientation tour on preoperative anxiety in candidates for coronary artery bypass grafting: a randomized clinical trial reyhaneh niknejad, mohsen mirmohammad sadeghi, mohammad akbari, ahmad ghadami (2019) quasi experiment the number of samples is 70 (control group= 35 respondens and intervention group= 35 respondents), randomized clinical trial study. anxiety instrument with state-trait anxiety inventory(stai) data was analyzed using t-test. anxiety levels were significantly lower in the intervention group (35.40 ± 10.24) compared to the control group (46.91 ± 9.51) (p < 0.001). so the preoperative orientation overview has a positive impact on the anxiety level of the prospective cabg patient. 3 the effect of health education on anxiety levels in pre-major surgery patients fadli, irmayanti, kassaming, (2019) quasi experiment the number of samples is 15 respondents, one group without control by purposive sampling. anxiety instruments with hars (hamilton anxiety rating scale). wilcoxon signed-rank test was used to analyze the data. there was a significant change in the average level of anxiety before and after health education to patients with pre-major surgery (23.67 to 17.93). so the average difference before and after is 5.73. the results showed p = 0.001. so there is deferent before and after education, it can be concluded that there is a significant effect of health education on reducing the level of anxiety in pre-major surgery 4. influence of preoperative information support on anxiety, pain, and satisfaction with postoperative analgesia in children and adolescents after thoracic surgery: a randomized, double-blind study lucyna tomaszek, grazyna cepuch, dariusz fenikowski (2018) quasiexperiment the number of samples is 112 consist control group subjects=56 who the nurse gave routine preoperative information, and the experimental group=56 offered additional psychological consultation by randomized, doubleblind study. anxiety instrument with state-trait anxiety inventory (stai). wilcoxon signed-rank test was used to analyze the data. in the experiment group, the level of state anxiety 48 hours post-surgery was significantly lower, <7/10 sten to the procedure. in the control group, the level of post-operative anxiety was substantially higher ³ 7 sten to the procedure. so, information support psychologists before thoracic surgery reduce post-operative anxiety levels. 5. the effect of health education on preoperative physical preparation in this research used quasi experiment the number of samples in this study amounted to 32 consists 16 respondents as intervention group questionnaire used t-mas. data were analyzed using wilcoxon signed-rank test there is a different level of anxiety in the treatment group and control group pvalue: 0.00 (p-value <0.05), meaning the effect of health education about physical hartanti (pre-operation education to reduce anxiety: literature review) vol. 3, no. 2, 2021, pp. 23-30 10.26555/eshr.v3i2.4301 27 no title, author method sample instrument and analysis used. result reducing anxiety in hernia patients puspita, miftahus (2017) and 16 respondents as control groups by consecutive sampling approach. and the mann whitney test. preparation on anxiety in hernia patients. 6. the effect of cardiac precatheterization health education on patient anxiety levels at the cardiac service installation lily misriani, feriana ira, agnis (2020) this study used a preexperiment the number of samples is 16 respondents. one group without control by purposive sampling approach. anxiety instrument with hars (hamilton anxiety rating scale) questionnaire. data were analyzed using wilcoxon signed-rank test. the result shows anxiety before being given health education was severe anxiety (19%), moderate anxiety (62%), mild anxiety (19%), whereas after health education, it became mild anxiety (75%) and no anxiety (25%). a p-value of 0.0001 (< 0.05) means providing cardiac precatheterization health education on the patient's anxiety level. 7. the effect health education using the leaflet media reduce anxiety levels in pre operations fitria anisa,mugi hartoyo,sudiart o (2019) this study used a quasiexperiment the number of samples is 30 respondents consisting of 15 respondents in the intervention group and 15 respondents in the control group by consecutive sampling approach. the anxiety questionnaire used hars (hamilton anxiety rating scale). data were analyzed using wilcoxon signed-rank test. the result showed an effect of health education using media leaflets on the level of anxiety (p=0.001). the post-test score of the intervention group was 9.13, and the control group 15.27, meaning health education with leaflets can reduce anxiety. 8. a study on the effects of a health education intervention on anxiety and pain during colonoscopy procedures feng-chi hsueh & chih-mei chen & chienan sun & yuching chou szu-mei hsiao & tsan yang, (2016) this study used a quasiexperiment the study sample was 213 consist of 103 patients in the intervention group and 110 in the control group. the questionnaire used a questionnaire state-trait anxiety inventory (stai). data were analyzed using a t-test. the anxiety score in the intervention group before health education was 48.7 + 11.6 and after health education 39.2 + 8.7. this study shows that multimedia health information about colonoscopy procedures effectively reduces anxiety and pain in colonoscopy patients. discussion the education program is vital in the pre-operative period. it is one of the alternative programs that can reduce patient anxiety (11). anxiety mostly comes from operation effects; therefore, increasing patients' pre-operative education can relieve their anxiety and stabilize their emotions (12). mental intervention in pre-operative patients can relax, promote the operation's success, improve the recovery and finally improve patients and their families (9). according to the analysis, almost all of the articles report that education effectively reduces anxiety before surgery. in madiun regional hospital, the study followed the research expectations; health education can decrease anxiety patients. communication is established hartanti (pre-operation education to reduce anxiety: literature review) vol. 3, no. 2, 2021, pp. 23-30 10.26555/eshr.v3i2.4301 28 between health workers and patients, so health education makes the patient feel cared (13). in coronary artery bypass grafting, patients with intervention had significantly lower anxiety than other groups without orientation. the reason is that the patients who participated in orientation education before surgery became familiar with operating room conditions, which helps them adapt to the new environment and feel secure. health education had positive effects on anxiety in coronary artery bypass grafting candidates. it can be used effective technique for relieving anxiety (14). primary surgery patients show that health education with leaflets can reduce anxiety. health education intervention was succeeding. a patient who experienced severe anxiety became anxiety mildly, felt moderate anxiety became mild anxiety and felt mild anxiety became less anxiety (15). at the thoracic surgery, the previous study showed that the patient whose preparation for surgery needs the information to support psychology. these results advocated training for the nurse to provide individually tailored information support to patients before thoraces surgery. patients with elevated levels of trait anxiety should be identified before surgery, and offers a dedicated educational program to prepare them for the surgical procedure adequately tho their emotional status (16). previous research mentioned that health education affects the anxiety of hernia surgery patients. health education is one of the nonmedical therapies that reduce pre-operative anxiety. education intervention is an additional intervention, especially for nurses, in reducing patient anxiety (17). according to masriani's research, the result showed an effect of health education on the anxiety level of pre-cardiac catheterization patients at the hearth service installation in syaiful anwar hospital. health education is an effort to change the respondent’s behavior, including change in thinking and acting to reduce anxiety. the research found an anxiety decrease after received health education (18). rizki found that there was an effect of health education with leaflet media. the intervention group has been shown to decrease anxiety compared to before the health education was given. the provision of health education using leaflet media can be used as an alternative for presenting information to prepare patients before surgery to decrease anxiety levels (19). hence, hsueh stated that education is necessary for patients with a certain characteristic. medical staff may design multiple healthcare programs for a patient with different characteristics. this study showed that multimedia health information about colonoscopy procedures effectively reduces anxiety and pain in colonoscopy patients (20). conclusion anxiety is an unpleasant psychological condition caused by the surgery that the patient will experience. non-pharmacological interventions with comprehensive and structured education can be applied as an intervention to reduce patient anxiety. providing education and adequate information is effective in reducing patient anxiety. authors' contribution rwh was responsible for research design, data collection, analysis, and drafting the first manuscript. lh monitored the research course and reviewed the manuscript. hartanti (pre-operation education to reduce anxiety: literature review) vol. 3, no. 2, 2021, pp. 23-30 10.26555/eshr.v3i2.4301 29 funding this research has not received external funding conflict of interest there is no conflict of interest in this research. references 1. apriansyah a, romadoni s, andrianovita d. the relationship between the level of preoperative anxiety with the degree of pain in post-section caesarian patients. j keperawatan sriwij. 2015;2(1):1–9. [in bahasa] 2. sutoto. national standard for hospital accreditation. garna ph, editor. jakarta selatan: komisi akreditasi rumah sakit (kars); 2017. 162 p. [in bahasa] 3. kurniawan a, kurnia e, triyoga a. preoperative patient knowledge in surgical preparation. j penelit keperawatan. 2018;4(2). [in bahasa] 4. majid a. perioperative nursing. yogyakarta: gosyen publishing; 2011. [in bahasa] 5. maryunani a. perioperative nursing. jakarta timur: trans info media; 2014. [in bahasa] 6. ritchie h. mental health our world in data [internet]. 2018 [cited 2021 jun 25]. available from: https://ourworldindata.org/mental-health 7. blvd w, arlington. anxiety disorders [internet]. 2021 [cited 2021 aug 9]. available from: https://www.nami.org/about-mental-illness/mental-health-conditions/anxiety-disorders 8. the indonesia ministry of health. national basic health research report [internet]. jakarta; 2018 [cited 2021 aug 10]. available from: http://labdata.litbang.kemkes.go.id/images/download/laporan/rkd/2018/laporan_nasio nal_rkd2018_final.pdf 9. sari yp, riasmini nm, guslinda. analysis of factors associated with patient anxiety levels pre-major surgery in space teratai. menara ilmu. 2020; xiv(02):133–47. [in bahasa] 10. al-abbadi ha, basharaheel ha, alharbi mr, alharbi ha, sindi d, bamatraf m. patients’ perspectives of surgical safety before and after their elective surgeries at king abdulaziz university hospital, jeddah, saudi arabia. cureus. 2019;11(11). 11. sari yk, widayati a, prayogi b. the effectiveness of counseling of thinking, feeling and acting (tfa) approach to blood pressure in patients with pre cataract surgery. j ners dan kebidanan (journal ners midwifery). 2018 aug;5(2):090–6. [in bahasa] 12. chabibi m, purwanti e, novyriana e. the relationship of nurse therapeutic communication on preoperative patient satisfaction at the central surgical installation of pku muhammadiyah hospital gombong. in: proceeding of the urecol: the 10th university research colloqium 2019 sekolah tinggi ilmu kesehatan muhammadiyah gombong hubungan. gombong: urecol; 2019. p. 464–72. available from: http://repository.urecol.org/index.php/proceeding/article/view/677/660 [in bahasa] 13. widyaningrum da. the effect of health education on changes in anxiety of pre-elective patients in 3rd class of rsud kota madiun. war bhakti husada mulia j kesehat. 2017;4(1). [in bahasa] 14. niknejad r, mirmohammad-sadeghi m, akbari m, ghadami a. effects of an orientation tour on pre-operative anxiety in candidates for coronary artery bypass grafting: a randomized clinical trial. arya atheroscler. 2019;15(4):154–60. 15. fadli, toalib i, kassaming. the effect of health education on anxiety levels in pre-major surgery patients. j ilm kesehat diagnosis vol. 2017;13(6):1–5. [in bahasa] 16. tomaszek l, cepuch g, fenikowski d. influence of pre-operative information support on anxiety, pain and satisfaction with post-operative analgesia in children and adolescents after thoracic surgery: a randomized double-blind study. biomed pap. 2019;163(2):172–8. 17. aryani hp, shomad m. the effect of health education on preoperative physical hartanti (pre-operation education to reduce anxiety: literature review) vol. 3, no. 2, 2021, pp. 23-30 10.26555/eshr.v3i2.4301 30 preparation in reducing anxiety herniapatient. j keperawatan dan kebidanan. 2017 aug;9(2):6–6. 18. masriani l, handian fi, kristiana as. the effect of providing cardiac pre-catheterization health education on the patient's level of anxiety in cardiac service installations. j ilm kesehat media husada. 2020 apr;9(1):28–35. [in bahasa] 19. annisa rizki f, hartoyo m, sudiarto. health education using the leaflet media reduce anxiety levels in pre-operation patients. jendela nurs j. 2019;3(1):49–57. 20. hsueh fc, chen cm, sun ca, chou yc, hsiao sm, yang t. a study on the effects of a health education intervention on anxiety and pain during colonoscopy procedures. j nurs res. 2016 jun;24(2):181–9. microsoft word 4_5514.edited.edited_manual ref.docx epidemiology and society health review| eshr vol. 4, no. 2, 2022, pp. 61-68 issn 2656-6052 (online) | 2656-1107 (print) 10.26555/eshr.v4i2.5514 61 research article correlation between education and age to the perception of covid-19 vaccination lana unwanah1*, sitti nur djannah1, dyah suryani1, yanasta yudo pratama1,2,3, annisa tristifanny3, andita khoilina rahmanda3, hamza sameeh abd el qader abuhilail4 1 faculty of public health, universitas ahmad dahlan, yogyakarta, indonesia 2 faculty of medicine, public health, and nursing, universitas gadjah mada, yogyakarta, indonesia 3 faculty of medicine, universitas islam indonesia, yogyakarta, indonesia 4 faculty of medicine, arab american university, palestine * correspondence: lana.unwanah@gmail.com. phone: +6282227246918 received 04 january 2022; accepted 22 april 2022; published 2 august 2022 abstract background: covid-19, a pneumonia-like disease, started to spread at the end of 2019 and became a pandemic globally. vaccination is one of the programs to reduce the severity of particular conditions, including covid-19. however, in indonesia, the response to covid-19 vaccination remains low. this study aimed to assess the correlation between age and educational background to the perception of covid-19 in yogyakarta city, indonesia. method: this cross-sectional study was conducted from august to september 2021 at several vaccination centers in yogyakarta city of yogyakarta province. total sampling was used to recruit participants during the mass vaccination period. data were analyzed using univariate and bivariate analysis. results: 1,068 participants joined this study, with an age average of 29.8. most respondents graduated from senior high school 528 (49.4%). bivariate analysis showed a significant correlation between education and knowledge about adverse events following immunization (p=0.01). conclusion: perception of the adverse event following immunization was significantly associated with education. keywords: covid-19; age; education; covid-19 vaccine introduction at the end of 2019, the pneumonia-like disease spread in wuhan, china, later known as covid-19. this disease is caused by severe acute respiratory syndrome coronavirus 2 (sars-cov-2). the manifestation of covid-19 varies, ranging from an asymptomatic symptom to acute respiratory distress syndrome and multi-organ dysfunction (1). covid-19 unwanah (correlation between education and age to the perception of covid-19 in yogyakarta) vol. 4, no. 2, 2022, pp. 61-68 10.26555/eshr.v4i2.5514 62 is one of the health problems in indonesia and even globally. the second wave of covid-19 in indonesia, in june 2021, reported a 381% increase in covid-19 cases from 25,396 to 26,067. then, in august 2021, active patients in indonesia were 3,979,456, with total mortality of 126,372 (2). it was estimated that this peak occurred after the long holidays when health protocols and physical distancing do not apply correctly among mobile people. the cases mainly increased in jakarta, west java, central java, and yogyakarta. the common severe risk factors of covid-19 are older and medical comorbidities like hypertension, diabetes, and cancer (3). the indonesian government took an essential vaccination program to prevent fatality from developing herd immunity in society. the government targeted 208,265,720 people who had been vaccinated. this program was started on january 13, 2021, beginning with the priority population, such as health workers, the elderly, and public servants (4). based on the government official data, on 1 january 2022, as many as 165,779,292 residents received the first dose and 114,044,659 second doses. yogyakarta is the third province in indonesia with 98.85% and 89.53% of covid-19 vaccination coverage for first and second doses, respectively. yogyakarta became one of the top 10 provinces with low active cases on december 31, 2021. during that time, only found 102 active cases; this number was relatively fewer than dki jakarta, west java, and central java (5). a study from the who in collaboration with the indonesia ministry of health revealed that 74% of the respondents reported knowledge about the government's intention to deploy covid-19 vaccines. about 65% of the respondents expressed their willingness to receive covid-19 vaccination if provided by the indonesian government, 27% reported hesitancy, and 8% refused to accept the covid-19 vaccine (6). referring to the health belief model, individual health behavior is determined by the threat of illness or disease with the belief of recommended health behavior (7). health behavior can also be predicted by intentions to do an action. intention refers to the need to perform a behavior, social norms, and the control that people perceive (8). other factors related to willingness to get vaccinated recommended by the government (9) are age, gender, location (urban/rural), level of education, income, perceived risk of being infected with covid-19 in the future, perceived severity of infection, having previous vaccination experience after age 18, having higher knowledge about covid-19 and vaccination were significantly associated with the acceptance of covid-19 vaccines (10). in the digital era, information about covid-19 spreads rapidly through social media. unfortunately, not all information spread on social media is accurate. even though this information will significantly affect a person's response to a government program, including the covid-19 vaccination (11), this leads to misinformation and conspiracy theories against vaccination. previous research reported that people exposed to anti-vaccine conspiracy theories showed less intention to vaccinate than those in the anti-conspiracy condition (12). although the vaccination rate in yogyakarta was relatively high, some groups still refused to receive the covid-19 vaccine. considering all backgrounds, this study aimed to assess the correlation between age and education to the perception of covid-19 in yogyakarta. unwanah (correlation between education and age to the perception of covid-19 in yogyakarta) vol. 4, no. 2, 2022, pp. 61-68 10.26555/eshr.v4i2.5514 63 method this cross-sectional approach was conducted during mass covid-19 vaccination from 1 august to 1 september 2021 in several vaccination spots in yogyakarta city. the population of this study was everyone who came to the vaccination spot during the mentioned period. total sampling was employed to recruit the participants. a questionnaire was used to collect the pre-tested data before using cronbach alpha 0.68. the questionnaire was installed on the google form platform, and the link was shared with the respondent via barcode. the respondents used their smartphones to access the questionnaire. if the respondent came without a smartphone, the researcher provided them with a smartphone. written informed consent was received before the participant filled out the questionnaire—deceptive and chisquare tests were used to analyze the data. the ethical consideration was approved by the research committee of universitas islam indonesia (12/ka. kom.et / 70/ ke/ iii/ 2022). results one thousand sixty-eight people participated in this study; all mass vaccination participants agreed to participate. the average participant was 29.8 years old, with a standard deviation of 14.07. in this study, the age ranged from 12 – 25 years old, 537 people (50.3%), 26 – 45 years old, 341 people (31.9%), 46 – 65 years old, 178 (16.7%), and >65 years old, 12 people (1.1%). 