database connection failed! understanding community’s behavioral responses towards covid-19: who comply, who don’t and reasons of incompliance indonesian scholars’ alliance ghmj (global health management journal) 2020, vol. 4, no. 1 open access perspec ves dyah anantalia widyastari understanding community's behavioral responses towards covid-19: who comply, who don't and reasons of incompliance ins tute for popula on and social research, mahidol university *corresponding author’s email: dyah.ana@mahidol.ac.th,dyah.anantalia@gmail.com doi: 10.35898/ghmj-41497 © yayasan aliansi cendekiawan indonesia thailand (indonesian scholars’ alliance). this is an open-access following crea ve commons license deed a ribu on-noncommercial-sharealike 4.0 interna onal (cc by-nc-sa 4.0) 1. introduc on since it was found as unknown pneumonia-like cases in december 2019 in wuhan, china (wang et al., 2020), the coronavirus disease-2019 (covid-19) has spread to most countries in the world. following its rapid transmission, in the end of january 2020 who declared a public health emergency to raise international concern. as the major pathogens that targets the upper human respiratory system, covid�19 has caused more infections and deaths than sars or mers, particularly with the majority of asymptomatic individuals who can spread viruses to others (rothan and byrareddy, 2020; wang et al., 2020). the government of all nations have been challenged to implement effective measures to fight the rapid spread of the infection since the evidence found only 3-7 days for the epidemic to double in size (park et al., 2020). lockdown, partial shutdown and quarantine for infected individuals are imposed to contain the virus and prevent further infection (anderson et al., 2020; kraemer et al., 2020; who, 2020). although it varies by the country’s policy, public testing was also implemented in order to screen the risky individuals (i.e. italy, indonesia, thailand) or general population (i.e. korea) to control the further increase in the number of new infections (balilla, 2020; harper et al., 2020). 2. behavioral responses towards covid-19 measures: who comply, who do not and reasons of incompliance covid-19 is not only challenging the government, but also poses a critical trial to the whole society. although the government have imposed various measures to contain the virus and prevent further spread of infection, the success of a country in halting the infection depends on the public’s compliance towards those regulations. the expected behavioral responses toward covid-19 comprise of complying the social distancing measure and shifting their outdoor into home-based activities. preventive measures such as hand washing and wearing mask are deemed important to prevent infection and reduce transmission (adhikari et al., 2020). although public health messages have been continuously delivered, there exists a subgroup in the population who are disengaged of information seeking. they feel unaffected by the situation and are being skeptical by showing irrational behavior in non-compliance with covid-19 policies such as going out or travelling, hang around in groups and ignoring the preventive measures such as wearing mask (paakkari and okan, 2020; wright et al., 2020). in many countries, thousands were arrested for 1 mailto:dyah.ana@mahidol.ac.th,dyah.anantalia@gmail.com https://dx.doi.org/10.35898/ghmj-41497 ghmj (global health management journal) 2020, vol. 4, no. 1 widyastari da violating curfew and social distancing measure by loitering on the roads, gathering and consuming alcohol at public grounds, or keeping restaurants open (colombopage, 2020; pakpour and griffiths, 2020; the star online, 2020; xinhuanet, 2020). scholars have attempted to understand community’s behavior in complying covid-19 measures. theoretically driven, individuals will be engaging in new (healthy) behavior depends on their risk perception towards the current health threat. the health believe model which was firstly formulated by irwin rosenstock in 1970s suggested perceive susceptibility as one of the underlying causes of behavior to occur (rosenstock, 1974a,b). those who feeling personally susceptible of infection are more likely to engage in hand washing and social distancing behaviors (kwok et al., 2020; wise et al., 2020) and practicing superficially helpful behaviors such as buying more food and water (wise et al., 2020). on the contrary, the feeling a false sense of invulnerability, misperception of risks covid-19 as being low for themselves and others have lead individuals to disengage in protective behaviors (paakkari and okan, 2020). the perceived susceptibility also could be expressed in the form of fear. studies documented a moderate positive correlation between adoption of new behavior and fear of covid-19, suggesting that negative emotion also motivate a range of behaviors that reduce the engagement in risky behaviors in response to the current pandemic, and could predict compliance (harper et al., 2020; pakpour and griffiths, 2020). females, older person and healthy individuals are more likely to adopt a greater degree of socialdistancing measures (atchison et al., 2020; barari et al., 2020; kwok et al., 2020; zhong et al., 2020) whereas younger males (kwok et al., 2020) and individuals with poor health are reported to have less compliant toward staying home policy, although it could be due to their frequent visits to hospitals or pharmacy (barari et al., 2020). individual’s economic status, knowledge and educational attainment appear to affect their responses toward covid-19 measures. those with relatively high level of socioeconomic status–in particular women–and have had good knowledge are more likely to perform appropriate practices towards covid-19 (atchison et al., 2020; barari et al., 2020; zhong et al., 2020) whereas younger males aged 16-29 years, never-married, bachelor’s degree or lower education and students were significantly associated with lower knowledge (zhong et al., 2020). those from economically disadvantage population and were less likely to work from home showed a less willingness to comply suggesting the influence of structural barriers in adopting preventive behaviors (atchison et al., 2020). 3. has the government convey the right messages to the public? despite the incompliance by a sub group of population, the public health messages have been heard. people understand how to keep themselves and others safe from the virus, and practicing the new behaviour. even the skeptical group who doubt the government policies are reportedly believe the public health messages and engage in the expected behaviours (barari et al., 2020). the information seeking behaviour also could inform the government on how the public respond the pandemic. google searches on ‘face mask’ and ‘hand washing’ including hand sanitizer brands and steps of hand washing not only indicating an increasing promotion of goods but might also reflecting an increasing awareness and engagement of the public (lin et al., 2020). there is no absolute approach that has been proven effective in combating covid-19. every government has selected the best policy fits to its context, culture, and socioeconomic condition both in macro and micro level, to ensure low fatality rate and minimize the socioeconomic impact of the pandemic. it is individual and community commitment in complying the measures that will define how long a country will be in the risky zone before gradually reached the new normal. 2 widyastari da ghmj (global health management journal) 2020, vol. 4, no. 1 references adhikari, s. p., meng, s., wu, y.-j., mao, y.-p., ye, r.-x., wang, q.-z., sun, c., sylvia, s., rozelle, s., raat, h., et al. (2020). epidemiology, causes, clinical manifestation and diagnosis, prevention and control of coronavirus disease (covid-19) during the early outbreak period: a scoping review. infectious diseases of poverty, 9(1):1–12. anderson, r. m., heesterbeek, h., klinkenberg, d., and hollingsworth, t. d. (2020). how will country-based mitigation measures influence the course of the covid-19 epidemic? the lancet, 395(10228):931–934. atchison, c. j., bowman, l., vrinten, c., redd, r., pristera, p., eaton, j. w., and ward, h. (2020). perceptions and behavioural responses of the general public during the covid-19 pandemic: a cross-sectional survey of uk adults. medrxiv. balilla, j. (2020). assessment of covid-19 mass testing: the case of south korea. available at ssrn 3556346. barari, s., caria, s., davola, a., falco, p., fetzer, t., fiorin, s., hensel, l., ivchenko, a., jachimowicz, j., king, g., et al. (2020). evaluating covid-19 public health messaging in italy: self-reported compliance and growing mental health concerns. medrxiv. colombopage (2020). sri lanka : police arrest 559 people for violating curfew in last 24 hours. http://www. colombopage.com/archive_20a/may16_1589612422ch.php. harper, c. a., satchell, l. p., fido, d., and latzman, r. d. (2020). functional fear predicts public health compliance in the covid-19 pandemic. international journal of mental health and addiction, page 1. kraemer, m. u., yang, c.-h., gutierrez, b., wu, c.-h., klein, b., pigott, d. m., du plessis, l., faria, n. r., li, r., hanage, w. p., et al. (2020). the effect of human mobility and control measures on the covid-19 epidemic in china. science, 368(6490):493–497. kwok, k. o., li, k. k., chan, h. h., yi, y. y., tang, a., wei, w. i., and wong, y. s. (2020). community responses during the early phase of the covid-19 epidemic in hong kong: risk perception, information exposure and preventive measures. medrxiv. lin, y.-h., liu, c.-h., and chiu, y.-c. (2020). google searches for the keywords of “wash hands” predict the speed of national spread of covid-19 outbreak among 21 countries. brain, behavior, and immunity. paakkari, l. and okan, o. (2020). covid-19: health literacy is an underestimated problem. the lancet public health. pakpour, a. and griffiths, m. (2020). the fear of covid-19 and its role in preventive behaviors. journal of concurrent disorders. park, m., cook, a. r., lim, j. t., sun, y., and dickens, b. l. (2020). a systematic review of covid-19 epidemiology based on current evidence. journal of clinical medicine, 9(4):967. rosenstock, i. m. (1974a). the health belief model and preventive health behavior. health education monographs, 2(4):354–386. rosenstock, i. m. (1974b). historical origins of the health belief model. health education monographs, 2(4):328–335. rothan, h. a. and byrareddy, s. n. (2020). the epidemiology and pathogenesis of coronavirus disease (covid19) outbreak. journal of autoimmunity, page 102433. the star online (2020). foreigners arrested for violating curfew rules in thailand’s popular tourist island of pha ngan. https://www.thestar.com.my/news/regional/2020/04/18/foreigners-arrested-forviolating-curfew-rules-in-thailand039s-popular-tourist-island-of-pha-ngan. wang, y., wang, y., chen, y., and qin, q. (2020). unique epidemiological and clinical features of the emerging 2019 novel coronavirus pneumonia (covid-19) implicate special control measures. journal of medical virology, 92(6):568–576. who (2020). considerations for quarantine of individuals in the context of containment for coronavirus disease (covid-19). https://www.who.int/publications-detail/considerations-for-quarantine-ofindividuals-in-the-context-of-containment-for-coronavirus-disease-(covid-19). wise, t., zbozinek, t. d., michelini, g., hagan, c. c., et al. (2020). changes in risk perception and protective behavior during the first week of the covid-19 pandemic in the united states. psyarxiv. wright, a. l., sonin, k., driscoll, j., and wilson, j. (2020). poverty and economic dislocation reduce compliance with covid-19 shelter-in-place protocols. university of chicago, becker friedman institute for economics working paper. xinhuanet (2020). over 55,000 arrested in sri lanka for violating curfew. http://www.xinhuanet.com/english/ 2020-05/15/c_139059878.htm. zhong, b.-l., luo, w., li, h.-m., zhang, q.-q., liu, x.-g., li, w.-t., and li, y. (2020). knowledge, attitudes, and practices towards covid-19 among chinese residents during the rapid rise period of the covid-19 outbreak: a quick online cross-sectional survey. international journal of biological sciences, 16(10):1745. 3 http://www.colombopage.com/archive_20a/may16_1589612422ch.php http://www.colombopage.com/archive_20a/may16_1589612422ch.php https://www.thestar.com.my/news/regional/2020/04/18/foreigners-arrested-for-violating-curfew-rules-in-thailand039s-popular-tourist-island-of-pha-ngan https://www.thestar.com.my/news/regional/2020/04/18/foreigners-arrested-for-violating-curfew-rules-in-thailand039s-popular-tourist-island-of-pha-ngan https://www.who.int/publications-detail/considerations-for-quarantine-of-individuals-in-the-context-of-containment-for-coronavirus-disease-(covid-19) https://www.who.int/publications-detail/considerations-for-quarantine-of-individuals-in-the-context-of-containment-for-coronavirus-disease-(covid-19) http://www.xinhuanet.com/english/2020-05/15/c_139059878.htm http://www.xinhuanet.com/english/2020-05/15/c_139059878.htm ghmj (global health management journal) 2020, vol. 4, no. 1 widyastari da cite this article as: widyastari da. understanding community’s behavioral responses towards covid-19: who comply, who don’t and reasons of incompliance. ghmj (global health management journal). 2020; 4(1):1-4. doi:10.35898/ghmj-41497 4 introduction behavioral responses towards covid-19 measures: who comply, who do not and reasons of incompliance has the government convey the right messages to the public? knowledge, attitudes, and hiv/aids risk behaviors of myanmar migrant workers in thailand ghmj (global health management journal) 2022, vol. 5, no. 1 indonesian scholars’ alliance open access photo essay politeknik kesehatan kemenkes palangka raya: health forum and international seminar the new normal : creating a pleasant virtual communication breast massage to support the success of exclusive breastfeeding among postpartum mothers in pekanbaru, indonesia elly susilawati, findy hindratni, cyntia rahmadani department of midwifery, poltekkes kemenkes riau, indonesia *corresponding author’s email: ellysusilawatiramli@gmail.com doi: 10.35898/ghmj-51597 selection and peer-review under responsibility of the scientific committee and the editorial board of the annual health forum and international seminar of the politeknik kesehatan kemenkes palangka raya © yayasan aliansi cendekiawan indonesia thailand (indonesian scholars’ alliance). this is an open-access following creative commons license deed attribution-noncommercial-sharealike 4.0 international (cc by-nc-sa 4.0) a lack of exclusive breastfeeding will increase the possibility of mother’s and infant’s death. high health costs, an increasing incidence of diarrhea, and other infections may also cause mortality. the global breastfeeding initiation rate was relatively high, yet only 40% of infants under 6 months are breastfed and only 45% breastfed for up to 24 months. in 2025, the world health assembly (wha) aims to achieve a minimum of 50% of exclusive breastfeeding for infants under 6 months (kemenkes ri, 2018). figure 1 exclusive breastfeeding mailto:ellysusilawatiramli@gmail.com https://dx.doi.org/10.35898/ghmj-51597 37 ghmj (global health management journal) 2022, vol. 5, no. 1 susilawati et al. an interview was conducted in a maternity clinic in pekanbaru and it was found that only 2 out of 10 mothers gave breast milk without infant formula in the first three days of delivery. the rest of the postpartum mothers claim to experience breastfeeding smoothness issues in the first week of delivery. this worries the mother if her baby cannot get enough breast milk so that infant formula is given. the smoothness issue of breastfeeding in the first three days of delivery is a merely physiological problem but becomes the main cause of the failure of exclusive breastfeeding. figure 2 central and local government support in exclusive breastfeeding the support of the indonesian government in providing exclusive breastfeeding is shown by issuing the government regulation no.33 of 2012 regarding exclusive breastfeeding, specifically in chapter iii article 6 stating that every mother who gives birth must provide exclusive breastfeeding to her baby. the same obligation is also stated in the constitution no.36 of 2009 concerning health, article 200 stating that anyone who deliberately hinders the program to provide exclusive breastfeeding as referred in article 128 paragraph (2) is imprisoned for a maximum of 1 year and a maximum fine of rp 100,000,000 (one hundred million rupiahs). in pekanbaru, the mayor is also very supportive towards the program and issues the mayor regulation no.48 of 2015 regarding exclusive breastfeeding, in which in chapter viii article 10 states that local government affords assistance and supervision of exclusive breastfeeding and infant formula. in article 11, it is emphasized that any health officer violating the provisions of article 10 is subject to administrative sanctions. the attempt to increase breast milk production in mothers after childbirth can be carried out using pharmacological and non-pharmacological methods. pharmacological methods are done by giving therapy such as metoclopramide, chlorpromazine, and domperidone. though, the effectiveness of these medicines in intensifying the production of breast milk is inseparable from some side effects such as headache, dry mouth, frequent thirst, diarrhea, stomach cramps, and redness of skin (william & carrey, 2016). further, nonpharmacological methods are usually completed in a natural way such as breast care, warm compress, back massage, woolwich, and endorphins massage (bahiyatun, 2008; rini & kumala, 2017; pamuji, 2014). susilawati et al. ghmj (global health management journal) 2022, vol. 5, no. 1 38 figure 3 woolwich massage in postpartum mothers to increase breast milk production woolwich massage is performed on the lactiferous sinus area, precisely 1-1.5 cm above the breast areola, to remove the milk that is in the lactiferous sinuses. this massage can stimulate nerve cells in the breast, the stimulation is transmitted to the hypothalamus and the anterior pituitary responds to release the hormone prolactin which will be circulated by the blood to the myoepithelial cells of the breast to produce milk, increase milk volume, and prevent damages in the breast that can cause breast swollen (pamuji, 2014). endorphine massage is a gentle touch massage technique that can normalize heart rate and blood pressure, as well as improve a relaxed state in the mother's body by triggering a feeling of comfort on the surface of the skin. the woolwich and endorphins massage method could influence the production of prolactin hormone and oxytocin as well as give relaxation which can fulfill the need of postpartum mothers in overcoming breastfeeding problems in the first days after childbirth. this is proven by barokah and utami (2017) who gave woolwich massage intervention in postpartum mothers in the first to third days whose result influenced the production of breast milk. hartono (2016) in his study also reveals that endorphins massage increases the breast milk volume. figure 4 endorphins massage on postpartum mothers to increase breast milk production 39 ghmj (global health management journal) 2022, vol. 5, no. 1 susilawati et al. a study was conducted on 20 postpartum mothers in which 10 of them were given woolwich massage intervention and the other 10 were given an intervention of endorphins massage on breast milk production. the study results show that the average breast milk production of mothers who were given endorphins massage (125.30 ml) was much more than those given woolwich massage (99.80 ml). there was a significant difference in breast milk volume between those given endorphins and woolwich massage by 25.50 ml. it is proven that the production of breast milk can be increased by giving endorphins massage; that is a massage technique done on the neck, arms, and hands of postpartum mothers. hidayati & hanifah (2019) affirm that when the endorphins massage is done, the spinal nerve is stimulated to release endorphins in the body which then stimulates oxytocin. for the breast nerve consists of many dorsal nerves coordinated along the spine, while being massaged, the spinal nerve will send signals to the brain to release oxytocin resulting in a contraction of myoepithelial cell that encourages the release of breast milk. figure 5 abundant breast milk production after the endorphins massage is completed references bahiyatun. (2008). buku ajar asuhan kebidanan nifas normal. jakarta: penerbit buku kedokteran. barokah, l & utami, f. (2017). terhadap produksi asi di bpm appi amelia bibis kasihan bantul. prosiding seminar nasional dan call paper, november, 243–250. hartono. (2016). massage endorphine terhadap volume asi pada ibu post partum. jurnal kebidanan, 8(2), 209– 214. hidayati, t.& hanifah, i. (2019). penerapan metode massage endorphin dan oksitosin terhadap peningkatan produksi asi pada ibu menyusui bayi 0-6 bulan di desa gading kabupaten probolinggo. journal of health and science, 12(1), 30–38. kementerian kesehatan ri. (2018). hasil utama riset kesehatan dasar. jakarta: kemenkes ri. pamuji, s. e. b. (2014). pengaruh kombinasi metode pijat woolwich dan endorphine terhadap kadar hormon prolaktin dan volume asi. jurnal ilmu dan teknologi kesehatan, 5(1), 1–14. rini, s. & kumala. (2017). panduan asuhan nifas dan evidace based practic. yogyakarta: deepublish. william, m. & carrey. (2016). domperidone untuk meningkatkan produksi air susu ibu (asi). jakarta: cermin dunia kedokteran cite this article as: susilawati e, hindratni f & rahmadani c. breast massage to support the success of exclusive breastfeeding among postpartum mother in pekanbaru, indonesia. ghmj (global health management journal). 2022; 5(1): 36-39. doi:10.35898/ghmj-51597 https://dx.doi.org/10.35898/ghmj-51597 knowledge, attitudes, and hiv/aids risk behaviors of myanmar migrant workers in thailand ghmj (global health management journal) 2022, vol. 5, no. 1 indonesian scholars’ alliance open access photo essay politeknik kesehatan kemenkes palangka raya: health forum and international seminar the new normal : creating a pleasant virtual communication improving the quality of pregnancy by fulfilling the physical and psychological needs of pregnant women in kuala kapuas, kapuas regency stephanie emmanuella yuri mahar* & oktaviani oktaviani department of midwifery, poltekkes kemenkes palangka raya, indonesia *corresponding author’s email: stephanieyuri12@gmail.com doi: 10.35898/ghmj-51595 selection and peer-review under responsibility of the scientific committee and the editorial board of the annual health forum and international seminar of the politeknik kesehatan kemenkes palangka raya © yayasan aliansi cendekiawan indonesia thailand (indonesian scholars’ alliance). this is an open-access following creative commons license deed attribution-noncommercial-sharealike 4.0 international (cc by-nc-sa 4.0) pregnancy is one of the significant and critical periods in a woman's life in which she has an additional responsibility and a new role to play in her life. although she's a wife today, she's also a mother, and that isn't easy. figure 1. a pregnant woman consuming her folate-rich milk https://dx.doi.org/10.35898/ghmj-51595 27 ghmj (global health management journal) 2022, vol. 5, no. 1 mahar & oktaviyani there are so many changes taking place in this period: in the figure of the woman, mentally and physically. some of the pregnant women’s physical needs are oxygen, nutrition, personal hygiene, and comfortable clothes which can fit their new body shape. meanwhile, some of the psychological needs of pregnant women are supported, a sense of security, and comfort from their husbands and families (tyastuti and wahyuningsih 2016). the occurrence of the body to the fetus would have a significant effect on maternal mortality. these physical and psychological changes often make the body of the mother have special needs that occur during her pregnancy. these needs are things that must be fulfilled to improve the quality of pregnancy so that when the mother delivers the baby, it can be born without any deficiencies. disruption and inhibition of development, as well as a lack of hb (haemoglobin) in the blood resulting in a lack of oxygen being transported across the body and brain, are examples. during early pregnancy, a woman needs a lot of adjustment physically and mentally, guidance, and support from the surrounding environment to get through the time. however, the physical and psychological needs of pregnant women are not always being fulfilled and not even being considered trivial. this has been proven by my research in kuala kapuas, where i conducted observations of pregnant women and the results show that there are still many pregnant women whose needs have not been met due to a lack of awareness and knowledge about their needs during pregnancy. unfulfilled physical and psychological needs of pregnant women will affect the quality of pregnancy and the health of the baby who will be delivered. figure 2. multigravida mom in deep conversion with her children regarding upcoming birth figure 3. healthy and fresh vegetables are available at stores; growing them in our yard may bring a peaceful environment. mahar & oktaviyani ghmj (global health management journal) 2022, vol. 5, no. 1 28 as already mentioned, pregnant women need more oxygen. therefore, pregnant women are advised to exercise regularly to help circulate air in the body. it is also important to avoid crowded places where there are a lot of people gathering or clustering around, thus she can get an adequate supply of oxygen. pregnant women who do not fulfill their oxygen needs will get headaches and dizziness. this commonly happens in the traditional markets where there are lots of people, and there are also stuffs crammed in the room that will make it crowded and stuffy. as for nutritional needs, a pregnant woman needs a lot of nutrition to help her fetus to grow well. even though sometimes nausea which occurs in the first trimester causes the mother to lose her appetite. it will harm the health of the mother and the fetus. therefore, it is very important to pay attention to the nutritional intake of pregnant women. especially in the first trimester where the fetal organs begin to form. consuming lots of vegetables and fruit is highly recommended for them since consuming fruits and vegetables will prevent pregnant women from developing anemia (hermawan, abidin, and yanti 2020). the other need of a pregnant woman is personal hygiene. cleanliness of the body of a pregnant woman is very important to reduce the possibility of infection caused by germs on the dirty body. pregnant women experience an increased metabolic rate which makes them sweat a lot more easily. this condition makes pregnant women need to continue maintaining a clean body and environment. frequent hand washing and bathing are highly recommended. clothes are also one of the things that must be considered for pregnant women. the growing belly definitely makes the mother uncomfortable if she has to wear tight rubbery clothes on the wrists. in addition, besides being uncomfortable, tight clothes made from rubber on the wrists will also inhibit blood circulation in pregnant women. figure 4. various fruits for extra vitamins during pregnancy figure 5. various fruits for extra vitamins during pregnancy 29 ghmj (global health management journal) 2022, vol. 5, no. 1 mahar & oktaviyani one of the crucial needs of a pregnant woman that must be fulfilled is the psychological need. pregnant women will experience mood swings and will easily experience overthinking and stress. (tyastuti and wahyuningsih 2016). therefore, a strong role from the family will be needed to be the support system for pregnant women. for example, it can be by showing appreciation and happiness for the wife’s pregnancy or by calming a wife who is worried about her pregnancy. besides that, the husband can also help ease the duties of the wife at home. support from the husband is very crucial currently (lewis, lee, and simkhada 2015; ngoma and chongo 2013). important support comes from the family (wiradnyani et al. 2016). a pregnancy that is welcomed and cared for by the family will bring happiness to the mother. bad moods should be avoided by pregnant women because it is bad for the foetus. the support from the husband and family will automatically create a good environment for the mother’s pregnancy. this will make the mother feel safe and comfortable. figure 6. a physical environment that does not support an adequate supply of oxygen for pregnant women figure 7. in-bound interaction with children, fetus, and a mother during her pregnancy figure 8. a supporting husband will encourage a pregnant wife both psychologically and emotionally. mahar & oktaviyani ghmj (global health management journal) 2022, vol. 5, no. 1 30 therefore, the role of the husband and family during this pregnancy is very important. both to meet physical needs, and to fulfill the psychological needs of pregnant women. the family and husband will be responsible and must ensure that every need of the mother can be met. improving the quality of pregnancy itself is also crucial. if the quality of the mother’s pregnancy is good, then the baby will also be born smoothly with a health condition. this will automatically have an impact on reducing the number of deaths and labor failures. today, a global pandemic of covid-19 has tremendously changed the way we live our daily life, not to mention, pregnant women. the indonesian government has issued a guideline for pregnant women during the pandemic (direktorat kesehatan keluarga 2020). the pandemic may spark a new form of psychological warfare in many pregnant women (davenport et al. 2020; erin michael n.d.; sade et al. 2020; suzumori, goto, and sugiura-ogasawara 2020). however, as long as their physical and psychological needs are fulfilled, plus as per health protocol, giving birth in the pandemic should not be an issue. acknowledgment the authors would like to thank all pregnant women in the frame, their supporting families. consent all pregnant women, in their home and traditional market, have given their permission regarding this work as well as no conflict of interest. figure 9. a pregnant woman in a traditional market; should have avoided the environment during pregnancy. figure 10. a healthcare who is also a pregnant woman practicing 20-second rules hand washing at the hospital. 31 ghmj (global health management journal) 2022, vol. 5, no. 1 mahar & oktaviyani references davenport, margie h. et al. 2020. ‘moms are not ok: covid-19 and maternal mental health’. frontiers in global women’s health 1. https://doi.org/10.3389/fgwh.2020.00001. direktorat kesehatan keluarga. 2020. pedoman bagi ibu hamil, ibu nifas, dan bayi baru lahir di era pandemi covid-19. jakarta, indonesia: kementerian kesehatan ri. http://www.kesga.kemkes.go.id/images/pedoman/pedoman bagi ibu hamil, bersalin, nifas dan bbl di era pandemi covid 19.pdf. erin, michael. (2020). ‘depression, anxiety rates increase among pregnant women, new mothers during pandemic’. https://www.healio.com/news/primary-care/20200625/depression-anxiety-rates-increaseamong-pregnant-women-new-mothers-duringpandemic?utm_source=trendmd&utm_medium=cpc&utm_campaign=healio__trendmd_1 (october 26, 2020). hermawan, dessy, zaenal abidin, and dwi yanti. (2020). ‘konsumsi sayuran hijau dengan kejadian anemia pada ibu hamil’. holistik jurnal kesehatan 14(1): 149–54. https://doi.org/10.33024/hjk.v14i1.1557. hidayat, a. a. (2010). metode penelitian kebidanan. salemba medika, jakarta.. lewis, sarah, andrew lee, and padam simkhada. (2015). ‘the role of husbands in maternal health and safe childbirth in rural nepal: a qualitative study’. bmc pregnancy and childbirth 15(1): 1–10. http://dx.doi.org/10.1186/s12884-015-0599-8. ngoma, catherine mubita, and charity chongo. 2013. ‘support during pregnancy, labour and childbirth by husbands in zambia’. african journal of midwifery and women’s health 7(4): 186–90. https://doi.org/10.12968/ajmw.2013.7.4.186. notoadmodjo, s. 2012. ‘promosi kesehatan dan perilaku kesehatan’. jakarta. rineka cipta. nursal, dga and kasman, r. 2018. ‘hubungan perilaku ibu, dukungan suami dan bidan dengan kehamilan resiko tinggi di puskesmas pauh’. jurnal kesehatan masyarakat andalas. https://doi.org/10.24893/jkma.v12i2.415 sade, shanny et al. 2020. ‘risk for depressive symptoms among hospitalized women in high-risk pregnancy units during the covid-19 pandemic’. journal of clinical medicine. https://doi.org/10.3390/jcm9082449. saifuddin, a. 2004. ‘buku panduan praktis pelayanan kesehatan maternal dan neonatal’. jakarta. pt. rineka cipta. suzumori, n., goto, s., & sugiura‐ogasawara, m. (2020). management strategy of pregnant women during covid‐19 pandemic. the australian & new zealand journal of obstetrics & gynaecology, 60(4), e9. https://doi.org/10.1111/ajo.13202. tyastuti, siti, and heni puji wahyuningsih. 2016. asuhan kebidanan kehamilan. jakarta: kementerian kesehatan ri. wiradnyani, l. a. a., khusun, h., achadi, e. l., ocviyanti, d., & shankar, a. h. (2016). role of family support and women’s knowledge on pregnancy-related risks in adherence to maternal iron–folic acid supplementation in indonesia. public health nutrition, 19(15), 2818-2828. https://doi.org/10.1017/s1368980016001002. cite this article as: mahar sey & oktaviani o. improving the quality of pregnancy by fulfilling the physical and psychological needs of pregnant women in kuala kapuas, kapuas regency. ghmj (global health management journal). 2022; 5(1):26-31. doi:10.35898/ghmj-51595 https://doi.org/10.3389/fgwh.2020.00001 https://doi.org/10.33024/hjk.v14i1.1557 http://dx.doi.org/10.1186/s12884-015-0599-8 https://doi.org/10.12968/ajmw.2013.7.4.186 https://doi.org/10.24893/jkma.v12i2.415 https://doi.org/10.3390/jcm9082449 https://doi.org/10.1111/ajo.13202 https://doi.org/10.1017/s1368980016001002 https://dx.doi.org/10.35898/ghmj-51595 knowledge, attitudes, and hiv/aids risk behaviors of myanmar migrant workers in thailand ghmj (global health management journal) 2022, vol. 5, no. 1 indonesian scholars’ alliance open access photo essay politeknik kesehatan kemenkes palangka raya: health forum and international seminar the new normal : creating a pleasant virtual communication reducing and preventing stunting through integrated posyandu with fathers and or child caregivers (posyandu bersayap) at watukapu public health center in ngada regency, east nusa tenggara province, indonesia ririn widyastuti* 1 , martinus v. ndona 2 1 midwifery study program, health polytechnic of health ministry kupang, ntt, indonesia 2 watukapu health center, ngada regency, ntt, indonesia *corresponding author’s email: ririenwidyastuti@gmail.com doi: 10.35898/ghmj-51603 selection and peer-review under responsibility of the scientific committee and the editorial board of the annual health forum and international seminar of the politeknik kesehatan kemenkes palangka raya © yayasan aliansi cendekiawan indonesia thailand (indonesian scholars’ alliance). this is an open-access following creative commons license deed attribution-noncommercial-sharealike 4.0 international (cc by-nc-sa 4.0) an important nutritional problem needing special attention in indonesia is stunting. stunting is a physical growth disorder in the form of a linear decrease in the growth rate. as a result, children fail to reach their optimal height potential. stunting can also be interpreted as a condition that occurs due to the impact of chronic malnutrition during the first 1000 days of a child's life (trihono et al., 2015). the prevalence of children under five with stunting in three years in the east nusa tenggara is decreasing. however, the value is still high which is at 27.5 percent (badan penelitian dan pengembangan kesehatan, 2019). the efforts made by the east nusa tenggara government to overcome nutritional problems are by reducing the number of stunting, wasting, or malnutrition, and being underweight for children under five. the program was carried out through intervention, provision of supplementary food for toddlers and pregnant women with chronic energy deficiency in 22 districts/cities through integrated posyandu (taolin, 2020). one of the posyandu's innovative activities in preventing stunting in watukapu district, ngada regency is posyandu bersayap. posyandu bersayap is a posyandu program involving the participation of fathers and/or child caregivers. posyandu activities are routinely carried out every month, whereas the posyandu bersayap program is carried out every march and september. the positive impact of this activity is the increasing visit of under-five children, the participation of parents and child caregivers increases, and the malnutrition cases decrease. mailto:ririenwidyastuti@gmail.com https://dx.doi.org/10.35898/ghmj-51603 71 ghmj (global health management journal) 2022, vol. 5, no. 1 widyastuti & ndona figure 1 watukapu public health center, ngada, east nusa tenggara posyandu bersayap program covers several activities: 1. registration figure 2 is the implementation of the posyandu program refers to the five-table posyandu implementation guidelines (kemenkes ri, 2011). the innovation of the posyandu bersayap is to involve fathers or child caretakers other than mothers including grandparents or babysitters which is proven in increasing the participation of under-five visits for weighing. figure 2 fathers and child caregivers participating in the program figure 3 participations of fathers in childcare can increase affection/bounding attachment between fathers or accompanying caregivers with children widyastuti & ndona ghmj (global health management journal) 2022, vol. 5, no. 1 72 2. weighing and measuring children figure 4 the participation of father (top left), grandmother (bottom left), and grandparents (right) in helping children weighing figure 5 height measurements routine weighing and height measurement can be used to monitor the nutritional status of infants and toddlers, improve nutritional status and prevent stunting. based on the results of the research, there was a relationship between regular posyandu visits and the nutritional status of children under-five based on weight/ age at posyandu ngudi mulyo dusun kembu, waru, kebakramat, karanganyar with a correlation coefficient value of 0.668 with a significance of 0.000 (riawati & sari, 2019). 73 ghmj (global health management journal) 2022, vol. 5, no. 1 widyastuti & ndona 3. recording of weighing and height measurement result figure 6 recording of weighing and height measurement result 4. nutrition counseling and service in nutrition counseling activities, parents (father, mother, or children’s caregivers) were given counseling on the use of local food to fulfill nutrition for children under five. local food such as corn, cassava, moringa, mung bean (vigna radiata), and fish. feeding children with mung beans and fish can overcome malnutrition (amra & juhartini, 2018). the addition of biscuits with a mixture of moringa has been shown to affect weight gain in toddlers with underweight nutritional status (juhartini, 2016). figure 7 food serving practice using provided food for under-five children appropriate with age, and serving size for children figure 8 food product from the program appropriate with age, and serving size for children widyastuti & ndona ghmj (global health management journal) 2022, vol. 5, no. 1 74 5. immunization figure 9 polio immunization references amra, n. & juhartini. (2018). daya terima makanan formula ikan dan formula kacang hijau pada balita gizi kurang di wilayah kerja puskesmas kalumata kota ternate tahun 2018. hospital majapahit, 10(2), 25-33. badan penelitian dan pengembangan kesehatan. (2019). national riskesdas report 2018: basic health research 2018 (laporan nasional riskesdas 2018: riset kesehatan dasar 2018). jakarta: lembaga penerbit badan penelitian dan pengembangan kesehatan.. juhartini. (2016). pengaruh pemberian makanan tambahan biskuit dan bahan makanan campuran kelor terhadap berat badan dan hemoglobin; studi pada balita dengan status gizi kurus di wilayah kerja puskesmas kalumpang kota ternate tahun 2015. hospital majapahit, 28(2), 19-28. kemenkes ri (2011). pedoman umum pengelolaan posyandu. jakarta: kemenkes ri riawati, d. & sari, a.n. (2019). analisis faktor keteraturan kunjungan posyandu balita dan status gizi balita berdasarkan berat badan/umur. jurnal kebidanan indonesia, 10(1), 137. taolin, a.u. (2020). prevalensi balita stunting di ntt capai 27,5 persen. retrieved from: https://www.gatra.com/detail/news/488170/kesehatan/prevalensi-balita-stunting-di-ntt-capai-275persen#:~:text=prevalensibalita stunting di ntt capai 27%2c5 persen %7c kesehatan&text=kupang%2c gatra.com– prevalensi,kasus meninggal sebanyak 57 orang. trihono, atmarita, tjandrarini, d.h., irawati, a., utami, n.h., tejayanti, t., et al. (2015). pendek (stunting) di indonesia, masalah dan solusinya. jakarta: lembaga penerbit litbangkes. cite this article as: widyastuti r, ndona mv. reducing and preventing stunting through integrated posyandu with fathers and or child caregivers (posyandu bersayap) at watukapu public health center in ngada regency, east nusa tenggara province, indonesia. ghmj (global health management journal). 2022; 5(1):70-74. doi:10.35898/ghmj-51603 https://dx.doi.org/10.35898/ghmj-51603 knowledge, attitudes, and hiv/aids risk behaviors of myanmar migrant workers in thailand ghmj (global health management journal) 2022, vol. 5, no. 1 indonesian scholars’ alliance open access photo essay politeknik kesehatan kemenkes palangka raya: health forum and international seminar the new normal : creating a pleasant virtual communication modification and nutritional outcome of food high-protein at sinta rangkang nursing home fretika utami dewi*, sugiyanto sugiyanto department of nutrition, poltekkes kemenkes palangka raya, indonesia *corresponding author’s email: dewiutami_f@yahoo.co.id doi: 10.35898/ghmj-51598 selection and peer-review under responsibility of the scientific committee and the editorial board of the annual health forum and international seminar of the politeknik kesehatan kemenkes palangka raya © yayasan aliansi cendekiawan indonesia thailand (indonesian scholars’ alliance). this is an open-access following creative commons license deed attribution-noncommercial-sharealike 4.0 international (cc by-nc-sa 4.0) one of the ministry of health's strategic plan is to maintain health in old age by understanding a variety of possible diseases that could happen. this could be achieved by maintaining a good diet by consuming balanced nutritional food and eat regularly according to mealtimes. based on data from the central statistics agency, the number of elderly people in the city of palangka raya has increased. in 2016 it was 4.79% while in 2017 it was 4.99% (badan pusat statistik, 2017). figure 1 elderly and their daily activities at sinta rangkang nursing home elderly people usually experience a variety of complex problems both physical, mental, and socioeconomic aspects which may affect their intake and nutritional status (fatmah, 2013; kemenkes ri, 2012; rohmawati, 2014). based on the results of field work practice in may 2018, approximately 41% of elderly at sinta rangkang nursing home suffered from malnutrition. sinta rangkang nursing home is located in banturung village, bukit batu sub-district, + 38 km from the city center of palangka raya. https://dx.doi.org/10.35898/ghmj-51598 41 ghmj (global health management journal) 2022, vol. 5, no. 1 dewi & sugiyanto figure 2 weighing the elderly with malnutrition before intervention they need nutritional intervention to improve the state of nutritional status. our goal was to increase their body weight and evaluate the acceptance of modified animal-side dishes and snacks given by the authors. the activities were carried out in july-august 2018. all menus were prepared consecutively 7 times in 7 days. the nutritional value of modified animal side dish was counted as 90 calories and 8 grams of protein. while for modified snack, it counted as 175 calories and 14 grams of protein. those modified foods were conseidred as high-protein meals. figure 3 providing nutritious food for the elderly (meals were processed in the culinary laboratory of poltekkes kemenkes palangka raya) all meals were provided by the nutrition support team from poltekkes kemenkes palangka raya. local ingredients such as catfish, anchovy, chicken meat, egg, cassava, pumpkin, green beans, and dragon fruit were used to make the dishes. at the time of distribution, the team motivated the elderly to finish their meals. dewi & sugiyanto ghmj (global health management journal) 2022, vol. 5, no. 1 42 figure 4 sample menu of modified food and snack: “cantik manis'' cakes and chicken roulade (from left to right) during the activity, there were problems with some elderly people who were sick so the mobility of food distribution was slightly disturbed. by observing the leftovers of all meals every day, the authors conclude a good acceptance of elderly towards all dishes served. according to short interview, the elderly said all meals were delicious. the appearance of the dishes has increased the appetite of elderly (sjahriani, & tita, 2018). figure 5 food distribution for the elderly 43 ghmj (global health management journal) 2022, vol. 5, no. 1 dewi & sugiyanto figure 6 weighing the elderly after 7 days of intervention the evaluation process was carried out by comparing their weight before and after intervention. after consuming the modified foods for seven days, many as 57.14% of respondents experienced an increase in body weight by the average of 0.6 kg. it is likely that the intervention is very influential because the intervention may improve nutritional status of the elderly. consent the elderly (identifiable) photographed have given their consent for their pictures to be used in the publication of this research. conflict of interest none. references badan pusat statistik. (2017). lansia. retrieved from https://palangkakota.bps.go.id/indicator/12/216/2/lansia.html. fatmah. (2013). nutrition elderly. jakarta: erlangga. kemenkes ri. (2012). guidelines for elderly nutrition services. jakarta: kemenkes ri. rohmawati, n. (2014). depression symptom and nutritional status of elderly in jember regency. juke unila, 4(8), 185-193. sjahriani, t. & tita, y. (2018). hubungan pola makan dan status gizi pada lansia di uptd pelayanan sosial tresna werdha natar, lampung selatan. medical health sciences, 5(2), 154-164. cite this article as: dewi fu, sugiyanto s. modification and nutritional outcome of food high-protein at sinta rangkang nursing home. ghmj (global health management journal). 2022; 5(1): 40-43. doi:10.35898/ghmj-51598 https://palangkakota.bps.go.id/indicator/12/216/2/lansia.html https://dx.doi.org/10.35898/ghmj-51598   cite this article as  macnab aj. the international conference on applied science and health (icash) in  promoting future health: excellence, relevance and cost benefit. global health  management journal. 2017; 1(2): 28‐30.    global health management journal  www.publications.inschool.id  published by  editorial issn 2580-9296 (online) the international conference on applied science and health (icash): promoting future health: excellence, relevance and cost benefit andrew j. macnab editor in chief, global health management journal *corresponding author. email: ajmacnab@gmail.com accepted 31 october 2017 © 2017 publications of yayasan aliansi cendekiawan indonesia thailand  this is an open access following creative commons license deed – attribution‐noncommercial‐sharealike 4.0 international (cc by‐nc‐sa 4.0)  the international conference on applied science and health (icash) celebrated advances in applied science and health research intended to benefit all sections of society, from the very young to the very old. the nature and strength of research inquiry is that each of us brings our own expertise, interests and experiences to the research we do, and this was illustrated by the many topics and many approaches represented. excellence is central to successful funding of research endeavour, as the immediate relevance and social importance of what we propose for the society in which we live. one key element often overlooked in the promotion of future health globally is a clear understanding of how the cost will be balanced by the benefits anticipated to come as a result of what we propose. at the 2nd session of icash, in addition to a keynote speech by professor sangkot marzuki on developing excellence and leadership in science and technology at a national level, we heard three focus talks on relevant and important contemporary themes:  why our children and what they learn at school are important for their future health by professor andrew j. macnab.  the central importance of water in all our lives, the impact of pharmaceutical and personal care products and risks of the current levels of contamination of this vital resource by professor rajna jindal, and  approach of health benefit assessment due to air pollution in thailand, by dr. thao pham. then, participants from across indonesia, thailand, and myanmar presented their papers on health issues of interest and relevance to them that highlighted the diversity and value of research being done by young investigators in the region. the sessions began with two ‘best practices’ presentations on the role of youth champions in school-based health promotion by ronald mukisa and the integrated action plan to eradicate malaria in thailand by chantana sowat. the presentations spoke to the theme "research for better society: developing science and technology to improve health and well-being" and underlined the importance of health promotion and prevention strategies, public health and clinical aspect in nursing, maternal and child health, applied science in education and health, and public health nutrition. detail on all the presenter’s work is available in the published proceedings available at http://publications.inschool.id/index.php/icash/issu e/view/3. 29                                 global health management journal, 2017, vol. 1, no. 2    this second edition of the journal includes 2 works from the selected papers from the first conference and 2 new submissions to the journal. the early initiation of breast feeding is recognized to benefit infants and their mothers. bernolian and sjaaf report on their evaluation of the opportunities and challenges encountered in running an early initiation program in an indonesian hospital. while practitioners reported having strong initiatives to implement breast feeding, their challenges included limited support from managerial staff and a lack of knowledge of the benefits of early initiation among mothers. as “knowledge is power” it is to be hoped the information gained in this evaluation can lead to improvement in the initiation of this important element of infant care. promoting child health at school has many facets. importantly, initiatives implemented must be evaluated for continuing benefit and relevance. the paper by mukisa et al. revisits an innovative teacher driven school-based program implemented to provide rapid diagnosis and prompt treatment for malaria for children taken ill in rural schools in uganda. follow up a year after the program evaluation was officially completed shows teachers continuing to provide screening care and treatment and that the whole-school focus on malaria has been sustained. children reported better health, more consistent attendance and improved academic achievement. pupils have maintained their knowledge about malaria and become proactive in prevention strategies; 6% fewer tested positive for malaria; and key health knowledge was being passed to new pupils. teacher administered diagnosis and care has reduced child morbidity from malaria significantly; essential knowledge generated has been sustained, led to new health practices and changed behaviors. clearly this who health promoting school model is effective, sustainable and hence applicable to other countries where malaria is endemic and morbidity high. basic science techniques are of potential benefit to all age groups. sawasdee et al. describe factors that determine the development of size-tunable polymeric nanoparticles which offer a unique delivery systems for drug delivery applications. poly lactide-co-glycolide nanoparticles have been widely used for drug delivery because of their biocompatibility, biodegradability, ability to deliver hydrophobic drugs and as they improve drug absorption to targeted cells with both oral and parenteral administration. the authors describe how these nanoparticles can be synthesized and how their formation during synthesis can affect their size, which is an important factor relevant to the successful development of a drug delivery system. the views and attitudes of minorities are important if equity is to be achieved in health care delivery. hoang and pham evaluated the extent and impact of misconceptions about hiv/aids among minority groups in vietnam. they found negative attitudes and misperceptions, and that these likely originate from media channels which are heavily relied on by this group as an hiv information resource. in contrast, hiv information provided by health officers, who are themselves members of the same ethnic minorities was more accurate and more effective in improving attitudes in the community. based on these data, the authors understandably recommend improving the quality of hiv messages delivered by the media by including the provision of public health information as a role for the health officers. we have more presentations to look forward to at icash 3 in july 2018. in the meantime anything we can do as individuals or members of the institutions where we work to promote health and improve the wellbeing of those of all ages in the societies in which we live will be important. in this context it is important to remember that a strong economic argument is often the best way to translate the research we do into a practical reality. finding a way to evaluate the cost benefit of any intervention we propose is an important element in how we justify and present our argument. improving health care is not a strong enough argument in its own right these days, as the limited nature of health-care resources mandates that resource-allocation decisions are guided by considerations of cost in relation to the expected benefit of any technology or intervention. yet many of us do not have the expertise necessary to calculate the economic impact of what we propose, so to do this interdisciplinary collaboration is often helpful. the principles of cost-effectiveness analysis are that the ratio of net health-care costs to net health benefits provides an index by which priorities may be set. the impact on quality-of-life global health management journal, 2017, vol. 1, no. 2   30      (both positive and negative) should be incorporated in the calculation of health benefits anticipated, as well as expected effects on life expectancy. these calculations can only be estimated but such analysis can increase the level of confidence in those making decisions about funding research, care programs or health promotion interventions, so we should include them, and make sure they are presented in ways that meet the needs of the various health-care decision makers we engage. references 1. arthur m. excellence in research. in: becoming a world-class university 2016 (pp. 77-90). springer international publishing. 