24 (2.2%) of participants graduated from elementary school, 108 (10.1%) graduated from junior high school, 528 (49.4%) graduated from senior high school, 355 (33.2%) graduated with a bachelor's degree, 50 (4.7%) graduated with a master's degree, and 2 (0.2%) graduated with a doctoral degree (table 1). table 1. distribution of research sample characteristics variable class n (%) age 12 – 25 537 50.3 26 – 45 341 31.9 46 – 65 178 16.7 >65 12 1.1 education elementary school 24 2.2 junior high school 108 10.1 senior high school 528 49.4 bachelor degree 355 33.2 magister degree 50 4.7 doctoral degree 2 0.2 table 2 shows the result of the bivariate analysis. we found a significant correlation between education and knowledge regarding adverse events following immunization (aefi) (p=0.001). meanwhile, other dependent variable analyses did not show a significant correlation (p-value >0.05). a total of 1025 from 1068 participants said that they believed in covid-19. however, this didn't correlate with the last educational background (p-value = 0.821). of 1068 participants, only 16 (1.5%) didn't believe in the covid-19 vaccine. this didn't correlate with the last educational background (p-value = 0.667). most participants (97%) in our study were motivated to recommend covid-19 vaccination to other people, and they also stated that they would obey the health protocols even after vaccination (99.7%). seven hundred fifty-two participants said they did not feel afraid or anxious before vaccination. this condition didn't correlate with educational background (p=0.403). we were also looking for the unwanah (correlation between education and age to the perception of covid-19 in yogyakarta) vol. 4, no. 2, 2022, pp. 61-68 10.26555/eshr.v4i2.5514 64 motivation behind vaccination on each participant; 85.2% of reasons were the personal intention, 5.9% came from an external factor, and the rest were from other intentions (8.9%) such as hajj travel conditions and domestic or international traveling term. table 2. the characteristics of respondents to the covid-19 vaccine perception statement n (%) belief in covid-19 yes no 1,025 (96) 43 (4) belief in the covid-19 vaccine yes no 1,052 (98.5) 16 (1.5) know about aefi yes no 741 (69.4) 327 (30.6) willingness to recommend the covid-19 vaccine to others yes no 1,036 (97) 32 (3) willingness to comply with health protocols after vaccinated yes no 1,065 (99.7) 3 (0.3) feeling before vaccination afraid not afraid 356 (33.3) 712 (66.7) motivation to take part in vaccination program personal intention encouragement from an external factor other intention 910 (85.2) 63 (5.9) 95 (8.9) most respondents believe in covid-19 (96%). the majority of them believed in the covid19 vaccine (98.5%). more than half (69.4%) of respondents reported they know about aefi. most respondents (97%) were willing to recommend the covid-19 vaccine to others. most (99.7%) said they would comply with health protocols after vaccination. regarding their feeling before vaccination, the majority of the respondent (66.7%) said they were not afraid. more than 80% of the respondents reported personal intention as their motivation to join the vaccination (table 2). table 3 shows the association between education background and age in the variables measured. it presents a significant association between educational background and knowledge about aefi with a p-value=0.01. while for age, there was no significant association among the variable measure. discussion the pandemic of covid-19 caused many impacts on life, increasing the mortality rate and causing difficulties in economic and social aspects. the indonesian government started the vaccination program in early 2021 for health workers, the elderly, and other public servants. the purpose of the vaccination program was to reach herd immunity and prevent the severity of symptoms. vaccination has been considered one "self-care" treatment for a long time. but, in this pandemic era, some people's opinions about vaccinations might create hazards for others (13). during the covid-19 vaccination program, the government found some obstacles, such as the hesitation to participate in this program because society doubts the unwanah (correlation between education and age to the perception of covid-19 in yogyakarta) vol. 4, no. 2, 2022, pp. 61-68 10.26555/eshr.v4i2.5514 65 safety and side effects of covid-19 vaccines. some people avoid getting vaccinated or recommend vaccines to others (14). various information from many sources is easily accessed today, but not everyone has a good filter on reliable information. table 3. correlation between education background and age to the covid-19 and the vaccine variable indicator p-value educational background belief in covid-19 0.82 belief in covid-19 vaccine 0.66 know about aefi 0.01 willingness to recommend the covid-19 vaccine to others 0.09 willingness to comply with health protocols after vaccinated 0.13 feeling before vaccination 0.40 motivation to take part in vaccination program 0.64 age belief in covid-19 0.93 belief in covid-19 vaccine 0.72 know about aefi 0.56 willingness to recommend the covid-19 vaccine to others 0.90 willingness to comply with health protocols after vaccinated 0.48 feeling before vaccination 0.324 motivation to take part in vaccination program 0.519 demographic characteristics such as age and educational experience influenced the quality of human resources. in this study, we assessed the association between education and age to some variables measured related to the perspective of covid-19. we found that educational background is associated with people's knowledge about aefi. adverse events following immunization (aefi) generally happen to vaccinated people. they might feel pain, mild fever, redness in the injection area, tiredness, headache, muscle ache, or even diarrhea (15). these are normal reactions, but if they cause shortness of breath or any other lifethreatening reaction, health workers should be aware of and educate people about this condition after getting vaccinated. however, severe reactions after vaccination, such as cardiovascular events like hypertension, hypotension, tachycardia, and peripheral coldness, were also reported. myocardial infarction effects after vaccination of covid-19 were reported in individuals above 75 years old (16). a cross-sectional study about knowledge and perception of aefi conducted in nigeria found that the majority of health workers knew about aefi (92%) and had been trained to treat aefi (80%) (17). our finding shows that education level determines people's knowledge about aefi; it could be because educated people have access to news media and have a positive cycle to get the correct information. a study on 1,000 participants aged 18 – 74 in germany found associations between low education level and higher perceived severity and between low education level and lower perceived probability. highly educated men were more worried about covid-19 than those with low levels of education. this study also showed no educational differences in perceived susceptibility or fear (18). another study in bangladesh about factors associated with covid-19 vaccines found that participants above 30 years old heard less about this information. this study also found that level of education was significant; respondents with university-level education heard more about covid-19 vaccines (19). unwanah (correlation between education and age to the perception of covid-19 in yogyakarta) vol. 4, no. 2, 2022, pp. 61-68 10.26555/eshr.v4i2.5514 66 another study in bangladesh shows that more educated people are more knowledgeable about their health (20). our study was conducted in early 2021 and targeted the elderly and public servants who are a priority during the vaccination mass. this significant association may be due to convenient access to recently updated information about adverse events related to covid-19 vaccination. this is also related to our study population, primarily young people with high educational backgrounds (senior high school and bachelor's degrees). complying with health protocols is one of the crucial factors in the control of covid-19 and also the vaccination process. those who adhere to and understand health protocols will realize the importance of vaccines. in our study, most respondents reported accepted vaccines because of personal intentions. this is also related to variables regarding the relationship of the last level of education with the information received. the better details about vaccines received by the public will tend to do vaccines of their own accord. however, it does not include rules from the government that require doing vaccines as one of the conditions for doing activities. one of the health protocols that need to be considered is masks. masks are one way to prevent the virus from becoming airborne, based on research conducted in california regarding pandemic simulations. masks do not have much effect if not combined with other health protocols such as hand washing, maintaining distance, and hand sanitizers in the absence of water (21). similar research was reported fromlangsa, aceh; that said the most significant number of respondents in adulthood with high school education level received a value of p=0.000, meaning meaningful. in the majority, there is a better level of compliance among adolescents and the elderly. and secondary education and college levels have higher adherence to health protocols: high school (80.6%) and lectures (92.1%). in our study, 1065 people agreed to follow health protocols, and only three refused. this is due to various aspects, such as the role of social media and excellent communication and media delivery, rather than the educator. the concern level before the covid-19 vaccine can occur due to several things, such as fear of side effects (49%), waiting for other people to use it until proven safe (35%), and different reasons. in our study, 712 respondents were not afraid (worried, anxious), and the remaining 356 felt concerned. this worry can be caused by scattered hoaxes and information less obtained by respondents (6). there is a lot of fear in people aged 18 – 24 years. this is because, in this age, social media be a favorite information source (22) , and much information spreads under uncontrol, including news about the side effects of covid-19 vaccination (6). the government and the public collaborate in voicing vaccines for the wider community. in our study, respondents were willing to recommend vaccines to people because they already understood the importance of vaccines. vaccines are not the most successful weapon or prevention; vaccines serve to provide immunity where immunity must be maintained with various health protocols. vaccines without health protocols will not succeed in making indonesia survive in the pandemic era and vice versa. all components must collaborate to protect us from the covid-19 pandemic. unwanah (correlation between education and age to the perception of covid-19 in yogyakarta) vol. 4, no. 2, 2022, pp. 61-68 10.26555/eshr.v4i2.5514 67 conclusion this study examined the relationship between age, education, and people's perception of covid-19 and the covid-19 vaccine. we found that knowledge about aefi is significantly associated with an educational background. authors' contribution lu contributes to research ideas, designing research concepts to collecting research data. yyp contributed to the collection of research data. at and akr contribute to research data processing and research data analysis. snd and ds contributed by providing input in writing this manuscript. funding this research has not received external funding. conflict of interest there is no conflict of interest in this research. references 1. singhal t. a review of coronavirus disease-2019 (covid-19). the indian journal of pediatrics. 2020 apr 13;87(4):281–6. 2. satgas covid19. analisis data covid-19 updated per 22 agustus 2021. 2021 [cited 2022 jan 2]. available from: analisis data covid-19 updated per 22 agustus 2021 3. wolff d, nee s, hickey ns, marschollek m. risk factors for covid-19 severity and fatality: a structured literature review. infection. 2021 feb 28;49(1):15–28. 4. kementerian kesehatan republik indonesia. program vaksinasi covid-19 mulai dilakukan, presiden orang pertama penerima suntikan vaksin covid-19. 2021 [cited 2022 jan 5]. available from: http://p2p.kemkes.go.id/program-vaksinasi-covid-19-mulaidilakukan-presiden-orang-pertama-penerima-suntikan-vaksin-covid-19/ 5. kementerian kesehatan republik indonesia. cakupan vaksinasi covid-19 dosis 1 dan 2 di indonesia. 2022 [cited 2022 jan 2]. available from: https://vaksin.kemkes.go.id/#/vaccines 6. world health organization, kementerian kesehatan republik indonesia. survei penerimaan vaksin covid-19 di indonesia. 2020 [cited 2022 jan 2]. available from: https://covid19.go.id/storage/app/media/hasil%20kajian/2020/november/vaccineacceptance-survey-id-12-11-2020final.pdf 7. guidry jpd, laestadius li, vraga ek, miller ca, perrin pb, burton cw, et al. willingness to get the covid-19 vaccine with and without emergency use authorization. american journal of infection control. 2021 feb;49(2):137–42. 8. wollast r, schmitz m, bigot a, luminet o. the theory of planned behavior during the covid-19 pandemic: a comparison of health behaviors between belgian and french residents. plos one. 2021 nov 4;16(11):e0258320. 9. malik aa, mcfadden sm, elharake j, omer sb. determinants of covid-19 vaccine acceptance in the us. eclinicalmedicine. 2020 sep;26:100495. 10. mahmud s, mohsin md, khan ia, mian au, zaman ma. knowledge, beliefs, attitudes and perceived risk about covid-19 vaccine and determinants of covid-19 vaccine acceptance in bangladesh. plos one. 2021 sep 9;16(9):e0257096. unwanah (correlation between education and age to the perception of covid-19 in yogyakarta) vol. 4, no. 2, 2022, pp. 61-68 10.26555/eshr.v4i2.5514 68 11. wong a, ho s, olusanya o, antonini mv, lyness d. the use of social media and online communications in times of pandemic covid-19. j intensive care soc. 2021 aug 22;22(3):255–60. 12. jolley d, douglas km. the effects of anti-vaccine conspiracy theories on vaccination intentions. plos one. 2014 feb 20;9(2):e89177. 13. cislak a, marchlewska m, wojcik ad, śliwiński k, molenda z, szczepańska d, et al. national narcissism and support for voluntary vaccination policy: the mediating role of vaccination conspiracy beliefs. group processes & intergroup relations. 2021 aug 3;24(5):701–19. 14. štěpánek l, janošíková m, nakládalová m, štěpánek l, boriková a, vildová h. motivation to covid-19 vaccination and reasons for hesitancy in employees of a czech tertiary care hospital: a cross-sectional survey. vaccines (basel). 2021 aug 1;9(8). 15. world health organization. side effect of covid-19 vaccines. 2019 [cited 2022 jan 5]. available from: https://www.who.int/news-room/feature-stories/detail/side-effects-ofcovid-19-vaccines 16. kaur r, dutta s, charan j, bhardwaj p, tandon a, yadav d, et al. cardiovascular adverse events reported from covid-19 vaccines: a study based on who database. international journal of general medicine. 2021 jul; volume 14:3909–27. 17. mohammed l, aliyu a, maiha b, isa a. knowledge, perception and reporting attitude of adverse effects following immunization among primary healthcare workers in sabon gari local government area zaria, kaduna state, nigeria. nigerian journal of basic and clinical sciences. 2018;15(1):81. 18. rattay p, michalski n, domanska om, kaltwasser a, de bock f, wieler lh, et al. differences in risk perception, knowledge and protective behaviour regarding covid-19 by education level among women and men in germany. results from the covid-19 snapshot monitoring (cosmo) study. plos one. 2021 may 12;16(5):e0251694. 19. paul a, sikdar d, mahanta j, ghosh s, jabed mda, paul s, et al. peoples’ understanding, acceptance, and perceived challenges of vaccination against covid-19: a crosssectional study in bangladesh. plos one. 2021 aug 20;16(8):e0256493. 20. islam mds, siddique ab, akter r, tasnim r, sujan mdsh, ward pr, et al. knowledge, attitudes and perceptions towards covid-19 vaccinations: a cross-sectional community survey in bangladesh. bmc public health. 2021 dec 13;21(1):1851. 