2. williamson p, altman d, blazeby j, clarke m, gargon e. driving up the quality and relevance of research through the use of agreed core outcomes. journal of health services research & policy. 2012.17(1):1-2. 3. weinstein mc, stason wb. foundations of costeffectiveness analysis for health and medical practices. new england journal of medicine. 1977. 296(13):716-21. 4. garber am, phelps ce. economic foundations of cost-effectiveness analysis. journal of health economics. 1997.16(1):1-31. 5. frew e. applied methods of cost-benefit analysis in health care. oxford university press; 2010. knowledge, attitudes, and hiv/aids risk behaviors of myanmar migrant workers in thailand ghmj (global health management journal) 2022, vol. 5, no. 1 indonesian scholars’ alliance open access photo essay politeknik kesehatan kemenkes palangka raya: health forum and international seminar the new normal : creating a pleasant virtual communication balancing online learning from home for children with outdoor activities during the pandemic hendrowanto nibel fakultas keguruan dan ilmu pendidikan, universitas palangka raya *corresponding author’s email: hendrowanto26@gmail.com doi: 10.35898/ghmj-51593 selection and peer-review under responsibility of the scientific committee and the editorial board of the annual health forum and international seminar of the politeknik kesehatan kemenkes palangka raya © yayasan aliansi cendekiawan indonesia thailand (indonesian scholars’ alliance). this is an open-access following creative commons license deed attribution-noncommercial-sharealike 4.0 international (cc by-nc-sa 4.0) indonesia has faced the effects of covid-19 pandemic. such a pandemic affects various age groups. the increased number of new positive cases in indonesia from march to june 2020 was threatening as shown in figure 1. there were 1,528 cases in march, 10,118 cases in april, 26,473 cases in may, and 56,385 cases in june (mukaromah, 2020). 0 10,000 20,000 30,000 40,000 50,000 60,000 maret april mei juni newcase positive covid-19 2020 maret april mei juni march april may june figure 1. number of covid-19 cases by month https://dx.doi.org/10.35898/ghmj-51593 17 ghmj (global health management journal) 2022, vol. 5, no. 1 nibel, h the covid pandemic causes a fluctuating number death. figure 2 shows that from 34 provinces in indonesia, of 28,233 infected with covid-19, around 1,698 died (6%) (ministry of health, 2020). anticipating the spread of the virus, the government restricts social activities in various sectors. in education, the indonesian ministry of education and culture issued a circular letter number 4 of 2020 on march 24, 2020, concerning the implementation of emergency education due to the covid pandemic. issued the letter, all schools carried out online classes from home (wajdi et al, 2020) despite different learning experiences. figure 2. the number of positive covid-19 cases in indonesia as per june 3, 2020 at 12.00 am wib. photo source: indonesian ministry of health, 2020 figure 3. children in in-person class (photo source: jupi.co.id) nibel, h ghmj (global health management journal) 2022, vol. 5, no. 1 18 online learning or distance learning itself aims to meet of the use of information technology connecting students and teachers. educators, parents and children change learning modes with various online methods such as whatsapp application, zoom meeting, google classroom, email, and other applications. as a result, time and space of using the gadgets or laptops are inevitable (basilaia, g. & kvavadze, d., 2020). figure 4. child using gadget figure 4. online learning decreases children's learning experience (wiresti, 2020; wulandari and purwanta, 2020). 19 ghmj (global health management journal) 2022, vol. 5, no. 1 nibel, h overcoming future impacts of online learningshould be our concern. according to law no. 20 of 2003 concerning the national education system, education is a conscious and planned effort to create a learning atmosphere and learning process so that students actively develop spirituality, self-control, personality, intelligence, noble character, and useful skills for themselves, the society, and nation. recommendations such as studying with siblings may instill the spirit of learning and social sensitivity. dewi (2020) said that parents have a role to support, improve and succeed home schooling, especially during the pandemic. more importantly, parents should be aware of their child’s psychological condition due to the lack of interaction with peers and being in a saturated point of school assignments (meutia, 2020). parents should foster learning and playing of their child proportionally. figure 5. online learning with siblings at home during the pandemic figure 6. parental assistance in online learning from home during the pandemic nibel, h ghmj (global health management journal) 2022, vol. 5, no. 1 20 (a) (b) (a) (b) outdoor playing is different before and after the pandemic. figures 7 show children enjoyed playing out door before the pandemic. giving children the freedom to play outside is likely to overcome their boredom. aliyyah et al. (2020) found play and recreation activities are stress-relief for children and parents. figure 8 shows that during pandemic children play outside the house toned to follow health protocols such as wearing masks, keeping social distance, and staying away from crowd. with health protocols, they can protect themselves and others (tampubolon, 2021). on the weekend, children can be encouraged to do outdoor activities minimal social contact with people to relieve burnout. optimizing child’s physical, mental, social, and cognitive conditions are important. this photo essay suggests that the online learning should be balanced with creative indoor and outdoor activities without violating the health protocols. therefore, children can grow and develop well. references aliyyah, r. r., rachmadtullah, r., samsudin, a., syaodih, e., nurtanto, m., & tambunan, a. r. s. (2020). the perceptions of primary school teachers of online learning during the covid-19 pandemic period: a case study in indonesia. journal of ethnic and cultural studies, 7(2), 90-109. basilaia, g., & kvavadze, d. (2020). transition to online education in schools during a sars-cov-2 coronavirus (covid-19) pandemic in georgia. pedagogical research, 5(4). dewi, w. a. f. (2020) 'the impact of covid-19 on the implementation of online learning in elementary schools', figure 7. children playing and observing out door in river (a) and amusement park (b) with friends before pandemic figure 8. children playing and observing out door solitary in sport (a) and homegarden (b) during pandemic 21 ghmj (global health management journal) 2022, vol. 5, no. 1 nibel, h educative: journal of educational sciences, 2 (1), pp. 55–61. doi: 10.31004 / educative.v2i1.89. ministry of health. (2020). per hari ini pasien covid-19 sembuh terbanyak di dki. link: http://p2p.kemkes.go.id/per-hari-ini-pasien-positif-covid-19-sembuh-terbanyak-ada-di-dki. accessed date: 03-062020. meutia, a. (2020). dampak pandemi covid 19 pada psikis dan ingatan anak (impact of the covid-19 pandemic on children's psyche and memory). elementary school journal pgsd fip unimed, 10(1), 60-66. mukaromah, v.f. (2020). melihat peningkatan kasus covid-19 di indonesia dari bulan ke bulan. https://www.kompas.com/tren/read/2020/09/01/200200165/melihat-peningkatan-kasus-covid-19-di-indonesiadari-bulan-ke-bulan?page=all. accessed date: 10-11-2020. putri, v. m., & eliza, d. (2021). the impact of gadget use on the aspects of early childhood language development during covid-19. international journal of emerging issues in early childhood education, 3(1), 0107. tampubolon, n. m. f. t. (2021). edukasi tentang protokol pencegahan covid-19 kepada anak-anak di lingkungan rumah. jpkm: jurnal pengabdian kepada masyarakat, 1(1). wajdi, m. b. n., kuswandi, i., al faruq, u., zulhijra, z., khairudin, k., & khoiriyah, k. (2020). education policy overcome coronavirus, a study of indonesians. edutec: journal of education and technology, 3(2), 96-106. wiresti, r. d. (2020). analisis dampak work from home pada anak usia dini di masa pandemi covid-19. jurnal obsesi: jurnal pendidikan anak usia dini, 5(1), 641. cite this article as: nibel h. balancing online learning from home for children with outdoor activities during the pandemic. ghmj (global health management journal). 2022; 5(1):16-21. doi:10.35898/ghmj-51593 https://dx.doi.org/10.35898/ghmj-51593 microsoft word 1. accepted editorial, andrew j macnab, 17-18.docx cite this article as macnab aj. knowledge transfer of advances in applied health and science. global health management journal. 2018; 2(2): 17-8. global health management journal www.publications.inschool.id published by editorial issn 2580-9296 (online) knowledge transfer of advances in applied health and science andrew john macnab editor in chief, global health management journal *corresponding author. email: ajmacnab@gmail.com accepted 27 june 2018 © 2018 publications of yayasan aliansi cendekiawan indonesia thailand this is an open access following creative commons license deed – attribution-noncommercial-sharealike 4.0 international (cc by-nc-sa 4.0) advances in applied health and science should be shared. knowledge transfer is possible in many ways – the international conference on applied science and health (icash) events and other conferences are examples, but ultimately the “gold standard” to aim for is publication in a peer reviewed journal. peer review is used to determine an academic paper suitability for publication; such reviews ensure that standards relating to the quality of your work and the way it is reported are maintained, and hence provide credibility for your work. peer review involves evaluation of what you have written by one or more people with expertise in your scientific field, and knowledge of disciplines related to how data are collected and analyzed, and results are presented and conclusions drawn from them. based on such review the editor-in-chief decides whether the work should be accepted as it is, sent back for revisions, or rejected. as most papers can be improved for clarity or accuracy, return with suggestions for revisions is commonplace. it is important to read and respond to the all the suggested revisions carefully; most often, while time consuming this is straightforward to do, however, if you feel strongly that a change should not be made this must be fully explained. peer review has a long history and is by no means a perfect process, but in a world where knowledge transfer makes millions of pages of new information available each day, it is reassuring that at least a significant subset of what is reported has been critically examined [1]. remember also that peer reviewers are experts qualified to perform an impartial review who volunteer their time. it is time consuming to provide a constructive review and the expectation is that any errors noted and suggestions made to improve the paper are attended to. peer review contributes to academic quality and is used in most major scientific journals, but the process does not guarantee that all research published is valid. there are a growing number of journals, particular those who offer rapid open access for a publication fee, where reviews happen too fast or are too shallow for them to promote an acceptable standard of scientific integrity and merit. standards are probably highest where peer reviewers are blinded to the authors’ names and institutional addresses, and remain anonymous, but open peer review is a growing trend, where the comments are visible to authors and readers, and the identities of the peer reviewers are also made available. setting out to write a report is always challenging. the sections conventionally required include an introduction to describe the problem the research is addressing, a description of the methods and population involved, the results which are often summarized in tables or graphs, and a discussion which summarizes what has been found and describes other related research. one way to make sure you provide all the information a reviewer and those who read your paper will want is to collect your ideas under the headings suggested by the respected scientific writer asher [2] – these are drawn from the poem “the elephant’s child” by rudyard kipling: global health management journal, 2018, vol. 2, no. 2 18 i keep six honest serving men (they taught me all i knew): they are what and why and when, and how and where and who. as asher says: “kipling's poem gives an admirable summary of the way we get most of our knowledge. most scientific enquiry is based on these six monosyllables, and the orderly presentation of a scientific paper is helped by trying to answer the six questions they pose”. another interesting way of presenting your ideas for publication is in a photo-essay. an article in this edition of global health management journal (ghmj) describes how to combine a series of images with a brief text, and short reference list to create a visually engaging and informative short report [3]. photo-essay is a novel and informative way to report on an applied health, social or scientific topic, and the concept comes from the discipline of photojournalism that uses images in order to tell a news story. only a small number of journals accept submissions of photoessays, but this format is an excellent one to use for a brief report, or to prepare a research presentation for a scientific meeting. photo-essays can also be used as the basis for progress reports to project supervisors or funding agencies, and are a good format for young investigators to consider. ghmj has a section for photo-essays and welcomes submissions for publications in this format. other articles in this edition of global health management journal include the following: hafizh muhammad noor presents a review of how carrageenans can be used in foods and for medical applications based on their biological activities [4]. these polysaccharides are extracted from certain red seaweeds; they are important as gelling, thickening and stabilizing agents, and advantages of their use include their ready availability and low cost. hoang et. al., report the risks for hiv infection among people who inject drugs in gia lai province in vietnam based on data from a 2014 cross-sectional survey [5]. the prevalence rate in this at risk group was 9.3%. risk factors identified where harm reduction intervention and behavior change communication may be feasible include shared needles, injecting for more than 3 years and sexual intercourse with more than one commercial sex worker per month. astuti and kurniati assessed teenager’s knowledge, attitude, perception, service access, and peer attitudes to lgbt issues with the aim of identifying factors relevant to efforts to prevent stigma towards lgbt individuals [6]. the principal causes of sigma were an individual’s level of knowledge about lgbt and their peer group attitudes; hence, counseling and/or education offer a means to reduce discrimination. pujiyono and budiyanti review issues surrounding selective abortion after preimplantation sex selection in indonesia [7]. their concussion is that it is an ethical, legal issue as well a medical one, and that it is appropriate for legislation to be introduced to guide decision making related to selective abortion after preimplantation sex selection. reading papers such as these, and looking at a wide variety of reports from different journals is the best way to get ideas about good ways to report your research. however you decide to share the advances in applied health and science that you have made, carefully follow the instructions for authors for the journal you have selected when preparing your manuscript. to prepare a good submission it is also important to keep what you write brief and to the point; make sure that you only include material under the headings introduction, methods, results and discussion that is meant to be in that section, and spell check the whole manuscript carefully. then, as an important last step before submission have a mentor or supervisor read through your final version. references 1. spier r. the history of the peer-review process. trends in biotechnology. 2002;20(8):357-8. 2. asher r. six honest serving men for medical writers. jama. 1969;208(1):83-7. 3. macnab aj, mukisa r, stothers l. the use of photoessay to report advances in applied health and science. global health management journal. 2018; 2(2): 44-7. 4. noor hm. potential of carrageenans in foods and medical applications. global health management journal. 2018; 2(2): 32-6. 5. hoang tn, pham dt, thu hnt. sentinel surveillance for hiv among people who inject drugs at gia lai province, vietnam. global health management journal. 2018; 2(2): 25-31. 6. astuti da, kurniati n. factors influencing stigma to lesbian, gay, bisexual and transgender (lgbt) among teenagers at ngaran village, gamping, sleman, indonesia. global health management journal. 2018; 2(2): 19-24. 7. pujiyono, budiyanti rt. selective abortion after preimplantation sex selection: an ethical and legal issue in indonesia. global health management journal. 2018; 2(2): 37-43. microsoft word 6. accepted review, andrew j macnab, 44-47.docx cite this article as macnab aj, mukisa r, stothers l. the use of photo-essay to report advances in applied health and science. global health management journal. 2018; 2(2): 44-7. global health management journal www.publications.inschool.id published by review issn 2580-9296 (online) the use of photo-essay to report advances in applied science and health andrew john macnab 1, ronald mukisa 1, lynn stothers 2 1 stellenbosch institute for advanced study, wallenberg research centre at stellenbosch university, south africa. 2 peter wall institute for advanced study, university of british columbia, vancouver, canada. *corresponding author. email: ajmacnab@gmail.com article info abstract article history: received 13 may 2018 reviewed 08 june 2018 received in revised form 27 june 2018 accepted 29 june 2018 background: in the applied health and science disciples there is an expectation that project work is reported through a publication. the conventional papers written to do this follow a structure that includes sections providing background, methods, results and a discussion or conclusion, supported by figures and tables. sometimes photographs are included, and with more on-line publications the opportunities have increased for these to be available in full color. borrowing from the field of photojournalism photo-essays are now a publication option where a series of images are used to tell the story; these are often related to health and well-being. aims: to summarize the methodology used to effectively combine a series of images with a brief text, and short reference list to create a visually engaging and informative short report. guidelines: images are taken throughout the project with consent obtained from those whose images will be recognisable. creative licence is used to compile representative images into a sequence that conveys the background, method, results and outcome(s) of the project. images need to be of high resolution; editing for light, colour and contrast, and cropping is allowed to increase their clarity and relevance. the ethics of photojournalism apply making inappropriate manipulation of images or erroneous captions unacceptable. conclusion: photo-essays are a novel and informative way to report on an applied health, social or scientific topic. the format is an excellent one to use for a brief report, or to prepare a research presentation for a scientific meeting. keywords: photograph photojournalism photo-manipulation © 2018 publications of yayasan aliansi cendekiawan indonesia thailand this is an open-access following creative commons license deed – attribution-noncommercial-sharealike 4.0 international (cc by-nc-sa 4.0) introduction photo-essay is a novel and informative way to report on an applied health, social or scientific topic. the concept of a photo-essay comes from the discipline of photojournalism, a particular form of journalism that uses images in order to tell a news story [1-3] the central premise is that a picture is “worth a thousand words,” hence by combining an effective photo or a series of photos a story can be told with the minimum of written text as the scene is set by the images, and often the immediate and key message of the story is actually presented through the image [4]. while the term photo-essay is usually understood to refer only to a series of still images and accompanying text, there are various adaptations on this theme, for instance the news stories used in broadcast journalism where video footage is accompanied by a reporter speaking on or off camera [5, 6]. 45 global health management journal, 2018, vol. 2, no. 2 for applied science and health reports to use the medium of photo-essay, a creative format is necessary that is not only informative but is also interesting to follow and which conveys the key elements of the story to the reader. a good model is the one used in journals like the international journal of epidemiology (https://academic.oup.com/ije/pages/instructions_t o_authors), which calls for photo-essays to 10 to 15 images with 200-500 words of accompanying text that relates to health and wellbeing. areas covered by published examples include: global health care delivery concepts [7]; roles of health care providers [8]; epidemiology of illness or injury [9, 10]; intervention to address a specific infectious disease [11], and how who ‘health promoting schools’ provide an environment that can help advance the un sustainable development goals (sdgs) [12]. another style just relies on the graphic content of the images chosen; here a larger number of photos are included, there is no accompanying text or reference list, but again short captions are used to explain each image. an example of this style depicts the care provided for the wounded during the iraq war [13]. the stark reality of this style of essay is at one end of the spectrum while at the other a more artistic style can be used where the photos are accompanied by artistically rendered text captions, along the lines of those in photobooks made using apple software, or on scenic postcards. an example is the report of a digital photographic experiment prepared by archeologists to that combines elements of archaeological ethnography with photography [14]. the purpose of this paper is to outline how an author unfamiliar with this form of publication can construct an effective photo-essay. guidelines during the conduct or evaluation of a project include the taking of digital images as a defined role of one of the team, and have the necessary consent forms prepared in order for those whose images will be recognizable in print to give their informed written consent for the to be used. plan to take images that will be: • interesting and add meaning and context of the topic of the essay. • objective, and a fair and accurate representation of the topic they depict in both content and tone. • complementary to each other and to the written elements of the essay • informative so that they make the facts and message of the essay more accessible and easily understood by the reader beyond this, the creator of a photo-essay has considerable scope to add artistic touches to his or her essay. the rules are few and the canvas broad. in putting the photo-essay together: • write the overview wording that describes the purpose of the essay • select from the pool of images ones that illustrate the narrative • write a caption for each selected image which clearly describes the elements that the image shows which are relevant to the essay topic. when choosing images: • select high resolution images for clarity in print versions of the essay, or when viewed as an on-line publication. • use a photo editing program to optimize contrast and lightness/darkness and crop extraneous detail. • avoid using images that are of poor quality in terms of exposure, focus, white balance or because of distracting content • begin the essay with an image or two that are general in nature to set the scene; these represent the issue the essay intends to portray, much the way the introduction does in a conventional paper. • next add images that relate to specific elements of the purpose of the essay topic; in the way the methods section of a paper does. • follow with close up images of people, devices or situations that show the key elements or effect(s) of the topic or intervention; these are like items presented in the results section of a scientific report. • end with general, outcome or closure images that indicate the end point(s) and relevance of the message of the essay. add appropriate reference to the text and in a conventional reference list: references: • include 10 and 15 to provide a source of background material which expands on the points covered in the essay or to corroborate specific facts, methods or data mentioned in the text. global health management journal, 2018, vol. 2, no. 2 46 • format the references and include them in the text as required by the journal chosen for your report – look at the instructions for authors. • number them in sequence in the text using superscript or inclusion in brackets if the vancouver style is required; this makes the text easier to read than harvard style which requires author names and year of publication in brackets • do not include references in the image captions as a general rule. however in certain circumstances where a particular fact or element of the essay is evident in the image, or include in the caption, that is not included in the accompanying text there is the option to add a reference. consider the ethics of your essay: • a major question for authors and editors relates to photo-manipulation. nowadays, digital images can be edited and even “photo-shopped” to such an extent that elements or individuals can be freely altered, or even deleted or added. ethically, there is no place for this in a conventional photo-essay, where such images are unacceptable. • most pictures are simply manipulated for contrast, color enhancement or to make them lighter or darker, and cropped to make them illustrate clearly the parts of the image relevant to the photo-essay. this form of editing (photo-manipulation) is acceptable. • another ethical issue relates to false or misleading captioning; captions must be accurate and informative and ideally they add wording that compliments and expands on the information provided in the written text. discussion this paper describes guidelines for preparing a photoessay to report on an applied health program or the conduct of a scientific project. only a small number of journals accept submissions of photo-essays, but this format is an excellent one to use for a brief report, or to prepare a research presentation for a scientific meeting. photo-essays can also be used as the basis for progress reports to project supervisors or funding agencies, and are a good format for young investigators to consider. it is important to remember that the images chosen are intended to tell the story, with the accompanying text providing background, methods and selected data that compliments the photographs. a good essay should engage the interest of the reader visually, and allow a rapid grasp of the topic, issue or approach presented. the ability for subject matter to be taken in quickly is important in a world where we have less and less time to read through complete articles and formal reports. also, photo-essays appeal to an audience that is broader than fellow scientists or educators; the lay public can also often learn a lot from a wellconstructed photo-essay. while considerable creative leeway exists in the construct of a photo-essay, as in photojournalism and broadcast journalism it is expected that a code of ethics is followed. this requires that work based on photographic images or video footage must tell the story with pictures that are honest and not inappropriately manipulated. simple photo-essays are readily assembled if a photographic record of sufficient depth and quality has been compiled during the planning, conduct and evaluation phases of a project. but, for those who wish, considerable opportunities exist to be creative in the design and execution of photo-essays. on-line publication in particular lends itself to faithful reproduction of full colour images and video montage in large formats. however, this option for creativity is counterbalanced by the subjective nature of the review process involved in assessing the merit of an image based submission, and its suitability for publication. conclusion the photo-essay format has its origins in photojournalism. applied to report advances in health and science, a series of photographs are used to tell a story or frame a report. the images should be of high quality both in terms of resolution and the impact of the subject matters they depict. to plan and create a photo-essay requires having digital cameras readily available and taking photos throughout the project to assemble the number and variety of photos in the portfolio from which the essay images will be selected. also, consent must be obtained as the images are acquired from those who will be able to be recognized in the published photos. acknowledgements this work was supported by the stellenbosch institute for advanced study (stias) through invitations to ajm and rm, and the peter wall institute for advanced studies (pwias) vancouver, canada through an appointment to ls as a distinguished scholar in residence, which enabled the authors to collaborate on this and related projects. 47 global health management journal, 2018, vol. 2, no. 2 conflict of interests none. references 1. caple h, knox js. online news galleries, photojournalism and the photo essay. visual communication. 2012;11(2):207-36. 2. marn r, roldn j. photo essays and photographs in visual arts-based educational research. international journal of education through art. 2010;6(1):7-23. 3. kobre, k. photojournalism: the professionals’ approach. 1980; somerville, ma: curtin & london, inc. 4. knox js. reporting bloodshed in thai newspapers. communicating conflict: multilingual case studies of the news media. 2008 mar 28:173-202. 5. zelizer, b. ‘journalism through the camera’s eye’ 2005; in allan s. journalism: critical issues: critical issues. mcgraw-hill education (uk). 6. layton, r. editing and news design: how to shape the news in print and online journalism. 2011; palgrave macmillan. 7. stothers l, macnab a. global implementation of advanced urological care: policy implementation research. canadian urological association journal. 2017;11(6):157-60. 8. mukisa r, macnab aj, stothers l. health promotion in low and middle income countries: “youth champions” as agents for change. proceedings of the international conference on applied science and health. 2017;2:6-13. 9. stothers l, mutabazi s, mukisa r, macnab aj. the burden of bladder outlet obstruction in men in rural uganda. international journal of epidemiology. 2016;45(6):1763-1766. 10. curry tj, strauss rh. a little pain never hurt anybody: a photo-essay on the normalization of sport injuries. sociology of sport journal. 1994;11(2):195208. 11. macnab aj. mukisa r, mutabazi s, steed r. malaria in uganda: school-based rapid diagnostic testing and treatment. international journal of epidemiology. 2016; 45(6):1759-1762. 12. macnab aj, mukisa r. the un sustainable development goals; using world health organization’s ‘health promoting schools’ to create change. global health management journal. 2017; 1(1): 23-7. 13. peoples ge, jezior jr, shriver cd. caring for the wounded in iraq—a photo essay. new england journal of medicine. 2004;351(24):2476-80. 14. hamilakis y, anagnostopoulos a, ifantidis f. postcards from the edge of time: archaeology, photography, archaeological ethnography (a photoessay). public archaeology. 2009;8(2-3):283-309. knowledge, attitudes, and hiv/aids risk behaviors of myanmar migrant workers in thailand ghmj (global health management journal) 2022, vol. 5, no. 1 indonesian scholars’ alliance open access photo essay politeknik kesehatan kemenkes palangka raya: health forum and international seminar the new normal : creating a pleasant virtual communication risks nurses faced during the covid-19 pandemic reny sulistyowati* ,1 , yuyun christyanni 1 , dedi cahyo nusantoro 2 1 department of nursing, politeknik kesehatan kemenkes palangka raya 2 doris sylvanus hospital, city of palangka raya *corresponding author’s email: reny_sulis@poltekkes-palangkaraya.ac.id doi: 10.35898/ghmj-51591 selection and peer-review under responsibility of the scientific committee and the editorial board of the annual health forum and international seminar of the politeknik kesehatan kemenkes palangka raya © yayasan aliansi cendekiawan indonesia thailand (indonesian scholars’ alliance). this is an open-access following creative commons license deed attribution-noncommercial-sharealike 4.0 international (cc by-nc-sa 4.0) the world health organization (who) states that covid-19 stands for coronavirus disease, with '19' referring to 2019, the year when the disease was originated (utomo, 2020). covid-19 can also be shortened to 2019 novel coronavirus or 2019-ncov. exposure to covid-19 causes mild to severe respiratory tract disorders and even death. covid-19 spreads quickly among humans and is hard to be managed. indonesia was the country with the 13th highest prevalence of covid-19. active cases consist of people diagnosed with covid-19 who are undergoing treatment and care in the hospital or who are undergoing self-isolation at home (suni, 2021). the indonesian government has made various efforts to contain the spread of covid-19, such as establishing the following policies: (1) staying at home; (2) social distancing; (3) physical distancing; (4) use of personal protective equipment (masks); (5) maintaining personal hygiene (washing hands); (6) working and studying from home; (7) suspending all crowd activities; (8) wide-scale social limitation; and (9) the new normal life (tuwu, 2020). in accordance with these policies, social, cultural, economic, political, and religious activities are carried out at home (harjudin, 2020). figure 1. people enjoying the view on the edge of the kahayan river without wearing masks or keeping their distance mailto:reny_sulis@poltekkes-palangkaraya.ac.id https://dx.doi.org/10.35898/ghmj-51591 7 ghmj (global health management journal) 2022, vol. 5, no. 1 sulistyowati, christyanni, & nusantoro figure 2. figure 2. people doing outdoor activities in palangka raya city park without wearing masks ever since the who officially announced the global outbreak of covid-19 in march 2020, public awareness of implementing health protocols has seemed to decline. some people do not wear masks or keep their distance, even in the crowd. the indonesian community's daily activities, such as relaxing in parks, restaurants, and cafes, were carried out regardless of health protocols. as humans as social creatures, people still have desire for outings after spending office hours at home. extroverted people may have their mood drained because of reduced interactions with other humans and disruption of daily activities, such as sports and business. the lengthy quarantine could inflict stress, anxiety, frustration, boredom, despair, or even suicidal thoughts (gunawan et al., 2020). doing activities without masks is against health protocols; otherwise, people who suffer from covid-19 experience moderate to severe symptoms that require treatment. the mild symptoms include runny nose, sore throat, cough, and fever. an estimated 80% of covid-19 patients can recover without the necessity of special treatment. approximately one in six people may develop serious illnesses gradually, such as pneumonia or difficulty breathing. although the covid-19 fatality rate is low (about 3%), the elderly and those with preexisting medical conditions (such as diabetes, raised blood pressure, and heart disease) are susceptible to becoming seriously ill. moderate symptoms include a fever of or above 38°c, shallow breathing, persistent cough, and sore/raw throat. in children, cough and tachypnea may occur. severe symptoms include persistent fevers (≥38oc); airflow passage infection with signs of an intensifying respiratory frequency (>30 times/minute) and shallow breathing (respiratory distress); cough; decreased consciousness; and oxygen saturation below 90%. the public should abide by health protocols by observing activities in areas with increasing positive cases. to end the covid-19 transmission cycle, the government has issued several rules that everyone must adhere to. the following is documentation of nursing service work in the intensive care unit (icu) for covid-19 patients with severe symptoms. given the main symptoms felt by patients are respiratory disorders, such as shallow breathing and decreased oxygen saturation, it is necessary to provide care in the icu. however, the rising number of sufferers has caused the hospital to be overwhelmed in providing icu slots (hasibuan, 2020). sulistyowati, christyanni, & nusantoro ghmj (global health management journal) 2022, vol. 5, no. 1 8 nurses as healthcare providers play a significant role in realizing the highest degree of community health. the who states that nurses are the backbone of in-service facilities because they are more significant than other health workers. they perform continuous service (24 hours) for the community (hatmanti, 2020). as health workers, they are always at the front row of providing health services during the covid-19 pandemic. much medical personnel, including nurses, have died throughout the pandemic because of several factors. many medical personnel do not realize they are dealing with covid-19 patients, and do not implement health protocols as a result. this usually occurs because patients are not open about their contact and travel history (ihsanuddin, 2020). this situation is worsened by poor personal protective equipment and fatigue due to long working hours. nurses are the frontline medical personnel who serve as the first point of contact in covid-19 treatment (safuni, 2020). figure 1 nurses on duty in the covid-19 icu giving sedatives and analgesics using a syringe pump figure 4. nurses in the covid-19 icu performing cardiac arrest resuscitation on cardiac arrest patients figure 5. nurses in the covid-19 icu applying covid-19 funeral procedures 9 ghmj (global health management journal) 2022, vol. 5, no. 1 sulistyowati, christyanni, & nusantoro taking into account the volume of medical personnel who have contracted covid-19, the who has stated that as many as 5.9 million new nurses are needed worldwide. the who recommends that countries with insufficient nurses need to increase nursing school graduates by about 8% each year (who, 2020). the demand for nurses will undoubtedly increase in countries with an aging population because, even without the deployment of covid-19, the demand for nurses to look after the elderly is high enough. the needs in these countries are met by accepting migrant nurses from several other countries, including indonesia; furthermore, the demand for nurses in indonesia has also increased throughout the pandemic (safuni, 2020). nurses who decide to remain in clinical practice may experience psychosocial consequences. nurses have reported experiencing stress due to being separated from family or loved ones, lack of sleep, and heavy workload leading to the demands of the health system and staff shortages (huang et al., 2020). additionally, ethical and resource issues that arise during the pandemic can negatively impact nurses. the psychological effect is predisposed to have short-term and long-term consequences for nurses. with the experience, they can help identify the causes of stress experienced by patients to help them overcome their problems (fernandez et al., 2020). this study concludes that nurses play a very important role in health services during the covid-19 pandemic. consent all participants have permitted their photographs to be used in the publication of this study. references: fernandez r; lord h; halcomba e; moxham l; middleton r; alananzeh i; ellwood l. 2020. implications for covid-19: a systematic review of nurses’ experiences of working in acute care hospital settings during a respiratory pandemic. gunawan, j., juthamanee, s., & aungsuroch, y. 2020. current mental health issues in the era of covid-19. in asian journal of psychiatry (vol. 51). elsevier. https://doi.org/10.1016/j.ajp.2020.102103 harjudin, l. 2020. dilema penanganan covid-19: antara legitimasi pemerintah dan kepatuhan masyarakat. kesejahteraan dan pelayanan sosial (jkps), 1, 90–97. hasibuan, l. 2020. pasien covid-19 bisa tembus 50 ribu, ri darurat ruang icu! https://www.cnbcindonesia.com/lifestyle/20200424123013-33-154190/pasien-covid-19-bisa-tembus-50ribu-ri-darurat-ruang-icu, accessed: 2020-07-06 hatmanti, n. m. 2020. peran perawat selama pandemi covid-19. https://duta.co/peran-perawat-selamapandemi-covid-19, accessed: 2020-07-06. huang, l., lei, w., xu, f., liu, h., & yu, l. 2020. emotional responses and coping strategies in nurses and nursing students during covid-19 outbreak: a comparative study. plos one, 15(8 august). https://doi.org/10.1371/journal.pone.0237303 ihsanuddin. 2020. gugus tugas: 38 dokter dan 17 perawat meninggal selama pandemi corona. https://nasional.kompas.com/read/2020/05/06/17352511/gugus-tugas-38-dokter-dan-17-perawatmeninggal-selama-pandemi-corona, accessed: 2020-07-06. safuni, n., hidayati, h., & fitriani, n. 2020. manajemen waktu selama pandemi covid 19 pada mahasiswa keperawatan di kotamadya banda aceh. idea nursing journal, 11(1). suni, n. s. p. 2021. tingginya kasus aktif dan angka kematian akibat covid-19 di indonesia. jurnal pusat penelitian badan keahlian dpr ri, xiii, 3. who. 2020. who and partners call for urgent investment in nurses. cite this article as: sulistyowati r, christyanni y, nusantoro dc. risks nurses faced during the covid-19 pandemic. ghmj (global health management journal). 2022; 5(1):06-09. doi:10.35898/ghmj-51591 https://dx.doi.org/10.35898/ghmj-51591 cite this article as riadini ay, suwandono a, runjati. a modified gentle human touch (ght) to increase oxygen saturation levels on low birth weight infants: a study at a private and public hospital in central java, indonesia. global health management journal. 2019; 3(1): 4-7. global health management journal www.publications.inschool.id published by original research article issn 2580-9296 (online) a modified gentle human touch (ght) to increase oxygen saturation levels on low birth weight infants: a study at a private and public hospital in central java, indonesia agi yulia riadini 1,*, agus suwandono 2, runjati 1 1 postgraduate applied science program in midwifery, poltekkes kemenkes semarang, semarang, indonesia. 2 faculty of public health, universitas diponegoro, semarang, indonesia. *corresponding author. email: agiyulia.strkeb@gmail.com article info abstract article history: received 25 august 2018 reviewed 04 september 2018 received in revised form 26 february 2019 accepted 28 february 2019 background: low birth weight (lbw) care in hospitals often causes discomfort and stress which affect changes in physiological function. modification of gentle human touch with the left lateral position is described as a treatment for developmental care that supports the comfort and supportive position of the lungs which is expected to have a positive effect on oxygen saturation and respiratory frequency for infants. aims: this study aimed to find the effect of gentle human touch modification with a left lateral position on oxygen saturation in lbw infants. methods: this study used a quasi-experimental design study. the population in this study was 36 lbw babies who received care, selected at a private and public hospital in central java, indonesia, using a consecutive sampling technique. the infants were then divided equally to: (i) a group who received a standard human touch given at the hospital, with a supine position (control), and (ii) a group where the infants have been provided with a modified gentle human touch with left lateral position (intervention). the statistical test used was mann whitney and wilcoxon test. results: from this study, it is acknowledged that modification gentle human touch with the left lateral position was more effective in increasing oxygen saturation than the control group when viewed from clinical changes. the oxygen saturation levels after intervention reached 98 to 99%. however, from the statistical analysis, it has been noted that the mean difference between the two groups is not significantly different at a level of 0.05. conclusions: a modified gentle human touch with the left lateral position proposed in this study presents a positive contribution to the oxygen saturation of low birth weight infants. thus, the findings may recommend the modification as a procedure in a hospital care unit for low birth weight infants at hospitals or at home. keywords: gentle human touch left lateral position low birth weight babies oxygen saturation © 2019 publications of yayasan aliansi cendekiawan indonesia thailand this is an open-access following creative commons license deed – attribution-noncommercial-sharealike 4.0 international (cc by-nc-sa 4.0) introduction low birth weight (lbw) is one of the complications in infants which contributes to infant mortality. deaths and disabilities in low birth weight and premature infants are caused by the failure of adaptation. after birth, a baby must be able to adapt to survive [1]. medical treatments and technology utilizations are used to improve the survival rate of premature infants and low birth weight babies. nevertheless, those procedures might bring discomfort to the babies and cause changes in their physiological function such as hypothermia, tachycardia, recurrent apnea and low spo2 which lead to the need of oxygen supplementation [2]. the alternative to ease the discomforts aforementioned is through touching, the first sense that was developed at the age of 7 weeks of pregnancy and is the foundation for the development of verbal communication, learning, regulation and social interaction. gentle human touch (ght) is a http://publications.inschool.id/index.php/ghmj/index http://publications.inschool.id/ http://inschool.id/ http://publications.inschool.id/index.php/ghmj/index mailto:agiyulia.strkeb@gmail.com http://inschool.id/ http://creativecommons.org/licenses/by-nc-sa/4.0/ 5 global health management journal, 2019, vol. 3, no. 1 riadini et al. global health management journal. 2019; 3(1):4-7 complementary therapy in the form of non-invasive touch without caressing or massaging that is easily combined with other therapies. ght therapy with the left lateral position is described as a treatment to support the comfort that is expected to have a positive effect on infants’ oxygen saturation and respiratory rate [3]. methods this study used a quasi-experimental design where the procedures have been approved by health research ethics commission of politeknik kesehatan kemenkes semarang (no.401/kepk/poltekkes-smg/ec/2018) on 21 june 2018. the population in this study were all lbw infants who were treated in bhakti asih hospital and brebes general district hospital, a private and a public hospital in brebes district, central java, indonesia. those two hospitals were selected as study sites since we found high lbw babies case. there were 36 lbw babies selected using a consecutive sampling technique by doing inclusion and exclusion until all the patients were recruited, started from 14 july 2019 to 2 august 2019. with inclusion criteria: babies weighing 1500-2500 grams, infants with gestational age ≥ 27 weeks and ≤ 41 weeks, infants with unstable clinical conditions such as respiratory aids, required ventilator to breath or phototherapy, and had a history of heart disease, sepsis, and cyanosis were excluded from the study. the low birth weight babies at the intervention group in this study were given a gentle human touch modification with the left lateral position, while at the control group the infants received a gentle human touch with a supine position. the treatment in both groups has been provided twice a day, in the morning and in the evening with 30 minutes duration in each time in five consecutive days. the treatment was addressed by certified midwives or nurses which had been trained prior to the treatment. modification gentle human touch with left lateral position was as follows: 1. washed both hands and arms with antimicrobial agents 2. the enumerator performs hand containment by placing both hands on both sides of the head, then place the left hand on the top of the head and right on the sole of the foot 3. position the baby with the left lateral position. use a cloth so that the baby is like hugging a pillow. 4. the enumerator placed the fingertips of one hand above the eyebrow line with the palm touching the lbw’s crown while the other hand was rested on the lower abdomen of the infant encompassing the waist and the hip. 5. gentle human touch is done twice in the morning and afternoon for 5 days. an observation sheet was used to record the data collected from the study. measurement of saturation values was done by an oximetry device. the data were analyzed using spss software. to determine the significant changes (mean difference) in oxygen saturation in each group, mann whitney test was used, while to test which groups has more influential, wilcoxon test was employed results characteristics of respondents the characteristics of respondents in this study were distributed based on birth status and gender. the result of the distribution of respondents’ characteristic is displayed on table 1. most of the respondents (75%) were in preterm birth status with the percentage in intervention and control group were 83% and 66.7%, respectively. in gender distribution, there were more male in control group (72.2%) than in intervention group (44.4%). the result of body weight measurement shows that the mean of body weight in intervention and control group were 1894 grams ±268.6 and 2030 grams ±3390, respectively. even at the control group the baby weight (mean ± standard deviation) is slightly higher, however, the difference is not significant (p value = 0.163). table 1. characteristics of lbw infants in brebes general district hospital and bhakti asih hospital (n=36) variables intervention control total birth status, n (%) preterm 15 (83.3) 12 (66.7) 27 (75.0) aterm 3 (16.7) 6 (33.3) 9 (25.0) sex, n (%) male 8 (44.4) 13 (72.2) 21 (58.3) female 10 (55.6) 5 (27.8) 15 (41.7) weight (gram)* 1894 ± 268.6 2030 ± 339.0 gentle human touch increases oxygen saturation in low birth weight infants from table 2, we noticed that the values of oxygen saturation (mean ± sd) at the two groups are increasing over the time. the results shows that the oxygen saturation given at the intervention group where a gentle human touch (ght) at the left lateral position present a significant increase at the day 1 from 96 ± 2.37 to 98 ± 2.31 while at the control group where the standard ght given at a supine position the significant raise was observed at the day 2 from 97 ± 2.07 to 98 ± 1.79. either global health management journal, 2019, vol. 3, no. 1 6 riadini et al. global health management journal. 