21. mniszewski sm, del valle sy, priedhorsky r, hyman jm, hickman ks. understanding the impact of face mask usage through epidemic simulation of large social networks. in 2014. p. 97–115. 22. sulistyawati s, rokhmayanti r, aji b, wijayanti spm, hastuti skw, sukesi tw, et al. knowledge, attitudes, practices and information needs during the covid-19 pandemic in indonesia. risk management and healthcare policy. 2021;14:163–75. available from: https://www.dovepress.com/articles.php?article_id=61222 microsoft word 5062-article text-19219-1-18-20220130-9feb.docx epidemiology and society health review| eshr vol. 4, no. 1, 2022, pp. 21-28 issn 2656-6052 (online) | 2656-1107 (print) 10.26555/eshr.v4i1.5062 21 research article assessment of reproductive health awareness among adolescent girls in a city of south india: an interventional study josephine priya k1*, ranganath t. sobagaiah2, ipsita debata3 1 senior assistant professor, department of community medicine, k.a.p. viswanatham government medical college, tiruchirapalli, tamilnadu, india 2 professor and hod, department of community medicine, bangalore medical college and research institute, bangalore, karnataka, india 3 associate professor, department of community medicine, akash institute of medical sciences and research center, bangalore, karnataka, india * correspondence: drjosephinek@gmail.com. received 25 october 2021; accepted 21 january 2022; published 31 january 2022 abstract background: an adolescent in the age group of 10 – 19 years is subjected to the vicious cycle of early marriage; early, repeated pregnancies; poor nutrition and ill health. in developing countries, close to 12.7 million girls under the age of 19 give birth each year. adolescents lacking in knowledge of reproductive health will not be able to make informed decisions. a study to evaluate and improve the existing awareness levels of reproductive health among adolescent girls in the south of india is the need of the hour. objectives: this study aimed to assess the existing reproductive health awareness among adolescent girls and evaluate the change in awareness levels of reproductive health after educational intervention. methods: a descriptive study with an educational interventional was carried out in high schools and pre university colleges in a city of south india. 800 students from class viii to xii from 6 educational institutions were studied using a standardized, pre validated questionnaire. baseline evaluation of reproductive health awareness among these students was done followed by an educational health intervention. post intervention awareness levels were assessed using the same questionnaire after an interval of three months to evaluate for change. results: the mean age of the study population was found to be 14.91 (+1.45) years. teaching intervention improves knowledge on reproductive and sexual health (p < 0.001). predictors of poor pre intervention knowledge levels: those with uneducated fathers (or= 0.31, p=0.005); not on social networking sites (or= 0.23, p<0.001); lower age (early adolescence) (or= 2.46, p<0.001); school going adolescents (or= 3.47, p<0.001) conclusion: this study highlights the gross deficiencies present among adolescent girls with respect to reproductive and sexual health awareness. various measures must be put into place to ensure better reproductive health of the adolescent. keywords: adolescent; reproductive health; intervention josephine priya (assessment of reproductive health awareness among adolescent girls in a city of south india) vol. 4, no. 1, 2022, pp. 21-28 10.26555/eshr.v4i1.5062 22 introduction the world health organization (who) identifies adolescence as the period in human growth and development that occurs after childhood and before adulthood, from ages 10 to 19 (1). in this critical phase of transition they are burdened by physical and mental changes and also have to deal with various other stressors. due to the psychological, emotional, hormonal and physical changes it is necessary to empower the adolescent with education regarding reproductive and sexual health. today's adolescents are 1.2 billion strong and constitute 16% of the world's population (2). more than half of the world’s adolescents live in asia. india has the highest adolescent population in the world, with an estimated 253 million adolescents, constituting 21.4% of the country's population (3,4). india also has the highest proportion of adolescents closely followed by china with 201 million adolescents (4). this age group is one of simple but crucial reproductive health needslike menstrual hygiene, contraception and safety from sexually transmitted infections (stis). these when unattended lead to problems of public health importance such as adolescent pregnancy, unsafe abortion, reproductive tract infections (rtis), stis and acquired immuno-deficiency syndrome (aids) and social problems. these in turn lead to adverse pregnancy outcomes like low birth weight (lbw) and high infant mortality rate (imr). adolescent girls in india are a largely invisible population, amounting to 113 million, or 20% of the world’s adolescent girls. they are trapped in a society with varied socio-cultural practices that leaves them powerless to make essential life-choices (5). issues such as lack of autonomy to take decisions regarding marriage, sexual relations, education, career, etc still plague this age group (6). adolescent females are often subjected to the vicious cycle of early marriage, early and repeated pregnancies, poor nutrition and ill health. in developing countries, close to 12.7 million girls under the age of 19 give birth each year (7,8). data from national family health survey4 (nfhs 4) reported 33,928 live births by women under 20 years of age in india (9). even with programmes such as the rashtriya kishor swasthya karyakram (rksk), reproductive, maternal, newborn, child and adolescent health, the health of the girl child has always been an area of neglect in our country. menstrual practices are also shadowed by unnecessary and sometimes even harmful cultural or superstitious practices in many countries (10,11) and this leads to a greater need for health awareness in the adolescent period. improving the reproductive health among adolescent girls can only occur by educating them and promoting health awareness and healthy behaviour among them. better reproductive health awareness will promote a decrease in morbidity and mortality, fair delivery of adolescent healthcare rights, and subsequently safeguard future generations (12). it has also been seen that menstruation also significantly impacts the education of the girl child (13). until recently still lack of data pertaining to reproductive health awareness among adolescent girls from south india. a study to evaluate and improve the existing awareness levels of reproductive health among adolescent girls in the south of india is the need of the hour. josephine priya (assessment of reproductive health awareness among adolescent girls in a city of south india) vol. 4, no. 1, 2022, pp. 21-28 10.26555/eshr.v4i1.5062 23 method a cross sectional study with an educational intervention was carried out among adolescent girls from randomly selected high schools and pre-university (pu) colleges in urban bangalore during the period from january to may 2017. based on a previous study by pratinidi et al. (14) the change in awareness levels post intervention was found to be 19.05% at 5% significance with 15% allowable error, sample size was calculated to be 754 (rounded off to 800). among the schools that consented to participate in the study, a total of 6 educational institutions, 4 schools and 2 pu colleges were randomly selected from the master list of eligible schools and pu colleges in the city. based on the strength of these institutions it was decided that all girl students in these schools and colleges will be included in the study in order to achieve the desired sample size. for the purpose of equal representation across the age group 400 students from high schools and 400 from pu colleges were included in the study. students absent on the day of the study-either for pretest or posttest were excluded from the study. data collection was started after obtaining clearance from the institutional ethical committee. permission was obtained from the education officer of bhruath bangalore mahanagara palike (for corporation schools), deputy director of public instruction, bangalore city (for private schools) and deputy director of pu board. as the students are minors, informed consent for study was obtained from the parents of the students through teachers, assent was obtained from students. pre and post test assessments were conducted six months apart. data regarding socio demographic profile and various aspects of reproductive health were collected by pre tested, semi-structured questionnaire administered to the students (self-administered questionnaire method). a modified who questionnaire on adolescent reproductive and sexual health was used. for the educational intervention, teachers selected by the institution were trained on relevant aspects of adolescent reproductive health. the educational intervention was delivered three months after the pretest with the aid of power point presentations, by the trained teacher in the presence of the doctor. education was carried out on topics such as physiology of pregnancy, sexually transmitted infections-modes and prevention, contraception, etc. for duration of 2 hours in each institution. for scoring, each right answered was scored as 1 and wrong answer as 0. the aggregate score of all domains was summed to arrive at the total score. the academic performance of the students was assessed based on the average score in the previous exam. this was recorded from the students’ marks card with the help of the class teacher. posttest evaluation was carried out three months after the educational intervention was delivered. data was entered onto a computerized excel (microsoft excel 2007) spread sheet and analyzed using spss version 20. descriptive analysis was done (means, proportions, and percentages) for demographic variables. categorical variables were compared using chi square test. intra group comparisons were done using the paired ttest (for continuous data) and wilcoxon matched pairs signed-ranks test (for categorical data). variables found to be significantly associated with knowledge levels by the chi square test were analyzed for their simultaneous influence on the same by logistic regression. p value of < 0.05 was considered significant. josephine priya (assessment of reproductive health awareness among adolescent girls in a city of south india) vol. 4, no. 1, 2022, pp. 21-28 10.26555/eshr.v4i1.5062 24 the following definitions were used for analysis: 1. educational status of parents: those with a minimum education of 10th standard were considered as educated while those with no formal education received/ less than 10th standard were considered as not educated 2. knowledge levels (pre and posttest): those with a score of 25 – 36 were categorized as good; 10 – 24 were considered average and 0 – 9 were classified as having poor knowledge levels 3. academic performance (based on the average score in the previous exam recorded from the students marks card) was classified as good if they had an annual average score of 80% or above; average if the annual average score was 65% 79% and poor when the annual average score was 64% or below results data analysis revealed a total of 800 students participated in the study. 474 (59.3%) study participants were from high schools and 326 (40.7%) from pre university colleges. the mean (sd) age of this group was found to be 14.91 (1.45) years. of the 800 students, 158 (20%) belonged to class 8, 174 (22%) to class 9, 142 (17%) were from class 10, 182 (23%) from class 11 and 144(18%) were from class 12.647 (80.9%) students were hindus, 86 (10.6%) were muslims, 60 (7.5%) were christians. there was significant improvement in knowledge levels post the educational intervention, in all domains-namely pertaining to puberty, menstruation, pregnancy, contraception, stds and hiv and abortion (p <0.001) [table 1]. table 1. knowledge across different domains knowledge domains mean (sd) p* pre-test post test puberty 1.72 5.36 <0.001 menstruation 4.54 6.11 <0.001 pregnancy 2.52 6.58 <0.001 contraception 1.05 4.14 <0.001 stds and hiv 2.97 6.97 <0.001 (*paired t test, at 95% ci) abortion (abortion is the best method of preventing pregnancy) 37.3% (n=298) 22.6% (n= 181) <0.001 (*mc nemar’s test) all students showed significant improvement in knowledge levels post educational intervention. during the pretest it was seen that 414 students and 71 students respectively were average and good in their knowledge levels, it improved to 75 only (average) and 723 (good) in the post-test. only 2 students who initially showed poor knowledge levels remained in the same group post the educational intervention (0.6%) [table 2]. josephine priya (assessment of reproductive health awareness among adolescent girls in a city of south india) vol. 4, no. 1, 2022, pp. 21-28 10.26555/eshr.v4i1.5062 25 table 2: change in performance of students in terms of knowledge categories post test total p* pre test poor average good <0.001 poor 2 51 262 315 average 0 22 392 414 good 0 2 69 71 total 2 75 723 800 (*wilcoxon matched pairs signed-ranks test, at 95% ci) the effect of the educational intervention was calculated using effect size and it was found that the maximum effect was seen in the puberty domain with an effect size of 1.8 [figure 1] figure 1. effect size of the various domains academic performance was seen to have a significant impact on the baseline knowledge possessed by the adolescent girls. among the good academic performers, 59.7% (n=228) were found to have good reproductive and sexual health awareness in the pre intervention stage [table 3]. table 3. association between academic performance and overall knowledge score prior to intervention (outcome variable) academic performance pre intervention knowledge levels total χ2 p poor good 0.002 good 154 (40.3%) 228 (59.7%) 382 average 91 (31.2%) 201 (68.8%) 292 poor 52 (49.1%) 54 (50.9%) 106 total 297 483 780 the knowledge levels of students with fathers who have an education of at least 10th standard were 0.31 times better than those whose fathers had lesser education. knowledge levels of adolescents who were a part of one or more social networking sites was 0.23 times better than 1,8 1,78 1,74 1,34 0,94 0 0,2 0,4 0,6 0,8 1 1,2 1,4 1,6 1,8 2 puberty pregnancy contraception stds and hiv menstruation effect size josephine priya (assessment of reproductive health awareness among adolescent girls in a city of south india) vol. 4, no. 1, 2022, pp. 21-28 10.26555/eshr.v4i1.5062 26 those who were not a part of social networking sites. older adolescents had significantly better knowledge than the younger adolescents (or = 2.46). adolescents with higher education (college) had significantly better knowledge than the school going adolescents (or = 3.47) [table 4]. table 4. predictors of pre intervention knowledge by regression analysis predictor variables odds ratio 95% confidence intervals p lower limit upper limit father’s education 0.31 0.138 0.699 0.005 socio-economic status 0.87 0.696 1.078 0.19 academic performance 0.81 0.633 1.032 0.087 social networking 0.23 0.117 0.440 <0.001 age groups 2.46 1.674 3.617 <0.001 educational status (in college vs school) 3.47 2.197 5.465 <0.001 discussion adolescence is an impressionable and vulnerable stage in a child’s life. foundations of a healthy and responsible lifestyle must be laid in the formative years. education plays a great role in shaping the behaviour and choices made by adolescents.this study highlights the gross lacunae that are present in adolescents with respect to reproductive and sexual health. the factors that are surprising and warrant consideration are that most of these adolescents have already attained menarche and are going through their reproductive cycles every month but are grossly ignorant regarding the physiology of the same. in an age and time where connectivity is highly valued and the internet is just a tap away, it is surprising to note that simple messages of menstrual hygiene, prevention of stds, importance of good health care in the adolescent age group, etc. have been ineffective in reaching the target group. a study conducted in government schools of delhi found that only 40% girls had prior knowledge of menstruation (15). a scoping review found puberty and menstruation knowledge among young adolescents in low-and middle-income countries to be inadequate (16). our study showed around 9% of the students possessed poor knowledge of menstruation prior to the intervention. this study shows a significant improvement in knowledge among the adolescents post educational intervention. this is similar to the studies by manjula r. et al. (17) and various other studies from india and abroad (18), who found that there was overall significant change in knowledge (p<0.001) after educational intervention. this is also similar to a study done by pratinidi a k et al. (14) where it was observed that the change in knowledge was 8 marks and 19.05% increase in percentage between pre and post-test (p < 0.00). a study conducted by rao r. et al. (19). showed that the knowledge regarding menstruation and menstrual hygiene among adolescent girls improved significantly from 77.2% to 95.6% and 91.8% to 100% respectively after intervention (p < 0.0001). there are not many studies that have looked at the impact of educational intervention in the different domains. our study has shown that the highest impact was in the puberty domain. this is probably because the adolescent students can better relate to this current phase of their life. however other domains followed closely in effect size. josephine priya (assessment of reproductive health awareness among adolescent girls in a city of south india) vol. 4, no. 1, 2022, pp. 21-28 10.26555/eshr.v4i1.5062 27 conclusion better reproductive health awareness is the need of the hour. with a fast growing adolescent population such as in our country, emphasis on educating girls on reproductive health will improve the general health of our population and reflect in the improvement of our health indicators. educational intervention, as seen from this study, is a highly effective means of achieving the same. in agreement with a study done among 12to 19-year-old females in karaj, iran (20), we also feel that it is important to maintain continuous training at the school level to improve the knowledge of these adolescent girls. thus, as seen in this study and taking into account the factors identified by a qualitative study done by zainab alimoradi, it is necessary to strengthen education pertaining to reproductive health while simultaneously improving healthcare access and delivery to adolescents (21). various measures must be put into place to ensure better reproductive health of the adolescent. at the individual level it is important to teach adolescent girls to pay attention to good nutrition, cleanliness, hygiene and responsible reproductive behavior. efforts must be made to teach and educate the girl child on the anatomy and physiology of the reproductive system. at the family level parents must take initiatives to assume their primary role in the sexual education of their children, rather than relying on the schools to provide the appropriate orientation. they must be encouraged to provide emotional and psychological support to the adolescent. at the community level it is vital to have culturally appropriate information, education and communication strategies for improving adolescent reproductive health. more teachers must receive training in sexual and reproductive health topics, taking into account the special characteristics of the adolescent population. appropriate curriculum, methodologies and materials should be developed taking into account cultural differences. this is further supported by findings of the study by sarah blake et al. (22) where in it was seen that adolescents showed interest in learning about reproductive health when provided with the appropriate resources. authors' contribution dr. jpkresearch design, data collection, analysis and manuscript writing. dr. rtsresearch design, analysis. dr. iddata collection, analysis funding this research has not received external funding” for research without a donor conflict of interest there is no conflict of interest in this research. references 1. adolescent health and development. who.int. 2021 [cited 10 january 2020]. available from: https://www.who.int/news-room/q-a-detail/adolescent-health-and-development 2. adolescent demographics unicef data. unicef data. 2021 [cited 18 may 2020]. available from: https://data.unicef.org/topic/adolescents/demographics/ josephine priya (assessment of reproductive health awareness among adolescent girls in a city of south india) vol. 4, no. 1, 2022, pp. 21-28 10.26555/eshr.v4i1.5062 28 3. adolescent development and participation. unicef.org. 2021 [cited 17 september 2020]. available from: https://www.unicef.org/india/what-we-do/adolescent-developmentparticipation 4. unicef. progress for children: a report card on adolescents (no. 10). unicef; 2012 april. p. 7. 