2019; 3(1):4-7 at control or intervention group, the highest oxygen saturation was noticed at the day 5. table 2. mean and standard deviation of oxygen saturation before and after treatment at the control and intervention group (n=36) observation day oxygen saturation (%) intervention control day 1 a pre test 1 96 ± 2.37 97 ± 2.50 post test 1 98 ± 2.31 97 ± 2.59 day 2 a,b pre test 2 97 ± 2.19 97 ± 2.07 post test 2 98 ± 1.62 98 ± 1.79 day 3 a ,b pre test 3 97 ± 1.97 96 ± 2.39 post test 3 99 ± 1.58 98 ± 2.01 day 4 a pre test 4 97 ± 1.70 97 ± 2.91 post test 4 99 ± 1.72 97 ± 2.74 day 5 a,b pre test 5 98 ± 1.69 97 ± 1.99 post test 5 99 ± 1.08 98 ± 1.97 significantly different between the pre and posttest (p value < 0.05) in the (a) intervention group, and (b) control group. the oxygen saturation by a modified gentle human touch with the left lateral position is slightly higher than the results by the standard touch at the supine position table 3 presents how the different position of touch affects the oxygen saturation among the low birth weight infants. a modified gentle human touch provided to the babies at the intervention group increase the oxygen saturation higher than those in the control group at the observation day 1 until the five days after touching was given. the highest difference (δ) between the two groups was observed at day 1, following with the day 4. however, even the delta reached 1.58, the mean difference of oxygen saturation between the control and intervention group is not significant (p value = 0.851). all the p values indicate that none of the days had the difference mean of oxygen saturation level between intervention group and control group (p>0.05). nevertheless, the data in delta column shows all the positive value which means that the improvements in intervention group were higher than control group. the values in delta column were obtained by subtracted intervention group to control group. table 3. delta (δ) oxygen saturation levels by group observation day oxygen saturation (%) p value* mean ± sd δ day 1 intervention 1.72 ± 1.629 1.58 0.851 control 0.14 ± 1.542 day 2 intervention 1.31 ± 2.289 0.7 0.857 control 0.61 ± 1.119 day 3 intervention 1.56 ± 1.806 0.14 0.642 control 1.42 ± 1.061 day 4 intervention 1.56 ± 1.806 1.25 0.581 control 0.31 ± 1.416 day 5 intervention 1.56 ± 1.773 0.73 0.607 control 0.83 ± 1.465 discussion oxygen saturation is a percentage of hemoglobin that binds in the arteries [4]. oxygen saturation is also an illustration of the flow of oxygen in the body which plays an essential role in optimizing the function of heart and other body organs because oxygen is one of the metabolic fuels [5]. the level of oxygen saturation in newborns is fundamental to know because if the levels of oxygen saturation in newborns are of low value it is worth watching for hemodynamic abnormalities in infants [6]. the factors that influence oxygen saturation including the amount of oxygen entering the lungs (ventilation), diffusion speed and hemoglobin capacity in carrying oxygen [7]. in addition to those factors, some studies also suggested that the position of the baby and stress due to the environment of baby care can also affect oxygen saturation levels in infants [8, 5]. the data in table 2 shows that the oxygen saturation level at the pretest (before ght given) at the control and intervention group was more than 90%. it indicates that no infants experienced hypoxemia during the participation [9]. this study acknowledges that a gentle human touch given to the low birth weight infants either with a supine position (control group) or with left lateral position (intervention group) orchestrates the increment of oxygen saturation level. this finding confirms that both treatment bring improvement to the lbw babies (patients). leading the oxygen saturation to be higher than 92% may deplete the probability of the lbw infants for having pneumonia [10]. research conducted for 6 months in france in premature infants suggested that the left lateral position was effective in improving lung function and could be an 7 global health management journal, 2019, vol. 3, no. 1 riadini et al. global health management journal. 2019; 3(1):4-7 alternative to the position of prone in infants with respiratory system disorders. the left lateral position is the same as the prone position can improve lung function by optimizing the amount of oxygen entering the lungs (ventilation). in this study, infants who were given a left lateral position had an average oxygen saturation level of 95% after the act of positioning the left lateral baby. thoracoabdominal synchronization plays an important role in the efficiency of lung ventilation. the left lateral position of the baby is associated with a more efficient respiratory pattern through chest wall stabilization and increased thoracoabdominal synchronization. thoracoabdominal synchronization makes the babies’ ventilation become optimal, causing the amount of oxygen entering the lungs to be increased [11]. moreover, the gentle human touch itself leads the very preterm hospitalized infant to be relaxed [12]. the results of this present study show that the modified ght at the intervention contributed a greater improvement than the standard ght at the control group, though it was not statistically tested. the result of the comparisson between intervention group and control group as shown on table 3 indicates that there was no significant difference recorded over the time since the first day after treatment to the last day 5. nevertheless, the value of changes in delta coloumn shows that the modified gentle human touch with the left lateral position in intervention group still performed better than the gentle human touch with a supine position in control group. conclusion this study presents the benefits of gentle human touch (ght) in low birth weight babies in increasing the oxygen saturation. the findings found that even not significantly different, a modified gentle human touch with the left lateral position given for 30 minutes 2 times a day within 5 days was more influential on increasing oxygen saturation in lbw infants compared to the standard gentle human touch with supine position. the oxygen saturation of lbw infants has increased by 1% to 2% and is stable at 98-99%. the findings suggest that the modified gentle human touch can be included as an alternative for low birth weight infants to increase the oxygen saturation in the neonatal intensive care unit. conflict of interests no conflict of interests in this study. references 1. kosim ms. gawat darurat neonatus pada persalinan preterm (neonatal emergency care in preterm birth). sari pediatri. 2016;7(4):225-31. 2. vinall j, grunau re. impact of repeated procedural painrelated stress in infants born very preterm. pediatric research. 2014;75(5):584. 3. im h, kim e, cain kc. acute effects of yakson and gentle human touch on the behavioral state of preterm infants. journal of child health care. 2009;13(3):21226. 4. triwijayanti a. studi deskriptif pemberian oksigen dengan head box terhadap peningkatan saturasi oksigen pada neonatus di ruang perinatalogi rsi kendal (descriptive study of supplying oxygen with head box to oxygen saturation on neonate in the neonatal intensive care unit of kendal hospital). fikkes. 2015;8(2):101-8. 5. sulistiyowati e. pengaruh perawatan metode kanguru terhadap stress fisiologis pada bayi berat lahir rendah di rsud sukoharjo (the effects of kangoroo methods to the physiologic stress on low birth weight baby in sukoharjo hospital). surakarta: stikes kusuma husada; 2017. 6. kaunang aw, wilar r, rompis j. perbandingan kadar saturasi oksigen hari pertama dan hari ketiga pada bayi baru lahir (the comparison level of oxygen saturation on baby at the first day and third day after birth). e-clinic. 2015;3(1):397-401. 7. kozier b. fundamentals of nursing: concepts, process and practice: pearson education; 2008. 8. noor m, hasanah o, ginting r. penggunaan nesting dengan fiksasi mampu menjaga stabilitas saturasi oksigen, frekuensi pernafasan, nadi dan suhu pada bayi prematur dengan gawat napas: studi kasus (the uses of a fixed nesting to keep the stability of oxygen saturation, respiration rate, pulse and temperatures of preterm infants with breathing difficulty: case studies). jurnal ners indonesia. 2016;6(1):64-75. 9. fine mj, hough lj, medsger ar, li y-h, ricci em, singer de, et al. the hospital admission decision for patients with community-acquired pneumonia: results from the pneumonia patient outcomes research team cohort study. archives of internal medicine. 1997;157(1):36-44. 10. majumdar sr, eurich dt, gamble j-m, senthilselvan a, marrie tj. oxygen saturations less than 92% are associated with major adverse events in outpatients with pneumonia: a population-based cohort study. clinical infectious diseases. 2011;52(3):325-31. 11. gouna g, rakza t, kuissi e, pennaforte t, mur s, storme l. positioning effects on lung function and breathing pattern in premature newborns. the journal of pediatrics. 2013;162(6):1133-7. e1. 12. smith jr. comforting touch in the very preterm hospitalized infant: an integrative review. advances in neonatal care. 2012;12(6):349-65. indonesian scholars’ alliance ghmj (global health management journal) 2019, vol. 3, no. 2 open access original research ni wayan putri larassita parwangsa*, krisnawati bantas determinants of condom use status among men who have sex with men (msm) group in 5 indonesian cities in 2015 department of epidemiology, faculty of public health, universitas indonesia *corresponding author’s email: larassitaputri9@gmail.com abstract background: significant increase in hiv cases among men who have sex with men (hereafter msm) group during the 2015-2016 period confirmed that sexual behavior is a major risk factor in exposure to hiv & aids with unprotected sexual intercourse as the dominant risk factor. this study aims to identify the determinants of condom use status among msm group in 5 cities in indonesia. methods: this study used a cross sectional design, carried out in 5 cities in indonesia: jakarta, bandung, semarang, surabaya, and denpasar using secondary data from the integrated biological and behavioural survey (ibbs) in 2015. results: variables that are significantly related to the condom use status were marital status, exposure to information on hiv&aids, and knowledge about condoms. the marital status variable has a por value of 1.351 (95% ci or 0.709 âăş 2.576), whilst exposure to hiv&aids information has 1.668 (95% ci or 1.148 âăş 2.422) por value, and knowledge about condoms has por value as much as 1.925 (95% ci or 1.274 âăş 2.907). conclusion: the number of respondents who used condoms consistently for the past one month were 76.1% and those who did not were 23.9%. variables that are significantly related to the behaviour of not using condoms are marital status, exposure to hiv&aids information, and knowledge of condoms. keywords: determinants, behavior, condom, msm, hiv&aids received: 12 march 2019; reviewed: 16 april 2019; revised: 26 april 2019; accepted: 30 june 2019 c©yayasan aliansi cendekiawan indonesia thailand (indonesian scholars’ alliance). this is an open-access following creative commons license deed attribution-noncommercial-sharealike 4.0 international (cc by-nc-sa 4.0) 1. introduction the problem of human immunodeficiency virus (hiv) and acquired immune deficiency syndrome (aids) infections has developed significantly and is increasingly alarming in terms of its quantitative aspect, specifically on high incidence of new hiv&aids infections. based on the data obtained from report on the global summary of the aids epidemic 2014 by unaids [1], until the end of 2014 there were 36.9 million people in the world living with hiv and 2 million people were newly infected with hiv. between 2000 and 2015, new hiv infections had decreased by 35%, and deaths from aids had decreased by 24% with the implementation of prevention efforts around the world. the heterosexual group still being the riskiest group of aids infection cases although it has shown a downward trend after 2013, but among the msm (men who have sex with men) risk group there has been a twofold increase during 2015-2016. in 2014, there were 391 new registered cases. this number increased to 510 cases in 2015. in fact, in 2016, the number of new aids cases caused by msm reached 1,180 cases [2]. hiv infection in msm groups has increased in major cities in asia in the last 15 years. in indonesia, hiv infection in msm groups also experienced a significant increase which can be seen from the trend of increasing hiv prevalence in the biological and behavior integrated survey data since 2007. based on data from the integrated biological and behavior survey (stbp) in 2007, 2011, and 2015 consecutive msm groups infected with hiv experienced a significant increase and increase in 2015. hiv prevalence in msm groups respectively from 2007, 2011 and 2015 was 5.2%, 8.5%, and 25.8% [3, 4, 5]. significant increase among the msm group in this period confirmed that sexual behavior is a major risk factor in exposure to hiv&aids where unprotected sex is the dominant risk factor for hiv&aids. not using sexually active condoms can provide the greatest protection against hiv&aids. 72 ghmj (global health management journal) 2019, vol. 3, no. 2 parwangsa nwpl and bantas k msm are very susceptible to hiv due to unsafe sexual practices, both anal and oral [6]. the risk factors for hiv&aids in msm group were low rate of condom uses, changing sexual partners, as well as anal and oral sex practices [7]. unprotected anal sex (without condoms) in men who have sex with men is a major risk for lgv infection (lymphogranuloma venereum), of which 89% of people with lgv are hiv positive [8]. the use of condoms can prevent hiv transmission effectively by 70% based on a study conducted by palmer et al., 2014. this research is also in accordance with findings from the us national institutes of health and the world health organization (who) which states that condoms are impermeable to against infectious disease pathogens including viruses. this is corroborated by research conducted by (weller, 1996) which states that the effectiveness of condoms in the prevention of viruses and bacteria is 69 94% [9, 10]. msm group who are hiv positive had a history of doing uai (unprotected anal intercourse) or anal sex behavior more often [11]. it causes hiv transmission to spread more easily so that consistent condom use is essential to prevent hiv transmission, especially among msm group. therefore, this research is important to comprehend and identify the determinants of condom use status among msm group in 5 cities in indonesia. 2. method 2.1 study design and sample this study used a cross sectional design and carried out in 5 cities in indonesia: jakarta, bandung, semarang, surabaya, and denpasar using secondary data from the integrated biological and behavioural survey (ibbs) in 2015. population in this study were men who had sex with men living in indonesia while the sample were men aged ≥15 years who had sex with men in the last one year and living in those 5 cities for at least one month and had met the inclusion criteria. the inclusion criteria were as follows: subject is male, aged ≥15 years who had sex with a man over the last one year, willing to be a respondent, and living in 5 cities which were selected as research locations: jakarta, bandung, semarang, surabaya and denpasar for at least one month. in this study there were 1320 interviewed respondents, but the number of respondents who had hiv test results and have complete data were only 1064 people. then, all respondents who were selected in the 2015 ibbs were included and used as samples. the process of our study is shown in figure 1. target population msm in indonesia in 2015 source population msm in indonesian cities in 2015 eligible subject = study entrant msm who fulfilled the inclusion and exclusion criteria and was chosen as the 2015 ibbs respondent 1494 respondents study participants 1064 respondents incomplete data = 430 (28.7%) figure 1. the process of the study the method of data collection is respondent driven sampling (rds), a snowball-based sampling technique based on recruitment quotas (which avoids the recruitment of a whole sample of limited individuals) and multiple incentives to motivate both recruiters and the recruits. rds started from a 73 parwangsa nwpl and bantas k ghmj (global health management journal) 2019, vol. 3, no. 2 small number of purposively selected participants called seed, who are chosen as heterogeneously as possible to ensure that any group member has a high probability of being recruited. selected seeds came from people with diverse characteristics. each seed was asked to recruit 3 other msm until the minimum sample is fulfilled. 2.2 variables this research was conducted by analysing interview data based on questionnaires from the integrated biological and behavioral survey in msm group. in this study, condom use status became the dependent variable, whilst predictor variables consisted of hiv status, age, marital status, knowledge of condoms, exposure to hiv&aids information, history of sexually transmitted disease (hereafter std), and history of injecting drug use. hiv status data were obtained from hiv serological examination, while data of the condom use status were obtained from interviews based on the 2015 ibbs questionnaire on msm group by answering questions about the latest condom use behaviour and on the last one month with non-permanent partners or extended encounters, shemale, or sex workers. (block 6). variables of age and marital status were obtained from direct interviews in accordance with the ibbs questionnaire. knowledge of condoms variable were measured from interview results by answering questions on the use of condoms in preventing hiv transmission, providing that the respondent answers 70% of the total eight questions correctly, he is considered to have good knowledge about condoms and if he can only answer less than 70%, they are considered to have poor knowledge about condoms. the questions used to measure knowledge are 10 questions about hiv & aids, condoms, hiv transmission, hiv & aids prevention with condoms. meanwhile, variable of exposure to hiv&aids information were measured from interview results by answering questions whether respondents had or had not received any information pertaining hiv&aids over the last one year. the stds history were measured using interview results by answering respondent’s history of sexually transmitted infections and its test results before the survey was conducted. last but not least, drugs injection history was measured using interview results by answering whether or not the respondents had previously used injecting drugs for the last one year. 2.3 data analysis acquired data were then analysed using univariate, bivariate, and multivariate methods with logistic regression analysis to assess prevalence odds ratio (por) and processed using spss 20 software. 3. results in this study, it was found that there were 76.1% of respondents who used condoms consistently and 23.9% were not. according to table 1, 25.8% were hiv-positive and 74.2% were hiv-negative. in the marital status of the respondent, majority of respondents were unmarried which accounts to 80.9%, 12.7% have married status, and 6.5% are divorced. it can be seen from table 1 above that respondent with the youngest age range in this study is 15 years old. most respondents were aged 15-45 years with a percentage of 89.8%. respondents who received hiv&aids information from ngos, healthcare workers, and relatives were up to 83.8% and those who did not accounted for 16.2%. in table 1, it can be seen that there were 88.5% of respondents who have good knowledge of condoms and those with poor knowledge were as much as 11.5%. 1.5% of respondents had a history of injecting drug use, while the rest of 98.5% noted to not having injecting drug use. respondents with a history of stds were amounted to 69.9%, whilst 30.1% did not have any stds history. results of bivariate analysis in table 2 above pointed that out of 7 variables, namely hiv status, age, marital status, knowledge of condoms, exposure to hiv&aids information, history of stds, and consumption of injecting drugs, there were 2 variables with significant correlations to the condom use status variable with p value of <0.05. these variables are knowledge of condoms and exposure to hiv&aids information. model candidates in the multivariate model were selected from variables with p value of <0.25 of bivariate analysis and were substantially related to condom use status of not using condoms. 74 ghmj (global health management journal) 2019, vol. 3, no. 2 parwangsa nwpl and bantas k table 1. distribution of determinant variable frequency of condom use status among msm group in 5 cities in indonesia (integrated biological and behavioural survey data 2015) characteristics n % status of condom use yes 810 76.1 no 254 23.9 hiv status positive 386 25.8 negative 1108 74.2 marital status unmarried 1208 80.9 married 189 12.7 divorced 97 6.5 age 15-25 years 333 22.3 26-35 years 714 47.8 36-45 years 294 19.7 >45 years 152 10.2 respondents who received hiv & aids information yes 1242 83.8 no 240 16.2 knowledge of condoms good 1320 88.5 poor 171 11.5 having injecting drug use yes 22 1.5 no 1448 98.5 stds history yes 202 69.9 no 87 30.1 in the final model of multivariate analysis, it was found that variables that are significantly associated with the condom use status were marital status, exposure to information on hiv&aids, and knowledge about condoms. the exposure to hiv&aids information has 1.668 (95% ci or 1.1482.422) por value, and knowledge about condoms has por value as much as 1.925 (95% ci or 1.2742.907). 4. discussion this study used a cross sectional design, causing limitations regarding the principle of temporality. it also employed secondary data so that researchers cannot control the bias at the stage of data collection. therefore, researchers had not been able to control the probability of non-differential misclassification bias. out of 1494 total respondents interviewed, only 1064 were eligible as samples with a participation rate of 71.2%. in the univariate analysis, it was found that out of the total msm sample, a high number was found in respondents who had hiv positive status of 25.8%. in the condom use behaviour variable, 23.9% of respondents did not use condoms consistently. out of those respondents who did not use condoms consistently, there were 24.8% who had hiv positive status. these results indicated high number of respondents who have positive hiv status in non-condom use respondents. variable of exposure to hiv & aids information has por value of 1.668 (95% ci or 1.148 2.422) in this study. result findings indicated that respondents without acquired information on hiv & aids possess condom use status 1.668 times higher than respondents who are info-savvy. hiv prevention information in the form of interventions in the form of hiv testing and free condoms 75 parwangsa nwpl and bantas k ghmj (global health management journal) 2019, vol. 3, no. 2 table 2. bivariate analysis of the determinants of condom use status among msm group in 2015 variables not using condoms using condoms p value por 95% ci n % n % lower upper marital status unmarried 48 18.9 88 10.9 0.293* 1.407 0.412 1.247 married 187 73.6 673 83.1 0.238 0.717 0.745 2.657 divorced 19 7.5 49 6 ref ref respondents who received hiv&aids information no 54 21.5 104 13 0.001* 1.842 1.279 2.653 yes 197 78.5 699 87 ref ref knowledge of condoms poor 43 16.9 76 9.4 0.001* 1.966 1.312 2.944 good 211 83.1 733 90.6 ref ref hiv status positive 63 24.8 232 28.6 0.234* 0.822 0.595 1.135 negative 191 75.2 578 71.4 ref ref having injecting drug use yes 7 2.8 9 1.1 0.069* 2.521 0.929 6.841 no 244 97.2 791 98.9 ref ref stds history yes 38 76 117 67.2 0.239* 1.543 0.749 3.176 no 12 24 57 32.8 ref ref age 15-25 years 55 21.7 167 20.6 0.072* 0.706 0.484 1.031 26-35 years 94 37.2 404 49.9 0.655 1.101 0.723 1.677 36-45 years 62 24.5 171 21.1 0.012 1.875 1.148 3.063 >45 years 42 16.6 68 8.4 ref ref can increase the level of consistency in the behavior of condom use. msm who used condoms at the last anal sex tended to consistently use condoms over the past month, which was influenced by exposure to hiv & aids information and condoms [12]. based on research conducted in china, it was shown that peer information (or = 2,632) and aids counseling (or = 2,347) had a lower risk of unprotected anal intercourse [13]. however, this finding turns out to be different to a research conducted by lia winahyu et. al. [14] who mentioned that the access to hiv & aids information does not have significant correlation to condom use status. information on prevention and transmission of hiv & aids can come from health workers and media such as the mass media, print media and online media. results suggested that consistent condom use status within the past one month was more prevalent in respondents who have a good level of knowledge about condoms that was equal to 83.1% compared to those with poor knowledge on them that was amounted to only 16.9%. knowledge about condoms has a por value of 1.925 (95% ci or 1.274 2.907), meaning that respondents with poor knowledge about condoms tended not to use condoms consistently 1.925 times higher than those with a good knowledge on them. this research findings are in line with [15] which found that respondents with good knowledge of condoms and lubricants will tend to use condoms and lubes consistently at 2.379 times higher than respondents who lack knowledge on them. it is also similar to the research conducted in [16], mentioning that specifically for people living with hiv & aids (plwha), appropriate knowledge about hiv & aids is very helpful in changing the behaviour of plwha in preventing hiv transmission by using condoms. 76 ghmj (global health management journal) 2019, vol. 3, no. 2 parwangsa nwpl and bantas k table 3. final model of multivariate analysis of the determinants of condom use status among msm group in 2015 variables p value por 95% ci lower upper respondents who received hiv&aids information no 0.007 1.668 1.148 2.422 yes ref ref knowledge of condoms poor 0.002 1.925 1.274 2.907 good ref ref a person’s knowledge can be a major determinant of a change in health behavior. the higher a person’s knowledge about health, the more conscious he will be to maintain his health. according to notoatmodjo [17], health behavior will last if it is based on correct knowledge about health. the knowledge of the definition of hiv & aids, modes of transmission, risk of transmission, and prevention methods is very important to know especially for risk groups such as msm. knowledge of hiv & aids prevention in msm groups can reduce risky sexual behavior and condom use as a means of preventing hiv transmission in anal sex. nowadays, msm are divided into 2 groups, namely groups of msm who are still closed groups and msm who have begun to open up and form communities. with the presence of closed msm groups it is difficult to provide intervention to these msm so that the behavior of using condoms is still unknown and uncontrolled. whereas for msm groups who have started to open up and have communities, the government and ngos have intervened through providing information about hiv & aids and condoms. in addition, msm are given assistance in accessing condoms more easily. it is hoped that in the future, the government and ngos will work together in an effort to screen msm groups and hiv screening so that they can capture all msm groups in indonesia. by knowing all the existing msm groups, it is expected that the government will be easier to provide intervention and help in accessing the availability of condoms. 5. conclusion the number of respondents who used condoms consistently for the past one month were 76.1% and those who did not were 23.9%. variables that are significantly related to the behaviour of not using condoms are marital status, exposure to hiv & aids information, and knowledge of condoms. the non-condom using behaviour could be improved through increasing knowledge about condoms and providing information on hiv & aids. therefore, it is expected that counseling and education activities on hiv & aids and condoms will be continuously carried out, especially for the msm groups. acknowledgments the author acknowledges the integrated biological and behavioral surveys (ibbs) program, ministry of health indonesia that approved the request for using the dataset of ibbs 2015. conflict of interest there is no conflict of interest. references 1. united nations program on hiv / aids (unaids). unaids report on the global summary of the aids epidemic 2014. genewa : 2015. 77 parwangsa nwpl and bantas k ghmj (global health management journal) 2019, vol. 3, no. 2 2. ministry of health of indonesia. laporan situasi perkembangan hiv/aids di indonesia (report on the situation of hiv / aids in indonesia). jakarta : 2016 3. mustikawati d, riono p, sutrisna a, siahaan t, bambang a, priyono j. analisis kecenderungan perilaku beresiko terhadap hiv di indonesia (analysis of risk behavior trends in hiv in indonesia: 2007 biological and behavior integrated survey report) jakarta: 2009. 4. ministry of health of the republic of indonesia. survei terpadu biologis dan perilaku (stbp) 2011 (biological and behavior integrated survey 2011) jakarta: 2011. http://www.kebijakanaidsindonesia.net/id/ dokumen-kebijakan/send/20-forum-hpn-kupang/1061-stbp-2011-surveilans-terpadu-biologisdan-perilaku-presentasi-kemenkes (accessed on 15 june 2019). 5. ministry of health of the republic of indonesia. (biological and behavior integrated survey [nonpublication] 2015). jakarta: 2015. 6. directorate general of disease control and environmental health of the ministry of health of the republic of indonesia. laporan perkembangan situasi hiv-aids di indonesia (hiv / aids situation report in indonesia). jakarta: 2017. http://siha.depkes.go.id/portal/files_upload/laporan_hiv_aids_tw_4_ tahun_2017__1_.pdf (accessed on 15 june 2019). 7. fitriani s. promosi kesehatan (health promotion). yogyakarta: graha ilmu; 2011 8. carter m. certain manifestation of stigma especially hurtfull for people with hiv. j aids 2009. 9. weller i. treatment of antiretroviral infections and drugs. important aids guidelines 1996; 3: 49âăş50. 10. unaids. report on the global hiv / aids epidemic: 4th global report. 4th ed. switzerland: 2004. 11. halkitis p, hart t., wolitski r., purcell d., gomez c, the seropositive urban men’s study team. sexual behavior among hiv-positive men who sex with men: what is in a label? the journal of sex research 2003; 40: 179-88. 12. chow e, wilson d, zhang l. patterns of condom use among men who have sex with men in china: a systematic review and meta analysis. aids behav 2012; 16: 653-63. 13. liu, jie, qu bo, ezeakile m, zhang y. factors associated with unprotected anal intercourse among men who have sex with men liaoning province, china. plos one 2012; 7. doi: 10.1371 / journal.pone.0050493. 14. winahyu l, husodo bt, indraswari r. faktor-faktor yang berhubungan dengan perilaku seksual berisiko pada trucker di pelabuhan tanjung emas semarang (factors that are related to risk sexual behavior in trucker in tanjung emas port semarang). jurnal kesehatan masyarakat (e-journal). 2016 nov 2;4(5):330-8. 15. wardhani pk, shaluhiyah z, demartoto a. perilaku penggunaan kondom dan pelicin pada lsl di kota surakarta. the indonesian journal of health promotion (behavior of the use of condoms and lubricants in msm in surakarta city). jurnal promosi kesehatan indonesia 2015; 10: 89-101. 16. priyono jb, syahboedin i, siahaan t, ruslam p, sutrisna a. situasi perilaku berisiko dan prevalensi hiv di tanah papua 2006 (risk behavior and hiv prevalence in tanah papua 2006: sthp results in papua 2006). jakarta: 2007. http://siteresources.worldbank.org/intindonesia/resources/publication/ papuahiv_en.pdf (accessed on 15 june 2019). 17. notoatmodjo s. promosi kesehatan dan ilmu perilaku (promotion of health and behavioral sciences). jakarta: rineka cipta; 2007. http://repository.ui.ac.id/dokumen/lihat/5848.pdf (accessed on 15 june 2019). cite this article as: parwangsa nwpl and bantas k. determinants of condom use status among men who have sex with men (msm) group in 5 indonesian cities in 2015. ghmj (global health management journal). 2019; 3(2): 72-78. 78 http://www.kebijakanaidsindonesia.net/id/dokumen-kebijakan/send/20-forum-hpn-kupang/1061-stbp-2011-surveilans-terpadu-biologis-dan-perilaku-presentasi-kemenkes http://www.kebijakanaidsindonesia.net/id/dokumen-kebijakan/send/20-forum-hpn-kupang/1061-stbp-2011-surveilans-terpadu-biologis-dan-perilaku-presentasi-kemenkes http://www.kebijakanaidsindonesia.net/id/dokumen-kebijakan/send/20-forum-hpn-kupang/1061-stbp-2011-surveilans-terpadu-biologis-dan-perilaku-presentasi-kemenkes http://siha.depkes.go.id/portal/files_upload/laporan_hiv_aids_tw_4_tahun_2017__1_.pdf http://siha.depkes.go.id/portal/files_upload/laporan_hiv_aids_tw_4_tahun_2017__1_.pdf http://siteresources.worldbank.org/intindonesia/resources/publication/papuahiv_en.pdf http://siteresources.worldbank.org/intindonesia/resources/publication/papuahiv_en.pdf http://repository.ui.ac.id/dokumen/lihat/5848.pdf introduction method study design and sample variables data analysis results discussion conclusion indonesian scholars’ alliance ghmj (global health management journal) 2019, vol. 3, no. 2 open access perspectives andrew j macnab teach your children well department of pediatrics, university of british columbia, room c323 4500 oak street, vancouver, bc. canada v6h 3n1 editor-in-chief ghmj (global health management journal) *corresponding author’s email: ajmacnab@gmail.com received: 7 may 2019; reviewed: 13 june 2019; revised: 14 june 2019; accepted: 19 june 2019 c©yayasan aliansi cendekiawan indonesia thailand (indonesian scholars’ alliance). this is an open-access following creative commons license deed attribution-noncommercial-sharealike 4.0 international (cc by-nc-sa 4.0) this perspective looks at the importance of providing parents with the information they need to make informed decisions about their children’s health, and particularly of encouraging parents to teach their children health-related practices that help prevent illness and injury; it is the viewpoint of a grandparent who is also a children’s doctor. in their song ’teach your children well’ crosby, stills, nash and young wrote [1]: "teach your children well... and feed them on your dreams... and know they love you. and you of tender years can’t know the fears that your elders grew by. and so, please help them with your youth. they seek the truth before they can die. teach your parents well... and feed them on your dreams... and know they love you." as in the words of this song, there is universal recognition that a central role for parents is to teach their children. in the animal kingdom the immediate survival of those newly born depends on what they learn from their mothers, and the continued wellbeing of young animals depends on how well they go on to learn from the herd as a whole. yet, among humans, a large proportion of our children worldwide suffer ill health and have poor quality of life because of conditions that could be prevented, even though much valuable prevention can be achieved by health promotion, including where parents pass on essential knowledge and teach their children healthy practices that can benefit them in their daily lives. promoting health involves three main strategies: 1. providing information 2. making use of technology 3. using rules and laws we can look at immunization for examples of such strategies. information is shared by health care providers when we give advice to parents, as well as when we teach children. in the context of immunization, such advice is shared in many ways, including when we deliver well-child preventive care, or are involved in campaigns to promote awareness of the need for and benefits of immunization. the primary aim is to promote health by increasing the number of children in a community who are protected against common childhood infectious diseases. technology is made use of in various ways, e.g. to combine multiple vaccines into one single dose, remove impurities from vaccines and make their administration as painless and problem free 40 ghmj (global health management journal) 2019, vol. 3, no. 2 macnab aj as possible. we also rely on communication technology such as tv and radio to educate and inform parents, and social media are increasingly used as a source of information. rules and laws are made where necessary to enforce health-driven action. examples of legislation include those put in place in the usa during the 2019 measles outbreaks; one required all parents of school age children to either produce proof of immunization against measles or to keep their children home from school, and another ordered unimmunized adults to get immunized within 48 hours or face fines as the situation was classified as a ’state of emergency’. the rationale for legislative action that mandates immunization is the concept known as ’herd immunity’ (hi); also called herd effect or social, community or population immunity, this is a form of indirect protection from infectious disease that occurs when a large percentage of a population is immune to an infection, as this provides an environment where there is a high measure of protection for individuals who are not immune [2]. the term ’herd immunity’ was first used almost 100 years ago but remains the fundamental principle behind today’s immunization programs. hi recognizes the statistical probability that the greater the proportion of individuals in a community who are immune, the smaller the probability becomes that those who are not immune will come into contact with an infectious individual. in a practical sense, when the majority of the ’herd’ are immune, this means that the natural progression of infection from an infected person to someone vulnerable to infection is disrupted, which stops or slows the spread of disease. an example of the problem when the opposite is true and the ’herd’ has low immunity, is that a man infected with measles in new york state in the current us outbreak travelled to the neighbouring state of wisconsin where he is believed to be the source for 41 new cases. there is a large body of literature which shows that immunization programs are the most effective way to prevent infectious diseases on a broad scale. since immunization has become available countless children’s lives and massive amounts of money have been saved by preventing diseases like polio, diphtheria tetanus and smallpox [3, 4], and measles immunization is estimated by who to have saved more than 20 million lives since the year 2000 alone. the global relevance of promotion of vaccination is also emphasized by the central place of immunization in the policies of the world health organization, and the fact that agencies such as the gates foundation consistently list advances in the formulation and availability of agents used to protect children among their top funding priorities. yet recent lessons from the measles outbreak in the usa, and data from who reporting that in the first three months of 2019 the incidence of measles worldwide has tripled compared with the same time last year, indicate that herd immunity has fallen to a low enough level for infection to be able to spread. lower immunization rates mean many more children are now vulnerable, even in countries like the usa and thailand where immunization rates traditionally were high. because measles is one of the most contagious viruses around, the rise in the number of cases may also reflect the increasingly interconnected nature of our world to some degree. but nothing about this virus has changed; it has not mutated to become more infectious or more dangerous, which means the answers to the problem of increased infection rates are entirely human. simply put, rates of child immunization are falling worldwide, leading to a rise in the number of individuals vulnerable to infection, which in turn increases morbidity and mortality from measles, and also from other diseases usually controlled by vaccinations. so, as health care providers, we need to understand the reasons why immunization rates are falling and be looking to find creative solutions we can apply in the communities we live in. as discussed in a recent editorial in this journal, for people in many countries there are important cultural and religious beliefs that influence their decisions about immunization [5]. while this applies to some extent in north america, us parents’ reasons mainly range from fear of possible dangers from vaccines to ambivalence about the need to immunize their children [6]. but whatever the reason, it is easy to have negative feelings towards such parents, but in reality, we must remember that the most fundamental of reasons that drive decision making by parents applies, namely the desire to protect their children. it is important for us to understand that parents in the usa today are from a generation which has had almost no first-hand experience of the ravages that childhood infectious diseases can cause. this also applies to many parents in europe but is probably a surprise to many of you reading this in other countries. another big issue globally is that mis-information about vaccines and immunization is a growing problem, largely because more and more parents choose to rely on their own research 41 macnab aj ghmj (global health management journal) 2019, vol. 3, no. 2 conducted through social media, where, as we all know, the information available ranges from excellent to wrong, with much in between that can be confusing, or in the worst cases is deliberately misleading. a 2015 survey in canada on attitudes toward vaccines indicated more than one in four canadians are hesitant or misinformed about vaccines [7]. this is a clear lesson that we all need to be part of the promotion of preventive health when it comes to immunization, and in particular must take every opportunity to provide parents who do not know the benefits with the facts they need and answers to questions they need answered. most countries provide recommendations and a schedule for childhood immunizations these are updated regularly and so we need to be aware of what our national immunization schedules for children are. but, in spite of vaccines being readily available in most parts of the world and generally accepted as safe and effective in preventing disease, debate continues about their necessity, efficacy, and safety. it has also been identified that reluctance to immunize in the usa and europe is occurring as part of a growing lack of trust in health care professionals; this lack of trust is seen as a consequence of parents turning more and more these days to social media as their resource of choice for health care decision making. so how should we go about discussing these issues with parents? several national and international agencies provide useful recommendations including the us center for disease control (cdc) [8, 9]; issues to consider include: 1. the general benefits of immunization 2. the specific benefits of an individual vaccine 3. an honest assessment of the general effects and potential risks associated with any vaccine 4. an evidence-based description of risks of the disease the vaccine prevents against including complications 5. an objective and non-judgemental review of possible consequences of refusing the vaccine 6. a summary of the recommendations from government and local health authorities about the vaccine 7. details of any follow up required and if the immunization requires a series of further doses 8. simple measures that can be used to make the process of immunization as painless and problem free for the child as possible. for example, giving a dose of pain killer / anti-inflammatory medication at the time the injection is given. 9. information about signs or symptoms of common side effects and complications, and what to do if these signs/symptoms occur. we must always remember the ethics of health promotion, especially where immunization is concerned. ethical questions play an increasingly part these days in our dealings with patients and especially where we are giving advice to parents about the health of their children. of course, our approach and advice are intended to be the best for those we care for, but we must understand that what we are presenting to parents is our own point of view, and that some parents may have strong views of their own, even if these are based more on personal experience, traditional beliefs or local opinion than the scientific evidence that we rely on as the basis for our advice. there is always an ethical question around how we weight the negative effects of parents not following advice. as in the cdc guidelines, we must be honest, used an evidenced-based approach and be objective and non-judgemental in what we say, but that does not require us to understate risks of a bad outcome for an unimmunized child. with measles, children can die from associated pneumonia or be left brain damaged by encephalitis. we must avoid blame and guilt but do have a responsibility to weight what we say so that individual parents understand clearly that there are potential risks and consequences if they do not follow advice and government recommendations and policies. when thinking about the ethics of immunization i am always reminded about how far we have come in respecting the rights of those that we care for, and ensuring that that they are fully informed about the benefits and risks of care we offer. also, that today we increasingly rely on the ethics committees at institutions such as our universities and hospitals to provide guidance and rules for us to follow, especially when we involve families in research. in this context i wonder how many of you have thought about the ethics of what dr. jenner did when he set out to prove the benefits of vaccination 42 ghmj (global health management journal) 2019, vol. 3, no. 2 macnab aj against smallpox? jenner practiced medicine, and had observed like many others that young women who had become infected with cowpox from their cows they milked were protected against smallpox. his hypothesis was that cowpox not only protected against smallpox but also could be transmitted from one person to another as a deliberate mechanism of protection. to test this, he found a young dairymaid with fresh cowpox lesions on her hands, and inoculated matter from these lesions into an 8-year-old boy he knew in the village where he lived. history does not tell us what he told the boy’s parents! the boy became unwell, but mildly so with developed mild fever, loss of appetite and discomfort from swelling in the axillae, and soon was much better. later, jenner inoculated the boy again, but this time used matter from a patient with active smallpox... (let’s not lose sight of how unlikely it would be today that an ethics committee would allow such an experiment with an infection that at the time was frequently fatal). however, as history records, the boy did not develop smallpox and so jenner in this single case has proven his hypothesis. in a short paper submitted to the royal society jenner presented his findings and conclusion that protection was complete. interestingly his paper was not accepted for publication, not on ethical grounds but probably because it was a single case report; also, jenner was not in fact the first to suggest that infection with cowpox provided immunity to smallpox nor the first to attempt cowpox inoculation for this purpose. however. but with more data jenner did publish his work and it is of course now regarded as the foundation for modern concepts of immunization [10]. i like to remember that there are other modern concepts about infection that most parents are happy to learn about. i talk to all parents about two of them, and use them to help parents who are reluctant to consider immunization to help develop an understanding about common infections; both how they happen and how they can be prevented. these concepts are: 1. the importance of hand washing, and, 2. the benefits of keeping teeth clean. we all know hand washing is important as infections from smallpox to the common cold are spread by hands contaminated from contact with others who are infected, or by handling a range of infected materials including coins and bank notes; and that personal hygiene is so important to reduce transmission of gastrointestinal diseases from one person to another, especially where use of the toilet is followed by food handling. do you remember to explain why soap and water work? parent and children who know why something works are far more likely to follow the advice you give than ones you just tell what to do. all soaps contain ’surfactants’ that break down the protective layer on the surface of bacteria that they rely on survive; adding water then removes them from the hands. a good example of how handwashing can be promoted among school children was reported by zhang; soap and a simple means of handwashing was made available for children in africa to use after they had been to the toilet, the incidence of handwashing increased and the number of those reporting stomach pains was reduced; this methodology can be widely applied [11]. parents and children know less about the importance of good oral health. dental caries and periodontal disease have a worldwide impact on the health of children, and there is an association between bad oral health and a growing number of significant systemic conditions that manifest later in life; these include adverse pregnancy outcomes, cardiovascular disease, stroke, and type 2 diabetes [12]. caries is regarded as the commonest preventable infectious disease affecting children, and periodontal diseases are estimated to affect up to 90% of the world’s population [13]. the mechanisms that explains why this happens is that caries develop when tooth surfaces are damaged by acids produced when bacteria present in the mouth ferment carbohydrates and food debris. periodontal disease involves chronic gum inflammation (gingivitis) which is also associated with the excessive growth of bacteria; these are what cause the breath to smell bad, but they also produce vasoactive agents called cytokines that over time damage blood vessels in the body and lead to systemic disease. importantly, prevention is simple as tooth brushing removes food particles that allow bacteria to multiply, and less acid is produced in the mouth, so gingivitis from the formation of deposits of bacteria-containing plaque under the gums is much less, and cavity formation from weakened tooth enamel is reduced. the tooth sticks used in many cultures to clean teeth can be just as effective as tooth brushes; but both should be used after meals and especially before going to bed to clean the teeth. 43 macnab aj ghmj (global health management journal) 2019, vol. 3, no. 2 reminding parents about these two health promotion strategies and encouraging them to teach their children good habits around hand hygiene and oral health as part of a daily living, is simple and yet very important and constructive way to promote child health. importantly washing their hands and cleaning their teeth are two elements that enable children to contribute independently to their own health and wellbeing. those in developing countries and from disadvantaged populations suffer disproportionately from the consequences of poor hand and oral hygiene, yet much of the primary disease and secondary pathology is preventable by simple and inexpensive measures that children can readily learn. for this reason, this perspective emphasizes why we must always give parents the information they need to help their children be healthy and say to them, "teach your children well." references 1. crosby, stills, nash, young. teach your children well. https://www.cs.ubc.ca/~davet/music/track/ powertrk_075/powertrk_075-12.html 2. fine p, eames k, heymann dl. herd immunity. clinical infectious diseases. 2011; 52(7):911-16 doi:10.1093/cid/cir007. pmid 21427399. 3. andre fe, booy r, bock hl, clemens j, datta sk, john tj, lee bw, lolekha s, peltola h, ruff ta, santosham m. vaccination greatly reduces disease, disability, death and inequity worldwide. bulletin of the world health organization. 2008;86:140-6. 4. worboys m. vaccines: conquering untreatable diseases. brit med j. 2007;334 (suppl 1):s19. 5. sinaga dm. vaccination: considerations to acceptance and refusal. global health management journal. 2018;2(1):1-3 6. dube, e.; laberge, c.; guay, m.; bramadat, p.; roy, r.; bettinger, j. (august 2013). vaccine hesitancy: an overview. human vaccines & immunotherapeutics. 2013. 9;(8): 1763-73. 7. payne e. survey raises concern about vaccine ’hesitancy’ among canadian parents, shows some harbour misinformation. national post [internet]. 2015 dec 18. available from:http://news.nationalpost.com/ health/survey-raises-concern-about-vaccine-hesitancy-among-canadian-parents-shows-someharbour-misinformation 8. cdc. talking to parents about infant vaccines. (2018) https://www.cdc.gov/vaccines/hcp/ conversations/talking-with-parents.html 9. leask j, kinnersley p, jackson c, cheater f, bedford h, rowles g. communicating with parents about vaccination: a framework for health professionals. bmc pediatrics. 2012;12(1):154. 10. riedel s. edward jenner and the history of smallpox and vaccination. proc baylor univ med cent. 2005;18(1):21-25. 11. zhang c, mosa aj, hayward as, matthews sa. promoting clean hands among children in uganda: a school-based intervention using ’tippy-taps’. public health. 2013;127(6):586. 12. macnab aj. children’s oral health: the opportunity for improvement using the who health promoting school model. advances in public health. vol. 2015, article id 651836, 6 pages, doi:10.1155/2015/651836 13. philstrom b, michalowic bs, johnson nw. periodontal diseases. lancet. 2005;366:1809-1820. cite this article as: macnab aj. teach your children well. ghmj (global health management journal). 2019; 3(2): 40-44. 44 https://www.cs.ubc.ca/~davet/music/track/powertrk_075/powertrk_075-12.html https://www.cs.ubc.ca/~davet/music/track/powertrk_075/powertrk_075-12.html http://news.nationalpost.com/health/survey-raises-concern-about-vaccine-hesitancy-among-canadian-parents-shows-some-harbour-misinformation http://news.nationalpost.com/health/survey-raises-concern-about-vaccine-hesitancy-among-canadian-parents-shows-some-harbour-misinformation http://news.nationalpost.com/health/survey-raises-concern-about-vaccine-hesitancy-among-canadian-parents-shows-some-harbour-misinformation https://www.cdc.gov/vaccines/hcp/conversations/talking-with-parents.html https://www.cdc.gov/vaccines/hcp/conversations/talking-with-parents.html cite this article as andriany a, tahir t, sjattar el, ake j, nuru h. wound healing angiogenesis: a perspective of nurse. global health management journal. 2019; 3(1): 1-3. global health management journal www.publications.inschool.id published by perspectives issn 2580-9296 (online) wound healing angiogenesis: a perspective of nurse alia andriany 1,*, takdir tahir 1, elly lilianty sjattar 1, julianus ake 2, hasanuddin nuru 3 1 department of nursing, medical faculty, hasanuddin university, indonesia. 2 department of nursing, graha edukasi makassar institute of health science, indonesia. 3 department of education and development, makassar city hospital, makassar, indonesia. *corresponding author. email: ns.aliaandriany2@gmail.com received 08 january 2019; reviewed 19 january 2019; received in revised form 25 february 2019; accepted 28 february 2019 © 2019 publications of yayasan aliansi cendekiawan indonesia thailand this is an open-access following creative commons license deed – attribution-noncommercial-sharealike 4.0 international (cc by-nc-sa 4.0) introduction wounds healing can be a clinical challenge, and a cause of morbidity and mortality. one aspect of wound repair that plays an important role for adequate healing is the creation of new blood vessels from pre-existing vessels; this process is called angiogenesis. clinically, new capillaries first become visible in the wound bed 3 – 5 days after injury, and their appearance is synonymous with granulation tissue, which acts as a matrix for proliferating blood vessels, migrating fibroblasts and new collagen. impaired granulation is a hallmark of chronic wounds, as encountered in patients with type 2diabetes and venous or arterial insufficiency [1]. a number of researchers have reported, chronic nonhealing wounds are impacted by insufficient angiogenesis; decreased vascularity and capillary density delay wound closure. this perspective describes the principles of wound healing angiogenesis, especially to the wound nurse specialist, in order to identify the impact and interventions that may promote wound repair. through this perspective, nurse specialists are expected to understand the concept of angiogenesis comprehensively. clinical nurses with good insight of angiogenesis must be able to select the appropriate dress which suitable for wound healing. utilizing modern bandage in acute and chronic wound management will accelerate the formation of growth factors that induce angiogenesis, and production of blood vessels. the role of angiogenesis in wound healing the process of angiogenesis provides oxygen required for wound repair. it plays a central role in wound healing by forming new blood vessels from pre-existing ones, as it promotes the growth of new capillaries to form granulation tissue. about three to five days after tissue injury, new capillaries become visible in the wound bed as granulation tissue, which acts as a matrix for proliferating blood vessels, migrating fibroblasts and new collagen. proliferating capillaries bring oxygen, cells, and micronutrients to growing tissue and eliminate catabolic waste products. during angiogenesis and proliferation excess cells either leave the wound or undergo apoptosis, and neovessels undergo regression, leaving mostly collagen and extracellular matrix (ecm) proteins in the wound. during this process, the ecm is broken down by matrix metalloproteinase (mmps) and metalloproteinase tissue inhibitors (timps) the type iii collagen was deposited during the proliferation phase is degraded and was replaced with stronger, thicker, and more permanent type i collagen forming the final scar [2, 3]. physiological control of angiogenesis the basic physiological processes involved in angiogenesis during wound healing are also seen in several female reproductive organs, including the ovary, endometrial lining of the uterus, and placenta. the vessels produced during this form of non-pathologic angiogenesis are characterized by their refinement, integrity, and ability to deliver nutrients to tissues in a controlled manner [4]. the production of angiogenic growth factors is regulated by genes expressed in response to hypoxia and inflammation, such as hypoxia inducible factor (hif) and cyclooxygenase-2 (cox-2). these factors are stored in platelets and inflammatory cells that circulate in the bloodstream, and are sequestered within the ecm. http://publications.inschool.id/index.php/ghmj/index http://publications.inschool.id/ http://inschool.id/ http://publications.inschool.id/index.php/ghmj/index http://inschool.id/ http://creativecommons.org/licenses/by-nc-sa/4.0/ 2 global health management journal, 2019, vol. 3, no. 1 andriany et al. global health management journal. 2019; 3(1):1-3 conversely, angiogenesis inhibitor factors suppress blood vessel growth. vascular growth is suppressed when there is a physiological balance between angiogenesis stimulators and inhibitors. during tumor growth, an “angiogenic switch” is always activated and remained on. angiogenesis regulating factors in wound healing wound healing is a natural physiological reaction to tissue injury; successful wound healing depends upon angiogenesis. the cascade of healing is divided into four overlapping phases: hemostatic, inflammatory, proliferative, and a remodeling stage. although, granulation is assigned to the proliferative stage, the growth of new blood vessels is initiated immediately after wounding occurs and is mediated throughout the entire wound healing process. a number of factors regulate wound angiogenesis including inflammation, growth factors, and hypoxia. inflammation the inflammatory phase is characterized by an influx of inflammatory cells and increased pro-angiogenic factor molecules in the wound. the level of angiogenesis in wounds often correlates with the inflammatory response, largely because inflammatory cells produce an abundance of proangiogenic factors. tissue injury leads to a rapid acute inflammatory response designed to clear microbes, dying cells, and debris. a high level of proangiogenic factors produced by stimulated macrophages and keratinocytes, and at least a part of the wound angiogenic response lies downstream of inflammation. thus, inflammation and the angiogenic response seem to be linked in the healing wound [5]. growth factors the angiogenic process involves growth factor activation of endothelial cells, leading to proliferation, migration, tubular morphogenesis, vascular loop formation, and stabilization of vessels to form a mature vascular network. the term growth factor refers to a broad family of proteins that promote cell proliferation and migration. at least 20 growth factors that stimulate angiogenesis have been identified, sequenced, and been cloned. among these are vascular endothelial growth factor, platelet derived growth factor, fibroblast growth factors, and transforming growth factors. one day after wounding, pdgf expression is detected on the vascular endothelium of injured skin. at day 5, basic fgf is expressed at its peak levels, which, by day 7 returns to baseline levels [6]. tgf-β stimulates the formation of granulation tissue by acting as a chemoattractant for neutrophils, macrophages and fibroblasts. hence, tgfβ is an important modulator of angiogenesis during wound healing by regulating cell proliferation, migration, capillary tube formation and deposition of ecm. vascular endothelial growth factor (vegf) is a potent vascular endothelial cell-specific mitogen that activates endothelial cell proliferation, microvascular permeability and regulates of several endothelial integrin receptors during sprouting of new blood [5]. vegf stimulates angiogenesis by inducing cell proliferation and vascular hyper permeability, and by promoting vascular survival. hypoxia hypoxia is an important driving force for angiogenesis process; in response, the damaged capillaries experiencing hypoxia show increased, abnormal expression of hypoxia-inducible factor-1 (hif-1) transcription factor. hif-1 is a transcriptional activator that promotes angiogenesis by upregulating target genes such as vegf-a, the main isoform in the wound, binds to its receptors on endothelial cells, directing vessel growth. vegf and other pro-angiogenic factors guide vascular growth to areas of low oxygen starting from the wound periphery into the wound bed [7]. this hypoxic gradient can also affect stromal cell function, as the proliferation of human dermal fibroblasts is greatly enhanced under acute hypoxia. fibroblasts were found to secrete up to nine times more transforming growth factorβ1 (tgf-β1) when exposed to hypoxic conditions, which demonstrates this increased activity. acute hypoxia thus induces a temporary increase in cellular replication and contributes to initiation of the healing process [8]. however, healing is defective where oxygenation is not sufficient. wound healing is triggered by temporary hypoxia after injury, however, prolonged or chronic hypoxia will impair the wound healing [9]. impaired angiogenesis in delayed wound healing imperfect angiogenesis is evident in all chronic wounds, such as diabetic ulcers, venous insufficiency ulcers and ischemic ulcers, and contributes to further tissue damage from chronic hypoxia and impaired micronutrient delivery. diabetic wounds, impacted by insufficient angiogenesis, show decreased vascularity and capillary density. wound closure is greatly delayed in diabetes, and chronic non-healing wounds are common [7]. venous insufficiency ulcers or venous stasis ulcers result from incompetent valves in lower extremity veins, leading to venous stasis and hypertension that makes the skin susceptible to ulceration. peripheral arterial disease (pad) may result in severe ischemia. konya, et al (2014) reported tissue hypoxia should initiate angiogenesis via inducing an hif-1α and angiogenic growth factors [10]. in patients with pad, serum levels of hepatocyte growth factor are elevated, as compared to normal subjects [10]. in contrast, a high level of angiogenesis has been 3 global health management journal, 2019, vol. 3, no. 1 andriany et al. global health management journal. 2019; 3(1):1-3 described in the formation of keloids, a particularly vigorous type of skin scarring. this idea is supported by clinical studies that have demonstrated that hypertrophic scar formation is linked to increased microvascular content. however, the mechanism by which excessive angiogenesis influences abnormal scarring, fibrosis and fibroblasts is currently unknown. conclusion angiogenesis is one of fundamental process during wound healing and hysto-integration of biomaterials. hypoxia, inflammation and growth factors have been known as angiogenic regulating factors. prolonged healing may occur in diseases such as diabetes, which characterized by a prolonged inflammatory phase and exhibit inadequate angiogenesis leading to the development of a chronic wounds, which is presented a significant health and economic burden to millions of individuals worldwide conflict of interests authors declared there is no conflict of interests. references 1. honnegowda t, kumar p, udupa e, kumar s, kumar u, rao p. role of angiogenesis and angiogenic factors in acute and chronic wound healing. plastic and aesthetic research. 2015;2(5):243-9. 2. ridiandries a, tan jtm, bursill c. the role of chemokines in wound healing. international journal of molecular sciences. 2018;19(3217):1-20. 3. xue m, jackson cj. extracellular matrix reorganization during wound healing and its impact on abnormal scarring. advances in wound care. 2015;4(3):119-36. 4. hanahan d, weinberg ra. hallmarks of cancer: the next generation. cell. 2011;144(5):646-74. 5. dipietro la. angiogenesis and wound repair: when enough is enough. journal of leukocyte biology. 2016;100(5):979-84. 6. li ww, tsakayannis d, li vw. angiogenesis: a control point for normal and delayed wound healing. contemp surg. 2003;1(2):5-11. 7. okonkwo u, dipietro l. diabetes and wound angiogenesis. international journal of molecular sciences. 2017;18(7):1419. 8. hong wx, hu ms, esquivel m, liang gy, rennert rc, mcardle a, et al. the role of hypoxia-inducible factor in wound healing. advances in wound care. 2014;3(5):3909. 9. guo s, dipietro la. factors affecting wound healing. journal of dental research. 2010;89(3):219-29. 10. konya h, miuchi m, satani k, matsutani s, tsunoda t, yano y, et al. hepatocyte growth factor, a biomarker of macroangiopathy in diabetes mellitus. world journal of diabetes. 2014;5(5):678-88. microsoft word 4. accepted original, wiworo haryani. 13-16.docx cite this article as haryani w, indahsari r, sutrisno. the relationship between levels of knowledge and interest in using the partial dentures: a case at yogyakarta’s private dental clinic, indonesia. global health management journal. 2018; 2(1): 13-16. global health management journal www.publications.inschool.id published by original research article issn 2580-9296 (online) the relationship between levels of knowledge and interest in using the partial dentures: a case at yogyakarta’s private dental clinic, indonesia wiworo haryani *, rachma indahsari, sutrisno department of dental nursing, poltekkes kemenkes yogyakarta, jl. kyai mojo no.56 pingit, yogyakarta, indonesia. *corresponding author. email: haryaniwiworo@gmail.com article info abstract article history: received 27 january 2018 reviewed 06 february 2018 received in revised form 24 february 2018 accepted 28 february 2018 background: missing or lost teeth after tooth extraction may lead to tooth decay and infection. many cases of tooth loss will not be followed with prosthodontics or rehabilitative treatments. patients might be aware of partial denture, however no concern to replace the missing teeth. aims: this study was to determine the relationship between the levels of knowledge and interest in using the partial dentures. methods: this study was an observational analytic survey with cross sectional design, conducted in october november 2017. the work involved 60 patients who had pulled teeth at kanina dental clinic, yogyakarta, indonesia, who had been selected using purposive sampling technique. levels of knowledge and interest among the participants were assessed by a set of questionnaire. the data obtained was then analysed using kendall's tau test. results: from the study, we found that 35 respondents had good knowledge and high interest to use partial dentures (58.3%), while the other 22 patients (40%) had been noted with less knowledge and poor maintenance. from kendall's tau test, we found a significant relationship between the patient's knowledge and partial removal denture maintenance of p value = 0.003. this study also highlights the role of patients’ peer to their decision to use the removable partial dentures. conclusion: respondents may consider loosing teeth affected to their physical aesthetics, masticatory system, and speaking comfort. data shows the higher knowledge to the benefits of partial dentures the higher their interest in using removable partial dentures after tooth extraction. keywords: knowledge interest use of partial dentures © 2018 publications of yayasan aliansi cendekiawan indonesia thailand this is an open access following creative commons license deed – attribution-noncommercial-sharealike 4.0 international (cc by-nc-sa 4.0) introduction based on the result of the primary health care survey (riskesdas) in 2013, revealed that the number of dental caries (tooth decay or cavity) was 67.2%, and increased into 72.3% in next survey. it’s said that the index to assess the status of oral and dental health in terms of permanent dental caries or decay missing filled-teeth (dmf-t index) in indonesia was only 4.6%. only 31.1% cases received treatment from medical personnel in dental practice, while the rest of 68.9% did not undergo any treatment. it is estimated from this data that there will be an increasing prevalence due to the decreasing of people’s awareness to rather keep their teeth instead of having it extracted [1]. missing tooth can be attributed to tooth extraction as a result of tooth decay (hollow tooth, broken tooth, global health management journal, 2018, vol. 2, no. 1 14 cracked tooth), and tooth infection [2]. the results of national health survey in the last 10 years showed that 60-70% of dental health prevalence in indonesia considered in poor level which led to the increase of teeth decay or even toothless condition for permanent teeth [1]. based on data of dental and oral health visits in sleman district, permanent tooth extraction cases increased from 6,219 in 2013 to 6,968 cases in 2014 [3]. people tend to choose tooth extraction to avoid or end the prolonged pain, and also due to consideration that tooth extraction is more practical, even though those teeth still actually can be maintained [4]. loosing tooth after tooth extraction is considered as the biggest problem. some side effects from tooth extraction can be in form of chewing problem or mastication, for the case of missing a great number of teeth and in a long period of time, there will be what-so-called temporomandibular joint (tmj) disorder. impacts on health include jaw pain, sore around the ear, difficulty chewing, facial pain, difficulty moving the jaw, headache, biting discomfort and uneven bite due to premature contact on one or more teeth. the later will lead to some further problems of speaking function and psychological aspects like aesthetics, in which event in some certain professions required very excellence dental health. many cases of tooth missing or removal were not balanced with or followed by prosthodontic or rehabilitative treatments. the average patients in dental police of godean 2, sleman, yogyakarta, have tooth loss of 2 to 5 teeth. and as many as 60% of patients have not or do not use denture [5]. dental rehabilitation is one of recovery efforts or restorations of dental function to shape back the teeth original state [6]. when individuals who loss a tooth visits a dentist, they may have three options; (1) not having replacement for the missing teeth, (2) pairing artificial tooth (dental implant), and (3) consider removable partial denture [7]. not only reducing physical aesthetics, missing teeth will also result in some problems of chewing and the intake of nutrients which will ultimately affect individual’s general health condition and his or her quality of life [8, 9]. in this level, there is a need to increase people’s awareness about the importance of restoring the teeth function after dental extraction and dental implant. moreover, it requires further explanation or information about some possibilities that likely be occurred due to dental implant (artificial teeth). it turns out that the causing factor why people tend to choose tooth extraction and dental implant is due to their lack of knowledge [10]. six levels of knowledge including knowledge, comprehension, application, analysis, synthesis, and evaluation, will direct individuals to determine their behavior to make efforts in order to reduce the risk of the threat of health problems [11]. education may define the knowledge which finally results in a good attitude towards health and can maintain dental health [12]. what mothers taught to their children will also influence their children’s dental health [13]. moreover, previous study also found how gender [14] and age [15] role oral health behavior. those two factors will also be observed in defining patients’ knowledge and interests in using partial dentures after tooth extraction. our preliminary result on the study site found that among the patients who removed their tooth only around 40% implanted artificial tooth, and the other 60% had not used the removable partial denture. those who did not use tooth implant experienced antagonist tooth extended to the tipping space (post-extraction hollow space in tooth). this study will gain information and experience about dental and mouth health related to their interest in using the dental implant (artificial teeth as removable partial denture). methods this study employed an observational analytic survey from october to november 2017. data was collected by cross sectional design where no treatment offered. a total of 60 patients who had tooth extraction was selected purposively from kanina dental clinic, a yogyakarta’s private dental clinic of indonesia, with following inclusive criteria; aged 45-59 years, tooth loss of 1 to 5 teeth, not using artificial teeth, cooperative, and willing to be respondents. all procedures in this study have been approved by ethic commission of politeknik kesehatan kemenkes yogyakarta on 19 september 2017 following the 1975 helsinki declaration, with number lb.01.01/ke01/xli/827/2017. respondents’ answers to a set of questionnaire consisted of 15 questions were score to define their knowledge (good, 15-11; sufficient, 10-6; poor, ≤ 5) and interest in using the partial dentures (high, 15-11; adequate, 10-6; low, ≤ 5). validity and reliability tests to the offered questions show the measurement tool used in this study was valid, with the p value was less than 0.005 for both validity and reliability test. the cronbach alpha value 0.930> 0.700 supports the 15 global health management journal, 2018, vol. 2, no. 1 questions given to the respondents were valid and reliable. data was then analyzed using kendall’s tau test, a non-parametric test to find out the correlation between levels of knowledge and the interest in using the removable partial denture among the participants. results as shown in table 1, during the study, more females (66.7%) are willing to be involved compared to the male counterpart (33.3%). more patients aged after 27 years considers to use the removable partial denture, with the highest age group of 28-38 years. only 3.3% of those who use the implants have poor knowledge, while 47 out 60 patients were notified with better information and knowledge to the importance of replacing the missing teeth with the artificial to avoid tooth migration. patients’ interest in using removable partial denture, was divided as high, adequate, and low. most of respondents (61.7%) have adequate interest while only 3 of 60 had declared low interest in using the artificial implants. from kendall’s tau test, we found there was a significant correlation between patients’ interest in using removable partial denture and their knowledge to that implants with level of 0.003. as shown in table 2, of 20 patients who had high interest, they were acknowledged having good (n=10) and sufficient (n=10) level of knowledge. when they have high interest in using the partial denture, none of them has poor knowledge. interestingly, 3.3% of participants, even they have low interest to the implants, they had been notified with good knowledge to the removable partial denture. table 1. respondents’ characteristics characteristics n % age 17-27 years 28-38 years 39-50 years 15 24 21 25 40 35 gender male female 20 40 33.3 66.7 knowledge good sufficient poor 47 11 2 78.3 18.3 3.3 interest high adequate low 20 37 3 33.3 61.7 5 discussion from results, we assume that female group tends to be more sensitive and faster in giving response. women may consider the impacts of losing teeth to their physical aesthetics, masticatory system, and speaking comfort. replacing the missing tooth with removable partial denture is for the sake of physical aesthetic and facial appearance [8]. data shows as aged increased, more request for tooth extraction. poor dental and mouth condition lead to the highest interest in using removable partial denture [16]. respondents consider replacing their missing teeth to better masticatory (chewing) function [9]. moreover, respondents highly wanted to have immediate removal to keep their dental and mouth in healthy condition. as higher their knowledge of the benefits of the removable partial dentures to their dental health, the patients will be more interesting to use the implants and maintain their behavior to healthy life [12]. no doubt we found in this study knowledge to the implant has a significant correlation to patients’ interest in using the removable partial denture. what we found from this study, there were 2 patients having good knowledge but low interest in using the implant. from this recent study we noted that lack of attention and time to maintain the teeth implant may lower their interest in using the removable partial dentures, even they know the adverse impacts of missing teeth. moreover, respondents may declare discomfort by having artificial teeth, and story of swallowing the artificial teeth may avoid them to using the dentures [17]. among the respondents who had high interest in using the implants received recommendation from their friends and family who had been used and experienced to the benefits of that dental treatment. interest increased when a person has a good or high knowledge thereby he or she will be able to understand about the benefits of the treatment. lack of knowledge would lead to a tendency in which a person will not be interested in doing certain activity. it could be happened because respondents with poor knowledge about artificial teeth considered that removable partial denture was not important or even needed, therefore they did not have any interest in applying artificial teeth [16]. this recent study found patients may trust their peers and received the information as true knowledge and as result their interest to use the partial dentures increased. information given to the patients lead to a global health management journal, 2018, vol. 2, no. 1 16 good desire as well, it’s expected consequently to grow a positive attitude that will evoke and even increase someone’s interest [18]. respondents may see better appearance of having teeth implant and may neglect the bad experience of others. thus, it should be noted that friends and family also play important role in improving patients’ knowledge and interest in using the artificial teeth after tooth extraction. table 2. knowledge and interest in using removable partial denture (n=60) characteristics interest in using removable partial denture p value rho coef. high adequate low level of knowledge n % n % n % good sufficient poor 10 10 0 16.7 16.7 0 35 1 1 58.3 1.7 1.7 2 0 1 3.3 0 1.7 0.003 0.379 conclusion among the patients in the study site of yogyakarta’s private dental clinic, we found level of knowledge to the benefits of partial dentures significantly higher their interest in using removable partial dentures after tooth extraction. conflict of interests no potential conflict of interest declared. references 1. kementerian kesehatan republik indonesia. primary health care survey (riset kesehatan dasar) 2013. jakarta: badan penelitian dan pengembangan kesehatan ri. 2013. 2. ramadhan ag. oral and dental health (serba serbi kesehatan gigi dan mulut). jakarta: bukune. 2010. 3. dinkes kota yogyakarta. health profile in yogyakarta 2014 (profil kesehatan kota yogyakarta tahun 2014). yogyakarta: dinas kesehatan pemerintah kotayogyakarta. 2015. 4. lethulur va, pangemanan dh, supit a. knowledge levels of tooth extraction to education and occupation among residences in west kombos regency (gambaran tingkat pengetahuan tentang pencabutan gigi pada masyarakat kelurahan kombos barat berdasarkan pendidikan dan pekerjaan). e-gigi. 2015;3(1). 5. agtini md. percentage of the artificial denture usage in indonesia (persentase pengguna protesa di indonesia). media penelitian dan pengembangan kesehatan. 2010;20(2 jun). 6. herijulianti e, indriani ts, artini s. dental health education (pendidikan kesehatan gigi). jakarta: egc. 2001;35:98. 7. gunadi ha, burhan lk, suryatenggara f, margo a, setiabudi i. textbook of removable partial dentures (buku ajar ilmu geligi tiruan sebagian lepasan). jilid ii jakarta: hipokrates. 1995:367-78. 8. preshaw p, walls a, jakubovics n, moynihan p, jepson n, loewy z. association of removable partial denture use with oral and systemic health. journal of dentistry. 2011;39(11):711-9. 9. agerberg g, carlsson ge. chewing ability in relation to dental and general health: analyses of data obtained from a questionnaire. acta odontologica scandinavica. 1981;39(3):147-53. 10. albrektsson t, zarb g, worthington p, eriksson a. the long-term efficacy of currently used dental implants: a review and proposed criteria of success. int j oral maxillofac implants. 1986;1(1):11-25. 11. gall md. the use of questions in teaching. review of educational research. 1970;40(5):707-21. 12. kay e, locker d. a systematic review of the effectiveness of health promotion aimed at improving oral health. community dent health. 1998;15(3):13244. 13. saied-moallemi z, virtanen j, ghofranipour f, murtomaa h. influence of mothers’ oral health knowledge and attitudes on their children’s dental health. european archives of paediatric dentistry. 2008;9(2):79-83. 14. östberg a-l, halling a, lindblad u. gender differences in knowledge, attitude, behavior and perceived oral health among adolescents. acta odontologica scandinavica. 1999;57(4):231-6. 15. schwarz e, lo e. dental health knowledge and attitudes among the middleaged and the elderly in hong kong. community dentistry and oral epidemiology. 1994;22(5):358-63. 16. graham r, mihaylov s, jepson n, allen p, bond s. determining'need'for a removable partial denture: a qualitative study of factors that influence dentist provision and patient use. british dental journal. 2006;200(3):155. 17. hashmi s, walter j, smith w, latis s. swallowed partial dentures. journal of the royal society of medicine. 2004;97(2):72-5. 18. exley ce, rousseau ns, steele j, finch t, field j, donaldson c, et al. paying for treatments? influences on negotiating clinical need and decision-making for dental implant treatment. bmc health services research. 2009;9(1):7. microsoft word 2. accepted original, niniek purwaningtyas, 4-8.docx cite this article as purwaningtyas n. the diagnostic and prognostic value of right ventricle systolic and diastolic function in inferior myocardial infarction patients. global health management journal. 2018; 2(1): 4-8. global health management journal www.publications.inschool.id published by original research article issn 2580-9296 (online) the diagnostic and prognostic value of right ventricle systolic and diastolic function in inferior myocardial infarction patients niniek purwaningtyas cardiologist at moewardi general hospital, sebelas maret university, surakarta, indonesia. *corresponding author. email: dewiayu.md@gmail.com article info abstract article history: received 5 september 2017 reviewed 17 october 2017 received in revised form 22 january 2018 accepted 28 february 2018 background: inferior myocardial infarction (mi) with right ventricular (rv) involvement will increase mortality and morbidity. data of systolic and diastolic rv function in inferior st-segment elevation mi (stemi) are useful to predict the rv involvement. aims: to evaluate the prognostic and diagnostic significance of rv systolic and diastolic function compared to rvmi diagnostic criteria by electrocardiography in inferior mi patients. methods: consecutive patients with first, acute, inferior stemi were prospectively assessed. the rvmi was defined as an st-segment elevation ≥ 0.1 mv in lead v4r. echocardiography was performed within 24 hours of the inferior stemi symptoms. we assessed the rvmi diagnostic criteria in inferior mi patients using echocardiography. results: out of 31 patients (mean age 56.39 ± 9.02 years), rvmi by electrocardiography and echocardiography was found in 18 (37%). moreover, multivariate analysis showed that two variables — rv systolic and diastolic function, were independent predictors of rvmi in inferior mi patients. sensitivity and specificity of the rv systolic function were 94.4% and 69.2%, respectively, while rv diastolic functions were 44% and 76.9%, respectively. conclusion: rv systolic function predict rvmi with relatively high sensitivity and specificity. rv diastolic function predicts rvmi with relatively low sensitivity but with high specificity. keywords: tissue doppler imaging right ventricular myocardial infarction systolic function diastolic function © 2018 publications of yayasan aliansi cendekiawan indonesia thailand this is open access following creative commons license deed – attribution-noncommercial-sharealike 4.0 international (cc by-nc-sa 4.0) introduction right ventricular (rv) myocardial infarction (mi) occurs in 30–50% of patients with inferior myocardial mi [1]. it is caused mainly by significant stenosis at proximal right coronary artery (rca) [2]. the rvmi could lead to rv dysfunction that increases mortality and morbidity in inferior mi patients [3]. early assessment of rv function in inferior mi patients has great importance, as it provides prognostic information measure and allows proper modification of therapy. the rvmi diagnosis remains a challenge since there is no gold standard ready to use in an emergency clinical setting. echocardiography allows morphological, hemodynamic, and functional assessment of the rv; however, this modality has limited value because of the asymmetric, pyramidal shape of the rv and nonconcentric contraction which resulted with difficulty for geometric assumptions [4]. some echocardiographic measurements include cavity size, regional contractility, tricuspid annular 5 global health management journal, 2018, vol. 2, no. 1 plane systolic excursion (tapse), and rv myocardial performance index (rvmpi) [5]. previous study of the usefulness of pulsed wave tdi in the diagnosis of rvmi in patients with inferior mi was available, however, there are conflicting data on the value of rv myocardial velocities derived from tdi in this group of patients [6]. this study was aimed to evaluate the prognostic and diagnostic significance of rv systolic and diastolic function compared to rvmi diagnostic criteria by electrocardiography in inferior mi patients. methods this study was an analytical observational study, designed and conducted prospectively. consecutive 31 inferior mi patients with first, acute, inferior stemi were undergone examination with echocardiography. echocardiography examinations performed within 24 hours after the onset of inferior mi were eligible in this study. the diagnosis of inferior stemi was based on the european society of cardiology (esc) criteria: chest pain lasting > 30 minutes; characteristic st-segment elevation of less than 0.1mv in two or more inferior derivation (leads ii, iii, avf) on ecg, and an increase in biomarkers: troponin i or creatine kinase (ck)-mb. patients with a history of coronary artery disease, severe valvular diseases, pulmonary embolism, pulmonary hypertension, chronic obstructive pulmonary disease, atrial fibrillation, or poor quality echocardiographic imaging were excluded. all patients gave their written consent. this study was approved by the hospital ethics committee. all patients with rvmi ecg criteria were assessed with echocardiography and were checked for their rv systolic and diastolic function to finally can be diagnosed as rvmi. electrocardiogram standard 12-lead ecg and right chest ecg used for rvmi diagnosis were performed immediately at the emergency department. the rvmi was defined as an st-segment elevation ≥ 0.1 mv in lead v4r according to esc recommendations [7]. all ecgs were assessed by an independent cardiologist, combined with clinical and echocardiographic data. echocardiography and tissue doppler imaging echocardiographic examinations were performed within 24 hours of the onset of inferior mi in all patients. echocardiographic examinations were performed using vivid i with phased-array 1.8–3.6 mhz transducer, equipped with tdi technology. cardiologists were asked to examine the clinical presentation and ecg parameters blindly. all measurements were performed according to the recommendations of the american society of echocardiograph. measurements of rv and right atrium diameters, inferior vena cava diameter during respiration, fractional area change of rv, and rv wall motion abnormalities were included in the standard echocardiographic examination. we followed a modified simpson’s rule and teicholtz measurement when calculated the left ventricular ejection fraction (lvef). statistical analysis descriptive statistics were used to describe the mean and standard deviation (sd) for continuous variables and frequency tables for categorical variables. variables were compared using t-test, anova, kruskal-wallis non-parametrical anova, chisquare test, fisher exact test, or mann-whitney test where appropriate. a logistic regression analysis was used to evaluate the predictive value of selected clinical presentation and echocardiographic parameter factors for the presence of ecg changes specifically for rvmi diagnosis. the included factors were age, systolic blood pressure, diastolic blood pressure, and echocardiographic parameters including rv function parameters (rv ef, mitral propagation, fractional area change of rv, and tapse) and tdi parameters (smrv, rv myocardial performance index, emrv). the model used in the analysis was pre-specified based on the current knowledge of rv dysfunction. the diagnostic value of parameters in rvmi diagnosis was evaluated by calculating a receiver operating characteristics (roc) curve. multivariate logistic regression analysis was carried out to assess the prognostic significance of rv myocardial velocities on the occurrence of the combined endpoint in patients with inferior stemi. the included factors were smrv, emrv, age, the extent of mi expressed as peak troponin i, lvef, st-segment elevation ≥ 0.1 mv in lead v4r. events which occurred following echocardiography with tdi were enrolled in the analysis of prognosis. analysis was carried out using spss 20. results this study consisted of 31 consecutive patients. mean age for this study was 56.39 ± 9.02 years with first, acute inferior stemi enrolled between 1 november global health management journal, 2018, vol. 2, no. 1 6 2014 and 31 december 2014. out of 18 patients (37%), first stemi was observed within 24 h of the onset of symptoms and with rv localization. all patients had to fulfil criteria for the diagnosis of type i mi according to the universal mi definition [8]. exclusive criteria including permanent atrial fibrillation, severe aortic valve disease, severe chronic obstructive pulmonary disease, bundle branch block, poor quality of echocardiographic examination result, and lack of sufficient medical documentation. the patients’ characteristics of the study as listed in the table 1. multivariate analysis showed that two variables — rv systolic and diastolic function, were independent predictors of in-hospital prognosis (table 2). sensitivity and specificity of rv systolic function to diagnose rv mi in inferior mi were 94.4% and 69.2%, respectively. while sensitivity and specificity of rv diastolic function to diagnose rv mi in inferior mi were 44% and 76.9%, respectively (figure 1). table 1. patients’ characteristics rv, right ventricle; tapse, tricuspid annular plane systolic excursion; fac rv, fractional area change rv; tdi mpi, tissue doppler imaging (tdi)-derived myocardial performance index (mpi); ef rv, ejection fraction rv; e/a, ratio of e (early diastolic) and a (late diastolic) velocities; s/d, ratio of pulmonary venous waveforms include peak systolic (s) velocity and peak anterograde diastolic (d) velocity. (a) (b) figure 1. receiver operating characteristics (roc) curve of diastolic (a) and systolic function (b). diagonal segments are produced by ties. variables rv mi (+) rv mi (-) mean of mi p value age 55.89 ± 9.19 57.08 ± 9.09 56.39 ± 9.02 0.03 systolic blood pressure 129.05 ± 28.73 119.15 ± 24.48 130.22 ± 30.57 0.08 diastolic blood pressure 78.33 ± 20.82 73.23 ± 13.72 80.39 ± 21.18 0.08 tapse 1.87 ± 0.58 2.00 ± 0.53 1.92 ± 0.56 0.02 s 0.11 ± 0.33 0.13 ± 0.31 0.12 ± 0.20 0.03 fac rv 51.27 ± 13.3 52.53 ± 19.6 51.80 ± 15.95 0.12 tdi mpi 475.77 ± 18.22 486.56 ± 18.61 480.26 ± 184.12 0.002 e/a rv 1.08 ± 0.46 1.24 ± 0.45 1.15 ± 0.5 0.001 ef rv 44.33 ± 8.51 58.76 ± 6.3 50.38 ± 10.47 0.001 mitral propagation 57.02 ± 5.1 58.01 ± 5.05 53.04 ± 42.02 0.01 s/d 1.14 ± 0.51 1.16 ± 0.46 1.15 ± 0.70 0.15 7 global health management journal, 2018, vol. 2, no. 1 table 2. multivariate analysis variables odds ratio p value ef rv 3,3 (2,5-4,1) 0,004 e/a rv 2,13 (1,8-2,53) 0,005 discussion the high value of rv systolic and diastolic function in the diagnosis of acute rvmi in patients with inferior stemi was orchestrated. in rvmi echocardiographic examination, the measurement of stroke volume is played by the shortening of longitudinal fibers [8]. meluzin et al. highlighted a peak systolic velocity of tricuspid annulus correlates with rvef. this measurement was confirmed by mri [9]. ueti et al. also found that there was a high correlation between rv systolic velocity and rvef. the examination was assessed by radionuclide ventriculography [10]. right ventricular ischemia or infarction will lead to impairment of diastolic function. in diastolic dysfunction, there will be a decrease of compliance and reduced filling of rv in echocardiographic examination [1]. echocardiography is the most widely available, semiquantitative rv assessment modality for rv measurement, however, this examination was limited by the complex morphology of the rv and may be further challenged if there was a poor acoustic windows [3]. tdi could overcome the technical challenge with non-geometric indices of rv function. the reproducibility of measurements of rv myocardial velocities was high in this work, and this has also been found by other authors [11]. it was recommended to keep high reproducibility in the acute phase of mi for echo examinations in acute coronary syndrome settings [12]. the results show the pulse wave tdi allowed simple, rapid and quantitative measurements. in this recent study, rv systolic and diastolic functions were found to be independent predictors of rv mi in inferior mi patients. meluzin et al. found that patients with systolic velocity of tricuspid annulus < 10.8 cm/s and with symptomatic advanced heart failure exhibited significantly worse event-free survival [13]. rvmi leads to increased early mortality and morbidity in patients with inferior stemi [3]. we realized that this work lacks of the gold standard for the diagnosis of rvmi suitable for the early phase of hospitalization in intensive cardiovascular care units. another limitation of this study was we didn’t randomize the sample, and we didn’t carry out this study in multicenter. we followed the ecg definition of rvmi by esc [7], however it is limited to the specificity and high dependence of a delay from the onset of symptoms during examination. the issue was disappeared after 24 hours performance on all diagnostic procedures. conclusion rv systolic function predicts the diagnosis of rvmi with relatively high sensitivity and specificity. rv diastolic function predicts a diagnosis of rvmi with relatively low sensitivity but with high specificity acknowledgment thank you for dewi ayu paramita, md, fiha for helping this research. conflict of interests there is no conflict of interests. nothing to disclosure. references 1. goldstein j. pathophysiology and management of right heart ischemia. journal of american college cardiology, 2002; 40: 841–853. 2. bowers tr, o’neill ww, pica m, et al. patterns of the coronary compromise resulting in acute right ventricular ischemic dysfunction. circulation, 2002; 106: 1104–1109. 3. kukla p, dudek d, rakowski t, et al. inferior wall myocardial infarction with or without right ventricular involvement — treatment and in-hospital course. kardiologia polska, 2006; 64: 583–588. 4. rudski lg, wyman wl, afilalo j, et al. guidelines for the echocardiographic assessment of the right heart in adults: a report from the american society of echocardiography endorsed by the european association of echocardiography and the canadian society of echocardiography. journal of the american society of echocardiography. 2010; 23: 685–713. 5. piestrzeniewicz k, łuczak k, piechowiak m, et al. the value of doppler-derived myocardial performance index and tricuspid annular motion in the evaluation of right ventricular function in patients global health management journal, 2018, vol. 2, no. 1 8 with acute inferior myocardial infarction. folia cardiolica. 2006; 13: 369–378. 6. hsiao sh, chiou kr, huang wc et al. right ventricular infarction and tissue doppler imaging: insights from acute inferior myocardial infarction after primary coronary intervention. circulation. 2010; 74: 2173–2180. 7. van de werf f, ardissino d, betriu a, et al. management of acute myocardial infarction in patients presenting with st-segment elevation. the task force on the management of acute myocardial infarction of the european society of cardiology. european heart journal, 2003; 24: 28–66. 8. thygesen k and alpert js. white hd; on behalf of the joint esc/accf/whf task force for the redefinition of myocardial infarction: universal definition of myocardial infarction. european heart journal, 2007; 28: 2525–2538. 9. kukulski t, hübbert l, arnold m, et al. normal regional right ventricular function and its change with age: a doppler myocardial imaging study. journal of the american society of echocardiography, 2000; 13: 194–204. 10. meluzin j, spinarova l, bakala j, et al. pulsed doppler tissue imaging of the velocity of tricuspid annular systolic motion. a new, rapid, and noninvasive method of evaluating right ventricular systolic function. european heart journal, 2001; 22: 340–348. 11. ueti om, camargo ee, ueti ade a, et al. assessment of right ventricular function with doppler echocardiographic indices derived from tricuspid annular motion: comparison with radionuclide angiography. heart, 2002; 88: 244–248. 12. meluzin j, spinarova l, hude p, et al. prognostic importance of various echocardiographic right ventricular functional parameters in patients with symptomatic heart failure. journal of the american society of echocardiography, 2005; 18: 435–444. 13. meluzín j, spinarová l, dusek l, et al. prognostic importance of the right ventricular function assessed by doppler tissue imaging. european journal of echocardiography, 2003; 4: 262–271. microsoft word 2. accepted original, dhesi ari astuti, 19-24.docx cite this article as astuti da, kurniati n. factors influencing stigma to lesbian, gay, bisexual and transgender (lgbt) among teenagers at ngaran village, gamping, sleman, indonesia. global health management journal. 2018; 2(2): 19-24. global health management journal www.publications.inschool.id published by original research article issn 2580-9296 (online) factors influencing stigma to lesbian, gay, bisexual and transgender (lgbt) among teenagers at ngaran village, gamping, sleman, indonesia dhesi ari astuti, nurul kurniati magister program in midwifery, faculty of health science, universitas aisyiyah yogyakarta, yogyakarta, indonesia. *corresponding author. email: dhesi_stikesayo@yahoo.co.id (daa), nurul.kurniati@yahoo.com (nk) article info abstract article history: received 6 february 2018 reviewed 12 february 2018 received in revised form 16 june 2018 accepted 27 june 2018 background: lesbian, gay, bisexual, and transgender (lgbt) still becomes a social, theological, and psychological problem. similar to trauma, low selfacceptance, low self-esteem, and anxiety, if it is not handled properly, the condition will be getting worse. aims: the objective of this study is to increase prevention efforts toward stigma to the lgbt, a growing phenomenon on the teenagers. methods: this is a quantitative study with one group pretest and posttest design. the work involved forty one (41) teenagers at at ngaran village, balecatur, gamping, sleman, indonesia. a set of questionnaires that has been tested for validity and reliability was given to the respondents to measure knowledge, attitude, perception, service access, and also peer’s attitude to lgbt. counseling was given once together with material content about lgbt awareness in family. statistical analysis was employed to process and analyze the data. results: the result showed the factors correlated to stigma about lgbt on teenagers such as knowledge, attitude, perception, access to any service, and peer’s attitude. the study noticed the knowledge to lgbt (p value < 0.001) and peers’ attitude (p value = 0.02) strongly build stigma among the teenagers. conclusion: the most influencing factor of the stigma on lgbt is knowledge and peer attitudes. involving peers in improving teenagers’ knowledge and better understanding to the phenomenon are necessary to suppress discrimination and negative stigma to the lgbt people. keywords: teenagers lesbian, gay, bisexual, and transgender lgbt stigma indonesia © 2018 publications of yayasan aliansi cendekiawan indonesia thailand this is an open-access following creative commons license deed – attribution-noncommercial-sharealike 4.0 international (cc by-nc-sa 4.0) introduction a preliminary study was conducted in may 2016 to teenagers of ngaran village of sleman, indonesia, where a group of lesbian, gay, bisexual and transgender (lgbt) has been seen as a controversy phenomenon. one of the respondents stated that he/she had ever seen a man kissed another man in a food stall in one evening. the other teenagers felt disgusted to hear the story and mocked that the couple were insane, and they had to be wary of them because it was a contagious disease. it may define stigma to the minor group among teenagers at the study site. factors known influencing stigma are: predisposing factors (knowledge, education, socioeconomic, cultural), enabling factors (facilities and infrastructure (access to health services), media, facilities, government policy), and reinforcing global health management journal, 2018, vol. 2, no. 2 20 factors (intervention officers, community leaders, peers, parents). lack of access to information in health services can cause a person to have a different stigma towards a group, this is because they access information from the internet, peers, mass media so that they can be less relevant information [1]. non reliable and ambiguous information provided by the media results inconsistence attitudes to the minor group simply because the recent knowledge is inadequate [2]. a research conducted by mustanski and his team (2010) in the united states also orchestrates how stigma of racial, gender, and sexual affected to the mental disorders among the lgbt teenagers [3] where a third of respondents had 17% mental disorders, 15% severe depression, and 9% posttraumatic stress disorder (anorexia and bulimia are rare), and 31% committed suicide. a previous study in two cities in indonesia, jakarta and yogyakarta, related to stigma, discrimination and violence to lgbt, shows that 89.3% of lgbt had experienced physical violence, 79.1% experiencing psychological violence, and 45.1% had sexual violence [4]. the indonesian government made policy to protect citizens which is contained in the law of 1945 article 28 related the human rights. article 28 paragraph i states that "everyone has the right to be free of discriminatory treatment on any basis and entitled to protection against discriminatory treatment". the article is included in the government policy based on the results of identification of stigma, discrimination and violence experienced by the lgbt community. methods this research uses a quantitative method with one group pretest-posttest design. this study involved 41 teenagers, recruited by a total sampling method, from ngaran village, balecatur, gamping, sleman, indonesia. data has been collected using a set of questionnaires and follow up plan form to measure knowledge level on the respondents after and before the given counseling. the counseling includes a onetime meeting with material presentation of lgbt awareness in the family. at a later stage, a follow-up plan for adolescents performed their roles to provide information, especially for the prevention efforts toward stigma to the lgbt, a growing phenomenon on teenagers. further, the data was processed and analyzed by software using computer. this study used t-test for statistical analysis. results respondents’ age, religion, occupation and education were noted and have been presented in the form of frequency distribution table, as table 1. the respondents were the youth aged from 12 to 25 years old, dominated by the group aged between 17 to 21 years old (56.3%) who had more individuals (11 from 41) having negative stigma to the lgbt people. the study shows that the age has association (p value = 0.03) to the lgbt stigma in adolescents, both through maturity of thinking, the process of interaction with the environment and understanding of information. the majority of respondents in the study are muslim, and seems the number of muslim teenagers to having positive and negative stigma are not different. we cannot see the significant difference of stigma between the two group, islam and non-islam, since the distribution of data are not difference (p value = 0.05). more than half of the adolescences had jobs. the data showed that more adolescents had positive stigma if had an occupation (26.8%), compared to the peers who were unemployed (9.8%). although statistically insignificant (p value = 0.09), a person who became employment allows more access to information than non-employees, it is likely to relate to how the teens stigmatize the lgbt group. interestingly, the stigma to the lgbt people on the teenagers at different education level is difference (p value = 0.02). among the respondents who were currently not attending a school, the number of those had positive stigma found higher. while the findings show more teenagers have negative attitude (51.2%) and perception (58,5%) to the lgbt, however, the results shows that teenagers’ attitude and perception has no significant association to their stigma, respectively at p value 0.4 and 0.41. however, interestingly, their peer’s attitude to the phenomenon significantly influence the teenagers’ stigma to the lgbt (p value = 0.02). out of 41 respondents, more than half described having friends with positive attitude to the lgbt (58.5%), and among them there are 17 teenagers measured having positive stigma. interestingly, the rest 17 respondents declared having peers with negative attitude toward lgbt, 13 of them noted with negative stigma to this phenomenon. the results showed that peer attitudinal variables on stigma showed that most often were positive peers with positive stigma about lgbt and the least positive peer attitude with negative stigma. moreover, the results on the access to public service to adolescent stigma about lgbt showed that the most accessible ones had negative stigma of 31.7%. 