5. owning her future -empowering adolescent girls in india. mumbai: the kiawah trust; 2012. 6. adolescents in india: a desk review of existing evidence and behaviours, programmes and policies." 2013. new delhi: population council & unicef. 7. darroch j, woog v, bankole a, ashford ls. adding it up: costs and benefits of meeting the contraceptive needs of adolescents. new york: guttmacher institute; 2016. 8. girlhood, not motherhood: preventing adolescent pregnancy. unfpa, the united nations population fund; 2015 [cited 18 july 2020]. available from: https://www.unfpa.org/publications/girlhood-not-motherhood 9. international institute for population sciences (iips) and icf. 2017. national family health survey (nfhs-4), 2015-16: india. mumbai: iips. 10. kaur r, kaur k, kaur r. menstrual hygiene, management, and waste disposal: practices and challenges faced by girls/women of developing countries. journal of environmental and public health. 2018;2018:1-9. 11. bobel c, winkler i, fahs b, hasson k, kissling e, roberts t. the palgrave handbook of critical menstruation studies. singapore: palgrave macmillan; 2020. 12. mcintyre p. adolescent friendly health servicesan agenda for change. world health organization; 2002. 13. miiro g, rutakumwa r, nakiyingi-miiro j, nakuya k, musoke s, namakula j et al. menstrual health and school absenteeism among adolescent girls in uganda (meniscus): a feasibility study. bmc women's health. 2018;18(1). 14. pratinidhi a, et. al. evaluation of sex education and aids prevention project in secondary schools of pune city. indian j commun med. 2001;26:155–61. 15. rastogi s, khanna a, mathur p. uncovering the challenges to menstrual health: knowledge, attitudes and practices of adolescent girls in government schools of delhi. health education journal. 2019;78(7):839-850. 16. coast e, lattof s, strong j. puberty and menstruation knowledge among young adolescents in lowand middle-income countries: a scoping review. international journal of public health. 2019;64(2):293-304. 17. manjula r, kashinakunti sv, geethalakshmi r g, sangam d k. an educational intervention study on adolescent reproductive health among pre-university girls in davangere district, south india. ann trop med public health 2012;5:185-9. 18. setyowati s, rizkia m, ungsianik t. improving female adolescents’ knowledge, emotional response, and attitude toward menarche following implementation of menarcheal preparation reproductive health education. asian/pacific island nursing journal. 2019;4(2):84-91. 19. rao r, lena a, nair n s, kamath v, kamath a. effectiveness of reproductive health education among rural adolescent girls: a school based intervention study in udupi taluk, karnataka. indian j med sci 2008;62:439-43. 20. farid m, barandouzi za, valipour ns. knowledge, attitudes, and coping strategies regarding pubertal changes among adolescent girls: risks and compliances for health promotion in puberty. j educ health promot. 2019 sep 30;8:176. 21. alimoradi z, kariman n, simbar m, ahmadi f. empowerment of adolescent girls for sexual and reproductive health care: a qualitative study. african journal of reproductive health. 2017;21(4):80-92. 22. blake s, boone m, yenew kassa a, sommer m. teaching girls about puberty and menstrual hygiene management in rural ethiopia: findings from a pilot evaluation. journal of adolescent research. 2017;33(5):623-646. microsoft word 3719-11255-editing-au-ss-au-final.edited-2.docx epidemiology and society health review| eshr vol. 3, no. 2, 2021, pp. 1-9 issn 2656-6052 (online) | 2656-1107 (print) 10.26555/eshr.v3i2.3719 1 research article entomological index and insecticide susceptibility status in dengue-endemic areas yogyakarta fardhiasih dwi astuti1* and arlina azka1 1 faculty of public health, ahmad dahlan university, yogyakarta, indonesia * correspondence: fardhiasih.dwiastuti@ikm.uad.ac.id. phone: +6281328299534 received 21 february 2021; accepted 30 july 2021; published 31 july 2021 abstract backgrounds: dengue hemorrhagic fever (dhf) is a disease that receives special attention because of causing outbreaks in some countries, including indonesia. the problems that often emerge on the dhf control program are the high vector density (aedes aegypti) and the vector resistance resulting from continuous insecticide use. this study describes the entomological index and susceptibility status of aedes aegypti against malathion and permethrin insecticides in sorosutan, umbulharjo, yogyakarta. methods: this study used a descriptive observational method with a cross-sectional design. an entomological survey was done at 354 houses in sorosutan, which was randomly selected. the sample of aedes aegypti was obtained through the larval collection and ovitrap installation in 100 places. susceptibility tests performed using the bioassay method with impregnated paper were based on the who standard. this study was conducted from december 2018 – february 2019. the data were analyzed using univariate analysis results: the entomological survey in sorosutan showed the house index value was 35.03%; container index was 16.68%; breteau index was 46.33; density figure was 5.00, and larva free rate was 64.97%; meaning that sorosutan had a high level of vector density. so, the risk of dhf transmission was high. the population of aedes aegypti in sorosutan has been tolerant against malathion, with 87.83% mosquito mortality. conclusion: sorosutan was an area with high dhf transmission risk. aedes aegypti population in sorosutan has been tolerant against malathion. keywords: entomological index; susceptibility status; aedes aegypti; malathion introduction dengue hemorrhagic fever (dhf) is a disease that receives concern globally because it continues to cause an outbreak in several countries. the incidence of dhf has increased rapidly worldwide in recent decades. it was estimated that as many as 390 million people per year were infected with dhf, of which 96 million people have clinical manifestations with a relatively high level of disease severity. in addition, as many as 3.9 billion people in 128 countries are at risk of being infected with the dengue virus (1). astuti (entomological index and insecticide susceptibility status in dengue-endemic areas yogyakarta) vol. 3, no. 2, 2021, pp. 1-9 10.26555/eshr.v3i2.3719 2 in indonesia, dengue has a moderately severe impact socially and economically. since the discovery of the first case in 1968, there has been an increase in dengue cases and endemic areas of dhf. the high number of dengue cases in indonesia is related to high population mobility, uncontrol urban growth, climate change, density changes, population distribution, low public awareness to maintain environmental sanitation, and other epidemiological factors that still require further research (2). dhf cases in indonesia are spread across cities in indonesia, including jakarta, surabaya, medan, bandung, and yogyakarta (3,4). yogyakarta city is an endemic area of dhf in daerah istimewa yogyakarta (diy). the highest incidence of dengue fever in this city in 2017 was in sorosutan village, with an incidence rate of 20.6 per 100,000 population (5). sorosutan village has the highest population compared to 44 other villages in yogyakarta city. with this condition, there is a potential for an increased risk of dengue transmission in the area. efforts to treat dhf so far are only based on the symptoms of the disease. however, in a situation where there is no specific dengue medicine, it is necessary to take effective countermeasures to reduce the incidence of dengue fever so that it does not continue to increase. vector control is the primary prevention effort that has been and is still being carried out by the government to break the chain of transmission of dengue fever (6). in addition, monitoring aedes sp larvae and the breeding place is also continuously carried out. vector density can be an indicator of the success of a dhf control program. the density of aedes sp can be identified using the larva free rate (lfr), house index (hi), container index (ci), breteau index (bi), and density figure (df). the density figure is a combination of hi, ci, and bi (7). besides mosquito nest eradication or psn in indonesia, chemical control is also carried out by applying fogging and household insecticides. malathion is a chemical for fogging that has been used in the dengue hemorrhagic fever eradication program in indonesia since 1973. this insecticide is one of the safe and cheap ones widely used in households (8). the use of malathion as a fogging solution in yogyakarta has been substituted with cypermethrin since 2016. dhf control by fogging is only carried out if cases are found and transmission occurs in the area (9). permethrin is one of the chemicals contained in overthe-counter household insecticides (10). the danger of using chemicals continuously can cause resistance to the dengue vector. vectors that have been resistant when they reproduce will produce offspring that have resistant genes. the higher the frequency of individual resistant vectors, the rate of resistant development will be faster. accordingly, the population will be dominated by resistant vectors. insects such as aedes aegypti can maintain and pass resistance traits to their offspring for a long time (11,12) resistance to malathion has been reported in several areas in indonesia, including simbangkulon village, buaran district, west kedungwuni village, kedungwuni district, and karangsari village, karang anyar district, pekalongan district (13). in the special region of yogyakarta (diy), aedes aegypti resistance to malathion was reported in panggungharjo village, bantul regency, plososkuning minomartani, and in several hamlets in gamping district, sleman district (14). malathion as a fogging chemical has not been followed by evaluating sensitivity to aedes aegypty in the sorosutan area. this study aimed to determine the entomological index and susceptibility status of aedes aegypti to malathion insecticides in sorosutan village, umbulharjo district, yogyakarta city. astuti (entomological index and insecticide susceptibility status in dengue-endemic areas yogyakarta) vol. 3, no. 2, 2021, pp. 1-9 10.26555/eshr.v3i2.3719 3 method this research was a descriptive observational study. an entomological survey was conducted in 354 houses in sorosutan village. mosquito samples were collected by collecting larvae and installing ovitraps in 100 purposively selected houses. house used for placing ovitrap should fulfill criterias: have a positive larval house, have 100 m distance previous ovitrap installed, and a house with poor lighting. mosquito breeding was carried out at the test animal maintenance laboratory, universita ahmad dahlan. vulnerability testing was carried out using impregnated paper according to who standards. impregnated paper with 5% malathion content was obtained from universiti sains malaysia (usm), penang, malaysia, a who collaborating centre. mosquito for testing pruposes was prepared by incubating aedes aegypty eggs from ovitrap installation. the hatched larvae were reared by feeding chicken liver powder, and water was distorted every two days. larval rearing was carried out until they became adults of the first generation (f1). mosquitoes used as samples for susceptibility testing were aedes aegypti adult females aged 3-5 days with sugar-water satiety conditions. the susceptibility test was carried out on treatment tubes containing impregnated paper and control (without impregnated paper). each tube was filled with 25 mosquitoes exposed to impregnated paper for one hour. then, the mosquitoes were transferred to the storage holding, observed the number of mosquitoes that fainted, and the number of deaths recorded after 24 hours. the test was carried out three times on each 5% impregnated paper malathion. vulnerability testing was carried out at the entomology laboratory of universitas ahmad dahlan. vulnerability status was obtained from the number of mosquito deaths which were then categorized as vulnerable (98% – 100%), tolerant (80% – 97%), and resistant (< 80%) (15). the research was conducted in december 2018 – february 2019. results sorosutan village entomological index the entomological index was obtained from an entomological survey in 18 rws in the sorosutan village, yogyakarta. table 1. sorosutan village entomology index december 2018 – january 2019 no. entomology index results 1 house index (hi) 35.03% 2 container index (ci) 16.68% 3 breteau index (bi) 46.33 4 density figure (df) 5.00 5 larva free rate (lfr) 64.97% table 1 shows that the hi, ci, and bi values in sorosutan village are pretty high, namely the hi of 35.03%, ci of 16.68%, and bi of 46.33. the combination of the three indicators produces a df value of 5.00. in addition, the larva-free rate (abj) obtained is relatively low, namely 64.97%. astuti (entomological index and insecticide susceptibility status in dengue-endemic areas yogyakarta) vol. 3, no. 2, 2021, pp. 1-9 10.26555/eshr.v3i2.3719 4 status of aedes aegypti susceptibility to malathion the following are the susceptibility test results to the malathion insecticide carried out on the aedes aegypti mosquito from the sorosutan village area. table 2 shows that the population of aedes aegypti in sorosutan village is tolerant to malathion insecticide with an average mortality of 87.83%. table 2. vulnerability status of aedes aegypti population in sorosutan village to malathion and permethrin insecticides insecticide average mosquito mortality (%) vulnerability status malathion 87.83 tolerant discussion based on the results of the entomological survey, the inspected houses and containers can be calculated values that are indicators of vector density and the risk of dengue transmission in the area, namely the house index (hi), container index (ci), breteau index (bi), density figure ( df), and larvae free rate (lfr). the hi value is 35.03%, and the ci is 16.68%. hi, values > 5% and ci > 10% indicate that the sorosutan area has a high risk of dhf transmission. meanwhile, based on the bi value obtained, 46.33, where the value is not more than 50, the transmission of dhf in the sorosutan area is not included in the high category (16). based on the df value, which is 5, it was indicated that the risk of dhf transmission in the sorosutan area is in the moderate category. the who stated that the hi value > 5% and/or bi > 20 for each region indicates that the region is sensitive to dengue fever. accordingly, sorosutan was categorized as a sensitive area to dengue fever (17). this result aligns with a study in the mamuju region, sulawesi, which shows a larva-free rate of 62.7% (july – august 2015) (18). the larva-free rate nationally for 2016-2019 showed 67.6%, 46.6%, 31.5% and 79.2%, respectively. this shows that areas in indonesia are at risk of dengue transmission. from 2010 to 2019, there was an increase in the area of dengue cases in indonesia. in 2019, 93.58% of the area in indonesia was infected with dengue fever. while in diy during 2019, the incidence rate was more than 49 per 100,000 population (85.9 per 100,000 population) (19). poor entomological indicators lead to a high risk of dengue transmission. this is because knowledge, behavior, and community participation to be directly involved in mosquito nest eradication (psn) activities are still inadequate (20,21). this can be seen from the results of the larva-free rate (lfr) in sorosutan of 64.97%, which was still far from the national target according to the indonesian ministry of health (95%). the low larva-free rate indicates that the psn program in sorosutan was still lacking. this is in line with research that states a relationship between psn's actions and the presence of larvae at pulang pisau port with a pvalue of 0.000. respondents who have bad actions have a 3.89 times greater risk of larvae than respondents who have good actions (22). some studies have shown a relationship between mosquito density and high dengue cases (23,24). community participation is needed to implement vector control mostly influenced by the community's knowledge, attitudes, and behavior (21). the implementation of vector control can be carried out through environmental management called integrated vector management astuti (entomological index and insecticide susceptibility status in dengue-endemic areas yogyakarta) vol. 3, no. 2, 2021, pp. 1-9 10.26555/eshr.v3i2.3719 5 (ivm). ivm combines mosquito breeding site elimination and chemicals by administering larvicides at mosquito breeding sites and fogging to kill adult mosquitoes that are implemented