21 global health management journal, 2018, vol. 2, no. 2 table 1. respondents’ characteristics and their stigma to lgbt variable stigma total p value negative positive f % f % f % age 12-16 years old 6 14.5% 8 19.5% 14 34.1% 0.03 17-21 years old 11 26.8% 11 26.8% 22 53.6% 22-25 years old 3 7.2% 2 4.8% 5 12.3% religion non islam 1 2.4% 2 4.9% 3 7.3% 0.05 islam 19 46.3% 19 46.3% 38 92.7% total 20 48.8% 21 51.2% 41 100% education no schooling 1 2.4% 3 7.3% 4 9.8% 0.02 elementary school 6 14.6% 2 4.9% 8 19.5% junior high school 0 0% 7 17.1% 7 17.1% senior high school 12 29.3% 8 19.5% 20 48.8% bachelor degree 1 2.4% 1 2.4% 2 4.9% total 20 48.8% 21 51.2% 41 100% occupation not yet working 5 12.2% 6 14.6% 11 26.8% 0.09 unemployment 4 9.8% 4 9.8% 8 19.5% employment 11 26.8% 11 26.8% 22 53.7% total 20 48.8% 21 51.2% 41 100% table 2. factors influencing stigma about lgbt on teenagers variables stigma total p value negative positive f % f % f % attitude 0.4 negative 11 26.8% 10 24.4% 21 51.2 positive 9 22% 11 26.8% 20 48.8 total 20 48.8% 21 51.2% 41 100% perception negative 13 31.7% 11 26.8% 24 58.5% positive 7 17.1% 10 24.4% 17 41.5% 0.41 total 20 48.8% 21 51.2% 41 100% peer’s attitude negative 13 31.7% 4 9.8% 17 41.7% positive 7 17.1% 17 41.5% 24 58.5% 0.02 total 20 48.8% 21 51.2 41% 100% service access negative 7 17.7% 9 22% 16 39% 0.42 positive 13 31.7% 12 29.3 25 61% total 20 48.8% 21 51.2 41 100% global health management journal, 2018, vol. 2, no. 2 22 table 3. correlation between knowledge about lgbt and stigma lgbt on teenagers variables mean ±sd t test δ mean± std error mean p value 95% ci pre test post test stigma 52.7 ±8.1 54.4±8.5 -3.67 2.27±1.23 0.00 50.11-55.21 table 4. factor influencing lgbt stigma on the teenagers independent variables dependent variable p value interpretation knowledge stigma lgbt on teenagers 0,00 related attitude 0,4 not related perception 0,41 not related service access 0,42 not related peer’s attitude 0,02 related table 5. independent multivariable analysis of the observed variables variables coefficient se wald df p value or ci 95% min max attitude 4.468 0.789 0.351 1 0,4 1.59 0.34 7.49 perception 4.38 0.73 0.359 1 0.55 0.64 0.15 2.70 access 5.81 0.75 0.6 1 0.04 2.04 0.4 7.82 peer’s attitude 2.27 0.82 7.68 1 0.006 0.1 0.02 0.51 constanta 0.7 0.7 1.1 1 0.027 2.1 service access 0.5 0.78 0.46 1 0.4 1.7 3.6 7.9 peer’s attitude 7.5 1 0.02 1.601 constanta 21.03 0.00 in summary, the bivariable analysis indicates that knowledge and peers’ attitude are the two factors influencing stigma to lesbian, gay, bisexual and transgender (lgbt) among teenagers at ngaran village, gamping, sleman, indonesia (see table 3 and table 4). variables that are not related to lgbt stigma in adolescents are attitude, perception, and service access, however, those three variables may influence the peers’ attitude. the or at table 5 shows the strength of relationship between the two parameters. from the table it is known that adolescents with far access to services tend to have a negative attitude or negative stigma 1.7 times greater than adolescents with access to services nearby. teenagers with good peers, potentially 1.6 times more likely to have a good stigma about lgbt. discussion roughly, it can be said that among the participated teenagers, we found that only 21 of 41 participants had positive stigma, while the rest 20 persons had negative stigma to the lgbt group. the level of education may generate a difference to one's understanding of something [5]. in this present study, we noticed a significance difference of lgbt stigma among the age group (p value = 0.02). however, it is not clear how education affects the stigma. though, adolescents with higher education tend to be easier to gain access to information; adolescents will have no trouble in getting information. teenagers with higher education may have better understanding of information in adolescents, however the result shows the number of the senior high school students having negative stigma is still high. the attitude shown is more to a negative attitude with a negative view of lgbt so that the stigma that exists from the negative attitude is a stigma of negative tendency. negative stigma to the lgbt group will be following with the negative attitude among the participants. although the present study does not show the statistically significant effect on the stigma on lgbt, negative attitudes about lgbt will result in negative stigma, and vice versa. in this case, an individual may have interaction and contact with the other members of her/his social group that might shape the attitudes toward lgbt [6]. 23 global health management journal, 2018, vol. 2, no. 2 the perceptions of the stigma about lgbt most commonly indicated negative perceptions with negative stigma of 31.7%, and the least was positive perception with negative stigma of 17.1%. not only lack of knowledge [7], the negative perception among the participants may be shaped by their environment that present meaning to their organization of thinking and experience [8]. by the socio-cultural factor in the society, a gay man might be seen as a source of sexually transmitted infections among men who have sex with men [9]. negative perceptions will lead to a negative stigma, further, contributing mental conditions in the gay group [9]. the general perception doctrine of the majority of society assumes that hetero is the "most correct" sexual orientation and behavior, and the others are wrong and deviant. man are in the hegemony by the viewing that hetero sexual is normal and natural, while homo is distorted, abnormal perpetrator, having mental and suffering mental illness [10, 11]. the phenomenon of lgbt behavior in the world today is very massive propaganda. in general lgbt behavior have a lot of contradictions to various perspectives, from the perspective of religion, mental health and psychiatric. acceptance to lgbt becomes the pros and cons in society. thus, by some groups it is considered as a discriminatory behavior to the minority group, the lgbt people [12]. religion is one of variables which is considered as factor influencing stigma among the teenagers to the lgbt phenomenon. muslim is obliged to hold the laws contained in it in order to become a human who is obedient to allah swt because every treatment will be accountable in the hereafter. however, the rejection occurred in the community may due to the explanation of the verses of the qur'an that same-sex relationships are strictly prohibited. the stigma arises usually from an inadequate understanding of religion or even the culture planted in the society [13], however in contrast to the present research, it shows that adolescents from both islam and non-muslim faiths cannot determine the stigma of lgbt where there is no relation between religion and stigma about lgbt. stigma, not necessarily arises, is explained in history in some classical islamic history literature which tells that abu nuwas, a poet who loves boys and wine, this poetical texts become a mockery of the people to abu nuwas but not to the level of slander. also alghazali, a mystical religious leader once composed poems for his young (male) lovers. however, alghazali refuses to be called as homo [14]. negative stigma and discrimination toward the lgbt group are often seen as lack access to health services [15]. stigma is illustrated by cynicism, excessive fear and negative perceptions that affect and degrade the quality of life including discrimination in health care. stigma and discrimination will also create an isolated/marginalized community [16]. the stigma about lgbt remains negative even though adolescents have affordability access to health services. if closer, teenagers will more easily get information about credible sexual diversity. there is a strong relationships between peers’ attitudes and stigma to lgbt among the participated adolescents. it is because peer attitudes and views can affect friends from the process of interaction and daily life. adolescents will tend to be affected, so peer attitudes will help determine how teens can show positive or negative stigma. however, some studies reveal that bad stigma about lgbt was not only in the general public but occurs among health workers where health care is difficult to obtain information about credible sexual diversity [17]. in the same region, our previous study on 2nd year midwifery students found that despite having access to media and information, they expressed negative attitudes toward lgbt, unwilling to be closer to lgbt and agree to keep way their children from the lgbt people [2]. stigma in some conditions will cause stress. the stress associated with the stigma is much in the past, because it is clear that negative stigma results adversely to the mental state of the lgbt people [18, 19]. the lgbt group is not well maintained, as most of them have poor health conditions, and marginalization occurs in this sexual minority [20]. not only in society, even the stigma among health workers makes lgbt groups get discrimination in terms of health services [21]. in this case, culture are the factors of the emergence of stigma, because in indonesian society, lgbt groups are still regarded as a minority group and still being debated. conclusion this study clearly found that the teenagers’ knowledge and attitudes of their friends to the lgbt are the most influencing factor to the stigma. involving peers in improving teenagers’ knowledge for better understanding to the phenomenon is necessary to suppress discrimination and negative stigma to the lgbt people. global health management journal, 2018, vol. 2, no. 2 24 conflict of interests there is no conflict of interests. nothing to disclosure. references 1. notoatmodjo s. pendidikan perilaku kesehatan cetakan 1 (health behavior education, first edition). yogyakarta: penerbit andi offset (60). 2003. 2. astuti da, hidayat a, humaira rz, widyastari da, sinaga dm. accessibility to media and its relation to stigmatization toward lesbian-gay-bisexual and transgender (lgbt) individuals: a study among 2nd year midwifery students in yogyakarta, indonesia. journal of health research. 2017;31(4):263-9. 3. mustanski bs, garofalo r, emerson em. mental health disorders, psychological distress, and suicidality in a diverse sample of lesbian, gay, bisexual, and transgender youths. american journal of public health. 2010;100(12):2426-32. 4. laazulva i. menguak stigma, kekerasan dan diskriminasi pada lgbt di indonesia (revealing stigma, violence, and discrimination towards the lgbt in indonesia). jakarta: arus pelangi. 2013. 5. iliyasu z, abubakar is, kabir m, aliyu mh. knowledge of hiv/aids and attitude towards voluntary counseling and testing among adults. journal of the national medical association. 2006;98(12):1917. 6. azwar s. sikap manusia dan teori pengukurannya (human attitude and its measurement theory). edisi ke-2 jakarta: pustaka pelajar. 2009. 7. de santis jp, hauglum sd, deleon da, provenciovasquez e, rodriguez ae. hiv risk perception, hiv knowledge, and sexual risk behaviors among transgender women in south florida. public health nursing. 2017;34(3):210-8. 8. stryker s. identity theory: developments and extensions. 1987. 9. frost dm, parsons jt, nanín je. stigma, concealment and symptoms of depression as explanations for sexually transmitted infections among gay men. journal of health psychology. 2007;12(4):636-40. 10. mulligan an. countering exclusion: the ‘st. pats for all’parade. gender, place & culture. 2008;15(2):15367. 11. qian j. narrating the trope of abnormality: the making of closeted experiences in gay public cruising. geoforum. 2014;52:157-66. 12. krisdianto d. konsepsi lesbian gay biseksual dan transgender (lgbt) perspektif jaringan islam liberal (jil) (conception of lesbian, gay, bisexual, and transgender (lgbt); perseption of liberal islam network): uin sunan ampel surabaya; 2017. 13. pimentel a. culture and stigma in religion: the westboro baptist church: kansas state university; 2016. 14. riyani i. research on (women's) sexuality in islam. islamika indonesiana. 2015;1(2):1-18. 15. brotman s, ryan b, cormier r. the health and social service needs of gay and lesbian elders and their families in canada. the gerontologist. 2003;43(2):192-202. 16. sosodoro o, emilia o, wahyuni b. hubungan pengetahuan tentang hiv/aids dengan stigma orang dengan hiv/aids di kalangan pelajar sma (relationship between the knowledge to hiv/aids and the stigma toward people living with hiv/aids among high school student). berita kedokteran masyarakat. 2009;25(4):210. 17. zuzelo pr. improving nursing care for lesbian, bisexual, and transgender women. journal of obstetric, gynecologic, & neonatal nursing. 2014;43(4):520-30. 18. lewis rj, derlega vj, griffin jl, krowinski ac. stressors for gay men and lesbians: life stress, gayrelated stress, stigma consciousness, and depressive symptoms. journal of social and clinical psychology. 2003;22(6):716-29. 19. meyer ih. prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. psychological bulletin. 2003;129(5):674. 20. lim fa, brown dv, jones h. lesbian, gay, bisexual, and transgender health: fundamentals for nursing education. journal of nursing education. 2013;52(4):198-203. 21. ard kl, makadon hj. improving the health care of lesbian, gay, bisexual and transgender (lgbt) people: understanding and eliminating health disparities. the fenway institute. 2012. critics on policy of soy-based infant formula in indonesia: compared to australian and new zealand food standards indonesian scholars’ alliance ghmj (global health management journal) 2019, vol. 3, no. 3 open access original research the 4th interna onal conference on applied science and health (icash 2019), 23-24 july 2019, faculty of graduate studies, mahidol university, thailand critics on policy of soy-based infant formula in indonesia: compared to australian and new zealand food standards agnescia clarissa sera nutri on department, poltekkes kemenkes palangka raya george obos 32, palangka raya 73112, central borneo, indonesia *corresponding author’s email: agnesciasera@gmail.com abstract background: world health organiza on (who) recommends breast milk as sole and the most complete infant food during the first 6 months. however, in certain circumstances, when breas eeding is not possible, not desired or not advised, infant formulas like those are made of soy can be given to newborns. however, the safety of long-term use soy-based formula has been argued due to the possible adverse effects of phytoestrogen, phytates and aluminum in human body as well as the consequences of agrochemicals residue. therefore, those problems should be taken into account while developing, reviewing or amending policy of infant formulas. this ar cle reviews the adequacy of soy-based infant formula policy in indonesia to an cipate issues in sif consump on. methods: australian and new zealand food standards code was used to compared to the decree of indonesian nadfc. the results were described narra vely and analyzed from the perspec ve of the author. results: accordingly, only small aspects of sif are regulated in indonesian policy. the use of spi for sif in indonesia is not a compulsory though scien fically another source may trigger diarrhea in newborn baby. no clause related to aluminum content, zinc to copper ra o, isoflavone level, gm soy and pes cide residue found in indonesian policy. conclusion: apparently, very limited provision regarding sif has been covered by indonesian policy. the regula on of sif marketed and manufactured in indonesia should be more specific and developed based on recent clinical and epidemiological studies. on the other hand, indonesia needs a comprehensive system where society may par cipate in reviewing the laws. keywords: soy-based infant formula, food policy, food standards received: 14 may 2019 reviewed: 18 june 2019 revised: 1 july 2019 accepted: 6 july 2019 doi: 10.35898/ghmj-33459 selec on and peer-review under responsibility of the scien fic commi ee and the editorial board of the 4th internaonal conference on applied science and health (icash 2019) © yayasan aliansi cendekiawan indonesia thailand (indonesian scholars’ alliance). this is an open-access following crea ve commons license deed a ribu on-noncommercial-sharealike 4.0 interna onal (cc by-nc-sa 4.0) 1. introduc on reviewing its history, soy-based infant formula (sif) was firstly introduced over a century ago in the united states in 1909 (westmark, 2017). health professionals advice the use of this lactose-free milk especially for babies with galactosemia, lactose intolerance and those whose parents were vegan (bosch, 2011; vandenplas et al., 2014). former generation of sif was based on soy flour and since 1960s and recent modification has been made of soy protein isolate (spi) to ease digestion. to date, sif has 152 mailto:agnesciasera@gmail.com https://dx.doi.org/10.35898/ghmj-33459 sera ac ghmj (global health management journal) 2019, vol. 3, no. 3 been supplemented with essential amino acids, lipids, vitamins and minerals to resemble the nutrient contents of breastmilk. however, the safety of long-term use of sif has been debated. this issue has been increasingly raised along with the introduction of genetically modified (gm) soybeans in early 1990s. despite of its health benefits as therapeutic agents for infants with gastrointestinal issues, many cross-sectional and pure experimental studies have found that natural genistein and daidzein in soybeans may alter human reproductive hormones leading to endocrine disruption. the researchers reported women fed with soy formula in early infancy tend to experience heavy menstrual bleeding, have higher maturation index and unfavorable effects on early menarche compared to those fed with non-sif (mccarver et al., 2011; stallings et al., 2017; upson et al., 2016). on the other hand, exposure of sif in male infants may suppress their steroidogenic capability leading to the disturbance of sex hormone release (abo-elsoud et al., 2019; chen and rogan, 2004; zhu et al., 2016). on top of that, according to chen and rogan’s study, genistein alone in daily sif consumption may equal to five contraceptive pills (22-45 mg/l) (chen and rogan, 2004; esch et al., 2016; yu et al., 2016). as comparison, breastmilk contains 1-10 µg/l isoflavones and the suggested safe level is 3.2 mg/kg (vandenplas et al., 2014). the fact shows that genistein is accumulated in human body due to frequent feeding hence brings some researchers to a speculation that may lead to the long-term effects for both male and female newborns. another conflicting area is related to the effects of phytates in mineral absorption. this antinutrient may impair the absorption of zn, ca, p, and fe in infant’s gastrointestinal tract (vandenplas et al., 2014). studies reported that soy infant formula contains 1.5% phytates and 1/3 of total phosphorus is phytate-bound (gomez et al., 2016; vandenplas et al., 2014). therefore, soy formula should be supplemented by those micronutrients, otherwise it will increase the risk of infant malnutrition. regarding the high level of aluminum content (200-700 μg/l) in sif compared to breastmilk and cow’s milkbased formula, another concern about possible risk of aluminum in sif has been addressed (burrell and exley, 2010; vandenplas et al., 2014; westmark, 2017). this aluminum exposure, which seems to come from the soybean itself and equipment residues while manufacturing milk formulas, may lead to serious health problems as aluminum can burden infant’s gastrointestinal tract and renal functions (chuchu et al., 2013; gomez et al., 2016; redgrove et al., 2019). the last major focus of sif’s controversial is the agrochemical residues such as benzene, toluene, chloroform, styrene and glyphosate (westmark, 2017). therefore, genetically engineered soy is proposed to be the solution of pesticide residue. however, the use of gm soybeans leads to another long discussion about its safety as some researcher found that transgenic soybeans poses a greater risk on health as a result of consuming foreign dna (lucht, 2015). given all those counter arguments, specific food regulation regarding the use of sif seems to be crucial. food regulation is a specific instrument aimed to protect public health and safety. this regulation will vary in every country or even every state. australia and new zealand food ministerial forum on food regulation, which consists of health and agriculture ministers from the states and territories as well as the australian and new zealand governments, has the authority to develop food policy in both countries (fsanz, 2019b). under the australian new zealand food standards code, the primary production, composition, processing, handling, labelling and safety of food (including those related to soy-based infant formula) in both countries are managed. these standards are enforced by australian state and territory as well as new zealand governments through their individual food acts. while in indonesia, food policy making takes place in such complicated political environments led by indonesian house of representatives in coordination with president (blomkamp et al., 2017). afterwards, relevant regulatory agencies like ministry of health, ministry of agriculture, ministry of maritime affairs and fisheries, ministry of industry and trades as well as national agency for drug and food control of the republic of indonesia (nadfc known as bpom) issued the technical policies. consequently, food policies in indonesia may overlap or be missing in some parts. to date, indonesian government introduced two legal references related to infant formula, namely health minister regu153 ghmj (global health management journal) 2019, vol. 3, no. 3 sera ac lation number 39 year 2013 on infant formula milk and other baby products and decree of nadfc number 1 year 2018 on supervision of processed food for special nutritional purposes. however, so far, there has been no review whether or not both policies facilitate the right regulation regarding soybased infant milk. therefore, this article may be important to act as policy analysis and evaluation of one part of the food policies in indonesia. at the end, this paper aims to provide recommendations to indonesian government to develop specific clauses to guarantee the health and safety of indonesian future generations who consume soy-based infant milk. 2. method basically, this paper was an analytical perspective of researcher, in which legal materials were used as secondary data. two relevant legal references, namely health minister regulation number 39 year 2013 on infant formula milk and other baby products and decree of nadfc number 1 year 2018 on supervision of processed food for special nutritional purposes were studied intensively and compared to standard 2.9.1: infant formula products (part of australian new zealand food standards code). google search engine was used to access the indonesian food policies. major information regarding the role, plans and programs related food were accessed from nafdc’s official website (www.pom.go.id) while the food policies of australia and new zealand were accessed from the food standards australia new zealand (fsanz)’s official website (www.foodstandards.gov.au). this study was conducted in april-may 2019. critics were made according to following guideline questions: 1. how is the model of food policy cycle in indonesia, australia and new zealand? 2. have the current food policies in indonesia anticipated issues in sif consumption? 3. results food regulations in australia and new zealand were developed by food standards australia and new zealand (fsanz), an independent agency consists of health and agriculture ministers from the states and territories of australian and new zealand. fsanz is responsible for developing and managing standards of food including the primary production, composition, processing, handling, labelling and safety of food manufactured and distributed in both countries. literally, everyone in australia and new zealand may access their food policies and give comments and advices by filling the specific application forms in fsanz’s official website. later, fsanz board will evaluate and decide whether or not to accept the advices and change the food standard codes. then, the changes will be notified to the australia and new zealand ministerial forum on food regulation. the forum has responsibility to reject, adopt and ask fsanz to review the decisions. on the other hand, anyone who accesses fsanz’s website can easily track the changes in codes and standards. therefore, they will always be updated to the valid policies. this process is carried out continuously while implementing the food standards. on the contrary, in indonesia, the general process of policymaking takes place in a complex political environment. before becoming an enacted food policy, the draft of policy should be approved by the parliament and the president. afterwards, relevant regulatory agencies like ministry of health, ministry of agriculture, ministry of maritime affairs and fisheries, ministry of industry and trades as well as national agency for drug and food control of the republic of indonesia (nadfc known as bpom) will issue the technical policies. in terms of sif regulations, indonesia has 2 relevant regulations, namely the health minister regulation number 39 year 2013 on infant formula milk and other baby products and decree of nadfc number 1 year 2018 on supervision of processed food for special nutritional purposes. the first policy can be accessed from indonesian ministry of health official website while the second policy can be found online under nadfc’s legal documentation and information network (sjdi) system. moreover, both regulations are present in indonesian and 154 sera ac ghmj (global health management journal) 2019, vol. 3, no. 3 english languages. under the nafdc’s official website, platform to make complaints have been provided and can be accessed by anyone. however, it seems to be too general and mainly used for services dissatisfaction. on top of that, in general, indonesian people are not aware of the existence of food policies unless they are part of indonesian political parties, government employee, food industry and scholars. more importantly, most of indonesian society do not know how to propose the changes of food policy as it is not well informed by the government. worldwide, at least 4 major issues have been debated regarding the consumption of sif in infant. first, the possible adverse effects of phytoestrogen which may alter human reproductive hormones leads to endocrine disruption. second, the effects of phytates that may impair the absorption of zn, ca, p, and fe in infant’s gastrointestinal tract. on the other hand, aluminum residue in sif formulas may burden infant’s gastrointestinal tract and renal functions. last, the use of transgenic soybeans which is still under debate though genetically engineered soy is proposed to be the solution of pesticide residue. those problems should be anticipated mainly by developing policy instruments. table 1 shows comparison between regulations of sif in indonesia and australia-new zealand. the composition, labelling and marketing of sif in australia and new zealand are regulated in standard 2.9.1: infant formula products (fsanz, 2019a). standard 2.9.1 was developed by food regulation standing committee in 1993 and the latest version was published in november 2017. while in indonesia, sif is specifically regulated in decree of nadfc number 1 year 2018 on supervision of processed food for special nutritional purposes. accordingly, the use of soy or spi is not mentioned in the decree of health minister though sif is considered as infant formula milk. moreover, only small aspects of sif are regulated in the decree of nadfc number 1 year 2018. for instance, the use of spi for sif in indonesia is not compulsory while vice versa in australia and new zealand. however, both indonesia and australia-new zealand have specified the maximum and minimum level of protein isolate in sif. likewise, in terms of calcium and phosphor ratio, both countries show quite similar proportion. on the other hand, there is no clause related to aluminum content and zinc to copper ratio in indonesian policy. apparently, very limited provision regarding sif can be found in indonesia and when regulations are present, they are too general or considered similar as other types of infant formula. 4. discussion food policy model in australia and new zealand has been well established. fsanz as the government agency has the important role in developing and managing food standards in both countries. moreover, it is clear that their society actively participate to build their food system. by contrast, general process of food policymaking in indonesia cannot be represented as a cycle like in australia and new zealand. even though the food policy in indonesia can be found online, public are not well informed about its policy cycle or the process of policymaking and at which stage they can participate to build a better food system. this means policy initiation is not raised from the bottom level. consequently, common people do not have the chance to review and propose the changes of policy when it is considered irrelevant and needs improvement. therefore, indonesian government should build a system where its people can improve their policy literacy and aware of their roles to jointly develop a system to ensure the health of all indonesians. australia and new zealand have shown good examples, in which their standard 2.9.1 regarding infant formula products have been frequently reviewed. for instance, sif marketed in australia should be made from spi, which has higher protein digestibility than soya flour. it is likely due to bleak history of soya flour, which has a low protein availability and may cause neonatal diarrhea (vandenplas et al., 2014; westmark, 2017). moreover, australian food regulation standing committee particularly assigned 0.1 mg/100 ml as the maximum standard of aluminum in soya infant formula. this level of aluminum was considered to be harmless for normal infant but was not recommended for preterm infants (chuchu et al., 2013). likewise, the maximum and minimum level of soy protein isolate, ratio of calcium and phosphor, ratio of zinc and copper as well as gm soy risk analysis were 155 ghmj (global health management journal) 2019, vol. 3, no. 3 sera ac table 1. specific provision regarding sif in indonesia, australia and new zealand aspects indonesia australia and new zealand regula ons decree of nadfc number 1 year 2018 on supervision of processed food for special nutri onal purposes australia new zealand food standards code, standard 2.9.1: infant formula products source of infant formula may be made from spi spi is the sole source of sif total protein isolate minimum 2.25 g/100 kcal (0.54 g/100 kj) 0.45 g/100 kj maximum 3.0 g/100 kcal (0.72 g/100 kj) 1.4 g/100 kj upper limit reference none none calcium: phosphor ra o minimum 1:1 1.2:1 maximum 2:1 2:1 zinc: copper ra o none max 15:1 aluminium not men oned max 0.1 mg/100 ml isoflavone level not men oned not men oned gm soy not men oned not men oned, but provided in different sec on, i.e.: standard 1.5.2 (food produced using gene technology) pes cide residue not men oned not men oned labelling and packaging requirements same as other infant formulas same as other infant formulas made based on scientific evidence. in general, this standard was relevantly developed to meet the who’s standard of infant formula, world trade organization agreements and nutrition policies in australia and new zealand. on the other hand, nafdc has not assigned more specific details of sif produced and marketed in indonesia. for instance, indonesia does not propose the legally required spi as a sole source of sif. this means manufacturers may produce sif from soya flour even though it may lead to neonatal diarrhea and it has a low bioavailability. fortification of sif with micronutrients including trace minerals should be a compulsory, otherwise it may increase the risk of malnutrition in newborn baby (gomez et al., 2016). moreover, the ratio of zinc and copper in indonesian sif are not mentioned. in fact, this is quite important in reconstitution of powdered milk product. improper ratio may result in traceelement nutrition unbalance (gomez et al., 2016). furthermore, certain standard of isoflavone level need to be assigned to prevent the possible effect on reproductive functions (abo-elsoud et al., 2019; chen and rogan, 2004; esch et al., 2016; vandenplas et al., 2014; yu et al., 2016; zhu et al., 2016). it is due to the evidences that women fed with soy formula in early infancy tend to experience heavy menstrual bleeding, have higher maturation index and unfavorable effects on early menarche compare to those fed with non-sif (mccarver et al., 2011; stallings et al., 2017; upson et al., 2016). similarly, in male infants, exposure of sif may suppress their steroidogenic capability which leads to the disturbance of sex hormone release (abo-elsoud et al., 2019; chen and rogan, 2004; zhu et al., 2016). in addition, the maximum level of aluminum in sif should be assigned by indonesian government. aluminium exposure from soybean and equipment residues in milk factory may lead to serious health problems in infant’s gastrointestinal tract and renal functions (burrell and exley, 2010; vandenplas et al., 2014; westmark, 2017). furthermore, issues related to gm soy should be anticipated. those all become an important homework for nafdc as indonesian primary agency to assess and formu156 sera ac ghmj (global health management journal) 2019, vol. 3, no. 3 late the national policies. indonesian nafdc needs to work together and engage with other relevant ministries, stakeholders including manufacturers, scientists and community to establish a better food regulation and policy system. hence, in the future, those references should become guidelines for all manufacturers to produce soy-based infant formula and provide adequate information to assist consumers, especially mothers who are not able to breastfeed their babies. on top of that, well-developed food standards will protect the health of indonesian generation. 5. conclusion indonesian food policies regarding sif is considered inadequate to protect indonesian generation who consume sif. very limited provisions and clauses regarding 4 major issues of sif consumptions have been covered by the decree of nadfc number 1 year 2018 on supervision of processed food for special nutritional purposes. on top of that, indonesian society are not well-informed to the process of policy review and analysis. this brings to the lack of food policy literacy among indonesian people. therefore, indonesia needs a comprehensive system where society may participate in reviewing the laws. considering issues about the extrapolating potential long-term effects of isoflavones, phytates, aluminum, pesticide residue and transgenic soy in human body, personally think, indonesian government should start developing specific regulations of soy infant formula. it could be recommended that certain standard of isoflavone level is set to prevent the possible effect on reproductive function. in terms of phytates issue, it may also be advisable if the fortification of iron, zinc, calcium, and phosphorus in soy infant formula become a compulsory for the milk manufacturers. furthermore, it may be regulated that sif is not recommended for preterm infants except certain technologies have been well established to anticipate the adverse effects on premature baby. however, to develop the regulation, it requires further clinical and epidemiological studies and may take a long journey. acknowledgments the authors would like to thank to all participants for participating in this study. conflict of interest there is no conflict of interest. references abo-elsoud, m., hashem, n., el-din, a. n., kamel, k., and hassan, g. (2019). soybean isoflavone affects in rabbits: effects on metabolism, antioxidant capacity, hormonal balance and reproductive performance. animal reproduction science, 203:52–60, doi: 10.1016/j.anireprosci.2019.02.007. blomkamp, e., sholikin, m. n., nursyamsi, f., lewis, j. m., and toumbourou, t. (2017). understanding policymaking in indonesia: in search of a policy cycle. no. june. bosch, a. m. (2011). classic galactosemia: dietary dilemmas. j inherit metab dis, 34(2):257–260, doi: 10.1007/s10545-010-9157-8. burrell, s.-a. m. and exley, c. (2010). there is (still) too much aluminium in infant formulas. bmc pediatrics, 10(1):63, doi: 10.1186/1471-2431-10-63. chen, a. and rogan, w. j. (2004). isoflavones in soy infant formula: a review of evidence for endocrine and other activity in infants. annu. rev. nutr., 24(1):33–54, doi: 10.1146/annurev.nutr.24.101603.064950. chuchu, n., patel, b., sebastian, b., and exley, c. 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(2016). daidzein impairs leydig cell testosterone production and sertoli cell function in neonatal mouse testes: an in vitro study. molecular medicine reports, 14(6):5325–5333, doi: 10.3892/mmr.2016.5896. cite this article as: sera ac. critics on policy of soy-based infant formula in indonesia: compared to australian and new zealand food standards. ghmj (global health management journal). 2019; 3(3):152-158. doi:10.35898/ghmj-33459 158 https://www.legislation.gov.au/details/f2017c00332 https://www.legislation.gov.au/details/f2017c00332 http://www.foodstandards.gov.au/about/safefoodsystem/pages/default.aspx http://www.foodstandards.gov.au/about/safefoodsystem/pages/default.aspx https://dx.doi.org/10.3168/jds.2016-11405 https://dx.doi.org/10.3390/v7082819 https://dx.doi.org/10.1002/bdrb.20314 https://dx.doi.org/10.3390/ijerph16050899 https://dx.doi.org/10.1096/fasebj.31.1_supplement.958.2 https://dx.doi.org/10.1097/ede.0000000000000508 https://dx.doi.org/10.1017/s0007114513003942 https://dx.doi.org/10.3389/fnut.2016.00059 https://dx.doi.org/10.3390/nu8060361 https://dx.doi.org/10.3892/mmr.2016.5896 introduction method results discussion conclusion indonesian scholars’ alliance ghmj (global health management journal) 2019, vol. 3, no. 2 open access original research anjari wahyu wardhani1*, chriswardani suryawati2*, puji harto3 cost awareness analysis on acute appendicitis treatment with social security agency for health (bpjs in health sector) at budi kemuliaan hospital batam 1budi kemuliaan hospital batam, indonesia 2faculty of public health, universitas diponegoro, semarang, indonesia 3faculty of economics and business, universitas diponegoro, semarang, indonesia *corresponding author’s email: anjariwardhani@gmail.com abstract background: financial costs are recognized as one of the causes of lack of access to adequate health services, not least in the treatment of acute appendicitis with social security agency for health (bpjs in health) in budi kemuliaan hospital, batam. data describing health workers’ awareness of costs is still limited. increasing awareness of health workers can encourage increased treatment efficacy and reduce wasteful spending costs. this research aims to analyze the cost awareness of health workers’ in the efficiency of acute appendicitis treatment. methods: this research was a qualitative descriptive study accompanied by direct observation on the implementation of clinical pathways and sop in cases of appendicitis acute in budi kemuliaan hospital, batam. in this study also conducted interviews involving nine main informants and three triangulation informants. results: the average loss value budi kemuliaan hospital in 2017 was rp. 3,898,635, and increased in 2018 to rp.5,597,241,-. low knowledge of health workers about case-mix which causes low cost awareness behavior. there was a low awareness of costs identified in the implementation of clinical pathways and sop in cases of appendicitis acute in general surgeons, resulting in high financing. there was also low management monitoring. this has the potential to be a source of financial loss for hospitals. conclusion: the lack of cost efficiency for appendicitis acute due to lack of cost awareness and monitoring of hospital management, so that it is necessary to carry out periodic monitoring related to the cost awareness behavior of health workers. keywords: cost awareness, appendicitis acute, social security agency for health, bpjs in health, cost efficiency received: 7 february 2019; reviewed: 29 april 2019; revised: 29 june 2019; accepted: 29 june 2019 c©yayasan aliansi cendekiawan indonesia thailand (indonesian scholars’ alliance). this is an open-access following creative commons license deed attribution-noncommercial-sharealike 4.0 international (cc by-nc-sa 4.0) 1. introduction social security agency for health (bpjs in health sector) appointed as the provider of the health service system with quality control and cost control framework [1]. implementation of health services that remain of good quality with efficient cost is carried out by implementing a patient safety program that refers to the edition 1 of the snars accreditation, by using clinical pathways in health services [2]. basically the situation of handling acute appedicitis with both social security agency for health and nonsocial security agency for health is no different. a little difference in terms of the timing of the implementation of the treatment, which social security agency for health patients must queue for surgery. in addition, the basic difference is in the way to hospital payment, if the patient uses bpjs then the payment is in the package system (ina cbgs), while the non-bpjs in health sector patient pays the fee for service system (depending on the type of service provided). financing of patient services for participants of bpjs in health sector for advanced health care providers such as hospitals is carried out with a casemix system or known as indonesian case-based groups (ina-cbgs). this made the hospital has to be observant in financial management because the income of ina-cbgs that are applied for payment of claims for health services for patients can seem 64 ghmj (global health management journal) 2019, vol. 3, no. 2 wardhani aw et al. small due to the presence of actions that did not reach the cost efficiency with a large portion of the cost of the set cost package. this happened due to the mindset of medical personnel in managing the services of patients not yet aware of the costs associated with drug efficiency, disposable materials, or for medical support [3]. bpjs in health sector program implemented by the government using a managed care system, so payment for providers did not use a fee for service pattern but uses a reimbursement system (prospective payment with a predetermined amount of fees). to get the benefit from bpjs in health sector, hospitals must be able to implement efficiency and cost-effectiveness, can develop good health management, good quality coding, claim quality and do not commit fraud. internal and external demands currently influence management of hospitals. the internal demands are formed cost containment (cost control), and the external demands are from stakeholders [4]. the essence of this cost containment was the realization of cost awareness for all parties in the hospital, head of the hospital and management. management is aware that the costs borne by the patient were the result of the work of the employee and all the components involved in the hospital. the management is also aware that no matter how wrong it was done and dissipation will make increasing cost that must be borne by the patient [5]. the doctor’s ignorance of costs, combined with their tendency to underestimate the expensive of drug prices and overestimate the low prices, shows a lack of appreciation of the large differences in costs between cheap and expensive drugs. this difference in appreciation can affect the whole drug expenditure [6]. budi kemuliaan hospital in batam is a non-profit hospital with type b under the budi kemuliaan batam foundation. budi kemuliaan hospital in batam collaborated with bpjs in the health sector since the start of the jaminan kesehatan nasional (jkn) program in 2014. this study used visit data from outpatients in 2017. there are 75,224 people, 58.3% were bpjs in health sector patients while inpatients were 10,390 people, bpjs in health sector patients as much as 63.2%. the majority of surgeons were receiving not much training in the health economy, and have poor knowledge about the costs of surgical equipment. however, there are opportunities to increase cost awareness in the operating room, which can lead to a reduction in dissipation and increased use of resources. many surgical cases at budi kemuliaan hospital in batam have the potential to be one of the examples of general surgery patients with guaranteed bpjs in health sector from inpatient claims data in the general surgery section in the period january to december 2017 totaling 993 patients. hospital income amounting to rp7,084,854,187 (±us$501,597; ±15,398,576 baht); ina-cbg’s income amounted to rp6,987,996,168 (±us$494,739; ±15,188,060 baht); negative difference of rp1,904,678,113 (±us$134,848; ±4,139,722 baht). there were 109 cases of acute appendicitis with appendectomy which caused a potential loss of rp491,043,714 (±us$34,765; ±1,067,258 baht) during 2017. the calculation of the potential loss of the hospital will be more detailed if it is calculated the real costs incurred by the hospital for acute appendicitis services. based on the results of the pre-survey in the budi kemuliaan hospital in batam, several allegations related to the cost of acute appendicitis services that have the potential to loss caused by the lack of understanding of general surgeons related to the function of the clinical pathway and low-cost awareness. so, hospital monitoring and cost control systems is required for these hospital to control costs that are used to perform the surgery acute appendicitis. these things were the basis of the research problem, "how is to analyze the costs awareness of health workers in the efficiency of treatment of acute appendicitis with bpjs in health sector at budi kemuliaan hospital, batam?" 2. method this research was a descriptive study using a qualitative approach with cross sectional design, document review of the procedure for claiming bpjs in health sector on the surgery acute appendicitis, structured and unstructured interviews with informants that have been determined. this research is a descriptive study using a qualitative approach with a cross sectional design, which is carried out by document review of the procedure for claiming social security agency for health in health sector on 65 wardhani aw et al. ghmj (global health management journal) 2019, vol. 3, no. 2 the surgery acute appendicitis and conducting structured and unstructured interviews with informants that have been determined. this study did not involve patients as research subjects, but only health workers, management and hospital owners. the sample in this study were health workers who were directly involved in acute appendicitis treatment measures, amounting to 12 people, including the main informant (9 people) and triangulate informants (3 people). the main informants of this research included 1 permanent general surgeon, 2 part-time general surgeons, 1 operating room nurse, 1 surgical inpatient nurse, 1 inpatient coder, 1 pharmacy/pharmacist head, 1 head of medical services, 1 head of the case-mix/ jkn section and triangulation informants were three informants, namely from the executive board of the budi kemuliaan association, the director of the hospital and the head of finance division. research variables include cost efficiency, knowledge of health workers, cost awareness of behavior, implementation of sop and clinical pathway. data collection was done by in-depth interviews with both the main informants and triangulate informants. qualitative analysis is carried out to see the relationship between research variables, which is done by analyzing the perspective of the main informants and compared with the results of observations and perspectives from triangulation informants. through a variety of perspectives is expected to obtain results closer to the truth. 3. results funding in the treatment of acute appendicitis with bpjs in health sector table 1. comparison of losses incurred in 2017 and 2018 year income of ina-cbgs income of hospital loss 2017 rp396,796,800 rp724,282,165 rp327,485,365 2018 rp407,775,200 rp900,332,424 rp492,557,224 rp1 = ±us$0.000071 = ±0.0022 baht based on the data of acute appendicitis patients in table 1, the trend of income disparity was increased. previously in 2017, the income disparity was negative (loss) of rp327,485,365 (±us$23,184; ±711,773 baht) and become higher with a negative value in 2018 of rp492,557,224 (±us$34,871; ±1,070,548 baht). even though the number of acute appendicitis patients in 2017 was 84 patients and increased to 88 patients in 2018. the average loss value in 2017 was rp3,898,635 (±us$276; ±8,473 baht) and increased in 2018 to rp5,597,241 (±us$396; ±12,165 baht). the value of loss (loss) is determined by several indicators, namely the length of the day of care (los), the use of disposal materials, the use of drugs and medical support (radiology / laboratory) conducted. the impact caused by an increase in losses (loss), then the hospital operating losses will increase, and if the loss (loss) falls, the profit of the hospital will increase. the effort that has been made by the hospital to suppress loss is by forming the casemix team, which is tasked to monitor the costs of bpjs in health sector patient services. table 2 describes cp which shows the implementation of acute appendicitis treatment based on clinical pathway, while ur is a method to ensure service quality related to cost savings. utilization review cost control mechanism by checking whether the service is medically provided and whether the service is given appropriately. of the five acute appendicitis patients, it is known that each service component cost exceeds the costs set at the utilization review. table 3 shows that the conditions in the acute appendicitis service in 2018, the average length of stay (los = length of stay) according to the clinical pathway (cp) is 3 days, but the real condition observed by the average los is 5 days. the average cost of disposal materials according to cp is rp1,106,000 (±us$78; ±2,403 baht) but the real costs incurred are rp1,005,445 (±us$71; ±2,185 baht). the average cost of using drugs according to cp is rp306,000 (±us$21; ±665 baht) but the condition of real costs in service is rp1,257,142 (±us$89; ±2,732 baht). the average cost of medical support (radiology / laboratory) according to cp is rp519,000 (±us$36; ±1,128 baht) but the real costs incurred are rp715,400 (±us$50; ±1,554 baht). 66 ghmj (global health management journal) 2019, vol. 3, no. 2 wardhani aw et al. table 2. data of acute appendicitis patients after utilization review on 2018 data analysis los disposable materials drugs medical support patient 1 cp 3 days rp1,106,000 rp306,000 rp519,000 ur 6 days rp1,298,500 rp1,654,000 rp1,894,000 patient 2 cp 3 days rp1,106,000 rp306,000 rp519,000 ur 6 days rp1,251,500 rp1,341,000 rp744,500 patient 3 cp 3 days rp1,106,000 rp306,000 rp519,000 ur 6 days rp748,500 rp1,585,500 rp289,000 patient 4 cp 3 days rp1,106,000 rp306,000 rp519,000 ur 6 days rp1,185,500 rp622,500 rp392,500 patient 5 cp 3 days rp1,106,000 rp306,000 rp519,000 ur 6 days rp1,368,500 rp3,819,500 rp689,000 rp1 = ±us$0.000071 = ±0.0022 baht table 3. comparison of ur and cp average on 2018 data analysis los disposable materials drugs medical support cp 3 days rp1,106,000 rp306,000 rp519,000 average of ur 5 days rp1,005,445 rp1,257,142 rp715,400 rp1 = ±us$0.000071 = ±0.0022 baht 3.1 knowledge of health workers the results of interviews with the main informants showed that the informants had known the services of acute appendicitis at a low cost, and also knowing that at any point it could cost a lot such as the use of old consumables, drugs, and los. some general surgeons argue that using inexpensive consumables has an effect on patient safety, and the small income of claims is a matter of hospital management, not their responsibility. so that understanding regarding payment for health is limited to just knowing. most informants do not understand and lack knowledge about coding and case-mix. the results of interviews with triangulation informants showed that the costs of acute appendicitis services were known to do a lot of waste done by general surgeons such as the use of consumables. table 4. in-depth interviews conclusions about casemix service cost and payment knowledge informant service cost casemix main it is known that service fees are small most doctors and units do not understand and lack knowledge about coding and case-mix. triangulate there is still a lot of waste on the use of consumables the resume is not filled, and the understanding of the case-mix is still lacking. 3.2 cost awareness behavior the results of interviews with the main informants revealed that many health workers who already knew about the cost of acute appendicitis treatment were low, but there was no awareness to do efficiency in consumables, drugs, and los to reduce losses due to small costs. every general surgeon has their treatment in the treatment of acute appendicitis which also has an impact on the selection of consumables used. the doctor does not approve emphasis on the cost of using cheap consumables because it is feared that it will reduce the quality of services that will also have an impact on the recovery of patients. in-depth results with triangulation informants are known to realize that costs are still low, especially in in guest doctor. there are still services which cost more than the income of ina-cbgs that have been packaged because some still like to experiment in the services of acute 67 wardhani aw et al. ghmj (global health management journal) 2019, vol. 3, no. 2 appendicitis. table 5. conclusion in-depth interviews about cost awareness behavior informant cost awareness behavior main many doctors know that the cost of acute appendicitis treatment is low, but there is no awareness of them to do efficiency in consumables, drugs, and los to reduce losses. triangulate there is no awareness of costs to behave economically to reduce losses. 3.3 implementation of sop and clinical pathway the form of commitment to implement the clinical pathway can be seen from the participation of general surgeons in making clinical pathways. every general surgeon is included in the making of a clinical pathway so that it should be able to hold on to what has been prepared in the implementation of services, but there are still many general surgeons who have not adhered to the clinical pathway that has been prepared with the management of the hospital. ... "if for the procedure in the operating room all must be complete from the laboratory results, content photos and all the preoperative preparations are re-checked after we have prepared it in full, for the appendicitis reference it is simple, so the operation is very simple ... "for operating sops there are and sometimes for sops that have not been obeyed, because each general surgeon is different ... "so the sop in budi kemuliaan hospital, batam is not standard because the general surgeon is different, so it is adjusted to the wishes of general surgeons ... "always quality standards for using packages from the hospital ... "for the quality standard is appropriate, but there are still many general surgeons who use consumables as they wish (main informant 2, male, 68 years old) commitments to implement the clinical pathway have begun with the preparation of the clinical pathway that already exists, and the tariff has been adjusted to bpjs in health sector income. from the calculation when preparing the clinical pathway, it was found that there was no loss of costs and that there was a profit even though the value was small. however, this is uncertain because the hospital has not yet made an analysis and made unit costs for the service of patients with guaranteed bpjs in health sector. one of the triangulation informants in this variable did not know about the formation of the clinical pathway. table 6. conclusions in-depth interviews about the suitability of acute appendicitis treatment with sop and clinical pathway informant services clinical pathway main the available sops have been obeyed some general surgeons follow the sop, and there are also those who use their clinical standards outside the provisions and optionally listed on clinical pathways. triangulate there is but does not affect cost savings not yet maximal and there is no punishment for general surgeons who are wasteful of consumables. there is a conflict of interest in decision making related to the punishment and implementation of the director that is structural and functional. 4. discussion 4.1 cost awareness many general surgeons already knew that the cost of acute appendicitis services in patients with bpjs in health sector insurance exceeds the received income from ina-cbgs so that it has the potential to 68 ghmj (global health management journal) 2019, vol. 3, no. 2 wardhani aw et al. lose money. based on paruntu study in 2012, it was found that the radiographers’ knowledge of costs at the sub-radiology of the navy hospital dr. mintoharjo was sufficient but only limited to any costs incurred because they were not involved in the purchase of health materials [7]. the general surgeons also did not know about the case-mix payment system. there was no cost awareness behavior from general surgeons that can be seen from the implementation of services that have not been by sop and clinical pathway. when general surgeons do not comply with sop, it means that directly, general surgeons do not comply with clinical pathways. general surgeons were involved in the making of clinical pathways, but the implementation was not yet appropriate because the commitment of general surgeons is still low. as a consequence, payment of services for health workers will be reduced, and may not even get payment of services at all. this is because hospitals suffer losses in terms of high maintenance costs but low income because payment is in accordance with the rates set by the bpjs in health sector. ziba rechou in 1992 stated that a person who aware of costs would certainly be able to view costs as important, but cost awareness should be reflected in behavior and thoughts [8]. the implementation of acute appendicitis services that are not by sop and clinical pathways occurs because of every doctor both general surgeons who are permanent and those who are guests, especially senior doctors, they work according to their own work experiences. some of the components that most often experience incompatibility with clinical pathways were the use of disposable materials such as the use of threads that can be different for each general surgeon. cheah in 2000 stated that hr commitment was very important for the successful implementation of the clinical pathway as one of the cost control and quality control tools [9]. spath in 1994 stated that doctor cooperation and acceptance in the implementation of clinical pathways is the key to the successful implementation of clinical pathways [10]. the disobedience of general surgeons to sop and clinical pathways shows a commitment to implement services by sop and the clinical pathway was low so it can be concluded that cost awareness of general surgeons was still lacking. commitments that were included in behavioral or affective commitments relate to the extent to which individuals feel their values and goals are by the values and goals of the organization [11]. 4.2 management monitoring management monitoring carried out on the service of acute appendicitis patients with bpjs in helath sector was by implementing a utilization review and monitoring of hospital income disparity with income from ina-cbgs. utilization review as a control system was intended so health service delivery could be by the patient’s needs, so there will be no fraud from general surgeons by providing excessive health services (overutilization), reducing health services (underutilization), or even providing inappropriate services [12]. the utilization review results in a doctor’s report document. there was no reward for general surgeons who have good report document (not overbilling). when the cost of services that carried out by general surgeons overbilling, it will be a report on the jkn team. furthermore, the jkn team reported to the head of the jkn division. reporting is continued to the head of the medical service, medical committee, and hospital director every once a week. based on existing reports, the director will call and admonish general surgeons who were overbilling in the service of acute appendicitis in patients with bpjs in health sector. management monitoring only comes to reprimand to general surgeons who were overbilling and have no follow-up. monitoring is already underway, but it was hampered by the principle of each doctor which was very difficult to change. in this jkn era, all services are regulated and limited in funding without reducing service quality. doctors must be encouraged to make the transition from the absence of economic thinking to the use of economically oriented devices and drugs. cost considerations in patient care do not have to be seen as decreasing levels of care but as a way to optimize patient care [13]. monitoring of disparity between hospital income and ina-cbgs income in the txt data was carried out by managers, that is the head of the jkn division with ward visitation. the hospital can estimate the advantages or disadvantages obtained from each operation performed by acute appendicitis. the disparity in hospital income and ina-cbgs income cannot yet be guaranteed to loss. calculations will be more certain and accurate using unit cost calculations. the unit cost will specify 69 wardhani aw et al. ghmj (global health management journal) 2019, vol. 3, no. 2 one by one service component, but until now, there has been no unit cost creation. the role of the head of the medical services was still lack of monitoring. the head of the medical services which was also a manager was still limited to receiving reports on the services of doctors who then forward reports to the medical committee and directors. from all reports that have reached the director, there has been no follow-up and only a direct warning that cannot permanently change cost awareness behavior. 4.3 cost efficiency the average cost of the components of patients acute appendicitis with bpjs in health sector in 2018, it was known that cost efficiency was found in the use of disposable materials. based on the interview results, it showed that disposable materials were more expensive than the ina-cbgs package and its use was not controlled. so, there was appeared an imbalance between the results of interviews with secondary data. inequality occurs due to incomplete txt data. the cost component that describes cost inefficiencies was los, drug use, and medical support. walintuka’s research in 2018 stated that the biggest negative difference for the case of appendectomy in gunung maria tomohon hospital was in the third bpjs in health sector treatment class because of the large number of patients and los which tended to be less controlled [14]. the inequality that arises from each component of the service cost of acute appendicitis is strengthened by incomplete txt data. inputting the hospital billing grouping to the txt data variable for bpjs in health sector patient was feared not yet appropriate because there was no monitoring of the data in txt. also, the coders as the jkn team were not medical personnel can be biased arose related to medical language. incomplete data shows that there was a lack of monitoring in-service reporting. all patient data should be inputted and become separate reports. data was an important component to find out whether the service of acute appendicitis was optimal and creates cost efficiency. data was also used in service evaluations that form the basis of policymaking. the role of the manager must be further enhanced in the monitoring and completeness of data related to services to bpjs in health sector patients. 5. conclusion lack of knowledge of health workers about the case-mix payment system that makes awareness behavior low and influences commitment to implement services by sops and clinical pathways. this shows that there is still a low cost awareness in the acute appendictitis service at budi kemuliaan hospital batam which ultimately also has an impact on increasing hospital losses. monitoring was carried out with utilization review, and monitoring disparity cost produces reports to the director, but there has been no follow-up of the results of the report. so that it is necessary to carry out periodic monitoring related to the cost awareness behavior of health workers who provide services for acute appendictitis services as well as other services performed in hospitals. cost awareness behavior monitoring can encourage hospitals in an effort to control the costs incurred for performing acute appendicitis surgery. acknowledgments we thank all who have helped in this research, both in terms of material and non-material support. some of the parties that have contributed to this research are budi kemuliaan hospital, batam; final assignment advisors for public health master’s degree program at universitas diponegoro; and many parties cannot be mentioned one by one. conflict of interest we declare that there is no conflict of interest in this article. 70 ghmj (global health management journal) 2019, vol. 3, no. 2 wardhani aw et al. references 1. social security agency. peraturan bpjs kesehatan no.1 tahun 2014 tentang penyelenggaraan jaminan kesehatan (bpjs health regulation no.1 of 2014 concerning the implementation of health insurance). jakarta: bpjs. 2014. 2. tri, pa. analisis penerapan manajemen pasien. analisis pku muhammadiyah surakarta penerapan manajemen pasien saraf dalam rangka peningkatan mutu pelayanan di rumah sakit (analysis of application of patient management. analysis of pku muhammadiyah surakarta application of management of nerve patients to improve service quality in hospitals). surakarta: 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(online). 2013, http:// mutupelayanankesehatan.net/index.php/component/content/article/22/835, accessed on may 24, 2018. 13. tiong, w.h.c., o’shaughnessy, m., o; sullivan, s,. cost awareness among doctors in an irish universityaffiliated teaching hospital. clinics and practice. 2011;1(4). 14. walintuka, h.c., s.l.h.v. joyce l., jimmy p. analisia perbedaan pendapatan riil dengan pendapatan inacbgs pasien bedah badan penyelenggara jaminan sosial (bpjs) kesehatan di rumah sakit gunung maria tomohon (analysis of the differences of real income with income of ina-cbgs on patients surgery with bpjs health insurance at gunung maria tomohon hospital). community health. 2018;2(4). cite this article as: wardhani aw, suryawati c, and harto p. cost awareness analysis on acute appendicitis treatment with social security agency for health (bpjs in health sector) at budi kemuliaan hospital batam. ghmj (global health management journal). 2019; 3(2): 64-71. 71 https://www.slideshare.net/aak6666/modul-cost-containtment https://www.slideshare.net/aak6666/modul-cost-containtment http://mutupelayanankesehatan.net/index.php/component/content/article/2 2/835 http://mutupelayanankesehatan.net/index.php/component/content/article/2 2/835 introduction method results knowledge of health workers cost awareness behavior implementation of sop and clinical pathway discussion cost awareness management monitoring cost efficiency conclusion knowledge, attitudes, and hiv/aids risk behaviors of myanmar migrant workers in thailand ghmj (global health management journal) 2022, vol. 5, no. 2 indonesian scholars’ alliance open access photo essay politeknik kesehatan kemenkes palangka raya: health forum and international seminar the new normal : creating a pleasant virtual communication family emotional communication in caring for patients with covid-19 at home: personal experience and story agnes dewi astuti department of nursing, poltekkes kemenkes palangka raya, indonesia *corresponding author’s email: agnesdewiastuti1980@gmail.com; agnes_senada@poltekkes-palangkaraya.co.id doi: 10.35898/ghmj-52935 selection and peer-review under responsibility of the scientific committee and the editorial board of the annual health forum and international seminar of the politeknik kesehatan kemenkes palangka raya © yayasan aliansi cendekiawan indonesia thailand (indonesian scholars’ alliance). this is an open-access following creative commons license deed attribution-noncommercial-sharealike 4.0 international (cc by-nc-sa 4.0) corona virus disease 2019 (covid-19) is a new type of disease that has occurred starting in 2019 which is caused by the coronavirus (kementerian kesehatan republik indonesia, 2019). this disease is a health problem for all human beings in the world, because it is a contagious and deadly disease. this is something that is frightening to everyone, where we will lose our health conditions, lose our loved ones, change our life patterns and we must comply with various phenomena in life (abudi et al., 2020). this condition is experienced by many people, groups and families today regardless of one’s status and position. this also happened in my family, where my parent and child were infected with the covid-19 virus. the family is the smallest unit in community which consists of two or more individuals who are joined by blood, marital relations or adoption, live in one household, interact with each other and have their respective roles and create and maintain a culture. all families in the world feel the impact of this covid-19 pandemic condition, especially for my family who has several family members diagnosed with covid-19 based on the results of a pcr (polymerase chain reaction) or swab (kementerian kesehatan republik indonesia, 2019). figure 1. pcr (polymerase chain reaction) examination or swab. mailto:agnesdewiastuti1980@gmail.com mailto:agnes_senada@poltekkes-palangkaraya.co.id https://dx.doi.org/10.35898/ghmj-52935 105 ghmj (global health management journal) 2022, vol. 5, no. 2 astuti ag the family has a role to foster and guide its members to adapt to every change that occurs in the family, namely the change from being healthy to being sick (harmon hanson, 2005). information for my family about family members diagnosed with covid-19 raises anxiety, fear in dealing with this condition, especially a lot of information that sometimes views the negative side of people with covid-19. from result observations, changes in communication and social life between humans change over time quickly with the emergence of prejudice against people diagnosed with covid-19 (dani & mediantara, 2020). but life must go on, as well as my family where i am temporarily the head of the family who has an important role in building and creating good and conducive conditions for all family members so that the family can have resilience and strength in dealing with this problem, one of which is through family emotional communication. when one or two of my family members were diagnosed with covid-19, the others members must try to be able to express emotions in each of us in a good way for example, in how to communicate in expressing sadness, anger, anxiety and fear to avoid alienation and confusion when interacting with one another. some rules that can be done are with affection that fosters love, appreciation, praise, focus on positive things and share gratitude and learn to understand what is heard in order to bring closeness (fauziah & afrizal, 2021). i have to implement peaceful communication, with correct information and ensure that these conditions are things that must be lived together, so that openness is needed for all families about what they feel, what they think, what they want, and what is needed because a disease pandemic situation that affects people's psychology widely and massive, starting from the way of thinking in understanding information about health and illness, changes in emotions (fear, worry, anxiety) and social behavior (avoidance, stigmatization, healthy behavior) (agung, 2020). for my family members who suffer from covid-19, treatment is carried out using independent isolation techniques both in the hospital and at home. this can make them feel alone and unnoticed. quarantine conditions will increase anxiety and isolation which can cause a person to experience anxiety and depression. conditions will be increasingly depressed because our culture is accustomed to establishing a social relationship with other people and because of the confirmed condition of covid-19, the activities of family members must be limited so that they need the support of others, especially family. when cases of covid19 become a pandemic, who asks citizens to stay at home or self-quarantine. sports centers and locations that are usually crowded with individuals are temporarily closed. residents have to stay at home for long periods of time, this can pose a huge challenge to staying physically active. sedentary behavior and low levels of physical activity can negatively impact an individual's health, well-being and quality of life. quarantine itself can also cause additional stress and can disrupt people's mental health. physical activity and relaxation techniques can be used as good ways to help achieve calm and maintain physical and mental health. the family facilitates in order to keep doing activities that are safe and healthy for all family members (sari, 2020). figure 2. my mother is behind the glass window during self-isolation or quarantining in the room astuti ag ghmj (global health management journal) 2022, vol. 5, no. 2 106 the family is part of a social being and is also an emotional creature, in which family support must be provided with the right techniques so that support can be felt and interpreted by the family properly, one of which is in the form of emotional communication. the ability to communicate emotions through emotional intelligence reminds us that emotions are part of our humanity and will always be present with us. our presence through good emotional communication will make families able to survive the current pandemic situation. when we feel wrong, we dare to admit it and when we are right, we try to remain calm and quiet. when my son forgot to wash his hands after playing with his beloved dog, he spontaneously said "ouch i forget" and then he rushed to wash his hands immediately. family facilitates family members to stay healthy, happy with everything around them. positive and effective communication in the family will foster a sense of security and comfort for all family members during the covid-19 pandemic (rayani, 2021) figure 3. playing with pets can be comforting in sorrow with due observance of health protocols i try to provide support to them through my words, attitudes and deeds by continuing to talk and discuss them with love, trust and confidence in them that they can get through this independent isolation well, so that it will speed up the healing process. what i can do is how to increase the immune system of my children and my mother, and reduce the aggravating condition because my elderly mother has other diseases (comorbid) by making them happy and happy with all their activities while being isolated because with high family support can improve the spirit and quality of life of the elderly with covid-19 (putri wiraini et al., 2021). figure 4. my mother made a video call with her sister and always make them happy 107 ghmj (global health management journal) 2022, vol. 5, no. 2 astuti ag another form of communication is that i try to make us all open up to each other by expressing our feelings and thoughts, when my husband had to be hospitalized and my child and mother were isolated independently at home. my family used online media, for example to create a "senada" family group to be able to communicate online because of the pandemic condition, we must keep our distance. figure 5. similar family groups on social media (wa) in the media, we tell each other how conditions are with each other, how they feel every day, give each other strength and pray for each other. groups as a means of communication that provide an overview of the condition of family members in order to reduce anxiety because of a family bond. emotional communication that exists in the family makes family members also feel what other family members feel can be done by trusting each other, being open and receiving information received by confirming (rayani, 2021). when my husband asked about the news "how are you kids? is it okay for all of you at home?", and i immediately replied "we're fine, you must still strong, excited and get well soon, we all love you daddy. ", my two children also replied to the chat with the same chat" rafa love daddy, have you eaten? how was it in the hospital, dad, did you sleep well? ”husband replied to the chat,“ daddy also loves you all, daddy has eaten just now and daddy is good sleeping here”. oral or written communication is conveyed as support for families to be able to go through this tough time together. family group media can also convey information related to covid-19. my husband, my children, and i share information on how to prevent and treat covid-19 patients. my family must be able to ensure that the information received is valid and reliable by avoiding false or hoax news or information. the conditions of the covid-19 pandemic also demand a change in the structure of my family, especially in living a healthy life with 3m (using masks, maintaining distance and avoiding crowds) (kementerian kesehatan republik indonesia, 2019). these changes in lifestyle have made my family have to be able to give understanding to all family members by communicating well and correctly. the obstacle that can occur is the disorder of one family member in obeying the rules, for example not using a mask, coughing in an inappropriate way, this can have a negative impact on other family members, because covid-19 is a disease that can be transmitted quickly through the air or something we touch. sometimes if the information we convey continuously every day will have an impact on boredom and displeasure, especially in children, and eventually there will be indifference to important information that we remind us. families need patience in conveying information and, if necessary, families can also use communication techniques in writing but fun, for example by using picture media posted on the walls of children's rooms, in order to remind people about health protocols that must always be carried out in the family. astuti ag ghmj (global health management journal) 2022, vol. 5, no. 2 108 figure 6. reminded of health protocols via embedded pictures. the family has a role in family health care to achieve the health conditions of all family members (harmon hanson, 2005). after undergoing treatment for about 3 weeks, my husband, my big son and my mother were declared cured with a health certificate from the hospital. this situation made my family happy and thanked god for his great love and i feel very proud of my husband, children and mother who have managed to go through the treatment and treatment period courageously and patiently by going through the swab examination process many times until finally the result is negative. figure 7. the results of the swab examination which state that my child recovered from covid-19 figure 8. they can play together again and be happy while adhering to health protocols. 109 ghmj (global health management journal) 2022, vol. 5, no. 2 astuti ag the current condition has changed, after all family members are declared healthy and with a new order in society, we are jointly committed to sticking to health protocols at home, for example always wearing masks and face shields, always washing hands diligently, maintaining distance. all done with sincerity and joy, because it is a must so that all family members can stay healthy. all my family activities inside the house and outside the house, still pay attention to and apply health protocols. the past experience is a valuable experience for us as a family, so that we always pay attention to personal health, family and the environment around them. the family always maintains interpersonal communication, is mutually responsible for maintaining personal and family hygiene with a healthy lifestyle, and is open in communicating all problems that exist in the family (kuswanti et al., 2020). through the ability to communicate emotions, families are expected to strengthen each other so that they can survive the covid-19 pandemic together. consent the family (identifiable) photograped have given their consent for their pictures to be used in the dissemination and publication of this paper. conflict of interest none acknowledgments the author would like to thank all those who have supported and helped all my family members in the process of healing the covid-19 disease and thank you for the enthusiasm that has been given to me so that i can be strong in providing support for my family. references abudi, r., mokodompis, y., & magulili, a. n. (2020). stigma terhadap orang positif covid-19. jambura journal of health sciences and research, 2(2), 77–84. https://doi.org/10.35971/jjhsr.v2i2.6012 agung, i. m. (2020). memahami pandemi covid-19 dalam perspektif psikologi sosial. psikobuletin: buletin ilmiah psikologi, 1(2), 68–84. https://doi.org/10.24014/pib.v1i2.9616 dani, j. a., & mediantara, y. (2020). covid-19 dan perubahan komunikasi sosial. persepsi: communication journal, 3(1), 94–102. https://doi.org/10.30596/persepsi.v3i1.4510 fauziah, n., & afrizal, s. (2021). dampak pandemi covid-19 dalam keharmonisan keluarga. sosietas jurnal pendidikan sosiologi, 5(1), 973–979. harmon hanson, s. m. (2005). family health cara nursing: theory, practice and research. in family health care nursing. f.a davis company. kementerian kesehatan republik indonesia. (2019). pedoman pencegahan dan pengendalian coronavirus disease. 4, 1– 214. kuswanti, a., munadhil, m. a., zainal, a. g., & oktarina, s. (2020). manajemen komunikasi keluarga saat pandemi covid-19. salam: jurnal sosial dan budaya syar-i, 7(8), 707–722. https://doi.org/10.15408/sjsbs.v7i8.16552 putri wiraini, t., zukhra, r. m., & hasneli, y. (2021). hubungan dukungan keluarga dengan kualitas hidup lansia pada masa covid-19. health care : jurnal kesehatan, 10(1), 44–53. https://doi.org/10.36763/healthcare.v10i1.99 rayani, d. (2021). pentingnya pembiasaan komunikasi positif dalam keluarga di masa pandemik covid 19. realita : jurnal bimbingan dan konseling, 5(2), 1067–1075. https://doi.org/10.33394/realita.v5i2.3414 sari, i. (2020). analisis dampak pandemi covid19 terhadap kecemasan masyarakat : literature review. bina generasi : jurnal kesehatan, 12(1), 69–76. https://doi.org/10.35907/bgjk.v12i1.161 cite this article as: astuti, ad. family emotional communication in caring for patients with covid-19 at home: personal experience and story. ghmj (global health management journal). 2022; 5(2):104-109. doi:10.35898/ghmj-52935 https://dx.doi.org/10.35898/ghmj-52935 microsoft word 3. accepted original, thang hoang nghia, 25-31.docx cite this article as hoang tn, pham dt, thu hnt. sentinel surveillance for hiv among people who inject drugs at gia lai province, vietnam. global health management journal. 2018; 2(2): 2531. global health management journal www.publications.inschool.id published by original research article issn 2580-9296 (online) sentinel surveillance for hiv among people who inject drugs at gia lai province, vietnam thang nghia hoang*, duoc tho pham, ha nguyen thi thu tay nguyen institute of hygiene and epidemiology, buon ma thuot, dak lak, vietnam. *corresponding author. email: nghiathang2k5@gmail.com article info abstract article history: received 28 may 2018 reviewed 31 may 2018 received in revised form 11 june 2018 accepted 29 june 2018 background: hiv remains a public health challenge, especially among people who inject drug (pwid). the hiv sentinel surveillance (hss), together with the hiv/aids case reporting, are two core components of the hiv/aids surveillance system providing systematic, on-going monitoring of hiv epidemic in viet nam. the hss was first conducted in 1994 to determine hiv prevalence among the high-risk group by collecting blood sample. but in 2009, this system was monitored the risk behaviors by addition of a brief behavioral questionnaire, known as hss+. in central highland, the hiv situation in gia lai province has primarily affected pwid, which are main criteria to select into the surveillance system. aims: this study aims to determine risk factors for hiv infection to improve intervention programs for pwid in gia lai province, vietnam. methods: we performed a cross-sectional survey of 150 randomly selected pwid from june to september 2014 in gia lai province. face-to-face interviews were conducted to collect information regarding drug use, sexual behavior, accessibility of hiv/aids counseling and testing services. blood samples were collected and tested for the presence of hiv antibodies using elisa and rapid test. for data analysis, the frequencies and proportions were calculated. chi-square or fisher’s exact tests and multivariable logistic regression were performed to assess the association between risk factors and hiv infection. results: we identified 14 infections among 150 pwid (prevalence = 9.3%). among pwid, 22.7% (34/150) had shared needles and 3 hiv prevalence among pwids injecting drug for at least 3 years was 2.4%. hiv prevalence among pwids who have had sexual intercourse with more than one commercial sex worker (csw) per month was 6.5%. in multivariable logistic regression, the odds of hiv infection with sharing needles, injecting for over 3 years, and sexual intercourse with more than one csw per month was 6.7 (95% ci: 1.6-27.7), 6.1 (95% ci: 1.2-30.3) and with 4.0 (95% ci: 1.0-15.3), respectively. conclusion: we identified a few modifiable risk factors among pwid. based on these data, we recommend improving harm reduction intervention and behavior change communication. the sentinel surveillance site should continue monitoring pwid behavior over time. keywords: hiv sentinel surveillance people who inject drug (pwid) gia lai vietnam © 2018 publications of yayasan aliansi cendekiawan indonesia thailand this is an open-access following creative commons license deed – attribution-noncommercial-sharealike 4.0 international (cc by-nc-sa 4.0) introduction in vietnam, a total of 216,254 hiv infections have been reported as of 30 november 2013 since the hiv became a notifiable disease in 1994 [1]. half of the hiv-infected individuals have been people who inject drugs (pwid) [2]. almost hiv-infected individuals have been people who inject drugs global health management journal, 2018, vol. 2, no. 2 26 (pwid) (pwid: 39.2% and heterosexual sex: 18%) [2]. hiv continues to affect high-risk groups such as pwid (incidence: 10.3%), commercial sex workers (csws) (incidence: 2.6%), and men who have sex with men (msm) (incidence: 3.9%). hiv continues to affect high-risk groups such as pwid, commercial sex workers (csws), and men who have sex with men (msm). geographic differences have been reported, such as in north western vietnam transmission among pwid appears to be more prevalent, whereas in south western vietnam sexual transmission is the top mode of hiv transmission [2]. the hiv sentinel surveillance (hss) and the hiv sentinel surveillance combine with behavioral (hss+) is national sentinel surveillance, which conducted annually, from may to september. first training and planning activities usually take place in may and provinces are expected to send data to regional or national institutions by the end of october. testing for hiv follows strategy 2, which means that only two types of testing methods with different assays, and therefore the test results are not confirmed by a third test to enable the confirmation for those who were screened positive of their results. the hss together with the hiv/aids case reporting, are two core components of the hiv/aids surveillance system providing systematic, on-going monitoring of hiv epidemic in viet nam. the hss was first conducted in 1994 in 10 provinces and then expanded to 12 provinces in 1995 and eventually to 40 out of 63 provinces nationally in 2003. it is expected that the hss data will provide evidence for (1) describing prevalence of hiv in different population groups; (2) monitoring trends of hiv prevalence among different sentinel populations; (3) programming and planning hiv activities in the provinces; and (4) serving as a key source of data for hiv estimation and projection at the national level. since its implementation, the hss targets two different groups of populations: (i) most at risk populations (marps) including pwid, csws, and msm and (ii)non marps including urban and rural pregnant women, males with sexually transmitted infection, tuberculosis patients and military recruits. since 2009, world health organization (who), vietnam administration of hiv/aids control (vaac), and national institute of hygiene and epidemiology (nihe) piloted a brief behavioral questionnaire added to hss. the revamped surveillance system is now known as “hss+”. hss+ includes behavioral questionnaires for three marps groups, and these questionnaires contain key behavioral indicators in addition to hiv prevalence. after the success of the pilot, who and joint united nations program on hiv and aids (unaids) advocated the vaac to expand the hss+ to as many hss provinces as a resource allows. in 2013, the number of provinces that implemented hss and hss+ increased to 40, with 22 provinces implementing hss+. in gia lai, which is one of the mountainous provinces in central highland with more than 1.4 million people in 2013, the hiv epidemic has primarily affected pwid. the hiv rates per 100.000 persons were 58 in the province. moreover, the hiv prevalence of gia lai province in according to the hiv surveillance data as of september 2014, 36% of 785 hiv-infected cases in the province were pwid, 2% were csw [3]. in central highland, gia lai is only province, which was included as part of the hss in 2004 and hss+ in 2012 to detect and identify hiv-infected individuals. in addition, the province has made efforts, such as free needles distribution programme and harm reduction activities, to implement hiv/aids prevention and control activities to reduce hiv. to date, despite the aforementioned efforts, gaps remain. first, the intervention programmes have not necessarily covered high-risk groups in gia lai province. second, risk behaviors and access to intervention services have not been well-studied, mainly because such data were unavailable. as of 2012, the sentinel surveillance system has collected behavioral information, providing an opportunity to investigate risk behavior related to hiv transmission among pwid in gia lai. there are many studies on hiv, but lack of study on risk behavior in gia lai province. in 2011, the behavioral and biological survey among pwid in central highland showed that gia lai was highest hiv prevalence (19.3%), following kon tum (11.4%), dak nong (8.4%) and dak lak province (6.4%) [4]. therefore, our findings aimed to determine risk factors for hiv infection by analyzing 2014 hiv sentinel surveillance data in gia lai, with the hopes of providing evidence to improve intervention programmes for pwid in gia lai province. methods study design and subject selection we performed a cross-sectional survey of 150 randomly selected pwid from june to september 2014 in gia lai province. this study is a part of the 27 global health management journal, 2018, vol. 2, no. 2 national hiv sentinel surveillance data, which compile information from annual cross-sectional studies that are performed according to the national technical guidelines for hiv/stis sentinel surveillance [5]. this cross-sectional study involves face-to-face interviews to collect information about drug use, history of drug use, and sexual behavior. in addition, the blood samples were collected and tested to determine the hiv status according to the guidelines [5]. for the purpose of our data analysis, individuals who were aged 16 years or older and have injected drugs in the past one month were identified using the provincial surveillance data, labor department records, and police records and were included in the analyses. data analysis we first used descriptive statistics to describe the data. chi-square or fisher’s exact tests were then used to compare proportions of hiv status among pwid with potential risk factors such as ever sharing needles, duration of drug use, ever having vaginal intercourse with csws, frequency of vaginal intercourse with csws in the past month and age. multivariable logistic regression was performed including the variables that were significant in the chi-square tests, to examine risk factors for hiv infection among pwid. for each variable, the odd ratio, 95% confidence intervals and p-values were calculated. the pvalue of less than 0.05 was considered to be statistically significant. the data were analyzed by epi-info 7.1 (cdc, atlanta, ga, usa). ethics the study was approved by irb of national institute of hygiene and epidemiology, vietnam on 27th may 2014 (reference number: vn01059-07). written informed consent was signed by all participants. extended information on material and methods have been reported previously. results descriptive analysis there were 150 pwid in 2014. the average age was 27 years (range 17-53 years) with the 20-24 year-old age group representing the largest group (30.7%) (table 1). in addition. the average age of the initiation of injection drug use was 23 years (range 14-46 years). there were 64.7% (97/150) who knew the place providing hiv testing service. of the 150 pwid, 14 were hiv positive, giving the prevalence of 9.3%. among the 150 pwid, 67 (44.7%) reported injecting drugs for more than 3 years, 50 (33.3%) reported having ever shared needles, and, of those who reported sharing needles, 34 (22.7%) reported sharing needles in the past one month. forty-six (30.7%) pwid reported having vaginal intercourse with csws and of those who had vaginal intercourse with csws, 11 (8.1%) reported having vaginal intercourse more than 1 time in the past month. there were remained the pwid do not use condom during intercourse with csws. among 139 pwid who reported having recent vaginal intercourse with either regular partners or csws, 81 (58.3%) regularly not used condoms (see table 1). risk factors for hiv the univariate analysis identified ever sharing needles, duration of injection drug use, ever having sex with csw, and frequency of sex with csw in the past month as significant risk factors for hiv infection (table 2). in multivariable analysis, all of these risk factors, but ever having sex with csw, remained significantly associated with hiv infection. the univariate analysis represented that the age group was not significantly difference between aged under 25 and aged more than 25. those people sharing needles and people injecting drug more than 3 years are more likely infected with hiv (0.1 times) than people who do not sharing needles and injecting drugs less than 3 years (p<0.05). the respondents have intercourse with csw have 0.3 times infected with hiv higher than those who do not have sex with csws (p<0.05). but pwid had intercourse with csws more than one time per month have 0.2 times higher than those who have intercourse with csws less than one time per month (p<0.05). moreover, the group aged 25 or older had 0.6 times infected with hiv than pwid under 25 years, but not statistically significant (p>0.05). in the results of multivariable showed that people sharing needles, injecting drugs seniority, sexual intercourse with csws and sexual intercourse with csws once per month, but age group had statistically significant with hiv status (p< 0.05). the people share needles have 6.7 times most likely at risk of hiv infected than those who do not sharing needles (95% ci: 1,6-27, p<0.05). the people injecting drugs more than 3 years have 6.1 times most likely to infect hiv than people injecting drugs under 3 years (95% ci: 1,2-30,3, p<0.05). other risk behaviors of pwid is having sex with csws, the results represented that the people global health management journal, 2018, vol. 2, no. 2 28 intercourse with csws has 1.8 times most likely at risk of infected with hiv than who do not have sex with csws, but the not statistically significant with hiv status (95% ci: 0.5-6.3, p>0.05). especially, the frequency of sexual intercourse with csws has 4.0 times most likely infected with hiv than those who had intercourse with prostitutes once per month (95% ci: 1,0-15,3, p<0.05). table 1. the characteristics of pwid in gia lai 2014 characteristics frequency (n) percentage (%) marital status (n=150) single 84 56.0 married 63 42.0 divorced 2 2.0 age group (n=150) <20 years 28 18.7 20-24 years 46 30.7 2530 years 33 22.0 >30 years 43 28.6 knew the place providing hiv testing service (n=150) yes 97 64.7 no 53 35.3 had ever sharing needles (n=150) yes 50 33.3 no 100 66.6 sharing needles in the past 1 month (n = 150) yes 34 22.7 no 116 77.3 duration of injection drug use (n=150) <3 years 83 55.3 ≥ 3 years 67 44.7 ever having vaginal intercourse with csws (n=150) yes 46 30.7 no 104 69.3 frequency of vaginal intercourse with csws in 1 month (n=136) ≤ 1 time 125 91.9 >1 time 11 8.1 using condom in most recent vaginal intercourse with csws (n=139) yes 58 41.7 no 81 58.3 discussion overall, the finding showed that 22.7% (34/150) had shared needles and 30.7% (46/150) had vaginal intercourse with csws in pwid group in gia lai. the study demonstrated three main risk factors for hiv infection among pwid in gia lai: having vaginal intercourse with csws in the past one month; ever sharing needles; and duration of injecting drugs over 3 years. 29 global health management journal, 2018, vol. 2, no. 2 table 2. the risk factors for hiv status among pwid in gia lai province in 2014 independent variables univariate multivariable hiv status (n=150) hiv status (n=150) positive n (%) negative n (%) or (95% ci); p value or 95% ci p value age group 0.5 (0.2 – 1.6); 0.284 < 25 years (ref) 5 (7.1) 69 (93) ≥ 25 years 9 (11) 67 (89) had ever sharing needles 0.1 (0.03 – 0.38); <0.001 no (ref) 3 (3.0) 97 (97) 1 yes 11 (22) 39 (78) 6.7 (1.6-28) 0.009 duration of injecting drugs 0.1 (0 – 05); 0.001 <3 years (ref) 2 (2.4) 81 (97.6) 1 ≥ 3 years 12 (18) 55 (82) 6.1 (1.2-30) 0.028 vaginal intercourse with csws 0.3 (0.1 – 0.9); 0.024 no (ref) 6 (5.8) 98 (94.2) 1 yes 8 (17.4) 38 (82.6) 1.8 (0.5-6.3) 0.382 frequency of vaginal intercourse with csws in 1 month 0.2 (0.04 – 0.8); 0.045 ≤ 1 time (ref) 8 (6.5) 117 (93.5) 1 >1 time 3 (23.0) 8 (77) 4.0 (1.0-15) 0.043 note: or: odds ratio. ci: confidence interval in our analysis, hiv prevalence among pwid in gia lai province was 9.3%. this result is similar with hiv sentinel surveillance in 2013 (9.3%), but lower than 2012 (9.7%) [6]. this result also is lower than that 19.7% of pwid estimated by the study of integrated biological and behavioral in the broader region of the central highlands of vietnam in 2011, and in ho chi minh city (46.1%), but was higher than da nang city (1%) [4, 7, 8]. moreover, the finding was inconsistent with the study in other countries including indonesia with high hiv prevalence in 2010 (60%) [9]. the hiv prevalence decline in comparison with previous studies may have been due to effective intervention strategies in pwid group conducted in 2014 in gia lai province, but the potential risk for community remaining as the hiv control challenge [2]. it is anticipated that pwid population in gia lai would face the threat of hiv infection, especially among needle sharing group. this study demonstrated that 22.7% of pwid had ever shared needles in the past month. this result was lower than other studies conducted in 20122013 (35.9% and 71.2%, respectively) and was lower than other provinces such as ho chi minh city (39.3%), da nang city (39%) in 2013 [2, 3]. moreover, this finding was lower than the similar study in dak lak provinces (76%), bac giang province (16.3%), thai nguyen province (15%), but higher than the similar study in hue city (18.7%) [10, 11, 12, 13]. the study in 23 cities of american showed 31.8% of pwid sharing needles, which was higher than this finding [14]. the result was similar with study in hanoi and ho chi minh city, where the pwids remained high hiv infection due to risk behaviors such as the history of infecting and the durian of injecting drugs [15]. this suggests that behavioral modification and safe injection counseling programs between 2012-2013 in gia lai were effective/successful in targeting pwid. the multivariable analysis supported our conclusion that sharing needles and longer duration of injecting drugs were associated with a higher risk of hiv infection. [15, 16]. in this study, there was 30.7% pwid reporting that they had ever had vaginal intercourse with csws, and global health management journal, 2018, vol. 2, no. 2 30 58.3% pwid having sex without using condom in the most recent. this percentage decreased from the result of hiv sentinel surveillance in 2012 and 2013 (68% and 61%, respectively) [1]. however, the figures are still higher than the national average in 2013 in having intercourse and in frequency of intercourse with csw (23% and 37.1%) [10]. this result were lower than the study in hue city with 44.7% pwid had intercourse with csws [13]. the multivariable analysis showed conclusion that the pwids with frequency of sexual intercourse with csws were associated with hiv infection [1, 16]. this risk behaviors among pwid in gia lai will lead to potential infection for the community. the findings possibly reflecting ineffectiveness and/or limited implementation of harm reduction activities specifically for csws by local government. main interventions were behavioral change communication activities and voluntary counseling and testing services offered only at provincial hiv/aids center, restricting access to those who live in remote areas. this study has a few limitations. first, additional risk behavior questions that are not currently included in the pwid questionnaire, such as sexual behaviors with men who have sex with men (msm), and regular sex partners, would have improved our understanding of different risks in pwid. second, the respondents may not have answered truthfully to the interview questions that are part of the hss+ questionnaire. third, the figures we presented may have underestimated the pwid population because pwid often fear capture by police and therefore may not admit injecting drug use. in addition, the data sources capturing pwid population are limited. however, we explored all possible sources to identify pwid. conclusion hiv prevalence among pwid in gia lai was 9.3%, where working age group, specifically ages between 20 and 24, was most prominent. there are 30.7% sharing needles and of which 58.3% had sex with csws without using condom. especially, there was remaining 22.7% pwid sharing needles. most frequent risk behaviors included ever sharing needles; duration of injecting drugs over 3 years; having sex with csw in the past one month. based on the findings, the further studies should be conducted to better understand underlying reasons for needle sharing behavior among pwid to provide evidence for future hiv prevention and interventions. the study findings suggest the need for strengthening harm reduction programme implementation by local government such as “free needles distribution”, “volunteering counseling and testing services”, and “methadone treatment”. the sentinel surveillance should continue to monitor the risk behaviors among pwid in gia lai, vietnam. acknowledgement the authors would like to thank dr. amy kasper (wpro), dr. mikiko senga (wpro), dr. hien do (who vietnam) and dr. matt moore (cdc vietnam) for their thoughtful review of the manuscript. conflict of interests none declared. references 1 abdala, n., white, e., toussova, o. v., krasnoselskikh, t.v., verevochkin, s., kozlov, a. p., and heimer, r. (2010). comparing sexual risks and patterns of alcohol and drug use between injection drug users (idus) and non-idus who report sexual partnerships with idus in st. petersburg, russia. bmc public health. 