simultaneously (23). ivm was proven by a study in makassar that reduced the incidence of dengue (24). based on the susceptibility test to malathion insecticide, it was found that the population of aedes aegypti in the sorosutan village area was in the tolerant category. malathion is an organophosphate insecticide. the way these insecticide works is by inhibiting the enzyme cholinesterase (ache) in nerve cells. this enzyme works to hydrolyze acetylcholine into acetate, and choline—acetylcholine functions as a neurotransmitter in the synaptic cleft. when the organophosphate is sprayed on the target organism, the ache enzyme cannot work normally. organophosphates phosphorylate the enzyme into a stable component form. so that acetylcholine cannot be decomposed in the postsynaptic (25). the research results in plosokuning yogyakarta showed that aedes aegypti in the area was already resistant, increasing the esterase enzyme activity. esterase enzymes detoxify organophosphates, carbamates, and pyrethroid synthesis by hydrolyzing ester bonds and binding pesticides to the active esterase site (26). resistance can arise due to the use of chemicals continuously for a long time and be given to the next generations of these mosquitoes. we found that in the household in sorosutan, most of them applied the insecticide daily and continuously. aedes aegypti is able to be given the resistant traits to their offspring for a long time (11). a study in the united states showed that the population of ae. albopictus in florida and new jersey were found to be resistant to malathion. the study also found significant differences in the activity of detoxification enzymes which suggest a metabolic-based resistance mechanism. malathion-resistant populations have increased esterase and glutathione s-transferase enzymes (27). the presence of esterase enzyme activity in the mosquito population will resist other insecticides with ester groups. therefore, in areas with mosquito populations resistant to malathion, it is advisable to choose an active ingredient not from the organophosphate group and has a different mechanism of action from malathion (13). the results of this study are in line with research conducted by sukmawati that the aedes aegypti population originating from makassar city is tolerant to 5% malathion with an average mortality of 87% (28). tolerance status can become resistant to malathion if the insecticide is used continuously without rotation. the area reported to be resistant to malathion is panggungharjo village, bantul, with a 0% mortality percentage (100% resistance) (14). in tomohon city with 0% mosquito mortality (29). in semarang, resistance was reported at tanjung emas port with mosquito mortality in the buffer area of 13% and perimeter of 20% (30). in pekalongan district, central java, the mortality of the test mosquitoes ranged from 13.75-25% (14). east jakarta has 53% mosquito mortality, west jakarta 75%, and south jakarta 53% (31). in banten province, including south tangerang, mosquito mortality was 73.9%, serang was 46.9%, and cilegon was 60.2% (32). in ambon city, maluku province, resistance was reported in the yos sudarso port area and the nusantara fisheries port with 20% mosquito mortality, at pattimura airport with 16% mosquito mortality in the perimeter area and 20% in the buffer area (33). resistance to a type of insecticide is generally based on three mechanisms: a decrease in target site sensitivity, changes in the cuticle layer that can reduce the penetration of astuti (entomological index and insecticide susceptibility status in dengue-endemic areas yogyakarta) vol. 3, no. 2, 2021, pp. 1-9 10.26555/eshr.v3i2.3719 6 insecticidal compounds into the insect's body, and an increase in detoxification enzymes. the mechanism of resistance can be determined by carrying out biochemical tests or molecular tests on vectors. biochemical test to see the activity of enzymes that detoxify insecticides (metabolic resistance) as the basis for the occurrence of insect resistance to insecticides. meanwhile, molecular tests were carried out to detect insect resistance to insecticides by finding the point mutation of the voltage-gated sodium channel (vgsc) gene as the target site of the insecticide workplace. the research results in palembang showed that based on biochemical tests, there is no increase in the level of insecticide detoxifying enzymes that neutralize synthetic pyrethroid insecticides. resistance is suspected due to a decrease in the sensitivity of the target site. this is evidenced by molecular tests showing mutations in the vgsc gene in aedes aegypti (34). the yogyakarta city government has substituted malathion as an active insecticide ingredient for fogging with cypermethrin since 2016. this step was an effort to prevent further resistance from occurring. however, the use of cypermethrin without aedes susceptibility testing is not appropriate because resistance has been reported in the yogyakarta city area to cypermethrin and permethrin in 2010 (35). several regions have stopped using malathion insecticide because resistance has occurred; after 5 10 years of retesting, the results still show resistance to the insecticide (36). cypermethrin is a synthetic pyrethroid insecticide like permethrin. permethrin is a third-generation pyrethroid, and cypermethrin is a fourthgeneration pyrethroid. in areas where resistance to permethrin is found, replacing (rotate) with other insecticides that work differently from pyrethroids is recommended. this method can prevent or reduce permethrin resistance to a higher level and not spread to other areas in indonesia (37). if cypermethrin is used continuously, it can pose a threat of resistance in the future. efforts that can be made to reduce the potential for insecticide resistance in an area are by rotating the active ingredients of the insecticides used. changes in the type and workings of insecticides for vector control must be carried out within a maximum of 2 – 3 years or 4 – 6 times of application. however, the change can be accelerated according to monitoring the vulnerability status (8). in addition to organophosphate and pyrethroid insecticides, carbamate insecticides can also be used for vector control by misting (8). however, the mechanism of toxicity of carbamate insecticides is the same as that of organophosphates, namely by inhibiting the action of the acetylcholinesterase enzyme so that it undergoes carbamylation. carbamates work by binding to the enzyme acetylcholinesterase, which functions to hydrolyze acetylcholine. the binding of the acetylcholinesterase enzyme causes a buildup of acetylcholine which causes the nerves to be continuously stimulated, causing tremors and other uncontrolled movements (9). this means that carbamate insecticides will not be effective when used on aedes aegypti populations resistant to organophosphates due to increased acetylcholinesterase enzymes. testing the sensitivity of the acetylcholinesterase enzyme in the biochemical microassay method using propoxur (a carbamate insecticide) to help detect the activity of detoxification enzymes involved in the resistance mechanism of mosquito larvae temephos (an organophosphate insecticide). a study showed that decreased acetylcholinesterase sensitivity also indicated the emergence of resistance to organophosphates and carbamates in the aedes albopictus population from selangor malaysia (38). as part of an effort to reduce the incidence of dengue hemorrhagic fever, insecticides (chemical control) should be an option to control mosquito vectors. environmental-based astuti (entomological index and insecticide susceptibility status in dengue-endemic areas yogyakarta) vol. 3, no. 2, 2021, pp. 1-9 10.26555/eshr.v3i2.3719 7 control with psn is the main activity that must always be carried out to suppress vector populations. the use of insecticides cannot continue to be a foundation because it has an unfavorable impact on the environment. therefore, environmental-based prevention and control efforts are the main focus, and the community's active role is needed. conclusion sorosutan village, yogyakarta city, has a high risk of transmission of dengue hemorrhagic fever (dhf). the population of aedes aegypti in the sorosutan village area was tolerant to malathion insecticides, with mosquito mortality of 87.83%. mosquito nests by being independent larvae monitor in their respective neighborhoods and consistently applying 3m were the three ms stands for menutup, menguras, and mengubur, meaning covering water containers, cleaning water containers, and burying discarded containers to avoid dhf. the main focus of dengue control is on environmental management by eliminating the breeding place for aedes sp. authors' contribution fda prepared the manuscript draft and research funding. aa was responsible for data collection and reviewed the manuscript. acknowledgment we thank ahmad dahlan university for the support of laboratory facilities in facilitating this research. conflict of interest there is no conflict of interest in this research. references 1. who. dengue and severe dengue [internet]. web. 2020 [cited 2021 feb 16]. available from: https://www.who.int/news-room/fact-sheets/detail/dengue-and-severe-dengue 2. indonesia ministry of health. infodatin: center for data and information ministry of health ri. jakarta. jakarta; 2016. [in bahasa] 3. utami rsb. the association knowledge and community practice with the incidence of dhf (study in the village of putat jaya surabaya on 2010–2014). j berk epidemiol. 2015;3(2):242–53. 4. indonesia ministry of health. the situation of dengue fever disease in indonesia 2017 [internet]. vol. 31, info dokter. 2018. p. 71–8. available from: https://www.kemkes.go.id/download.php?file=download/pusdatin/infodatin/infodatinsituasi-demam-berdarah-dengue.pdf. [in bahasa] 5. yogyakarta city health office. number of patients with dhf and dss per kelurahan in yogyakarta city in 2017. yogyakarta; 2018. [in bahasa] 6. indonesia ministry of health. dengue hemorrhagic fever in indonesia year 1968-2009. buletin jendela epidemiology [internet]. 2010;1–14. available from: http://www.depkes.go.id/folder/view/01/structure-publikasi-pusdatin-buletin.html. [in bahasa] 7. john s. mosquito ecology field sampling methods (3rd ed.). new york: springer; 2008. 8. indonesia ministry of health. guidelines for the use of insecticides (pesticides) in vector control. jakarta; 2012. astuti (entomological index and insecticide susceptibility status in dengue-endemic areas yogyakarta) vol. 3, no. 2, 2021, pp. 1-9 10.26555/eshr.v3i2.3719 8 9. yogyakarta city health office. efforts to control dhf in yogyakarta city. yogyakarta; 2018. [in bahasa] 10. joharina as, alfiah s. descriptive analysis of household insecticide in community. vektora j vektor dan reserv penyakit. 2012;4(1):22–32. 11. trisyono ya. insecticides that interfere with the growth and development of insects. yogyakarta: ugm press; 2013. [in bahasa] 12. kristinawati e. cypermethrin and malathion resistance test on aedes aegypti in dengue hemorrhagic fever endemic area, west lombok regency. j media bina ilm. 2013;7(2):31–4. 13. widiastuti d, ikawati b. malathion resistance and esterase enzyme activity in aedes aegypti mosquito populations in pekalongan regency. balaba j litbang pengendali penyakit bersumber binatang banjarnegara. 2016;12(2):61–70. [in bahasa] 14. sofiana l, rahman ms. differences in vulnerability status of aedes aegypti mosquitoes to malathion in bantul regency, yogyakarta. j kesehat masy. 2016;11(2):302. [in bahasa] 15. who. guidelines for testing mosquito adulticides for indoor residual spraying and treatment of mosquito nets. geneva: who; 2006. 16. focks da. review of entomological sampling methods and indicators for. geneva; 2003. 17. who. guidelines for dengue surveillance and mosquito control. second edi. manila: who; 2003. 18. murni, molanda, risti, nelfita, mustafa h. description of entomological index vectors of dengue fever, mamuju utara regency, west sulawesi. in: seminar nasional pendidikan biologi dan saintek (snpbs) ke-v 2020 isu-isu strategis sains, lingkungan, dan inovasi pembelajarannya. 2020. p. 659–63. [in bahasa] 19. indonesia ministry of health. indonesia health profile year 2019. jakarta; 2020. 497 p. [in bahasa] 20. parulian manalu hs, munif a. community knowledge and behavior in dengue hemorrhagic fever prevention in west java and west kalimantan provinces. aspirator j vector-borne dis stud. 2016;8(2):69–76. [in bahasa] 21. sulistyawati s, astuti fd, umniyati sr, satoto tbt, lazuardi l, nilsson m, et al. dengue vector control through community empowerment: lessons learned from a communitybased study in yogyakarta, indonesia. int j environ res public health. 2019;161013. 22. nani n. the relationship between psn behavior with existence larvae of aedes aegypti in port of pulang pisau. j berk epidemiol. 2017;5(1):1. 23. who. handbook for integrated vector management [internet]. vol. 24. geneva: who/htm/ntd/vem; 2012. 1–78 p. available from: http://openurl.ingenta.com/content/xref?genre=article&issn=17431026&volume=24&issue=3&spage=142 24. wahid i, ishak h, hafid a, fajri m, sidjal s, nurdin a, et al. integrated vector management with additional pre-transmission season thermal fogging is associated with a reduction in dengue incidence in makassar, indonesia: results of an 8-year observational study. plos negl trop dis. 2019;13(8):1–13. 26. mulyaningsih b, umniyati sr, satoto tbt, diptyanusa a, nugrahaningsih daa, selian y. insecticide resistance and mechanisms of aedes aegypti (diptera: culicidae) in yogyakarta. j thee med sci (berkala ilmu kedokteran). 2018;50(01):24–32. 27. marcombe s, farajollahi a, healy sp, clark gg, fonseca dm. insecticide resistance status of united states populations of aedes albopictus and mechanisms involved. plos one. 2014;9(7). 28. sukmawati, ishak h, arsin aa. susceptibility test for insecticides malathion and cypermethrine (cyf 50 ec) against aedes aegypti mosquito populations in makassar city and barru regency. hygiene. 2018; vol 4, no.:issn (print) 2443-1141. issn (online) 2541-5301. [in bahasa] 29. soenjono sj, siwarja, pandean mm. resistance status of aedes aegypti against malathion , in tomohon city. j vektor penyakit. 2017;11(2):43–8. 30. iswidaty t, martini m, widiastuti d. status of aedes aegypti mosquito resistance to 0.8% astuti (entomological index and insecticide susceptibility status in dengue-endemic areas yogyakarta) vol. 3, no. 2, 2021, pp. 1-9 10.26555/eshr.v3i2.3719 9 malathion in the perimeter and buffer area of tanjung emas port, semarang (test based on bioassay and biochemical techniques). j kesehat masy. 2016;4(1):211–7. [in bahasa] 31. prasetyowati h, hendri j, wahono t. status of resistance of aedes aegypti (linn.) to organophosphates in three municipalities of dki jakarta. balaba j litbang pengendali penyakit bersumber binatang banjarnegara. 2016;12(1):23–30. [in bahasa] 32. hendri j, kusnandar aj, astuti ep, pengendalian l, bersumber p, ciamis bpb, et al. identification of types of active ingredients and use of anti-mosquito insecticides and vulnerability of dhf vectors to organophosphates in three dhf endemic cities in banten province. 2016;8(2):77–86. [in bahasa] 33. tasane i. malathion insecticide resistance test of 0.8% against aedes aegypti mosquitoes in the fogging area of class ii port health office ambon. j kesehat masy. 2015;3(3):162–74. [in bahasa] 34. ghiffari a, fatimi h, anwar c. detection of insecticide synthetic pyrethroid resistance on dengue vector aedes aegypti (l.) in palembang using polymerase chain reaction. aspirator. 2013;5(2):37–44. [in bahasa] 35. widiarti, heriyanto b, boewono dt, widyastuti u, mujiono, lasmiati, et al. resistance map of dengue hemorrhagic fever aedes aegypti to organophosphate, carbamate and pyrethroid group insecticides in central java province and yogyakarta special region. bul penelit kesehat. 2011;39(n0.4):176–89. [in bahasa] 36. sudiharto m, udiyono a, kusariana n. status of resistance of aedes aegypti to malathion 0.8% and cypermethrin 0.05% in baai island port, bengkulu city. j kesehat masy. 2020;8(2):243–9. [in bahasa] 37. mantolu y, kustiati k, ambarningrum tb, yusmalinar s, ahmad i. status and development of resistance of aedes aegypti (linnaeus) (diptera: culicidae) strains of bandung, bogor, makassar, palu, and vcru to permethrin insecticide with five generations of selection. j entomol indones. 2016;13(1):1–8. [in bahasa] 38. chen cd, nazni wa, lee hl, norma-rashid y, lardizabal ml, sofian-azirun m. temephos resistance in field aedes (stegomyia) albopictus (skuse) from selangor, malaysia. trop biomed. 2013;30(2):220–30. microsoft word 7257-revisi.edited 10.03.2023.ss-manual ref.docx epidemiology and society health review| eshr vol. 5, no. 1, 2023, pp. 41-50 issn 2656-6052 (online) | 2656-1107 (print) http://journal2.uad.ac.id/index.php/eshr/index eshr@ikm.uad.ac.id 10.26555/eshr.v5i1.7257 41 research article distribution and behavior of anopheles maculatus and its potential as a malaria vector in indonesia riyani setiyaningsih1, sapto prihasto1, fahmay dwi ayuningrum1, arif suryo prasetyo1, mega tyas prihatin1, sekar negari1, siti alfiah1, lulus susanti1, evi sulistyorini1, jery cahyandaru1, tri wibowo ambar garjito2 1 institute for disease vector and reservoir research and development (ivrcrd), salatiga, central java, indonesia 2 vector-borne and zoonotic diseases research group, research center for public health and nutrition, national research and innovation agency, salatiga, indonesia * correspondence: riyanisetia@gmail.com. phone: +62081575529529 received 06 january 2023; accepted 11 march 2023; published 12 march 2023 abstract background: anopheles maculatus is one of the mosquito species that has been confirmed as a malaria vector in indonesia. the potential of a mosquito as a vector is influenced by its behavior. information on the distribution and behavior of an. maculatus needs to be carried out to determine the potential for malaria transmission transmitted by the species in an area. the study aimed to obtain information on the distribution, behavior, and potential of maculatus as a malaria vector in several provinces in indonesia. method: mosquito collection was carried out using human-landing collection, animal-baited trap, cattle-bait, light-trap, and resting morning. a survey of mosquitoes was carried out in 29 provinces in indonesia. mosquitoes were identified for the species and detected the blood-sucking behavior with an enzyme-linked immunosorbent assay and the presence of plasmodium using a polymerase chain reaction. results: the results showed that an. maculatus was found in the riau islands, lampung, bangka belitung, west java, central java, east java, and central sulawesi. anopheles maculatus has known to suck the blood of humans and animals with a predominance of animals. anopheles maculatus is also known to suck blood outdoors predominantly. in general, the activity of an. maculatus sucking blood begins around 18.00 in the evening. central java province was the province with the highest density of an. maculatus mosquitoes, thereby increasing the potential for transmission of malaria cases. conclusion: anopheles maculatus was spread in riau islands, lampung, bangka belitung, west java, central java, east java, and central sulawesi. this species was known to suck the blood of people and humans, and its blood-sucking activity starts around 18.00 in the evening. keywords: anopheles maculatus, malaria, vector malaria setiyaningsih et al. (distribution and behavior of anopheles maculatus and its potential as a malaria vector in indonesia) vol. 5, no. 1, 2023, pp. 41-50 10.26555/eshr.v5i1.7257 42 introduction anopheles maculatus is a malaria vector species in indonesia found in some provinces such as central java, west java, diy, east java, bali, lampung, north sumatra, west sumatra, riau, jambi, and south sumatra. 