2010; 10: 676. 2 national hygiene and epidemiology institute (2013). hiv/aids integrated biological and behavioral in 2013. vietnam administration of hiv/aids control (vaac). 2013 3 provincial hiv/aids authority center (pac) gia lai. annual report of gia lai province 2013. provincial hiv/aids authority center (pac) gia lai. 2013 4 vietnam ministry of health. integrated biological and behavioral survey among pwid in central highland 2011. vietnam ministry of health. 2013 5 a vietnam ministry of health. circular no.09/ttmoh in 24/05/2012 about guidelines of sentinel surveillance on hiv/stis. vietnam ministry of health. 2012 6 vietnam administration of hiv/aids control (vaac). vietnam sentinel surveillance report 2012. vietnam administration of hiv/aids control (vaac). 2012 7 national hygiene and epidemiology institute (2011). the hiv/sti integrated biological and behavior surveillance in vietnam — round ii 2009.usaids, cdc. 2011. 31 global health management journal, 2018, vol. 2, no. 2 8 vietnam ministry of health. hiv/aids situation and intervention programme report 2011. vietnam ministry of health. 2012 9 shelly i, diba b, teddy h, ike mp, lucas p. (2010). high-risk behavior for hiv transmission among former injecting drug users: a survey from indonesia. bmc public health, 2010; 10: 472doi:10.1186/1471245810472. 10 ha nguyen t. m., anh h. t., the risk of hiv infection among people who inject drugs in 4 bolder provinces, vietnam. vietnam population and development journal. 2015. 9 (173). 11 long n, t., huong p. t. t., et al . risk behaviors and hiv prevalence among people who inject drugs in mountainous areas in bac giang province 2010. practical medicine journal.2010; (743): 197-199. 12 anh hoang, son hoang thai (2010). risk behaviors and hiv prevalence among people who inject drugs and commercial sex worker in thai nguyen province 2010. practical medicine journal.2010; (743): 139-143. 13 son ly van, thanh d. c., ngoc t. t., et al. the situation of hiv infection among people who inject drugs in hue city 2014. the preventive medicine journal. 2016; 9(182). 14 centre for disease control and prevention (2005). hiv associated behaviors among injecting drug users 23 cities, united states, may 2005 february 2006. cdc, april 10, 2009; 58(13): 329 332. 15 bdul-quader, a.s., quan, v.m., & o’reilly, k. a tale of two cities: hiv risk behaviors among injecting drug users in hanoi and ho chi minh city, vietnam. drug and alcohol review. 1999; 18, 401-407. 16 taryn vian, katherine semrau1, davidson h. hamer., le thi thanh loan, and lora l. sabin,hiv/aids-related knowledge and behaviors among most-at-risk populations in vietnam, science journal of public health. 2014; 2(3): 209-215 cite this article as huong dtt. social factors associated to the multiple risk behaviors among high school students: a case study of hanoi high school students, vietnam. global health management journal. 2018; 2(3): 48-56. global health management journal www.publications.inschool.id published by original research article issn 2580-9296 (online) social factors associated to the multiple risk behaviors among high school students: a case study of hanoi high school students, vietnam duong thi thu huong sociology department, academy of journalism and communication, 36 xuan thuy, cau giay, hanoi, vietnam. *corresponding author. email: duonghuong_xhh@yahoo.com article info abstract article history: received 30 april 2018 reviewed 04 june 2018 received in revised form 10 october 2018 accepted 21 october 2018 background: young people who engaged in different risk behaviors attracted concern nowadays. noticeably, the concurrent multiple risk behaviors generate adverse effect to health and their future life. aims: the objectives of this study were to investigate the prevalence of the concurrent multiple risk behaviors and to evaluate the association between social factors and the concurrent multiple risk behaviors among the high school students in hanoi, vietnam. methods: a quantitative survey with a cross sectional design was applied involving a total of 1,333 hanoi high school students. the survey was conducted in the end of 2016. the multivariate linear regression models were applied to examine the social factors associated with the concurrent multiple risk behaviors of hanoi high school students. eighteen different risk behaviors had been selected for constructing a composite variable of the total risk behaviors that students have engaged in. results: on average, the high school students have been reported involving in 4.88 behaviors of the 18 selected observed risk behaviors. the multivariate linear regression models with demographic factors and different social connections of high school students could explain for about 37.6% of the difference in composite variable of the total risk behaviors. this present study reveals several factors that increase the number of risk behaviors the students may engage, including the connection to the family's members or friends, duration in social media, and the number of friends in the online network. in the contrast, strong family connection has been demonstrated to provide a "safe haven" for protecting the high school students from involving in increasing multiple different risk behaviors. conclusion: the research findings strongly recommend early prevention strategies should be conducted among the high school students. the identified concurrent risk behaviors should be targeted as prevention actions rather than focusing on controlling individual risk behaviors. in addition, the involvement of their parents and friends are suggested to be the target audience together with students in concurrent risk behaviors controlling and preventing programs among the high school students and young generation. keywords: risk behaviors social factors high school students adolescents vietnam © 2018 publications of yayasan aliansi cendekiawan indonesia thailand this is an open-access following creative commons license deed – attribution-noncommercial-sharealike 4.0 international (cc by-nc-sa 4.0) http://publications.inschool.id/index.php/ghmj/index http://publications.inschool.id/ http://publications.inschool.id/index.php/ghmj/index http://inschool.id/ mailto:duonghuong_xhh@yahoo.com http://inschool.id/ http://creativecommons.org/licenses/by-nc-sa/4.0/ 49 global health management journal, 2018, vol. 2, no. 3 introduction risk behaviors involvement by adolescents is a noticeable issue all over the world as it relates to the physical, mental health as well as the future's prospect of the of the young generation. many evidences from social studies showed that adolescent is now facing with the risk of involving in many different risk behaviors [1]. it also poses a threat to their future with many different diverse health consequences and then challenges the socio economic development and the social burden [1, 2, 3, 4, 5]. according to the world health organization (who), there were about 2.6 million young people from 10 24 years old, die each year and most of these deaths due to the preventable causes such as violence, suicide, sexually transmitted diseases, traffic accidents, and drug abuse. according to the report, there were about 16 million adolescent girls give birth and about three million girls aged 1519 undergo unsafe abortions every year. in terms of the hiv infection, young people from 15 to 24 were accounted for 40% new hiv infections among adults. about 150 million young people use tobacco and high number die every day due to the road traffic injuries and interpersonal violence [6] notice about the importance of the issue, many studies focus on different risk behaviors of adolescent in both developed and developing countries. the evidences also showed that there were many common risk behaviors among young people such as: violence, unsafe sex, alcohol and tobacco and drugs use, unsafe traffic behaviors, and suicide intention [3, 4, 5, 7, 8]. noticeably, high school students in many countries also have already engaged in multiple risk behaviors and it would be a new crisis of the young generation nowadays [5, 8, 9]. it was showed from the high school students' study in 42 states of us that more than 50% of all high school students had at least 2 risky behaviors and there was about 15% of all had 5 risky behaviors or more than 5 [3]. the similar result was also demonstrated in the study of sychareun in laos with the noticeable proportion of students had 2, 3, 4 or more concurrent risk behaviors. [4]. the evidence from some studies showed that adolescents tend to take a cluster of risk behaviors when they have already engaged in one risk behaviors and the concurrent of health risk behaviors was evaluated to be a very risk issue of young people nowadays [5,8,9]. adolescents are accounted for about 30% all population in vietnam and they are believed to be a gold labor resource for vietnam in the next few years. findings from savy2 (survey assessment of vietnamese youth round 2) with the respondents from 15 to 24 years old showed the prevalence of the different risk behaviors including: tobacco smoking, alcohol drinking, drugs using, violent behaviors, unsafe sex. in addition, traffic accidents and injuries were demonstrated to be the burden of the population from 15 years old. [10, 11, 12, 13, 14]. the prevalence of each individual risk behavior in vietnam had been clearly explored by savy2 and many other studies. for example, 10.6 % of young people reported to have injury due to the traffic accidences in 12 months before the survey, 7.6% of them did suffer violent behaviors from people outside their family [10, 11, 12, 13, 14]. however, the status of acquiring concurrent risk behaviors of young people is still a question in vietnam and it need to be investigated comprehensively. the involvement in concurrent risk behaviors could be seen as the risk of facing with higher risk that threatening their lives and their future. with the aim of exploring the status of having multiple risk behaviors as well as to investigate the different social factors associated with the risk of having multiple risk behaviors, the study was conducted with the sample of more than 130 high school from hanoi. the findings from this study would contribute to the better understand about risk behaviors among adolescent in general and to identify the different social factors which could be the protectors or the risk factors for identifying further effective intervention programs. methods study design, data collection and sampling method a cross sectional study design was selected to investigate the status of the concurrent risk behaviors and the social factors associated with the status of engaging in multiple different risk behaviors of high school students in hanoi, vietnam. a quantitative method with prepared questionnaire was conducted with a sample size of more than 1,330 students. among 12 districts, there were about 80 high schools including both public and private schools and about 72,000 high students estimated by hanoi education department in 2015 [15]. participants were selected from 6 hanoi's high schools and the survey was conducted in december 2016. the sampling process was divided into different phases for randomly selection on districts, schools, classes and then the respondents. of 12 districts in hanoi, 3 districts were randomly selected for population selection. from each global health management journal, 2018, vol. 2, no. 3 50 district, the list of all public schools and the nonpublic schools had been established, then 3 private schools and 3 public schools had been randomly selected from each list. all international schools or specialized schools were excluded from the selection list, therefore the conclusion of this study is not applied for the students study with international curriculum. at each selected school, two classes of each grade [10, 11, 12] were selected randomly, therefore six classes of each school had been selected. all students from these selected classes were invited to do the survey after receiving full information about the goals and the anonymity of this survey. in total, 1,333 respondents from 36 classes of six high schools had completed the survey. the proportion of the students from public school and private schools were 55% and 45% respectively. there was 33% of all respondents from 10th grade and the students from 11th and 12th class accounted for 32% and 35% respectively. the dependent variables the study focused on exploring the risk of having concurrent multiple risk behaviors among the selected 18 risk behaviors, including tobacco smoking; alcohol drinking (had ever drunk by wine or beer); shisha smoking; drugs uses; hallucinogenic substances uses; three (3) violent behaviors (physical violent behaviors, face to face bullying, indirect bullying (by facebook or cell phone)); self-violent behaviors (selfinflicted injury); suicide intention; suicide attempt; and seven (7) unsafe traffic behaviors (travelling by motorbike without helmet; actively violate the common traffic regulations including speeding/crossing during the red light/ traveling on the wrong lane; driving and carrying passengers by motorcycles of 50 cm3 or less; traveling on motorbike carrying more than 2 persons; hard traffic law violation; to be penalized by the polices; motorbike racing). the value of the composite variables of the total risk behaviors was scored from 0 to 18 and the value is interpreted as the total number of different risk behaviors each student had engaged in. the risk behaviors that students had engaged in were assumed to be occurred not too far from the time the data was collected, and students still can clearly remember and recall about their involvement. the independent or explaining variables the study involved vary social connections as the independent variables. family connection status was evaluated through 3 indicators: parents mariage status (living together or seperation/ divorce); the strength of family connection; and connection with family's members engaging in different risk behaviors. the school connection status includes the connection's status with schools, teachers and friends that may involve in different multiple risk behaviors. social media networks connection was interpreted as the volume of engaging in social media networks (average time spending for social media networks per day and the estimation of online friends). other social connections such as the participation in different social activities (involve in after-school clubs; volunteer or charity's activites; doing part time jobs) were also considered affecting the risk behaviors. ethical considerations the data of this article is a part of the doctor thesis study of the author, which was reviewed and approved by ho chi minh national political academy in terms of the ethical and scientific aspects. the author has successfully completed the doctoral dissertation and been awarded to be a doctor of sociology. data analysis the multivariate linear regression models were applied to examine the social factors associated with the concurrent multiple risk behaviors of hanoi high school students. eighteen different risk behaviors were selected for constructing composite variable of the total risk behaviors that students have engaged in. results the concurrent multiple risk behaviors among hanoi high school students tabel 1 presents the detail proportion of each risk behaviors among hanoi high school students. with 1,333 respondents, 52% of all were males and 48% of all were females, while the 55% students were from public schools and 45% from private schools. the proportion of students from class 10, 11 and 12 were: 33%, 32% and 35% respectively. it was clear from the result that high school students had involved in different risk behaviors at the noticeable proportions, since the high school students had been facing the very high risk of alcohol drinking, unsafe traffic activities, and vary violent behaviors. the potential high risk behaviors such as: drugs and hallucinogenic substance uses, traffic accidents causes, and suicide attempt, were also found with noticeable high proportion among hanoi high school students: drug uses (6.9%), hallucinogenic drug taking (6.8%); physical violent behaviors (24%), suicide attempt (4.8%), and motorbike races (7%). 51 global health management journal, 2018, vol. 2, no. 3 table 1. the frequency of different single risk behaviors of high school students risk behaviors number % smoking, alcohol drinking and drugs uses smoking (have ever smoked) 280 21 alcohol drinking (drunk) 846 63.5 have ever smoked shisha 291 21.8 drugs uses 92 6.9 hallucinogenic drug uses 91 6.8 using/ involving in violent behaviors physical violent behaviors 320 24 direct bullying 259 19.4 indirect bullying (through social media networks or cell phone) 167 12.5 have at least one of the three violent behaviors 460 34.5 self-injury, suicide intention or suicide attempt self inflicted injury 272 20.4 suicide intention 244 18.3 suicide attempt 64 4.8 unsafe traffic behaviors travelling by motorbike without helmet 792 59.4 actively violate the common traffic regulations 689 51.7 driving motorcycles of 50 cm3 or less but carry passengers 670 50.3 traveling by motorbike carrying more than 2 persons 608 45.6 traffic accidents causing 483 36.2 hard traffic law violation and was penalized by the police 288 21.6 racing 93 7 having at least one unsafe traffic behavior 1165 87.4 in addition to the high prevalence of multiple risk behaviors, table 2 shows high proportion of students engaging in more than 2 different risk behaviors. on average, the students were reported to have 4.88 risk behaviors, and 84.3% of all respondents had 2 or more risk behaviors. the proportion of students having from 5 risk behaviors or more was more than 45% of all. noticeably, there was nearly 14% of all respondents said that they had ever had 8 or more risk behaviors among the 18 observed risks. in terms of the violent behaviors, 34.5% of all students were reported to be involved in at least 1 of the three selected violent behaviors and 15.6% of all reported to be involved in two or three violences (physical violent behaviors, direct or indirect bullying). with 7 different unsafe traffic behaviors, each student had involved in 2.7 of all on average and one third of all students had involved in 4 or more unsafe traffic behaviors table 2. the frequency of involving in different total number of risk behaviors number of risk behaviors students had involved in total number % 0 72 5.4 1 -2 287 21.5 3 -4 336 25.2 5-6 261 19.6 7-8 189 14.2 9 and more 188 14.1 total 1,333 100 global health management journal, 2018, vol. 2, no. 3 52 table 3. multivariate linear regression models analyzing the association between social factors and the concurrent multiple risk behaviors among hanoi high school students predictors model 1 model 2 b stand. beta b stand. beta socio-demographic factors and others sex male students (vs female ones) .358*** .054 .347** .053 class grade 10 (vs grade 11 & 12) -.965*** -.138 -.480*** -.069 academic outcome excellent and good (vs average and week) -.976*** -.124 -.573*** -.073 parents' education parents' education level (higher score showed a better education outcome of both parents) -.396*** -.122 -.243*** -.075 students' school public schools (vs non-public schools) -.830*** -.135 -.234*** -.035 r square = 9.1%; sig = 0.000 social connections: family connection's status parents relationship both parents (vs divorce/ separation) -.414* -.042 family connection strength family is believed to be a sweet home and all members maintain good relationships. (measured by score: the higher score showed the better evaluation from respondents) -.100*** -.111 family can provide students the spiritual supports and they do not suffer the stress and high pressure from family (measured by score: the higher score showed the better evaluation from respondents) .063* .048 connecting to family's members with different risk behaviors the number of risk behavior types that family's members have involved in (the value of the variable is increased with the increasing number of risk behaviors that their family members have engaged in) .714*** .255 school connection strength close connection to the school (measured by score: the higher score showed the better evaluation from the respondents -.060 -.042 close connection to the schools' friends (measured by score: the higher score showed the better evaluation from the respondents) .036 .026 close connection to the schools' teachers (score scale measured: the higher score showed the better evaluation from the respondents) -.009 -.008 connecting to friends involve in different risk behaviors the number of different risk behavior that their close friends have engaged in (the value of the variable increased with the increasing number of the risk behaviors that their members have engaged in) .646*** .306 53 global health management journal, 2018, vol. 2, no. 3 predictors model 1 model 2 b stand. beta b stand. beta social connections: others social connections and social media networks connections involving in volunteer/ charity yes (vs no) .250 .030 doing part time jobs yes (vs no) .291 .027 joining in after school clubs yes (vs no) .289 .040 average times spending for social media networks from 3 hours or more (vs less than 3 hours) per day on average .643*** .090 estimation of student's online friends from 1,000 online friends or more (vs less than 1000 online friends) .736*** .106 r square = 37.6%; sig = 0.000 notes: model 1: social demographic factors. model 2: more variables had been added: family connections, school connections and the other social connections. n (sample size) = 1,333; * p < 0.05; ** p < 0.01; *** p < 0.001. the family connection strength and school connection strength: different dimensions and aspects of each connection have been explored by multiple questions. each question was measured through the 5 points scale: the higher score shows the better relationships or closer connection of each measured dimensions. table 3 exhibits the association between the different social factors and the risk of having multiple risk behaviors among high school students, multivariate linear regression models have been applied to identify the protective factors and risk factors. two multivariate linear regression models had been applied: the first model was built with the predictors of all social demographic factors and other students' individual factors. in the second model, all social connections factors had been added including: family connections, school connection and other social activities & social medial networks connections. the result showed that with only the demographic factors and other student's individual factors (academic outcome, school type), the statistic model can only explain for about 9.1% of the variation. however, when the model has been added with varied factors of the social connections (family connections, school connections and other social connections), the updated model had been improved and can explain for about 37.6% of the variation in composite variable of the total risk behaviors that students have engaged in. in terms of the socio demographic factors and the other factors, the protective factors can help to reduce the risk of having increasing total number of the multiple risk behaviors including: good academic outcome, the 10th grade students, students from public schools and students living with high educated parents. in the contrast, male students were at higher risk of engaging in multiple risk behaviors in comparison to female students. in terms of the family and school connections, the noticeable protective factors for having additional risk behaviors including: student's family connection status (parents living together and family is believed to be a sweet home and all members maintain good relationships). the statistic also showed that the relationship between the strength of school connection and the risk of having increasingly number of risk behaviors was not significant. however, both having family's members or friends engaging in different risk behaviors have demonstrated to be the significant risk factors for engaging in increasing concurrent risk behaviors of high school students. in terms of the other social connections, two other main social connections had been investigated: connection to social activities (involving in volunteer/ charity activities; doing part time jobs; joining in after school clubs) and the volume of students' connection to social media networks. it was showed that the global health management journal, 2018, vol. 2, no. 3 54 relationship between involving in different social activities and the risk of having increasing concurrent risk behaviors was not significant. however, close connection to social media networks, which was indicated in the long time spending on different social networks such as facebook, instagram (from 3 hours or more per day) or having too many online friends (from 1000 online friends and higher), both of these indicators had demonstrated to have a close relationship with the risk of having multiple concurrent risk behaviors. discussion the purpose of this study was to investigate the prevalence of different risk behaviors among high school students and to examine the social factors explaining for the concurrent risk behaviors among high school students. the result showed that concurrent multiple risk behaviors was a noticeable issue among the participated high school students of hanoi, vietnam. this social issue was also labeled as the "risk behavior syndrome" occurring among adolescents in some other countries. for example, the study of concurrent multiple risk behaviors among america's high school students also showed that there was more than 50% of all had from 2 risk behaviors, and more than one third of all have from 3 risk behaviors or more [1]. a survey conducted in luangnamtha province of laos which focused on 7 very high risk behaviors (alcohol use, smoking, substance use, having sex, having the first sex before 15 years; two or more partners during the last six months, not using condoms for the last sexual intercourse), the proportion of students who had 1, 2, 3, 4 and 5 risk behaviors were: 39.3%, 8.1%, 4.2%, 1.2%, and 0.4% respectively [5]. it raises the needs to question what and how one or more specific risk behaviors could cause to have additional risk behaviors among young people. the new contribution of this study was to identify and demonstrate the different social connections which can be the potential predictors of the concurrent multiple risk behaviors of young people. the importance of the family's role had been mentioned in browlby's theory which was highlighted the important of the "family bond" to be a "safe haven" for the children [16]. moreover, this "safe haven" could help strengthening their capacity for their well engagement with the healthy relationships and social networks outside their families throughout their childhood and their adulthood. it was also the main contribution of berkman and her colleagues which highlighted the importance of the social attachment and social connection and the way it contributes for the human's positive health. the argument that social integration and social attachment can provide the spiritual and material supports for the participants, therefore, could contribute for improving their health status through different pathways: (1) providing of social support; (2) providing social influence; (3) strengthening social engagement and attachment; and (4) accessing to different resources and material goods [17]. this present study explains how in the traditional vietnamese context, family connection was believed playing very strong role in how the adolescents involving to varied risk behaviors. nowadays, with the intensive process of industrialization and modernization, parents in a big city like hanoi usually are very busy with their work and their personal interests. therefore, the time spending for their children after school is believed to be limited or being reduced. in addition, the number of high school student living in divorce families in hanoi city is noticeable where 8.2% students from public school and especially 19% of students from private schools living in separated or one parent family (the statistic from this survey). therefore, it could be predicted that the strength of family connection in the big city like hanoi would be weaker in the future. in addition to the family connection, the strength of school connection is also being effected by the overpopulation in the big cities. as the school's system being heavyly overloaded and each teacher has to be in charge of the increasing number of students of each class and it is very hard for them to keep the good relationship and strong connection to a large amount of students. [18]. the weaker family connection and school connection would be the risk factors contributing to the potential of having additional risk behaviors among high school students. it was also the finding of the survey that not all the close and strong social connections can be the protectors of involving in multiple risk behaviors among high school students. having a close connection to the social media networks, which is showed in the long time spending on the online networks and having too many online friends, had been demonstrated to be the risk factors of having concurrent risk behaviors. social media networks and online connections are very new issues nowadays which have posed many concerns and advert consequences for young people. joinning on the online neworks space, adolescents as well as the adults 55 global health management journal, 2018, vol. 2, no. 3 are now equally in accessing on any information and spaces. however, the problem is that the very young students and also the new members of social media network may not have enough experience and life skills to cope with the risk of informal information and different temptations from social media networks or from online friends. therefore, unhealthy information from different social networks and unhealthy online friends could influence them, including encouraging them by direct or indirect ways to involve in different risk behaviors. this is a very new emerging issue that need to be investigated in more detail on the potential risk of social networks overusing and the way it influences on young generation in terms of engaging in concurrent risk behaviors. the limitation of this study is that all 18 individual risk behaviors were treated equally, therefore, the composite variable of the total 18 risk behaviors was simply constructed by adding all risk behaviors among 18 mentioning behaviors. it could be claimed that some risk behaviors may be more dangerous than the others. however, there was no reference for justifying the volume of the risk of each behavior in terms of the "potential risk" to be converted to the "real life" suffering. this issue is also the question for the future investigations to provide more information and evidences on that. conclusion it was highlighted from the study that there are many different risk behaviors that come to be prevalent among high school students. in addition to the prevalence of the different single risk behaviors, many students have already engaged in multiple risk behaviors and this situation posed the high school students to the vary risks and disadvantages for their future as well as threatening their physical and mental health. it was found that good family relationships and strong family connection were the protective factors for engaging in additional multiple risk behaviors among high school students. in contrast, connecting with family's members or friends who involved in multiple risk behaviors as well as maintaining a strong connection with social media networks were demonstrated to be the risk factors of acquiring additional multiple risk behaviors. the findings suggest the needs of policy implication to address concurrent multiple risk behaviors among young generation. controlling and intervening concurrent multiple risk behaviors should be integrated on youth development strategy as a key issue to be addressed. it was demonstrated from this study that the social factors, especially the different social connections have a strong influence on the risk of having concurrent different risk behaviors. therefore, reducing multiple risk behaviors among young people should include the involvement of the family's members, teachers, schools, social workers and other different authorities. the risk behaviors' intervention and controlling programs should be delivered at early stage and should focus on multiple risk behaviors rather than the single risk ones. the high risk groups such as male students, students living in broken families or living in poor connection families, students who live with family's members or friends engaging in multiple risk behaviors, students addicted social media networks or spending too much time for online relationship and online activities, should be targeted in some specific and intensive intervention programs with the proffessional assistance from different experts. conflict of interests this research is independent and have no conflict of interests. references 1. dilemente, r. et al. handbook of adolescent health risk behavior. new york. 1996 2. arias, a., et al. prevalence of pattern of risky behaviors for reproductive and sexual health among middleand high-school students, rev. latino – am. enfergem. 2010; 18(2): 170 – 184 3. fox, h. et al. significant multiple risk behaviors among u.s. high school students. the national alliance to advance adolescent health. 2010. 4. ruangkanchanasetr, s. , plitponkarnpim, a. , hetrakul, p . youth risk behavior survey: bangkok, thaland. journal of adolescent health. 2005; 36(3): 227-235. 5. sychareun, v. et al. concurrent multiple health risk behaviors among adolescents in luangnamtha province, lao pdr. bmc public health. 2011; 11: 36 46. 6. who adolescent development, available at: http://www.who.int/maternal_child_adolescent/topic s/adolescence/dev/en/. 2014. [access on 27/11/2015]. 7. huong, n.t., tien t.q. a number of risk factors and protective factors associated with depression and anxiety of hanoi secondary school students. viet nam journal of public health. 2009; 13 (13): 9 16. global health management journal, 2018, vol. 2, no. 3 56 8. xing, y, cheng-yi. co-occurrence of health-risk behaviors among beijing middle school students, china. j adolesc health. 2003; 33: 215-216. 9. anteghini, m., fonseca, h., ireland, m., blum, r.w. health risk behaviors and associated risk and protective factors among brazilian adolescents in santos, brazil. j adolesc health. 2001; 29: 352-8. 
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[access on: 18/12/2015]. 15. hanoi education department, available at: http://hanoi.edu.vn/phong-gd-pho-thong-c556.aspx 16. bowlby, j. attachment and loss. london: hogarth press.1969. 17. berkman, l. f., and glass, t. social integration, social networks, social support, and health. in: l. f. berkman & i. kawachi, editors. social epidemiology, oxford, uk: oxford university press; 2000. 18. ha, l. nguyen ha, school system is overloaded because of too many new sky buildings dantri, truong hoc qua tai vi nha cao tang. dantri. 2016. available at: https://dantri.com.vn/giao-duc-khuyenhoc/truong-hoc-qua-tai-vi-nha-cao-tang20160115100500292.htm cite this article as hadi, hadisaputro s, ramlan d. potential of garlic (allium sativum) essence in changing blood lipid profile of the hypertension patients with hypercholesterolemia. global health management journal. 2019; 3(1):14-19. global health management journal www.publications.inschool.id published by original research article issn 2580-9296 (online) potential of garlic (allium sativum) essence in changing blood lipid profile of the hypertension patients with hypercholesterolemia hadi 1,*, suharyo hadisaputro 2, djamaluddin ramlan 2 1 postgraduate applied science program in nursing, poltekkes kemenkes semarang, semarang, indonesia. 2 poltekkes kemenkes semarang, semarang, indonesia. *corresponding author. email: purhadi75@gmail.com article info abstract article history: received 25 august 2018 reviewed 03 september 2018 received in revised form 24 february 2019 accepted 28 february 2019 background: as like hypertension, hypercholesterolemia is a major risk factor for cardiovascular disease and hypertension and its complications are one of the highest causes of death in the world. aims: this study aims to determine the potential of garlic essence (allium sativum) mixed with honey in changing blood pressure and lipid profile of blood in the hypertension patients with hypercholesterolemia, and to compare the effectiveness with those who received simvastatin, the most preferred pharmacological treatment of hyperlipidemia. methods: this research is a quasy experiment study with a nonequivalent control group design. there were 22 hypercholesterolemia outpatients purposively selected from local health centers. the respondents were then divided equally to (a) a control group where the patients were provided with generic simvastatin 10 mg single dose taken once in the afternoon, and (b) an intervention group where the respondents received a nonpharmacological supplement of garlic essence in 2 grams honey. the blood pressure and the blood lipid profile were examined before (pretest) and at the day 22 after the treatment (posttest). the collected data was then analyzed using a t-test to define the significant mean difference between two groups, and a cohen’s effect was measured to interpret the size of changes. results: either the additions of simvastatin or the provision of garlic essence mixed with honey decreased the blood pressure (systole and diastole) and the cholesterol, triglyceride, and ldl cholesterol, but increased the hdl cholesterol. while significant difference was observed for all parameters at the intervention group, the improvement at the control group for triglyceride was not significant (p value = 0.041). overall, by the cohen's effect size effect, we can interpret that the changes was moderate for diastole and systole blood pressure, and also triglyceride and dld-cholesterol; however the effect size was low for cholesterol and hdl-cholesterol. conclusion: the findings show the importance of the garlic essence mixed with honey to be offered as a nutritional supplement for hypertensive patients with hypercholesterolemia. keywords: garlic (allium sativum) essence simvastatin hypertension hypercholesterolemia blood pressure blood lipid profile © 2019 publications of yayasan aliansi cendekiawan indonesia thailand this is an open-access following creative commons license deed – attribution-noncommercial-sharealike 4.0 international (cc by-nc-sa 4.0) introduction hyperlipidemia is a situation where found with an increasing in cholesterol levels and / or triglycerides [1]. cholesterol here includes: total cholesterol, lowdensity lipoprotein (ldl-cholesterol) and highdensity lipoprotein (hdl-cholesterol); these substances are essential for the body to maintain normal function but if excessive will increase the risk of heart disease and stroke [2-4]. hypertension is a major risk factor for various cardiovascular diseases including coronary heart disease, stroke, kidney disease, and http://publications.inschool.id/index.php/ghmj/index http://publications.inschool.id/ http://inschool.id/ http://publications.inschool.id/index.php/ghmj/index mailto:purhadi75@gmail.com http://inschool.id/ http://creativecommons.org/licenses/by-nc-sa/4.0/ 15 global health management journal, 2019, vol. 3, no. 1 hadi et al. global health management journal. 2019; 3(1):14-19 retinopathy. at a hypertension patients, an increasing of blood pressure was observed greater than 140/90 mmhg [5]. in most cases, hypertension is detected during a physical examination for reasons of certain diseases, so it is often called the "silent killer". without realizing the patient has complications in vital organs such as the heart, brain or kidneys [6]. knowing the causes or risk factors for hypertension is vital for the prevention and management of adequate hypertension in an effort to reduce the risk of cardiovascular disease [7]. hypertension and its complications are one of the highest causes of death in the world. vascular complications caused by hypertension can cause coronary heart disease, cardiac infarction (tissue damage), stroke, and kidney failure [8]. likewise, hyperlipidemia is a primary risk factor for coronary heart disease and ischemic stroke. one study showed that for every decrease of ldl-cholesterol by 30 mg/dl, there would be a decrease in relative risk for coronary heart disease by 30% [9]. management of hyperlipidemia cases is divided into two, namely non-pharmacological and pharmacological therapy. non-pharmacologically controlling cholesterol levels can be done with therapeutic lifestyle changes (tlc) which includes: dietary tightening, weight loss and sports activities. if tlc is not successful, a pharmacological control is needed where statins are the main choice in the treatment of hyperlipidemia [10-12]. many natural substances that are believed to be used to control blood cholesterol levels as an alternative for the community in addressing hyperlipidemia minimal side effects [13].. garlic (allium sativum) is one of the food ingredients that are widely used every day by our society as a complementary spice and is known to have many properties including anti-hypertension and anticholesterol. garlic contains allyl methyl sulphide (ams) and diallyl sulphide (das) which inhibit the reaction of angiotensin ii-stimulated-cycle in aortic smooth muscle cells and activate the sodium pump in the kidneys to reduce intracellular na+ concentration to control blood pressure. moreover, the lipid profile of aliin and allicin derivatives, s-allyl cysteine sulfoxide decreases the activity of reductase enzyme 3-hidroxy-3methylglutaryl-coa in cholesterol biosynthesis. methods this research is a quasy experiment study with a nonequivalent control group design. there were 22 hypercholesterolemia outpatients purposively selected from local health centers. inclusion criteria in sample selection were patients with: systolic blood pressure >130 mmhg, diastolic blood pressure >85 mmhg, and total cholesterol >200 mg/dl. exclusion criteria were patients with: comorbid disease or pregnant women.the respondents were then divided equally to (a) a control group where the patients were provided with generic simvastatin 10 mg single dose taken once in the afternoon, and (b) an intervention group where the respondents received a non-pharmacological supplement of garlic essence in 2 grams honey. the procedures and preparations have been approved by the health research ethics committee of the politeknik kesehatan kemenkes semarang on june 21st, 2018, prior the intervention, with number 291/kepk/poltekkes-smg/ec/2018. the independent variables in the control group was the provision of 10 mg of simvastatin whereas at the intervention group the essence of garlic in 2 grams honey was introduced as the independent variable. the dependent variables measured in this present study were blood pressure systole and diastole, total cholesterol, ldl-cholesterol, hdl-cholesterol and triglycerides. simvastatin 10 mg was taken once in the afternoon while 5 ml of garlic essence in 2 grams honey was given at the intervention group twice a day at morning and evening. the effects of the additions to blood lipid profile and the blood pressure of hypertension patients with hypercholesterol were carried out for 21 days. the blood pressure and the blood lipid profile were examined before (pretest) and at the day 22 after the treatment (posttest). for the observation before and after the treatment, the blood pressure was measured using digital tensimeter, performed by the professional nurses as the enumerator while the lipid profile of the respondents was examined by the certified staffs at the chod-pap method in patra medika cepu laboratory. the measurement tools have been calibrated before the test with certification number 051/bp/sk/v/18 on may 10, 2018. the collected data was then analyzed using a t-test to define the significant mean difference between two groups, and a cohen’s effect was measured to interpret the size of changes. results respondents’ characteristics the characteristics of respondents recruited in this study were displayed on table 1. there were totally 22 respondents recruited in this study with no drop out recorded. this present study noticed that the hypertension outpatients were distributed at 4 age groups, where at the control group the most were in age range of 36-45 and 5665 while at the intervention group the respondents were at 36 to 65 years old. interestingly, more females were observed having hypertension. of 11 of each group, there were 7 female respondents (63.6%) at control group, and 6 female outpatients at intervention group (54.3%). patients with university degree level dominated the group global health management journal, 2019, vol. 3, no. 1 16 hadi et al. global health management journal. 2019; 3(1):14-19 where half of respondents both at control and intervention group are those graduated from the university. the control group was dominated by farmers, entrepreneurs and civil servants while at the intervention group 4 of 11 respondents were civil servants. table 1. frequency distribution of respondent’s characteristics (n=22) characteristics control intervention total n % n % n % age (year) 26-35 1 9.1 2 18.2 3 13.6 36-45 4 36.4 3 27.3 7 31.8 46-55 2 18.2 3 27.3 5 22.7 56-65 4 36.4 3 27.3 7 31.8 gender male 4 36.4 5 45.5 9 40.9 women 7 63.6 6 54.5 13 59.1 education junior school 3 27.3 2 18.2 5 22.7 high school 3 27.3 4 36.4 7 31.8 university 5 45.5 5 45.5 10 45.5 occupation farmer 3 27.3 2 18.2 5 22.7 entrepreneur 3 27.3 3 27.3 6 27.3 private 2 18.2 2 18.2 4 18.2 goverment 3 27.3 4 36.4 7 31.8 effects of supplementations to blood lipid profile and the blood pressure in hypertension patients with hypercholesterolemia table 2 presents the univariate test for the mean difference in preand postat the control and intervention groups. either the additions of simvastatin at control group or the provision of garlic essence mixed with honey at intervention group decreased the blood pressure (systole and diastole) and the cholesterol, triglyceride, and ldl cholesterol, but increased the hdl cholesterol. the results acknowledged that the provision of simvastatin 10 mg to the hypertension patients until the day 22 presents the significant effect at level of 0.05 for the blood pressure and the blood lipid profile except triglyceride, however, the 5 ml of garlic essence in 2 grams honey given at the intervention group twice a day at morning and evening delivers significant changes to all parameters. the provision of simvastatin at the control group decreased the blood pressure systole and diastole until 17.64 and 3.91 mmhg, respectively, while at the intervention group the decline was relatively higher at 21.27 and 7.00 point, respectively. from the t-test we found that compared to the value at the control group, supplementing the garlic essence with honey will affect significant contribution to blood pressure diastole at 0.05 confidence level. this non-pharmacological supplement decreased the cholesterol and ldl-cholesterol respectively at 66.27 and 23.643 mg/dl, which slightly higher if compare to the results if administered with the pharmacological therapy with simvastatin 10 mg at 57.72 and 14.63 point. however, we can noticed that providing simvastatin 10 mg decreased the blood lipid triglyceride at 29.81 point, which slightly lower than the result by the supplementation of the essence garlic. moreover, from this study, the measurements orchestrate that the garlic essence with honey is more effective to increase the hdl-cholesterol level to 13.09 mg/dl, compared to the simvastatin provision at 8.00 point only. overall, by the cohen's effect size effect, we can interpret that the change was high for blood pressure systole and diastole, compared to the blood lipid profile. however, among the blood lipid profile, highest alteration was observed for triglyceride. the results also present that the supplementation was not really effective to decrease the cholesterol level in the hypertension patients where the effect size was only at 0.1 point. discussion all recruited participants in this study were equally distributed into control group and intervention group, considering their age, gender, education and occupation. these characteristis are considered as the confounding factors that can affect the independent variables. the age of participants is linear with the occurence of hypertension and dyslipidemia due to the changes in the wall of the blood vessels which can narrow it and make it more stiff [14]. a study also found a correlation of age and parity with hypertension incidence among pregnant women [15]. in gender characteristic, estrogen which is more aboundant in non-menopausal women can act as the protector with its advantage effects in decreasing total cholesterol, ldl-cholesterol, and increasing hdlcholesterol [16]. education level of participants can be the indicator of their ability in undertanding health information particularly regarding hypertension and hypercholesterol. the job of participants also can affect their hypertension and hypercholesterol status through various pressure that occur in each type of job [17, 18]. in univariate analysis, it shows that there were significant improvements in all parameter except triglyceride which was actually improved but statistically insignificant. this findings confirm that the given treatment either in intervention group or control group could improve participants’ status. nevertheless, the mean values in intervention group were higher than control group though the two groups were not compared in univariate analysis. 17 global health management journal, 2019, vol. 3, no. 1 hadi et al. global health management journal. 