1–4 anopheles maculatus was a malaria vector in thailand, the philippines, malaysia 5,6, afghanistan, pakistan, china, and india.7 the potential of mosquitoes as malaria vectors can be seen from their behavior. the results of research in thailand and purworejo central java, indonesia; an. maculatus was known to suck the blood of animals and humans.5,8 the behavior of sucking mosquito blood significantly affects its potential as a malaria vector. mosquitoes that have the behavior of sucking human blood have the opportunity to be able to transmit plasmodium from human to human. another factor that supports mosquitoes in becoming malaria vectors is their long life and resistance to plasmodium entering their body.9–11 studies on the distribution and behavior of an. maculatus as a malaria vector need to be carried out considering the importance of this species as a malaria vector in several provinces in indonesia. mosquito behavior that influences its potential as a malaria vector is resting behavior and blood-sucking behavior. this was also because there were possible differences in mosquito behavior in locations because each region has different environmental conditions. based on this background, this study aims to discover the development of an: maculatus' distribution behavior and its potential as a malaria vector in indonesia. method the research was conducted in 29 provinces in indonesia. we selected three districts in each province and six sampling points in each district. each point represented forest, non-forest, and coastal ecosystems near and far from settlements. sampling was conducted for five days at each point, so with six points in one district, the sampling duration was 30 days.2 a list of sampling locations can be found in table 1. dki jakarta province was an exception because no forest ecosystem was found, so sampling was conducted at locations representing the dki jakarta area. the selected locations were central jakarta, west jakarta, south jakarta, east jakarta, north jakarta, and the thousand islands. this study was cross-sectional, and the sample was taken at a particular time. the research sample was an. maculatus which was caught using various research methods in all provinces. the study population was mosquitoes caught in all provinces. the research variables were the number of an. maculatus responded every hour in each province, the number of an. maculatus mosquitoes caught in each method in all provinces, and plasmodium sp positive in an. maculatus mosquitoes in each province. mosquitoes were caught using the human landing collection method, livestock bait, animalbaited trap (abt), light trap, and morning resting collection. mosquitoes caught in each method identified their species using a mosquito identification key.12,13 the time used to catch mosquitoes in each technique was different. a list of fishing times and fishing hours per hour can be seen in table 2. setiyaningsih et al. (distribution and behavior of anopheles maculatus and its potential as a malaria vector in indonesia) vol. 5, no. 1, 2023, pp. 41-50 10.26555/eshr.v5i1.7257 43 table 1. sampling location of an. maculatus in several provinces in indonesia number provinsi city/county name 1 papua biak, merauke , sarmi 2 central java pati, pekalongan, purworejo 3 south sumatra banyuasin, lahat, organ komeling ilir (oki) 4 central sulawesi parigi moutong, tojo una una, toli-toli 5 aceh aceh timur, aceh barat, pidie 6 west sumatra pesisir selatan, padang pariaman, pasaman barat 7 lampung tanggamus, lampung selatan, pasawaran 8 bangka belitung bangka, belitung, bangka tengah 9 west java garut, subang, pangandaran 10 east java malang, banyuwangi, pasuruan 11 banten pandeglang. lebak, serang 12 nusa tenggara barat lombok barat, bima, lombok utara 13 nusa tenggara timur belu. ende, sumba tengah 14 west kalimantan sambas, ketapang, kayong utara 15 south kalimantan barito kuala, kota baru, tanah laut 16 north sulawesi minahasa, kota manado, kota belitung 17 southeast sulawesi muna, konawe, bombana 18 maluku maluku tenggara barat, maluku tenggara, kepulauan aru 19 north maluku halmahera tengah, halmahera selatan, pulau morotai 20 riau bengkalis, dumai, kepulauan meranti 21 jambi bungo, sarolangun, tanjung jabung barat 22 special region of yogyakarta kulon progo, gunung kidul, bantul 23 bali jembrana, badung, karangasem 24 central kalimantan gunungmas, pulang pisau, murung raya 25 south sulawesi pangkajene kepulauan, bulukumba, luwu timur 26 west papua raja ampat, manokwari, fak-fak 27 riau islands kota batam, bintan, lingga 28 dki jakarta central jakarta, west jakarta, south jakarta, east jakarta, north jakarta, the thousand islands. 29 north kalimantan bulungan, nunukan, tarakan table 2. the duration and catchment method of anopheles maculatus method catch time length of catchment indoor human bait 6 am 6 pm 40 minute outdoor human bait 6 am 6 pm 40 minute animal baited trap 6 am 6 pm 15 minute cattle bait 6 am 6 pm 15 minute morning resting 6 pm 9 pm 3 hour anopheles maculatus found in all capture methods was prepared by separating the head and thorax from the abdomen and then analyzing its plasmodium's presence using pcr. primers used in detecting plasmodium were rplu1 (5’ tca aag att aag cca tgc aag tga – setiyaningsih et al. (distribution and behavior of anopheles maculatus and its potential as a malaria vector in indonesia) vol. 5, no. 1, 2023, pp. 41-50 10.26555/eshr.v5i1.7257 44 3’), rplu5 (5’ cct gtt gtt gcc tta aac tcc – 3’), rplu3 (5’ ttt tta taa taa gga taa cta cta cgg aaa agc tgt – 3’), rplu4 (5’ tac ccg tca tag cca tgt tag gcc aat acc – 3’) 14,15 the blood-fed or half-gravid an maculatus mosquitoes will be tested their blood feed using the direct-elisa method. results based on the results of the study showed that an. maculatus was not found in all provinces in indonesia. the results of the survey in 29 provinces in indonesia, an. maculatus was distributed in riau islands, lampung, bangka belitung, west java, central java, east java, and central sulawesi (figure 1). in all seven provinces, 141 an. maculatus mosquitoes were collected. the highest density of mosquitoes an. maculatus was found in central java province. figure 1. distribution an. maculatus in indonesia anopheles maculatus collection in each province showed different fluctuations and densities. based on the behavior of sucking blood, an. maculatus suck blood starting at 6:00 p.m. in all provinces. however, the an. maculatus activity of sucking blood generally does not occur all night. an. maculatus in central java province was found sucking blood throughout the night with peak density at 21.00-22.00. fluctuations in mosquito density based on blood-sucking time in each province showed in figure 2. setiyaningsih et al. (distribution and behavior of anopheles maculatus and its potential as a malaria vector in indonesia) vol. 5, no. 1, 2023, pp. 41-50 10.26555/eshr.v5i1.7257 45 figure 2. density fluctuation an. maculatus based on blood-sucking time in indonesia. the results of mosquito catching by various methods show that, generally, an. maculatus dominant was found to suck blood in animals (96.67%), and only a small percentage were found to suck people's blood outside the home (3.33% ). the distribution and percentage of an. maculatus behavior in sucking blood in each province can be seen in table 3. table 3. blood-sucking behavior of anopheles maculatus in various provinces in indonesia province name the number of mosquitoes by the method abt cb ihb ohb mr riau islands 0 0 0 1 0 lampung 0 0 0 1 0 bangka belitung 0 0 0 1 0 west java 0 0 0 1 0 central java 68 26 0 0 0 east java 1 0 0 0 0 central sulawesi 21 0 0 0 0 total 90 26 0 4 0 the total base of blood-sucking behavior 116 4 percentage of mosquitoes sucking animal blood. 96.67 percentage of mosquitoes sucking human blood. 3.33 discussion our study shows that an. maculatus was found in some provinces in indonesia, for example, in the riau islands, lampung, bangka belitung, west java, central java, east java, and central sulawesi. based on previous studies, an. maculatus was known as a malaria vector in the provinces of central java, west java, diy, east java, bali, lampung, north sumatra, west sumatra, riau, jambi, and south sumatra.2 the previous study also mentioned that an. maculatus be a malaria vector in laos with an. rampae, an. sawadwongporni, an. 0 5 10 15 20 25 30 18-19 19-20 20-21 21-22 22-23 23-24 24-01 01-02 02-03 03-04 04-05 05-06 n um be r of m os qu ito a n. m ac ul at us (t ai l) time of collection riau islands lampung bangka belitung west java central java east java central sulawesi information: abt: animal-baited trap; cb: cattle-bait; ihb: indoor human-bait; ohb: outdoor human-bait; mr: morning resting setiyaningsih et al. (distribution and behavior of anopheles maculatus and its potential as a malaria vector in indonesia) vol. 5, no. 1, 2023, pp. 41-50 10.26555/eshr.v5i1.7257 46 pseudowillmori, an. dravidicus, an. minimus, an. aconitus, an. pampanai, an. harrisoni, an. dirus, an. baimaii, an. nemophilou,16 peninsula malaysia, along with an. cracens.17 in addition, an. maculatus was also known as the primary malaria vector in morong, bataan, philippines, along with an. flavirostris.18 the discovery of an. maculatus in several provinces in indonesia shows the potential for transmission and an increase in cases of malaria transmitted by an. maculatus. east java province was a malaria-receptive area because an. maculatus was found, previously confirmed as a malaria vector despite receiving a malaria elimination certificate. meanwhile, riau, lampung, bangka belitung, west java, central java, and sulawesi provinces can transmit malaria because the provinces were still found in malaria-endemic areas.19 the potential of an. maculatus as a malaria vector can be seen from its blood-sucking and resting behavior. based on the results of studies showing that an. maculatus was known to be dominantly found to suck the blood of livestock, but it was also found to suck human blood. although it was not dominantly found to suck human blood, contact with humans allows malaria transmission in the local area. this was because most of the regions found by an. maculatus were malaria-endemic areas.19 studies on china's hainan island also show an. maculatus was found to suck human and animal blood. anopheles maculatus in the area was known to have blood-sucking behavior several times during one gonotrophic cycle. this condition increases the possibility of malaria transmission.20 results of research in bangladesh an. maculatus was also known to suck human and animal blood.21 study in laos an. maculatus was the dominant species whose behavior was sucking animal blood (98%).16 study in pu teuy village, sai yok region, kanchanaburi province, west-central thailand, and morong, bataan pilipina an. maculatus was also found to be predominantly sucking the blood of livestock compared to human blood.05,18 study in vietnam an. maculatus tends to be zoophilic and predominantly sucks the blood of buffaloes and cows.22 the potential of an. maculatus as a vector was also influenced by its ability to survive when plasmodium enters and develops in its body. although the results showed no discovery of plasmodium in the an. maculatus examination, considering that the species has been confirmed as a malaria vector, the potential for malaria transmission transmitted by the species can occur again if in the environment there are still cases of malaria. results of studies in thailand and myanmar an. maculatus was known to be positive for plasmodium with a sporozoite index of 1.1%. anopheles maculatus was known to be the dominant species in the area alongside an. sawadwongporni.23 studies in nepal also show an. maculatus was known to be sporozoite positive with an. fluviatile during the spring and found in the vicinity of cages in the forests of churia hills and during the summer in the village without spraying.24 study in northern central vietnam. an. maculatus with an. sinensis, an. aconitus, an. harrisoni, an. sawadwongporni, an. peditaeniatus, and an. philippinensis found protein circumsporozoite.22 based on the study of an. maculatus blood-sucking activity starting at 18:00 in all provinces, with different fluctuations. in general, blood-sucking activities do not occur throughout the night. in contrast to an. maculatus in central java province, it was found that blood-sucking activity occurred throughout the night. this will enlarge contact with humans allowing the transmission of malaria. the results of a study in the philippines an. maculatus found that the peak of density occurred at 22.00-00.00. the opportunity of an. maculatus as a malaria vector was also influenced by its density. central java had the highest density of mosquitoes compared to other provinces. high density has the potential to increase the occurrence of setiyaningsih et al. (distribution and behavior of anopheles maculatus and its potential as a malaria vector in indonesia) vol. 5, no. 1, 2023, pp. 41-50 10.26555/eshr.v5i1.7257 47 contact with humans, thereby increasing the chances of malaria transmission. the results of the research in purworejo, central java, an. maculatus was found to be dominant compared to other species. some of the species found together with an. maculatus include an. balabacensis (19.76%), an. vagus (11.74%), an. kochi (5.23%), an. barbirostris (3.53%), an. aconitus (3.40%), an. minimus (1.28%), an. flavirostris (1.00%), an. annularis (0.04%), an. tesselatus (0.01%), and an. koliensis (0.01%).8 based on studies in thailand, an. maculatus has a high density in the highlands, and the highest density occurs in the rainy season.25 a survey in bataan pilipina an. maculatus revealed that peak density occurs at the end of the dry season.18 based on studies showing that an. maculatus, in general, was found sucking blood outdoors. this behavior causes the potential for malaria transmission transmitted by an. maculatus tends to occur outdoors. studies in malaria-endemic areas, umphang valley, tak province, western thailand an. maculatus was also found predominantly found outdoors.26 studies in sub-saharan africa have the potential for malaria transmission to occur outdoors; this was because malaria vectors were found outdoors. the discovery of mosquito blood-sucking activities outdoors can be caused by vector control in the house with insecticidal mosquito nets and indoor residual spraying (irs).27 studies on guinea's bioko island show an. gambie was previously found indoors after prolonged application of vector control in the home with insecticidal mosquito nets caused the mosquito to adapt and change its behavior of sucking blood outdoors.28 studies in sub-saharan africa show the application of insecticidal mosquito nets and the irs can reduce cases and deaths caused by malaria. however, the application of vector control in the home impacts changes in vector behavior and vector types that play a role in malaria transmission. this will affect the control methods that should be carried out.27 studies in uganda of vector control applications with the irs and insecticidicide mosquito nets, in addition to decreasing vector populations and the average number of sporozoites, also led to changes in the type of vectors that act as malaria vectors. the mosquito that worked as a malaria vector before the application of vector control in the house was an. gambiae. in contrast, the one that acts as a vector after applying vector control was an. arabiensis. the species was widely found outdoors.29 due to changes in vector behavior, vector control was also carried out indoors and outdoors.30 another factor that affects an. maculatus can play the role of a vector was the breeding places. in general, an. maculatus was found in ponds with clear, muddy water containing aquatic plants with an environmental situation of shading. an. maculatus was also found around rivers with slow water flow.5,6 the potential of an. maculatus is a malaria vector because apolipoprotein d and cathepsin d proteins were found in the salivary glands in this species.7 conclusion anopheles maculatus was distributed in the riau islands, lampung, bangka belitung, west java, central java, east java, and central sulawesi. anopheles maculatus predominantly sucks the blood of livestock and partially sucks the blood of people, with most of its activity occurring outdoors. anopheles maculatus generally sucks blood starting around 18:00, and blood-sucking action typically does not happen overnight. central java province had the highest density of mosquitoes and blood-sucking activities at night. anopheles maculatus was a potential malaria vector in central java compared to several other provinces. setiyaningsih et al. (distribution and behavior of anopheles maculatus and its potential as a malaria vector in indonesia) vol. 5, no. 1, 2023, pp. 41-50 10.26555/eshr.v5i1.7257 48 acknowledgment the authors would like to thank the directors and all coordinators of ivrcrd who provided direction during the data collection until the article writing process. we also thank the researchers, technicians, and administrative team who have assisted in completing the research and all parties involved in the research process (the coordinators, team leaders, and enumerators). declarations authors' contribution rs was the main contributor responsible for a technical research team, supervising the research process, analyzing data, compiling research articles, and improving the results of research article revisions. sp was the main contributor to data analysis and the technical research team. mtp is responsible for the technical team of research and data analysis. fda, asp, and sn as technical research teams. sa, ls, and es as a technological research and management tennis team. twag as a technical research team and research article reviewer. jc was an auxiliary contributor in charge of creating a distribution map of an. maculatus funding statement the ministry of health of the republic of indonesia funded this research. research funding was provided from 2015-2018 conflict of interest there was no conflict of interest in this research. references 1. elyazar irf, sinka me, gething pw, tarmizi sn, surya a, kusriastuti r, et al. the distribution and bionomics of anopheles malaria vector mosquitoes in indonesia. adv parasitol. 2013;83:173–266. 2. b2p2vrp. pedoman pengumpulan data vektor (nyamuk) di lapangan. salatiga; 2017. 3. garjito ta, widiastuti u, mujiyono m, prihatin mt, widiarti w, setyaningsih r, et al. genetic homogeneity of anopheles maculatus in indonesia and origin of a novel species present in central java. parasites and vectors. 2019;12(1):1–11. 4. rattanarithikul r, harbach re. anopheles maculatus (diptera: culicidae) from the type locality of hong kong and two new species of the maculatus complex from the philippines. mosq syst. 1990;22(3):160–83. 5. muenworn v, sungvornyothin s, kongmee m, polsomboon s, bangs mj, akrathanakul p, et al. biting activity and host preference of the malaria vectors anopheles maculatus and anopheles sawadwongporni (diptera: culicidae) in thailand. j vector ecol. 2009;34(1):62–9. 6. rohani a, najdah wmaw, zamree i, azahari ah, noor im, rahimi h, et al. habitat characterization and mapping of anopheles maculatus (theobald) mosquito larvae in malaria endemic areas in kuala lipis, pahang, malaysia. southeast asian j trop med public health. 2010;41(4):821–30. 7. armiyanti y, arifianto rp, riana en, senjarini k, widodo w, fitri le, et al. identification of antigenic proteins from salivary glands of female anopheles maculatus by proteomic analysis. asian pac j trop biomed. 2016;6(11):924–30. 8. shinta, sukowati s, pradana a, marjianto, marjana p. beberapa aspek perilaku anopheles maculatus theobald di pituruh, kabupaten purworejo, jawa tengah. bul setiyaningsih et al. (distribution and behavior of anopheles maculatus and its potential as a malaria vector in indonesia) vol. 5, no. 1, 2023, pp. 41-50 10.26555/eshr.v5i1.7257 49 penelit kesehat. 2013;41(3):131–41. 9. mitchell sn, catteruccia f. anopheline reproductive biology: impacts on vectorial capacity and potential avenues for malaria control. cold spring harb perspect med. 2017;7(12):14. 10. brady oj, godfray hcj, tatem aj, gething pw, cohen jm, ellis mckenzie f, et al. vectorial capacity and vector control: reconsidering sensitivity to parameters for malaria elimination. trans r soc trop med hyg. 2016;110(2):107–17. 11. edalat h, hassan moosa-kazemi s, abolghasemi e, khairandish s, hassan moosakazemi s. vectorial capacity and age determination of anopheles stephens liston (diptera: culicidae), during the malaria transmission in southern iran. j entomol zool stud jezs. 2015;3(1):256–63. 12. panthusiri, rattanarithikul r, prachong. illustrated keys to the medically important mosquitoes of thailand. thailand; 1994. 1–66 p. 13. o’connor c., soepanto a. kunci bergambar nyamuk anopheles dewasa di indonesia. jakarta; 1999. 1–46 p. 14. moll k, kaneko a, scherf a, wahlgren m. methods in malaria research. uk: evimalar glasgow; 2013. 1–474 p. 15. b2p2vrp. pedoman pemeriksaan deteksi agen penyakit. salatiga; 2015. 16. marcombe s, maithaviphet s, bobichon j, phommavan n, nambanya s, corbel v, et al. new insights into malaria vector bionomics in lao pdr: a nationwide entomology survey. malar j. 2020;19(1):1–17. 17. lau y, lee w, chen j, zhong z, jian j. draft genomes of anopheles cracens and anopheles maculatus : comparison of simian malaria and human malaria vectors in peninsular malaysia. plos one. 2016;june(27):1–24. 18. torres ep, salazar np, belizario vy, saul a. vector abundance and behaviour in an area of low malaria endemicity in bataan, the philippines. acta trop. 1997;63:209–20. 19. p2ptvz. situasi terkini perkembangan program pengendalian malaria di indonesia tahun 2018. jakarta: kementerian kesehatan republik indonesia; 2018. 1–20 p. 20. guo ax, li c, wang g, zheng z, dong y, xing d, et al. host feeding patterns of mosquitoes in a rural malaria-endemic region in hainan island, china. j am mosq control assoc. 2014;30(4):309–11. 21. bashar k, tuno n, ahmed tu, howlader aj. blood-feeding patterns of anopheles mosquitoes in a malaria-endemic area of bangladesh. parasites and vectors. 2012;5(39):1–10. 22. manh c do, beebe nw, van vnt, quang t le, lein ct, nguyen d van. vectors and malaria transmission in deforested, rural communities in north-central vietnam. malar j. 2010;9(259):1–12. 23. kwansomboon n, chaumeau v, kittiphanakun p, cerqueira d, corbel v. vector bionomics and alaria transmission along the thailand-myanmar border : a baseline entomological survey. j vector ecol. 2017;42(1):84–93. 24. shrestha sl, vaidya rg, shrestha jd. anopheline mosquito (diptera : culicidae) ecology in relation to malaria transmission in the inner and outer terai of nepal, 1987-1989. entomol soc am. 1993;30(4):665–82. 25. sumruayphol s, chaiphongpachara t, samung y, ruangsittichai j. seasonal dynamics and molecular differentiation of three natural anopheles species (diptera : culicidae) of the maculatus group (neocellia series) in malaria hotspot villages of thailand. parasit vectors. 2020;13(574):1–11. 26. tananchai c, pattanakul m, nararak j, sinou v, manguin s, chareonviriyaphap t. diversity and biting patterns of anopheles species in a malaria endemic area, umphang valley, tak province, western thailand. acta trop. 2018 feb;1–40. 27. sougoufara s, ottih ec, tripet f. the need for new vector control approaches targeting outdoor biting anopheline malaria vector communities. parasit vectors. 2020;13(295):1– 15. 28. reddy mr, overgaard hj, abaga s, reddy vp, caccone a, kiszewski ae, et al. outdoor host seeking behaviour of anopheles gambiae mosquitoes following initiation of malaria setiyaningsih et al. (distribution and behavior of anopheles maculatus and its potential as a malaria vector in indonesia) vol. 5, no. 1, 2023, pp. 41-50 10.26555/eshr.v5i1.7257 50 vector control on bioko island, equatorial guinea. malar j. 2011;10(184):1–10. 29. musiime ak, smith dl, kilama m, rek j, arinaitwe e, nankabirwa ji, et al. impact of vector control interventions on malaria transmission intensity, outdoor vector biting rates and anopheles mosquito species composition in tororo, uganda. malar j. 2019;18(445):1–9. 30. zhu l, müller gc, marshall jm, arheart kl, qualls wa, hlaing wm, et al. is outdoor vector control needed for malaria elimination? an individual-based modelling study. malar j. 2017;16(266):1–11. kartu antri antrian dosis 2 epidemiology and society health review| eshr vol. 4, no. 1, 2021, pp. 1-11 issn 2656-6052 (online) | 2656-1107 (print) 10.26555/eshr.v4i1.4641 1 research article a community-based study of milk adulteration and childhood malnutrition in bangalore rural district, india amita mukhopadhyay1, ipsita debata2*, ravikiran p kamate2, nagendra nagaiah3, priyanka rodrigues4 1 associate professor, department of community medicine, dr. chandramma dayananda sagar institute of medical sciences and research (cdsimer), harohalli, ramanagara district, karnataka, india 562112 2 assistant professor, department of community medicine, dr. chandramma dayananda sagar institute of medical sciences and research (cdsimer), harohalli, ramanagara district, karnataka, india 562112 3 mbbs student, akash institute of medical sciences and research centre, prasannahalli main road, near kempegowda international airport, devanahalli, bengaluru, karnataka, india 562110 4 statistician (former), department of community medicine, dr. chandramma dayananda sagar institute of medical sciences and research (cdsimer), harohalli, ramanagara district, karnataka, india 562112 * correspondence: drdebataipsita@gmail.com. phone: +91-9972483237 received 08 august 2021; accepted 25 august 2021; published 14 september 2021 abstract background: milk promotes child growth; however, adulterated milk reduces nutritional value and exposes children to harmful chemicals. therefore, this study aimed to assess the nutritional status of children aged 1–5 years living in the selected study area and test milk samples from the children's households for common adulterants. the study further aimed to explore the association between malnutrition and milk adulteration. methods: we used a community-based cross-sectional study design conducted in the service area of a tertiary healthcare institute in bangalore rural district, karnataka state, india. systematic random sampling was used to recruit 180 children aged 1–5 years. primary data was collected through interviews, anthropometry, and strip tests for milk adulteration. statistical analysis consisted of descriptive analysis, chi-square tests, odds ratios, and 95% confidence intervals. results: prevalence of underweight, stunting, wasting, and low body mass index (bmi) was 13.33%, 38.33%, 15.0%, and 26.7%, respectively. general adulterants detected were neutralizers in 97 (53.9%) and maltodextrin in 90 (50%) samples. higher proportions of stunting, underweight and low bmi were found in children drinking adulterated milk. low bmi was significantly associated with joint family and lower maternal education. conclusion: our study found a high prevalence of malnutrition in children, particularly stunting. the study also detected widespread adulterants in milk and a potential association with malnutrition. the authors recommend further studies with a larger sample size to accurately delineate the relationship between milk adulteration and malnutrition. keywords: malnutrition; milk adulteration; under-five; stunting; underweight; wasting mukhopadhyay (a community-based study of milk adulteration…) vol. 4, no. 1, 2021, pp. 1-11 10.26555/eshr.v4i1.4641 2 introduction in india, 38 percent of under-5 children are stunted, a manifestation of chronic undernutrition. malnutrition is responsible for nearly half of all child deaths globally (1). there are significant inequalities across states and socioeconomic groups, with rural areas and the poorest people being the worst affected (2). bangalore rural district in karnataka state is below expected standards in key indicators of nutrition. the national family health survey 2015-16 (nfhs-4) results reveal stunting in 38.5% of under-five children, wasting in 26.9%, and underweight in 37.7%, a worrisome prevalence (3). in the indian population, approximately 12% of the dietary intake consists of milk and food products derived from milk (4). in karnataka state, as much as one-fifth (22.2%) of the population is lactovegetarian which means milk is the only source of animal-based protein for these families and their children (5). however, research has revealed that approximately 80% of children in the 1–6 years age group in karnataka consume less than 50% of the recommended daily intake (rdi) of milk and milk-based foods (6). undernourished children who regularly drink milk show better growth and cognition and improvements in biochemical and functional indicators of nutrition, thereby enhancing health and reducing mortality (7). however, adulterated milk is a serious public health issue, with around 68.7 percent of milk not satisfying the standards of the food safety and standards authority of india (fssai) (8). adverse consequences of drinking adulterated milk are well documented worldwide (9–11). therefore, in our capacity as public health researchers working in a tertiary healthcare institution, we proposed the present study. our objectives were to assess the nutritional status of children aged 1–5 years, to test milk samples from the children’s households for common adulterants, and further to explore the association of milk adulteration with malnutrition in children so that baseline data could be made available and utilized in future to confront these two important public health issues. method this study was designed as a community based cross-sectional study in the catchment area of the rural health and training centre (rhtc) of a tertiary health institute. the rhtc serves a total population of over 25000, of which around 2500 were estimated to be children aged five years or less (approximately 10% based on census 2011 data) (12). among this group, children aged 1-5 years were included in the study as infants may be largely dependent on maternal nursing. we calculated a sample size of 180 based on an initial estimate of 150 using the formula n = z2p(1-p)/d2,(13) taking z = 1.96 at 95% confidence level, d = 0.05, p = 0.11 taking 11% prevalence of severe wasting based on nfhs-4 data (3) and adding 20% for non-response. the inclusion criteria were age 1-5 years, residence in the area for at least the past six months, and the guardian's consent for the child to participate in the study and provide a sample of raw milk purchased the same day for testing. we carried out a house-to-house survey, using systematic random sampling, and collected data using a pretested objective questionnaire administered to the mothers of the selected children, or if the mother was absent, the following primary caregiver. the questionnaire contained basic identifier data, followed by education, occupation and income, and healthmukhopadhyay (a community-based study of milk adulteration…) vol. 4, no. 1, 2021, pp. 1-11 10.26555/eshr.v4i1.4641 3 related information such as vaccination status, breastfeeding, recent illnesses, and others. this was followed by obtaining a sample of raw milk for testing and anthropometric assessment of weight and height/length as described in the world health organization (who) child growth standards training manual (14). milk was tested for the presence of water, starch, urea, and detergent using methods recommended by fssai (15) and for maltodextrin, hydrogen peroxide, and neutralizers using strip tests, developed through technology transfer from national dairy research institute (ndri) (16). raw data were tabulated and cleaned. descriptive analysis was performed using classifications such as age group, educational level, and economic class. socioeconomic status was coded using modified prasad’s socioeconomic scale criteria (17). milk adulteration was defined according to fssai criteria (15). underweight was defined as weight for age (wfa) less than two standard deviations (-2sd) below the median of the who child growth standards (whocgs), stunting as height for age (hfa) less than 2sd below the whocgs median, and wasting as weight for height (wfh) less than 2sd below the whocgs median. bivariate analysis was done using chi-square tests. odds ratios and 95% confidence intervals were derived. ethical clearance for the study was obtained from the institutional ethics committee of akash institute of medical sciences and research centre, devanahalli, karnataka (reference id aimsrc/rp/ec/14/2019). results demography we studied 91 girls and 89 boys, of mean age 29.3 7± 13.72 (sd) months. the age and gender distribution of the study sample are shown in figure 1. figure 1. age and gender distribution of the study participants mukhopadhyay (a community-based study of milk adulteration…) vol. 4, no. 1, 2021, pp. 1-11 10.26555/eshr.v4i1.4641 4 among the 180 children, 67 (37.2%) belonged in the 12-23 months age group. the nuclear family was the predominant family type, with 115 (63.9%) children in this category. almost all the children, viz., 175 (97.2%), fell in the lower and lower-middle-class socioeconomic category. (table 1) table 1. socio-demographic profile of the participants characteristic frequency (n=180) percentage (%) religion hindu 170 94.4 muslim 10 5.6 christian 0 0.0 type of family nuclear 115 63.9 joint 65 36.1 socio-economic status* high 0 0.0 upper middle 5 2.8 lower middle 55 30.5 upper lower 111 61.7 lower 9 5.0 mother’s education illiterate 7 3.9 primary 46 25.6 secondary 127 70.6 father’s education illiterate 11 6.1 primary 48 26.7 secondary 121 67.2 mother’s occupation unemployed/ homemaker 173 96.1 employed 7 3.9 father’s occupation unemployed/ homemaker 2 1.1 employed 178 98.9 *as per modified prasad’s socioeconomic scale 127 (70.6%) mothers and 121 (67.2%) fathers had received secondary level education among the parents. most of the mothers were homemakers, and most fathers were employed in occupations outside the home. anthropometry we did not note any significant gender differences in underweight, stunting, and wasting. assessment of body mass index (bmi) as per who bmi standards showed a statistically significant gender difference with more boys being overweight/obese compared to girls (16/89 boys; 17.97% vs 5/91 girls; 5.49%, chi-square = 6.8, df = 1, p = 0.009, or = 3.77, 95%cior = 1.32–10.79). table 2 shows the proportions of underweight, stunting, and wasting observed in the study participants. mukhopadhyay (a community-based study of milk adulteration…) vol. 4, no. 1, 2021, pp. 1-11 10.26555/eshr.v4i1.4641 5 table 2. anthropometric indices of the participants characteristic male (n=89) n (%) female (n=91) n (%) total (n=180) n (%) weight for age (wfa)* underweight (median-3sd <wfa <median-2sd) 9 (10.11) 13 (14.29) 22 (12.22) severely underweight(wfa <median-3sd) 0 (0.0) 2 (2.19) 2 (1.11) overweight (wfa>median+2sd) 4 (4.49) 1 (1.09) 5 (2.78) height for age (hfa)† stunted (median-3sd <hfa < median-2sd) 22 (24.68) 20 (21.98) 42 (23.33) severely stunted (hfa < median-3sd) 13 (14.60) 14 (15.40) 27 (15) hfa > median+2sd 0 (0.0) 2 (2.19) 2 (1.11) hfa >median+3sd 2 (2.19) 7 (7.69) 9 (5) weight for height (wfh)‡ wasted (median-3sd <wfh< median-2sd) 7 (7.86) 4 (4.39) 11 (6.11) severely wasted (wfh< median-3sd) 11 (12.36) 5 (5.49) 16 (8.89) wfh>median+2sd 4 (4.49) 0 (0.0) 4 (2.22) wfh >median+3sd 8 (8.99) 0 (0.0) 8 (4.44) body mass index (bmi)§ underweight (<18.5) 28 (31.46) 20 (21.97) 48 (26.7) healthy weight (18.5–24.9) 45 (50.56) 66 (72.53) 111 (61.7) overweight (25.0–29.9) 4 (4.49) 2 (2.20) 6 (3.3) obese (≥30.0) 12 (13.48) 3 (3.30) 15 (8.3) *underweight: weight for age (wfa) less than whocgs median-2sd †stunting: height for age (hfa) less than whocgs median-2sd ‡wasting: weight for height (wfh) less than whocgs median-2sd § bmi: as per who bmi standards milk adulteration a striking proportion of the milk samples in our study, 158 out of 180 (87.8%), were adulterated with water and/or other chemicals, with neutralizers being the most common adulterant. urea as an adulterant was not detected in any sample (figure 2a). we observed that 65 (36.1%) milk samples had two types of adulterants mixed, followed by any one type of adulterant in 58 (32.2%) milk samples (figure 2b). figure 2. types of adulterants (a) and presence of multiple adulterants (b) in milk samples mukhopadhyay (a community-based study of milk adulteration…) vol. 4, no. 1, 2021, pp. 1-11 10.26555/eshr.v4i1.4641 6 association between malnutrition and adulteration the proportions of underweight, stunting and low bmi were higher among children drinking adulterated milk, although these differences were not statistically significant. the proportion of wasting was found to be higher in children drinking unadulterated milk. this difference was also not statistically significant (table 3). table 3. association between adulteration and malnutrition variable: underweight (wfa < median-2sd) normal underweight total χ 2 p value n % n % n % unadulterated milk 20  90.91 2 9.09 22 100 0.39 0.532 adulterated milk 136 86.08 22 13.92 158 100 total 156 86.67 24 13.33 180 100 variable: stunting (hfa < median-2sd) normal stunted total χ 2 p value n % n % n % unadulterated milk 15 68.18 7 31.82 22 100 0.45 0.502 adulterated milk 96 60.76 62 39.24 158 100 total 111 61.67 69 38.33 180 100 variable: wasting (wfh < median-2sd) normal wasted total χ 2 p value n % n % n % unadulterated milk 18 81.82 4 18.18 22 100 0.199 0.656 adulterated milk 135 85.44 23 14.56 158 100 total 153 85.00 27 15.00 180 100 variable: low bmi (bmi < 18.5) normal low bmi total χ 2 p value n % n % n % unadulterated milk 17 77.27 5 22.72 22 100 0.199 0.656 adulterated milk 115 72.78 43 27.22 158 100 total 132 73.33 48 26.66 180 100 socio-demographic associations of malnutrition we noted that odds of being undernourished were significantly lower in children living in nuclear families and significantly higher in children whose mothers were not educated beyond primary school level (table 4). table 4. association between socio-demographic variables and malnutrition sociodemographic variables undernourished (bmi < 18.5) not undernourished (bmi ≥ 18.5) total χ2; p-value or; 95% cior n % n % family type nuclear 25 21.7 90 78.3 115 3.95; 0.047 0.507; 0.258–0.996 joint 23 35.4 42 64.6 65 mother's education primary 21 39.6 32 60.4 53 6.448; 0.011 2.431; 1.212–4.872 ≥secondary 27 21.3 100 78.7 127 mukhopadhyay (a community-based study of milk adulteration…) vol. 4, no. 1, 2021, pp. 1-11 10.26555/eshr.v4i1.4641 7 discussion the present study reported the overall prevalence of underweight/undernutrition, stunting, wasting, and low bmi as 13.33%, 38.33%, 15.0%, and 26.7%, respectively. this is similar to the findings of the study by meshram et al. (18) among under-5 children in surat, gujarat. a notable finding of our study is that there were no significant differences in undernutrition between boys and girls, which points towards the absence of discrimination against girls in feeding and care. however, there was a marked gender difference in the overweight/obese category, significantly more boys than girls. this finding indicates that while girls may not be overtly mistreated, boys are still possibly receiving preferential care related to feeding and household chores. the observed prevalence of stunting (38.33%) in this study suggests widespread chronic malnutrition in our study population. this was consistent with findings of studies done by sahoo et al. (42.2%) (19) and popat et al. (46.1%) (20). most children in this study, viz 115 (63.9%), belonged to nuclear families. malnutrition was found to be more common in children from joint families compared to nuclear families. similar findings were reported by gopinath et al. (21) and kodavanti rao et al. (22). this study also revealed a significant association between a mother's education and a child's bmi, which is concordant with results reported by sahoo et al. (19) and mittal et al. (23). this finding can be attributed to educated mothers having better knowledge about breastfeeding, complementary feeding, and immunization, which would profoundly affect the child's nutritional status. this is supported by research findings from india and other countries (24– 29). the commonest adulterants detected in our study were neutralizers found in 97 (53.9%) samples and maltodextrin found in 90 (50%) samples. in rural areas, dairy farms may not be modernized, and the cold chain may be faulty, leading to milk spoilage. sowmya et al. observed that middlemen add neutralizers to extend the shelf life of milk by neutralizing the acids produced by bacterial activity, which can maximize the seller's profit but cause significant harm to consumers, especially children (30). the national milk safety and quality survey 2018 report has also noted the presence of maltodextrin in 156 (out of 6432) samples (31). the report notes that while these may not directly threaten health, such instances of adulteration must nevertheless be prevented by instituting stringent curbs. hydrogen peroxide was the next most common adulterant, found in 55 (30.6%) samples. researchers have documented the longstanding and worldwide use of hydrogen peroxide (h2o2) as an adulterant in milk to preserve and lengthen its shelf life. (32, 33). however, it is not desirable to have this contaminant either in trace amounts as a residue of cleaning or due to active adulteration by profiteers. the addition of peroxides and detergents to milk may be responsible for symptoms of gastro-intestinal distress (34). this study showed that 47 (26.1%) of our milk samples were diluted with added water. according to handford et al., the fssai 2012 national survey had reported extensive use of water to adulterate milk, making it the most common milk adulterant in india. this practice results in low-quality milk with poor nutritional value (9). similarly, grace et al., in their study on milk safety in north east india, reported finding water used to dilute milk in samples from all dairies (35). mukhopadhyay (a community-based study of milk adulteration…) vol. 4, no. 1, 2021, pp. 1-11 10.26555/eshr.v4i1.4641 8 this study shows a trend of higher proportion of stunting, underweight and low bmi in the children drinking adulterated milk compared to those who drank milk without any detectable adulterants. however, our results were not found to be statistically significant. the consistent trend of these indicators of malnutrition showing higher prevalence in children drinking adulterated milk is a pointer to the deleterious effect of adulterants, even in trace quantities, on young children. handford et al. echo this concern, stating that diluting milk with water harms its nutritional value. this may lead to severe challenges with malnutrition in infants and children (9). in india, milk is a chief source of protein for a largely vegetarian population. we must consider the possibility that the extensive prevalence of milk fraud in india, as reflected in the fssai 2012 milk safety survey, could be a causative factor in childhood malnutrition (36). the proportion of wasting in this study did not follow a similar trend of being higher in children drinking adulterated milk. however, wasting is related to acute nutritional deficiencies and infectious diseases compared to stunting, which is an indicator of chronic malnutrition. there may be confounding factors at play in the scenario of acute malnutrition, which may mask the effect of milk adulteration. thus, stunting may be a more appropriate indicator of the effects of long-term consumption of diluted/contaminated milk that is nutritionally subpar and exposes the child to prolonged, sub-lethal doses of various harmful adulterants. a fundamental limitation of this study was that testing for milk adulterants was qualitative. the strip tests used in this study only indicated the presence or absence of adulterants and not the concentration in which they were present. resource and feasibility constraints prevented quantitative analysis from assessing the exact amount of each adulterant in the samples. we observed a high proportion of adulterated milk samples, which resulted in correspondingly very few unadulterated samples. this may have affected the statistical analysis, in which a specific minimum count is required in each cell for the tests of association to be dependable. conclusion this study attempts to elucidate the relationship between milk adulteration and childhood malnutrition. the key findings of this study were a high percentage of stunting (38.33%), low bmi (26.7%), wasting (15%), and underweight (13.33%) among children, and an alarming presence of adulterants in nearly 90% of the milk samples tested. undernutrition was significantly associated with joint family and lower maternal education, and a potential association was detected between malnutrition and milk adulteration. our findings emphasize the importance of maternal education. the results of this study warrant further research with larger sample sizes to accurately delineate the relationship between milk adulteration and malnutrition, and quantitative analysis of adulterants to gain a clearer picture of the extent of adulteration dose-response relationship, if any, between various adulterants and malnutrition. authors' contribution am: research design, analysis, and manuscript writing; id: data collection, analysis, and manuscript writing; rpk: manuscript writing; nn: research design, data collection; pr: analysis. mukhopadhyay (a community-based study of milk adulteration…) vol. 4, no. 1, 2021, pp. 1-11 10.26555/eshr.v4i1.4641 9 funding this project was carried out under a short term studentship grant from the indian council of medical research (icmr sts, reference id 2019–04155). acknowledgment the authors acknowledge the children who participated in this study and thank the parents for their consent. conflict of interest the authors declare that there are no conflicts of interest. references 1. unicef. stunting [internet]. 2017 [cited 2017 nov 29]. available from: http://unicef.in/whatwedo/10/stunting 2. helping india combat persistently high rates of malnutrition [internet]. 2013 [cited 2017 nov 29]. available from: https://www.worldbank.org/en/news/feature/2013/05/13/helpingindia-combat-persistently-high-rates-of-malnutrition 3. government of india. national family health survey [internet]. 2015 [cited 2017 nov 29]. international institute for population science. 2015. p. 1–5. available from: http://rchiips.org/nfhs/pdf/nfhs4/ka_factsheet.pdf 4. longvah t, toteja g, upadhyay a. iodine content in bread, milk and the retention of inherent iodine in commonly used indian recipes. food chem. 2013;136(2):384–388. available from: https://pubmed.ncbi.nlm.nih.gov/23122074/ 5. agrawal s, millett cj, dhillon pk, subramanian s, ebrahim s. type of vegetarian diet, obesity and diabetes in adult indian population. nutr j. 2014 sep 5;13(89):1-18. available from: https://pubmed.ncbi.nlm.nih.gov/25192735/ 6. harinarayan cv, akhila h, shanthisree e. modern india and dietary calcium deficiency— half a century nutrition data—retrospect–introspect and the road ahead. front endocrinol. 2021 apr 6;12:583654. available from: https://www.ncbi.nlm.nih.gov/pmc/articles/pmc8056136/ 7. dror dk, allen lh. the importance of milk and other animal-source foods for children in low-income countries. food nutr bull. 2011;32(3):227–243. available from: https://pubmed.ncbi.nlm.nih.gov/22073797/ 8. misra s. most indians drinking adulterated milk, finds fssai survey [internet]. 2012 [cited cited 2020 feb 14]. available from: https://www.downtoearth.org.in/news/most-indiansdrinking-adulterated-milk-finds-fssai-survey--35646 9. handford ce, campbell k, elliott ct. impacts of milk fraud on food safety and nutrition with special emphasis on developing countries. compr rev food sci food saf. 2016;15(1):130–142. available from: https://pubmed.ncbi.nlm.nih.gov/33371582/ 10. kandpal sd, srivastava a, negi k. estimation of quality of raw milk (open & branded) by milk adulteration testing kit. indian j community heal. 2012 jul;24(3):188–192. available from: https://www.iapsmupuk.org/journal/index.php/ijch/article/view/248/248 11. singh p, gandhi n. milk preservatives and adulterants: processing, regulatory and safety issues. food rev int. 2015 jul 3;31(3):236-261. available from: https://www.tandfonline.com/doi/abs/10.1080/87559129.2014.994818 12. government of india. karnataka population census data 2011 [internet]. 2017 [cited 2021 aug 13]. available from: https://censusindia.gov.in/2011-common/censusdata2011.html mukhopadhyay (a community-based study of milk adulteration…) vol. 4, no. 1, 2021, pp. 1-11 10.26555/eshr.v4i1.4641 10 13. pourhoseingholi ma, vahedi m, rahimzadeh m. sample size calculation in medical studies. gastroenterol hepatol bed bench. 2013 winter; 6(1): 14–17. available from: https://www.ncbi.nlm.nih.gov/pmc/articles/pmc4017493/ 14. world health organization. training course on child growth assessment. geneva: who; 2008. available from: https://www.who.int/childgrowth/training/module_b_measuring_growth.pdf 15. food safety helpline. fssai shares testing methods to find adulteration in milk & milk products [internet]. 2014 [cited 2019 jan 23]. available from: https://foodsafetyhelpline.com/fssai-shares-the-testing-methods-for-adulteration-in-milkmilk-products/ 16. united news of india. milk testing strip developed by ndri scientists of karnal [internet]. 2016 [cited 2019 jan 23]. available from: http://www.uniindia.com/milk-testing-stripdeveloped-by-ndri-scientists-of-karnal/states/news/443849.html 17. sharma r. revision of prasad’s social classification and provision of an online tool for real-time updating. south asian j cancer. 2013;2(3):157. available from: https://www.ncbi.nlm.nih.gov/pmc/articles/pmc3892518/pdf/sajc-2-157.pdf 18. meshram ii, rao mk, reddy cg, ravindranath m, sharad kumar s, sreerama kk et al. prevalence of under nutrition and its predictors among under 5 year children in surat region, gujarat, india. j clin nutr diet. 2016;2(1):1-12. available from: https://clinicalnutrition.imedpub.com/prevalence-of-under-nutrition-and-its-predictors-among-under-5year-children-in-surat-region-gujarat-india.php?aid=8181 19. sahoo dp, dehmubed a, jajulwar mb. an epidemiological study of acute malnutrition in children of age 6 months to 5 years in an urban slum of mumbai, maharashtra. j datta meghe inst med sci univ. 2017;12(3):181-186. available from: http://www.journaldmims.com/article.asp?issn=09743901;year=2017;volume=12;issue=3;spage=181;epage=186;aulast=sahoo 20. popat cn, chaudhari ai, mazumdar vs, patel sv. a cross sectional study to measure the prevalence of malnutrition and factors associated with malnutrition among under five children of an urban slum of vadodara city. j res med dent sci. 2014;2(3):59–64. available from: https://www.jrmds.in/abstract/a-cross-sectional-study-to-measure-theprevalence-of-malnutrition-and-factors-associated-with-malnutrition-among-under-f1549.html 21. gopinath tt, logaraj m, john kr . assessment of nutritional status of children aged under five years in tribal population of jawadhu hills in tamil nadu. int j community med public heal. 2018 feb 24;5(3):1041-1046. available from: https://www.ijcmph.com/index.php/ijcmph/article/view/2448/1859 22. rao mk, balakrishna n, laxmaiah a, venkaiah k, brahmam g. diet and nutritional status of adolescent tribal population in nine states of india. asia pac j clin nutr. 2006;15(1):64– 71. available from: https://pubmed.ncbi.nlm.nih.gov/16500880/ 23. mittal, singh j, ahluwalia s. effect of maternal factors on nutritional status of 1-5-year-old children in urban slum population. indian j community med. 2007;32(4):264-267. available from: https://www.ijcm.org.in/article.asp?issn=09700218;year=2007;volume=32;issue=4;spage=264;epage=267;aulast=mittal 24. gopal bs, devaramani ys. infant mortality, its components and correlates: findings from a longitudinal study in rural karnataka, india. genus. 1991; 47(1-2): 89–108. available from: https://pubmed.ncbi.nlm.nih.gov/12284827/ 25. huq mn, tasnim t. maternal education and child healthcare in bangladesh. matern child heal j 2007 121. 2007;12(1):43–51. available from: https://link.springer.com/article/10.1007/s10995-007-0303-3 26. saleem af, mahmud s, baig-ansari n, zaidi akm. impact of maternal education about complementary feeding on their infants’ nutritional outcomes in lowand middle-income households: a community-based randomized interventional study in karachi, pakistan. j mukhopadhyay (a community-based study of milk adulteration…) vol. 4, no. 1, 2021, pp. 1-11 10.26555/eshr.v4i1.4641 11 health popul nutr. 2014;32(4):623-633. available from: https://www.ncbi.nlm.nih.gov/pmc/articles/pmc4438693/ 27. johri m, subramanian s v, sylvestre m-p, dudeja s, chandra d, koné gk, et al. association between maternal health literacy and child vaccination in india: a crosssectional study. j epidemiol community heal. 2015;69(9):849–857. available from: https://jech.bmj.com/content/69/9/849 28. balogun sa, yusuff ha, yusuf kq, al-shenqiti am, balogun mt, tettey p. maternal education and child immunization: the mediating roles of maternal literacy and socioeconomic status. pan afr med j. 2017; 26 (april 2017):1-8. available from: https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5491723/ 29. iftikhar a, bari a, bano i, masood q. impact of maternal education, employment and family size on nutritional status of children. pakistan j med sci. 2017;33(6):1401-1405. available from: https://www.ncbi.nlm.nih.gov/pmc/articles/pmc5768833/pdf/pjms-331401.pdf 30. sowmya r, indumathi kp, arora s, sharma v, singh ak. detection of calcium based neutralizers in milk and milk products by aas. j food sci technol. 2015;52(2):1188– 1193. available from: https://pubmed.ncbi.nlm.nih.gov/25694738/ 31. food safety and standards authority of india (fssai). national milk safety and quality survey 2018 executive summary. [internet]. 2019 [cited 2019 oct 25]. available from: https://fssai.gov.in/upload/uploadfiles/files/report_milk_survey_nmqs_final_18_10_20 19.pdf 32. martin nh, friedlander a, mok a, kent d, wiedmann m, boor kj. peroxide test strips detect added hydrogen peroxide in raw milk at levels affecting bacterial load. j food prot. 2014;77(10):1809–13. available from: https://pubmed.ncbi.nlm.nih.gov/25285503/ 33. ivanova as, merkuleva ad, andreev sv, sakharov ka. method for determination of hydrogen peroxide in adulterated milk using high performance liquid chromatography. food chem. 2019; 283 (15 june 2019):431–436. available from: https://pubmed.ncbi.nlm.nih.gov/30722894/ 34. azad t, ahmed s. common milk adulteration and their detection techniques. int j food contam. 2016; dec 5;3(1):22:1–9. available from: https://foodcontaminationjournal.biomedcentral.com/articles/10.1186/s40550-016-00453 35. grace d, baker d, randolph tf. innovative and participatory risk-based approaches to assess milk-safety in developing countries: a case study in north east india. paper presented at the international association of agricultural economists (iaae) conference in beijing, china, 17-22 august 2009. nairobi (kenya): ilri 2009; available from: https://cgspace.cgiar.org/handle/10568/1119 36. singh r, wright t. usda foreign agricultural service, global agricultural information network. fssai conducts national survey on adulteration of milk. [internet]. 2012 [cited 2021 sep 2]. available from: http://agriexchange.apeda.gov.in/marketreport/reports/fssai%20conducts%20nation al%20survey%20on%20adulteration%20of%20milk_new%20delhi_india_1-132012.pdf