2019; 3(1):14-19 table 2. effects of the supplementation on blood pressure (systole, diastole) and blood lipid profile (cholesterol, triglyceride, ldl, hdl cholesterol) in hypertension patients at the control and intervention group variables control intervention p value effect size mean sd delta mean sd delta systole (mmhg) pretest 148.91 12.28 17.64 149.00 12.70 21.27 0.256 0.5 posttest 131.27 8.17 127.73 6.75 p value 0.001 0.001 diastole (mmhg) pretest 86.91 49.69 3.91 88.55 4.32 7.00 0.041 0.5 posttest 83.00 3.16 81.55 2.46 p value 0.004 0.001 cholesterol (mg/dl) pretest 248.91 27.49 57.72 255.64 27.08 66.27 0.466 0.1 posttest 191.18 29.50 189.36 20.72 p value 0.001 0.001 triglyceride (mg/dl) pretest 152.36 55.54 29.81 181.76 112.80 25.72 0.872 0.4 posttest 122.55 15.49 155.64 122.10 p value 0.241 0.006 ldlcholesterol (mg/dl) pretest 137.91 13.29 14.63 147.91 24.92 23.63 0.301 0.3 posttest 123.27 11.98 129.27 22.85 p value 0.001 0.017 hdlcholesterol (mg/dl) pretest 37.64 7.92 8.00 34.09 5.07 13.09 0.242 0.2 posttest 45.65 8.54 47.18 7.76 p value 0.041 0.001 this findings also can present the glimpse about the advantages of garlic essense which were given to intervention group and eventually lead them to the better improvement than control group. simvastatin is a type of medicine used in pharmacological treatment for hypercholesterolemia and hypertension patient, while garlic is one of the natural ingredients which used in nonpharmacological treatment and proposed to be given for the hypertension patients at this present study. the mechanism of action of simvastatin itself in lowering cholesterol and ldl levels is by inhibiting the enzyme 3hydroxy-3-methyl glutaryl-coenzyme a (hmg-coa) reductase competitively. this drug inhibits the activity of the enzyme hmg-coa reductase which converts acetylcoa to mevalonic acid. in the process of synthesis of cholesterol in the liver, simvastatin can increase ldl receptor activity which makes the speed of ldl metabolism by the liver becomes faster and plasma ldl deposit become reduced [19]. there are several mechanisms for cholesterol synthesis that are affected by garlic. first, garlic contains saponins which act as an inhibitor of cholesterol absorption in intestines which results in a decrease in plasma cholesterol levels. second, garlic contains water-soluble compounds, such as s-allyl cysteine (sac), s-ethyl cysteine (sec), and s-propyl cysteine (spc) which are the potential inhibitor for the synthesis of cholesterol, yet the mechanism is still not comprehendly understood [20]. one study found that garlic extract reduces cholesterol synthesis by 75% without evidence of cellular toxicity. this result indicates that the containing compound, allyldisulfide or allyl-sulfhydryl group are most likely responsible for inhibiting the synthesis of cholesterol and this inhibition is likely mediated in sterol 4 alpha-methyl oxidase. this suggests that water-soluble compounds such as sac in old garlic extracts are less cytotoxic and more efficient at inhibiting cholesterol biosynthesis than organosulfur-fat-soluble compounds such as das [21]. thus, the result also shows that intervention group which was given garlic extract had better improvement of ldlcholesterol than control group. although the components of garlic have pharmacological effect in lowering blood pressure, the nature of the components of garlic that affects blood pressure is not thoroughly known. one observation study found that the treatment of allicor dose of 600 mg/day resulted in a decrease in systolic and diastolic blood pressure [22]. another study showed that allyl methyl sulfide (ams) and diallyl sulfide (das) as the compounds derived from global health management journal, 2019, vol. 3, no. 1 18 hadi et al. global health management journal. 2019; 3(1):14-19 garlic could inhibit the reactions of angiotensin iistimulated-cycle in aortic smooth muscle cells. thus, they could be targeted as effective antioxidants in arterial remodeling in hypertensive patients. another activity shown by garlic extract is the activation of the sodium pump in the kidneys by reducing intracellular na + concentration so as to normalize blood pressure [23]. in bivariate test, only one (diastolic bp) out of six variables showed significant difference between control and intervention group. the intervention group made significant better improvements than control group in diastolic bp. moreover, in the rest variables it also shows that the intervention group made better improvements than control group except in triglyceride which showed the opposite result. additionally, effect size confirms the magnitude of the improvements despite statistical calculation. based on cohen’s effect size reference, the present study also acknowledged that the changes was moderate for diastole and systole blood pressure, and also triglyceride and dld-cholesterol; however the effect size was low for cholesterol and hdl-cholesterol. conclusion this present study concludes that either the provision of simvastatin at the control group or the oral administration of garlic (allium sativum) with honey, for 21 days supplementation, in hypertension subjects with hypercholesterolemia decreased the blood pressure (diastole, systole) and the blood lipid profile (cholesterol, ldl-cholesterol, triglyceride), but increased the hdlcholesterol. while significant difference was observed for all parameters at the intervention group, the improvement at the control group for triglyceride was not significant at 0.05 difference level. the findings show the importance of the garlic essence mixed with honey to be offered as a nutritional supplement for hypertensive patients with hypercholesterolemia. conflict of interests authors declared there is no conflict of interests involved in the study. references 1. stone nj, robinson jg, lichtenstein ah, merz cnb, blum cb, eckel rh, et al. acc/aha guideline on the treatment of blood cholesterol to reduce atherosclerotic cardiovascular risk in adults: a report of the american college of cardiology/american heart association task force on practice guidelines. the american college of cardiology. 2014. 2. kreisberg ra, reusch jeb. hyperlipidemia (high blood fat). the hormone foundation. 2005. 3. nelson rh. hyperlipidemia as a risk factor for cardiovascular disease. elsevier. 2013;40:195–211. 4. stapleton pa, goodwill ag, james me, brock rw, frisbee jc. 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nutritional sciences. 2001. 22. singh vk, singh dk. pharmacological effects of garlic (allium sativum l.). arbs annual review of biomedical sciences. 2008;10:6-26. 23. bhandari pr. garlic (allium sativum l.): a review of potential therapeutic applications. international journal of green pharmacy. 2012;6:118-29. knowledge, attitudes, and hiv/aids risk behaviors of myanmar migrant workers in thailand indonesian scholars’ alliance ghmj (global health management journal) 2019, vol. 3, no. 3 open access original research the 4th interna onal conference on applied science and health (icash 2019), 23-24 july 2019, faculty of graduate studies, mahidol university, thailand knowledge, attitudes, and hiv/aids risk behaviors of myanmar migrant workers in thailand nitchamon rakkapao1* , pradabduang kiattisaksiri1 , ronnapoom samakkekarom2 1faculty of public health, thammasat university, lampang campus, lampang, thailand 2faculty of public health, thammasat university, rangsit campus, patumthani, thailand *corresponding author’s email: nitchamonbt@fph.tu.ac.th abstract background: hiv/aids is s ll a problem in the health care system of developing countries. migrant workers are consideredavulnerablepopula onforhiv infec on.thecurrent informa ononhiv/aidsandmigrantworkers is useful to provide suitable effec ve health interven ons for the preven on of hiv/aids. this study aims to describe knowledge, a tudes and hiv/aids risk behaviors among myanmar male migrant workers in thailand. methods: across-sec onal studywasconducted inmyanmarmalemigrantworkersaged18-60yearscollected fromfebruary tomay2018.atotalof400migrantworkerswho live inpatumthaniprovinceswereselectedbya convenience sampling method. descrip ve sta s cs were used to explore knowledge, a tudes and hiv/aids risk behaviors of par cipants. results: the mean age of the par cipants was 33 years, ages ranged from 18 to 60 years old, achieved primary school (40.40%), and married (54.30%). an average living in thailand was 3.25 years and monthly income was 9,166 baht (∼286 usd), respec vely. a majority of par cipants had a poor level of hiv/aids knowledge (55.25%) and a fair level of an a tude about hiv/aidsdisease and preven on (61.25%). riskbehaviors related to hiv/aids of par cipants who had sex with non-partners were 40.58%. conclusion: most par cipants had poor knowledge and a fair a tude of hiv/aids. risk behaviors related to hiv/aids of the par cipants were rela vely high. moreover, most of par cipants had less access to health care services. this results confirmed that an urgent need to provide health interven on to increase knowledge on hiv/aids of myanmar migrant workers in thailand. keywords: myanmar migrant workers, hiv/aids, risk behavior, thailand received: 19 may 2019 reviewed: 8 june 2019 revised: 24 june 2019 accepted: 1 july 2019 doi: 10.35898/ghmj-33452 selec on and peer-review under responsibility of the scien fic commi ee and the editorial board of the 4th internaonal conference on applied science and health (icash 2019) © yayasan aliansi cendekiawan indonesia thailand (indonesian scholars’ alliance). this is an open-access following crea ve commons license deed a ribu on-noncommercial-sharealike 4.0 interna onal (cc by-nc-sa 4.0) 1. introduc on hiv/aids is still a major public health problem around the world. although the number of new cases hiv infections globally continued to decline from 3.40 million in 1996 to 1.80 million in 2017, progress is far slower than what is required to reach the 2020 milestone of less than 500,000 new infections. in 2017, epidemiology of aids around the world is 36.90 million and a majority was found in adults and africa region. approximately 5.20 million people in asia-pacific region (mostly china, india, indonesia, malaysia, myanmar, pakistan, papua new guinea, vietnam, and thailand) were infected with hiv (unaids, 2018b). in 2017, the prevalence of hiv in thailand aged 15 to 49 years was 1.10 per 84 mailto:nitchamonbt@fph.tu.ac.th https://dx.doi.org/10.35898/ghmj-33452 rakkapao n et al. ghmj (global health management journal) 2019, vol. 3, no. 3 100,000 persons (unaids, 2018a). although an overview of hiv prevalence decreased more than 10 years, hiv prevalence has been increased or stable in some groups, in particular, a vulnerable group like migrant workers (thepthien et al., 2015). migrant workers are considered a vulnerable population for hiv infection. most migrant workers separated from their families and familiar social. they may face language barriers, substandard living conditions, and working conditions and a lack of social protection, such as health insurance and other social security benefits. the resulting isolation and stress may lead migrant workers to engage in risky behaviors, such as unsafe sex (unaids, 2019). in 2015, according to the report of the international organization for migration (iom) found that there are approximately 257.7 million people worldwide (iom, 2017). mobility of migrant workers directly affects to health care system of origin and destination country. previous studies were also found that hiv infection was high among migrant workers who moved back to their former homeland (alvarez-del arco et al., 2017; fakoya et al., 2015). thailand has had continued economic growth for more than twenty years and has combined with international policy of asean community that aims to cooperate in 3 main issues (political-security, economic, and socio-cultural). this has a result of the increased movement of migrant workers in asia, especially thailand where migrant workers come from neighboring countries like myanmar, laos, and cambodia. in 2018, thailand has about 39 million migrant workers, most of which are from myanmar (2.06 million) following cambodia (720,000) and lao pdr (220,000) (iom, 2019). a majority of migrant workers are young and separated from spouses and their family that making them feel isolated or stress and may lead to a high risk of hiv/aids (weine and kashuba, 2012). mostly they lack hiv. in addition, knowledge (amirkhanian et al., 2011; sena et al., 2010; mullany et al., 2003) in accordance with the report from bureau of epidemiology department of thailand in 2013 shows that the morbidity rate of hiv/aids of myanmar migrant workers has not decreased and the prevalence of hiv/aids was 1% (boe, 2013). besides, most migrant workers faced with the language or finance barriers (particular in migrant workers with irregular legal status) that make them less access to health care services. little information is known about hiv/aids risk behaviors in myanmar migrant workers in thailand because of the language barrier and access to migrant workers. understanding knowledge, attitudes, and hiv/aids risk behaviors in migrant workers is very important in planning hiv/aids at the national and international levels of the health care system. therefore, the objective of this study is to describe knowledge, attitudes, and hiv/aids risk behaviors among myanmar male migrant workers in thailand. 2. method 2.1 study design and sample this cross-sectional study was conducted among myanmar male migrant workers living in patumthani province, thailand. the data were collected from february to may 2018. a total of 400 male migrant workers aged 18-60 years who have lived in thailand over 6 months were selected based on convenience sampling at one private market of patumthani province. myanmar male migrant workers who were diagnosed with hiv/aids and not literate in the myanmar language were excluded. permission to collect the data was obtained from the head of the private market, and all participants provided informed consent. the study protocol was approved by the ethics committees of thammasat university (082/2560). 2.2 instruments the questionnaire was developed in the thai version and was proved for content validity by three experts with extensive experience working in the hiv/aids field. the next step was translated to myanmar version by the certified language institute of mahidol university. the questionnaire consists of four parts. part 1 was data about sociodemographic characteristics. part 2 was knowledge of hiv/aids containing statements about transmission and prevention. it was 12 items that had an an85 ghmj (global health management journal) 2019, vol. 3, no. 3 rakkapao n et al. swer as ”yes”, ”no”, and ”don’t know”. the correct answer was given 1 scores and incorrect answer was given 0 scores. the scores of hiv/aids knowledge were categorized into three levels (poor, fair, and good). a total of scores less than 60% (less than 8) was considered as a poor level of knowledge, score 60-79% (8 and 9) was considered as a fair level of knowledge, and score 80% and over (10-12) were considered as a good level of knowledge. part 3 was an attitude about hiv/aids disease and prevention. it was comprised of 15 items of pro and con attitude about disease and prevention. each item was likert scale rating from strongly agree, agree, neutral, disagree and strongly agree, with 5, 4, 3, 2, and 1 score, respectively. in terms of negative items, the score was reversed. scores of attitudes were categorized into three levels include poor, fair, and good. a total of a score less than 60% (15-44) was considered as a poor level of attitude, score 60-79% (45-59) was considered as the fair level of attitude, and score 80% and over (60-75) were considered as a good level of attitude. part 4 was risk behaviors related to hiv/aids and accessibility to health care services. the questionnaire was pretested on thirty male myanmar migrant workers in another province (phra nakhon si ayutthaya) close to patumthani province. the results from pre-tested were used to improve the questionnaire. data was collected using a self-administered questionnaire. 2.3 sta s cal analysis epidata version 3.1 was used to enter the data, and the logic check mode was used to check for data errors. descriptive statistics were summarized using means and standard deviations, for continuous variables, and frequencies and percentages for categorical data. 3. results 3.1 demographic characteris cs of par cipants a total of 400 myanmar male migrant workers completed the questionnaire (response rate : 100%), and their ages ranged from 18 to 60 years old (mean=33.42). most participants achieved primary school education (40.40%), married (54.30%), an average living in thailand 3.25 years, an average monthly income 9,166 baht ( 286 usd). half of participants did not understand the thai language. the demographic characteristics of the participants are presented in table 1. table 1. demographic characteris cs of par cipants (n=400) characteris cs frequency % age group (years) 18-24 63 15.8 25-40 259 64.7 41-60 78 19.5 mean=33.42, sd=8.07 educa on level unschooled 89 22.3 primary school 162 40.4 high school 144 36.0 bachelor degree 5 1.3 marital status single 164 41.0 married 217 54.3 widowed/divorced/separated 19 4.7 have children 86 rakkapao n et al. ghmj (global health management journal) 2019, vol. 3, no. 3 yes 224 56.0 no 176 44.0 occupa on labor 186 46.5 seller 108 27.0 others 106 26.5 living in thailand alone 44 11.0 wife 144 36.0 rela ve 146 36.5 friend 36 9.0 employer 20 5.0 others 10 2.5 average living 3.25 years, sd 1.86, max 15 years, min 6 months understand thai language do not understand 200 50.0 mild understanding and can not speak 115 28.7 moderate understanding and can speak some issue 69 17.3 good understanding and can speak on every issue 16 4.0 average income 9,166 baht per month, max 22,400 baht, min 1,240 baht family income enough 240 60.0 not enough 160 40.0 other history diseases yes 57 14.2 no 343 85.8 smoking never 241 60.3 quit 37 9.3 smoking someday 39 9.7 smoking everyday 83 20.7 drinking alcohol never 226 56.6 quit 47 11.7 drinking someday 67 16.7 drinking everyday 60 15.0 table 2 reveals the hiv/aids knowledge of participants. the result found that a majority of participants have a poor level of hiv/aids knowledge (55.25). only 13.75% have a good level of hiv/aids. an average score is 6.97 (sd=2.71) and a range of 0-12. in some essential questions, the result found that participants answered correctly less than half. for example, ”hiv people who do not have symptoms cannot spread hiv to other people” and ”aids can be cured”. table 2. sdia/vih knowledge 87 ghmj (global health management journal) 2019, vol. 3, no. 3 rakkapao n et al. yes(%) no(%) do not know(%) 1. hiv /aids transmits through blood 337 (84.3) 24 (6.0) 39 (9.7) 2. hiv /aids transmits through sex 326 (81.4) 33 (8.3) 41 (10.3) 3. hiv /aids transmits through ea ng 189 (47.3) 136 (34.0) 75 (18.7) 4. hiv /aids transmits through contact e.g. hug, hold hand 214 (53.4) 101 (25.3) 85 (21.3) 5. hiv /aids transmits through mosquito bite 109 (27.3) 207 (51.7) 39 (9.7) 6. hiv people who do not have symptoms cannot spread hiv to other people 152 (38.0) 133 (33.3) 115 (28.7) 7. aids can be cured 170 (42.5) 134 (33.5) 96 (24.0) 8.havingsexwithtemporarypartnerwithoutcondomusethat will be high risk to hiv /aids 249 (62.3) 57 (14.2) 94 (23.5) 9. hiv /aids transmits thought using of sharp objects with people, such as razor blades 259 (64.7) 61 (15.3) 80 (20.0) 10. drinking alcohol before having sex that maybe led to unsafe sex 226 (56.5) 58 (14.5) 116 (29.0) 11.usingcondomwithnon-partnercanreducehiv/aidsrisk 248 (62.0) 68 (17.0) 84 (21.0) 12. having mul ple partners that may be led to a high risk of hiv /aids 310 (77.4) 25 (6.3) 65 (6.3) 13. level of the hiv knowledgeof samples fromoverall scales poor (<8) 221 (55.25) fair (8-9) 124 (31.00) good (10-12) 55 (13.75) an average score was 6.97 (sd=2.71) and the range was 0-12 table 3 presents the results of an attitude about hiv/aids disease and prevention. it was found that a majority of participants have a fair level of hiv/aids attitude (61.25). only 33% have a good level of hiv/aids attitude. the average score is 54.53 (sd = 8.64) and the range of 23-75. more than third-one of the participants still had the wrong attitude in some questions. for example, ”i think that have to use a condom with a temporary partner”, ”i think that if i take medicine to prevent sexually transmitted diseases (stds) before having sex with a sex worker that will prevent hiv/aids”, and ”i think that using a condom is cumbersome”. table 3. a tude about hiv/aids disease and preven on i think that... frequency (%) strongly agree agree not sure disagree strongly disagree 1.havingmul plepartners increaserisk of hiv/aids 230 (57.5) 107 (26.7) 25 (6.3) 18 (4.5) 20 (5.0) 2. drinking alcohol increase risk of unsafe sex 184 (46.0) 122 (30.4) 31 (7.8) 31 (7.8) 32 (8.0) 3. using razor blades with people increase risk of hiv/aids 172 (43.0) 116 (29.0) 63 (15.8) 29 (7.2) 20 (5.0) 4. if your hand is wounded and touches thebloodorsecre onsofhiv/aidspaent that increases risk of hiv /aids 147 (36.7) 129 (32.3) 75 (18.7) 24 (6.0) 25 (6.3) 5. i have a risk of hiv /aids 83 (20.7) 89 (22.3) 86 (21.4) 73 (18.3) 69 (17.3) 6. aids is a disgus ng disease and cannot be cured 171 (42.8) 91 (22.7) 62 (15.5) 52 (13.0) 24 (6.0) 88 rakkapao n et al. ghmj (global health management journal) 2019, vol. 3, no. 3 7. hiv/aids pa ent will suffer both physically and mentally 159 (39.7) 111 (27.7) 77 (19.3) 40 (10.0) 13 (3.3) 8. hiv/aids disease has high cost 190 (47.5) 71 (17.7) 64 (16.0) 54 (13.5) 21 (5.3) 9. hiv/aids pa ent will have reduced ability to work 186 (46.5) 98 (24.5) 69 (17.3) 27 (6.7) 20 (5.0) 10.havetousecondomwithtemporary partner 154 (38.5) 101 (25.3) 70 (17.5) 46 (11.5) 29 (7.2) 11.havetousecondomwithsexworker 171 (42.7) 123 (30.7) 51 (12.8) 28 (7.0) 27 (6.8) 12. if i take medicine to prevent hiv/aids before having sex with sex worker that will prevent hiv/aids 97 (24.3) 99 (24.8) 70 (17.5) 71 (17.7) 63 (15.7) 13. i can buy condom conveniently 143 (35.8) 81 (20.2) 110 (27.5) 28 (7.0) 38 (9.5) 14. using condom is cumbersome 85 (21.1) 59 (14.8) 129 (32.3) 66 (16.5) 61 (15.3) 15. wearing a condom reduces sexual feelings 100 (25.0) 55 (13.7) 114 (28.5) 62 (15.5) 69 (17.3) 16. level of an a tude of hiv/aids disease and preven on from overall scales poor (23-44) 23 (5.75) fair (45-59) 245 (61.25) good (60-75) 132 (33.00) an average score was 54.53 (sd=8.64) and the range was 23-75 table 4 exhibits results on risk behaviors related to hiv/aids and access to health services. the results found that participants who did not use a condom with non-partners were 40.58%. accessing health care service after getting sexually transmitted diseases, mostly they bought medicine at the pharmacy and visited private clinics. the annual average to see doctor is 3.67 times. mostly, they got information about stds from friends (38.93%). table 4. risk behaviors related to hiv /aids and access health services frequency (n) % 1. age at first having sex (average 21.77, sd = 3.01, min 15, max 40) 2. have more than one partner in last year (n =398) yes 77 19.3 no 321 80.7 3. have sex with sex worker in last year yes 75 18.7 no 325 81.3 4. partner-have sex with non no 331 82.75 yes 69 17.25 4.1. use condoms yes 41 59.42 no 28 40.58 5. used to check blood tests for hiv /aids (n=397) yes 169 42.56 no 228 57.44 89 ghmj (global health management journal) 2019, vol. 3, no. 3 rakkapao n et al. 6. use drugs or alcohol drinking before having sex (n=397) yes 101 25.44 no 296 74.56 7. previously had other stds (n=399) no 368 92.23 yes 31 7.77 7.1 how to treat? (n=23) not cured 3 13.04 went to government hospital 4 17.39 went to private hospital 1 4.35 went to private clinic 5 21.74 went to pharmacies 7 30.44 others 3 13.04 8. average to see doctor per year 3.67, sd = 2.03 min 1 , max 5 *9. source of informa on about stds friends 197 38.93 health personal 148 29.25 family or rela ve 70 13.84 media 59 11.66 others 32 6.32 *can answer more than one op on table 5 provided results about an association between potential risk factors and risk behaviors related to hiv/aids and did not use a condom, which in this study refers to having sex with nonpartner. in this research, we could not demonstrate statistically significant associations between risk behaviors related to hiv/aids and potential risk factors. however, perusal of table 5 shows relationships between these variable in our sample. for example, younger men had a considerably higher rate of not using condoms in our sample demonstrated worse behavior compared to older men (30.8%). also, married men (44.6%) with 51.2% men not wearing condoms compared to 30% and 16.7% for single and widowed/sperated/divorced men, respectively. interestingly, other history of disease was also a major factor obseved in our sample for lack of condom use (57.1% vs 38.2%). table 5. cross-tabula on analysis of condom use and poten al risk factors (n=69) independent variables having sex with non-partner used condoms not using condoms χ2 p-value age group (years) 0.833 0.535+ 18-40 38 (55.4) 25 (44.6) 41-60 9 (69.2) 4 (30.8) educa on level 0.925 0.646 unschooled 12 (66.7) 6 (33.3) primary school 13 (52.0) 12 (48.0) high school 15 (57.7) 11 (42.3) marital status 3.982 0.164+ single 14 (70.0) 6 (30.0) married 21 (48.8) 22 (51.2) 90 rakkapao n et al. ghmj (global health management journal) 2019, vol. 3, no. 3 widowed/divorced/separated 5 (83.3) 1 (16.7) have children 0.941 0.237 yes 23 (53.5) 20 (46.5) no 17 (65.4) 9 (34.6) occupa on 0.796 0.699 labor 20 (58.8) 14 (41.2) seller 11 (64.7) 6 (35.3) others 9 (50) 9 (50) living in thailand 0.495 0.831+ wife 22 (61.1) 14 (38.9) rela ve 14 (56.0) 11 (44.0) others 4 (50.0) 4 (50.0) understand thai language 2.365 0.320 do not understand 15 (70.0) 6 (30.0) mild understanding and can not speak 17 (48.8) 22 (51.2) moderate understanding and can speak some issue 8 (80.0) 2 (20.0) family income 1.169 0.202 enough 21 (52.5) 19 (47.5) not enough 19 (65.5) 10 (34.5) other history diseases 1.647 0.235 yes 6 (42.9) 8 (57.1) no 34 (61.8) 21 (38.2) smoking 0.513 0.940 never 16 (59.3) 11 (40.7) quit 11 (52.4) 10 (47.6) smoking someday 5 (62.5) 3 (37.5) smoking everyday 8 (61.5) 5 (38.5) drinking alcohol 0.802 0.877 never 14 (51.9) 13 (48.1) quit 8 (61.5) 5 (38.5) drinking someday 4 (66.7) 2 (33.3) drinking everyday 14 (60.9) 9 (39.1) level of hiv knowledge 3.774 0.175 poor (<8) 28 (62.2) 17 (37.8) fair (8-9) 5 (35.7) 9 (64.3) good (>9) 7 (70.0) 3 (30.0) level of a tude of hiv/aids 4.259 0.156 poor (15-44) 3 (50.0) 3 (50.0) fair (45-59) 30 (66.7) 15 (33.3) good (60-75) 7 (38.9) 11 (61.1) p-value from fischer’s exact test 91 ghmj (global health management journal) 2019, vol. 3, no. 3 rakkapao n et al. 4. discussion although an overview of hiv/aids new cases globally decreased and the number of aids patients related deaths also decreased due to the development of antiretroviral therapy (unaids, 2018b), hiv/aids problem in the vulnerable group like migrants is still a serious problem in many countries. besides, hiv/ aids problem has changed from individual problem to social problem as a result of population mobility. epidemiology of hiv/aids in migrant workers is a national and an international problem of developing countries. in south-east asia like thailand, hiv prevalence among migrant workers from neighboring countries was four times higher than that among the general population (unaids, 2018b; thepthien et al., 2015). limited access to health information and health care services of migrant workers were the main barrier in managing hiv/aids problems. the update information on hiv/aids and migrant workers are very necessary to set a good health intervention, to decrease hiv/aids prevalence in this population. a vast majority of epidemics of hiv/aids are among predominantly males, leading this study to focus on male migrant workers working in pathumthani. the demographic characteristics of the participants in this study were similar to other studies (fuller and chamratrithirong, 2009; zafar et al., 2014). mostly migrant workers are adult, single, and low education. regarding personal factors of migrant workers that make them have a high risk of hiv/aids (weine and kashuba, 2012). moreover, this study found that most myanmar male migrant workers have a low level of hiv/aids knowledge. similar to other studies (unaids, 2018b; iom, 2017; akinsulure-smith, 2014; amirkhanian et al., 2011; weine et al., 2008), correct knowledge leads to correct behavior. therefore, health intervention aims to raise hiv/aids knowledge as an urgent need in this group. a fair level of an attitude about hiv/aids of participants was found in this work. however, wrong attitudes still found in some essential questions. attitude or belief of a person affects their health behaviors. these results confirmed that an urgent need to provide hiv/aids intervention in migrant workers in thailand. another aspect in terms of attitude about hiv/aids that maybe will consider less importance or concentrated when migrant workers want to seek new sex experience in the destination country. 40.58% of participants who had sex with non-partners has risk behaviors related to hiv/aids. using a condom with safe sex was accepted the best way to protect hiv/aids. similar to several studies that found that there is limited condom use among labor migrants (weine and kashuba, 2012; weine et al., 2008). the prevalence of risk behaviors related to hiv/aids in this study is relatively high. this may explain by the acculturation theory about adapted to a new culture of migrants. individuals from one culture integrate into a different culture either from birth or through immigration, forcing the individuals to modify their self-identity and relationship to each culture (berry, 1997). sexual values from the origin country of migrants will gradually reduce concentration and will combine new values from destination countries because of available and more convenient resources (unaids, 2018b,a; lee and hahm, 2010). for access to health care service, most of the participants in this study bought medicine from the pharmacy, went to a private clinic, and received information about stds from friends and family. these suggested that hiv/aids intervention should cover not only migrant workers but also their friends and family. hiv/aids intervention should be integrated with thai in their workplace or community. moreover, hiv/aids knowledge should be available on social networks or social media for migrant workers. although there are some health strategy and intervention of thai government, specialized ngo, and united nations which aimed to prevention hiv/aids by increasing knowledge among migrant workers such as standard management of hiv/aids workplace activities. prevention of hiv/aids among migrant workers in thailand project (phamit), and comprehensive hiv-prevention among most at-risk population by promoting integrated outreach and networking (champion) (unaids, 2019; ipsr, 2012), knowledge and attitude regarding hiv/aids of myanmar migrant workers still need to more improve. besides, our failure to demonstrate an association 92 rakkapao n et al. ghmj (global health management journal) 2019, vol. 3, no. 3 between risk behaviors related to hiv/aids and potential risk factors may be due to the lack of relationship, equally, it may be due to the rarity of the outcome (underestimate). this suggests that future research should focus on these issues. there are some limitations in this study. firstly, the sample could not be selected with random sampling. secondly, the findings of this study are based on self-reported data, participants may have avoided participation due to the sensitive nature of these particular health risk behaviors. a third, and perhaps the most important, limitation is that admitting to sexual engagement with a non-partner was not particularly prevalent in our sample with only 69% (17.25) of the 400 participants originally approached admitting to this behavior. the implication of this is that our study was restricted to purely descriptive statistics, as any formal analysis would have been severely underpowered. this is perhaps best demonstrated where we observed quite large differences in the condom use behavior among certain groups (e.g. age, marital status, and history of disease), that could not be demonstrated as statistically significant. however, this cross-sectional survey may provide further insights into current information about hiv/aids among myanmar migrant workers in thailand. future research should focus on culture related to sexual behavior of myanmar migrant workers living in thailand. 5. conclusion this study found that a majority of participants had a poor level of hiv/aids knowledge and a fair attitude level of hiv/aids .disease and prevention risk behavior related tohiv/aids of participants is relatively high .and also less access to health care services this current information is confirmed that an urgent need to provide health intervention to increase knowledge on hiv/ aids among myanmar migrant workers in thailand. acknowledgments the authors would like to thank all the participants and research assistants for data collection .appreciation for the funding from the faculty of public health, thammasat university, thailand for supporting and all authors declare no conflict of interest. conflict of interest there is no conflict of interest. references akinsulure-smith, a. m. (2014). exploring hiv knowledge, risk and protective factors among west african forced migrants in new york city. journal of immigrant and minority health, 16(3):481–491, doi: 10.1007/s10903-013-9829-1. alvarez-del arco, d., fakoya, i., thomadakis, c., pantazis, n., touloumi, g., gennotte, a.-f., zuure, f., barros, h., staehelin, c., göpel, s., et al. (2017). high levels of postmigration hiv acquisition within nine european countries. aids, 31(14):1979–1988, doi: 10.1097/qad.0000000000001571. amirkhanian, y. a., kuznetsova, a. v., kelly, j. a., difranceisco, w. j., musatov, v. b., avsukevich, n. a., chaika, n. a., and mcauliffe, t. l. (2011). male labor migrants in russia: hiv risk behavior levels, contextual factors, and prevention needs. journal of immigrant and minority health, 13(5):919–928, doi: 10.1007/s10903-010-9376-y. berry, j. w. (1997). immigration, acculturation, and adaptation. applied psychology, 46(1):5–34. boe (2013). hiv infection situation among migrant workers in thailand. 93 https://dx.doi.org/10.1007/s10903-013-9829-1 https://dx.doi.org/10.1097/qad.0000000000001571 https://dx.doi.org/10.1007/s10903-010-9376-y ghmj (global health management journal) 2019, vol. 3, no. 3 rakkapao n et al. fakoya, i., álvarez-del arco, d., woode-owusu, m., monge, s., rivero-montesdeoca, y., delpech, v., rice, b., noori, t., pharris, a., amato-gauci, a. j., et al. (2015). a systematic review of post-migration acquisition of hiv among migrants from countries with generalised hiv epidemics living in europe: mplications for effectively managing hiv prevention programmes and policy. bmc public health, 15(1):561, doi: 10.1186/s12889-015-1852-9. fuller, t. d. and chamratrithirong, a. (2009). knowledge of hiv risk factors among immigrants in thailand. journal of immigrant and minority health, 11(2):83–91, doi: 10.1007/s10903-008-9163-1. iom (2017). migration data portal. https://migrationdataportal.org/?t=2017. (accessed on 1 april 2019). iom (2019). thailand migration report 2019. https://thailand.iom.int/thailand-migration-report2019-0. (accessed on 5 april 2019). ipsr (2012). prevention of hiv/aids among migrant workers in thailand (phamit) project 2. institute for population and social research, mahidol university, nakhon pathom. lee, j. and hahm, h. c. (2010). acculturation and sexual risk behaviors among latina adolescents transitioning to young adulthood. journal of youth and adolescence, 39(4):414–427, doi: 10.1007/s10964-009-9495-8. mullany, l. c., maung, c., and beyrer, c. 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(2014). knowledge, attitude and practices regarding hiv/aids among adult fishermen in coastal areas of karachi. bmc public health, 14(1):437, doi: 10.1186/1471-2458-14-437. cite this article as: rakkapao n, kiattisaksiri p, samakkekarom r. knowledge, attitudes, and hiv/aids risk behaviors of myanmar migrant workers in thailand. ghmj (global health management journal). 2019; 3(3):84-94. doi:10.35898/ghmj-33452 94 https://dx.doi.org/10.1186/s12889-015-1852-9 https://dx.doi.org/10.1007/s10903-008-9163-1 https://migrationdataportal.org/?t=2017 https://thailand.iom.int/thailand-migration-report-2019-0 https://thailand.iom.int/thailand-migration-report-2019-0 https://dx.doi.org/10.1007/s10964-009-9495-8 https://dx.doi.org/10.1080/0954012021000039761 https://dx.doi.org/10.1089/apc.2009.0135 https://www.unaids.org/en/regionscountries/countries/thailand https://www.unaids.org/en/regionscountries/countries/thailand https://www.unaids.org/sites/default/files/media_asset/unaids-data-2018_en.pdf https://www.unaids.org/sites/default/files/media_asset/unaids-data-2018_en.pdf https://www.unaids.org/sites/default/files/media_asset/04_migrants.pdf https://www.unaids.org/sites/default/files/media_asset/04_migrants.pdf https://dx.doi.org/10.1007/s10903-007-9103-5 https://dx.doi.org/10.1007/s10461-012-0183-4 https://dx.doi.org/10.1186/1471-2458-14-437 introduction method study design and sample instruments statistical analysis results demographic characteristics of participants discussion conclusion microsoft word 1. accepted editorial, doni marisi sinaga, 1-3.docx cite this article as sinaga dm. vaccination: considerations to acceptance and refusal. global health management journal. 2018; 2(1): 1-3. global health management journal www.publications.inschool.id published by editorial issn 2580-9296 (online) vaccination: considerations to acceptance and refusal doni marisi sinaga global health management journal, yayasan aliansi cendekiawan indonesia thailand (indonesian scholars’ alliance) *corresponding author. email: dms.sinaga@gmail.com; doni@inschool.id received 15 january 2018; reviewed 23 january 2018; received in revised form 22 february 2018; accepted 28 february 2018 © 2018 publications of yayasan aliansi cendekiawan indonesia thailand this is an open access following creative commons license deed – attribution-noncommercial-sharealike 4.0 international (cc by-nc-sa 4.0) introduction vaccination is one efficient and crucial tool for preventing and controlling disease. however, with remarkably low coverage rate of common diphtheriatetanus-pertussis or measles vaccines in low-income countries [1], there is a need to evaluate context behind acceptance and refusal of the immunization programs at a national level. overwhelming evidence of the effectiveness of vaccination to lower morbidity and mortality associated with these preventable diseases are not satisfying enough to increase participation and encourage parents to vaccinate their children [2]. as a consequence, with declined vaccination, individuals have significantly higher risk of measles [3] and pertussis [4]. more studies claim groups of those are vulnerable to vaccine-preventable diseases (e.g., measles, poliomyelitis, rubella) including children and adults can enable epidemics [5, 6] and further cause multiple outbreaks [7, 8], even to the well-immunized neighboring communities [9]. this short review questions what factors lead to acceptance and refusal of vaccines in society. methods for this article, a literature review was conducted, from november to december 2017, using 3 electronic databases: science direct, proquest and google scholars for the years 1980-2017 with full text in english. only relevant works examined acceptance and refusal of vaccine were included. focus of the study differentiated between factors that affect an individual’s choice to vaccinate their own child, and factors that affect the community’s perception of the safety and efficacy of vaccines. cultural factors inhibiting immunization program individual beliefs, religious concerns, or cultural reasons intensively define how an individual accepts or refuses immunization [10]. jehovah’s witnesses has been instructed initially by the watch tower society to refuse blood transfusions which they consider not following god’s law [11]. giving health interventions to a healthy person has been viewed as alteration to god’s will, and this perception has led communities in pakistan to refuse immunization programs [12]. christian scientists in the united states are opposed to immunization and all medical care since they believe diseases are manifestation of spiritual problems that can be cured by praying [13]. political propoganda inhibiting immunization program misinformation and other related-politic story spread in the community throughout the country insisted people to escape and withhold the immunization global health management journal, 2018, vol. 2, no. 1 2 program that initiated by the government. in 1990, a tetanus vaccination program in cameroon failed since students feared the injection would sterilize them [14]. political and religious leaders in 3 states in northern nigeria advocated against immunization since they believed the oral polio vaccine (opv) could be contaminated by birth control substances, and even the hiv virus and cancerous agents; consequently, it forced the local government to suspend the immunization program for 12 months [15]. interestingly, this official boycott also led to refusal of opv in northwestern pakistan [12]. immunization in progress when vaccination is considered for safety, those who faced and directly experienced to disease may change their belief to the vaccine program. a review of 6 populous faith traditions (i.g., hinduism, buddhism, jainism, judaism, christianity, and islam) noted that safety and personal belief organized socially around their religious community are more highly considered, rather than to objections theologically, in refusing the immunization [10]. for example, parents who members in christian scientists of the united states mostly did not refuse vaccination given to their children after these pupils exposed to measles outbreaks in camp school [13]. today, religious and cultural doctrines have changed and became “softer” and “not absolutely prohibited” [16], and later considered as a matter of personal choice [17]. religion and culture provide significant identity and existence to a community [18]; and as the result, relationships with their religious leaders play important roles to how individuals perceived an immunization program [19]. a study in 1994, among jehovah’s witnesses in the us, shows that an early discussion with religious leaders and church elders about the compatibility of the vaccine with their religious beliefs can be a good strategy for immunization program [20]. scholars also raise the importance of immunization programs clearly describing the substances contained in the vaccine that might be considered impure to the religious community. moreover, many muslim countries now are developing halal vaccines that assures no prohibited ingredients contained, using science and technology with religious jurisprudence [21]. potential challenges it is so important to understand the complex factors that play a role in why people refuse and accept vaccination. trend changes, but the emergency to save 25 million lives from death by vaccine-preventable diseases in 2020 also required effort to prevent further rejection [22]. it should be noted that building community trust regarding the health intervention is essential to promoting an immunization program. in addition to state and local governments, immunization campaign programs should involve parents and community leaders for participation [15]. if messaging only relies on the health workers, no doubt, the more frequent the health workers visit the community, the more resistant the parents to the campaign [23]. parents may think the vaccine was contaminated by virus, bacteria, pork, and birth control, or perceive it has western agenda [12], or distrust to the lack efficacy of western medicine [15] and trauma to the country for being used to drug trial [24]. in northern nigeria, to prove that vaccine was not contaminated with hiv, as spread throughout the country, political and religious leaders from many countries were invited for meetings where they ran a test to provide evidence and help to design research ethics committee to approve or reject health intervention to the community [24]. scholars have stressed the importance of raising basic understanding of vaccines to make parents realize the benefits and increase willingness to immunize their children [23]. however, in addition to educating individuals, it is also necessary to deeply understand the complex culture in community. while letting male health workers enter the female quarters of household will be considered as immoral in many muslim countries [12], reaching communities can be successfully done through radio, television, music, theatre, and festivals to deliver immunization messages in understandable language [15]. 3 global health management journal, 2018, vol. 2, no. 1 references 1. world health organization. global vaccine action plan 2011-2020. global vaccine action plan 20112020. 2013. 2. roush sw, murphy tv, group v-pdtw. historical comparisons of morbidity and mortality for vaccinepreventable diseases in the united states. jama. 2007;298(18):2155-63. 3. salmon da, haber m, gangarosa ej, phillips l, smith nj, chen rt. health consequences of religious and philosophical exemptions from immunization laws: individual and societal risk of measles. jama. 1999;282(1):47-53. 4. feikin dr, lezotte dc, hamman rf, salmon da, chen rt, hoffman re. individual and community risks of measles and pertussis associated with personal exemptions to immunization. jama. 2000;284(24):3145-50. 5. may t, silverman rd. ‘clustering of exemptions’ as a collective action threat to herd immunity. vaccine. 2003;21(11):1048-51. 6. silverman rd. no more kidding around: restructuring non-medical childhood immunization exemptions to ensure public health protection. annals health l. 2003;12:277. 7. hahné s, macey j, tipples g, varughese p, king a, van binnendijk r, et al. rubella outbreak in an unvaccinated religious community in the netherlands spreads to canada. euro surveill. 2005;10(5):e050519. 8. hahné s, macey j, van binnendijk r, kohl r, dolman s, van der veen y, et al. rubella outbreak in the netherlands, 2004–2005: high burden of congenital infection and spread to canada. the pediatric infectious disease journal. 2009;28(9):795800. 9. bauch ct, bhattacharyya s. evolutionary game theory and social learning can determine how vaccine scares unfold. plos computational biology. 2012;8(4):e1002452. 10. grabenstein jd. what the world's religions teach, applied to vaccines and immune globulins. vaccine. 2013;31(16):2011-23. 11. muramoto o. bioethics of the refusal of blood by jehovah's witnesses: part 1. should bioethical deliberation consider dissidents' views? journal of medical ethics. 1998;24(4):223-30. 12. murakami h, kobayashi m, hachiya m, khan zs, hassan sq, sakurada s. refusal of oral polio vaccine in northwestern pakistan: a qualitative and quantitative study. vaccine. 2014;32(12):1382-7. 13. novotny t, jennings ce, doran m, march cr, hopkins rs, wassilak s, et al. measles outbreaks in religious groups exempt from immunization laws. public health reports. 1988;103(1):49. 14. feldmansavelsberg p, ndonko ft, schmidtehry b. sterilizing vaccines or the politics of the womb: retrospective study of a rumor in cameroon. medical anthropology quarterly. 2000;14(2):159-79. 15. jegede as. what led to the nigerian boycott of the polio vaccination campaign? plos medicine. 2007;4(3):e73. 16. muramoto o. recent developments in medical care of jehovah's witnesses. western journal of medicine. 1999;170(5):297. 17. sniecinski r, levy jh. what is blood and what is not? caring for the jehovah's witness patient undergoing cardiac surgery. lww; 2007. 18. ukah af-k. african christianities: features, promises and problems: johannes gutenbertguniversität; 2007. 19. antai d. faith and child survival: the role of religion in childhood immunization in nigeria. journal of biosocial science. 2009;41(1):57-76. 20. roy-bornstein c, sagor ld, roberts kb. treatment of a jehovah's witness with immune globulin: case of a child with kawasaki syndrome. pediatrics. 1994;94(1):112-3. 21. norazmi mn, lim ls. halal pharmaceutical industry: opportunities and challenges. trends in pharmacological sciences. 2015;36(8):496-7. 22. maurice jm, davey s. state of the world's vaccines and immunization: world health organization; 2009. 23. khan tm, sahibzada muk. challenges to health workers and their opinions about parents’ refusal of oral polio vaccination in the khyber pakhtoon khawa (kpk) province, pakistan. vaccine. 2016;34(18):2074-81. 24. yahya m. polio vaccines: difficult to swallow: the story of a controversy in northern nigeria. institue of development studies, 2006. knowledge, attitudes, and hiv/aids risk behaviors of myanmar migrant workers in thailand ghmj (global health management journal) 2022, vol. 5, no. 2 indonesian scholars’ alliance open access photo essay politeknik kesehatan kemenkes palangka raya: health forum and international seminar the new normal: creating a pleasant virtual communication a new drug-free life: the essence of professional’s presence in drug survivor’s family yeyentimalla 1 *, sri suryawati 2 1 department of nursing, poltekkes kemenkes palangka raya, indonesia 2 faculty of medicine, public health, and nursing, universitas gadjah mada, yogyakarta, indonesia *corresponding author’s e-mail: yeyentimalla@polkesraya.ac.id doi: 10.35898/ghmj-52940 selection and peer-review under responsibility of the scientific committee and the editorial board of the annual health forum and international seminar of the politeknik kesehatan kemenkes palangka raya © yayasan aliansi cendekiawan indonesia thailand (indonesian scholars’ alliance). this is an open-access following creative commons license deed attribution-noncommercial-sharealike 4.0 international (cc by-nc-sa 4.0) figure 1 the galilee foundation for drug rehabilitation palangka raya the story begins at the galilee foundation drug rehabilitation center in palangka raya city in july 2018. we are a team that provides professional assistance to drug survivors at the panti (in indonesia, rehabilitation homes for drugs users are termed panti). one of the four-drug survivors enrolled in our study was jeremy, 19 years old. we were helping jeremy to reconnect with his family. this activity was a part of the social reintegration activity of the drug rehabilitation program. social reintegration is an international mandate as stated in article 38 of the single convention on narcotics drugs. “the parties shall give special attention to and take all practicable measures for the mailto:alfeusmanuntung@gmail.com https://doi.org/10.35898/ghmj-52940 133 ghmj (global health management journal) 2022, vol. 5, no. 2 yeyentimalla & suryawati prevention of abuse of drugs and early identification, treatment, education, after-care, rehabilitation, and social reintegration of the persons involved and shall coordinate their efforts to these ends.” (united nations, 1961). the international narcotics control board (incb) continuously calls on government of countries and territories around the world to coordinate and formulate policies according to the needs of their countries regarding the prevention, curation, rehabilitation, and social reintegration of drug abuse as an important component in a strategy to reduce drug demand and reduce the impact of drugs (international narcotics control board, 2017). in indonesia, social reintegration has not received adequate attention and placed nowhere in national rehabilitation programs. the relapse is high, i.e., 60-70%. drug survivors are sent back to the family while they and their families are not well prepared to reunite. no guidelines or training are available for the implementation of social reintegration. the term “social reintegration” is unfamiliar to the program managers. there is a term “post-rehabilitation”, which is two months after rehabilitation when drug survivors are prepared to return to the community. unfortunately, this activity does not involve the families and therefore has little impact on restoring the communication gap between drug survivors and their families (https://fk.ugm.ac.id/reintegration-social-tanggulangi-bahaya-narkoba; https://bnn.go.id/kambuh-relapse; https://republika.co.id/berita, accessed october 14, 2020). jeremy comes from a broken home family. her father left his wife, jeremy, and two younger siblings to marry another woman. jeremy got angry with his father and started taking drugs. one day jeremy rode a motorcycle under drugs and got into an accident. he broke his left thigh and underwent surgery for pen implants. in an interview at the panti, jeremy expressed his disappointment with his father. when jeremy was at the panti, his mother married a divorced man. jeremy said not close to his stepfather, but he thought it was good for her mother as she had a life partner to share the sorrow. figure 2 jeremy with his female cousin after inserting a pen into his left thigh post a traffic accident in 2014 damage to emotional relationship with families is a common problem among drug users/addicts of narcotics, psychotropic substances, and addictive substances. even if they have completed a rehabilitation program and are awarded “drug survivor”, the damage is usually unhealed (mcvey & quarles, 2013). this is a true sadness as experts always recommend that when a family is unable to repair damaged relationship among its members because of limited knowledge, will and abilities, they need professional help (shea, 1996, wahlroos, 1995). https://fk.ugm.ac.id/reintegration-social-tanggulangi-bahaya-narkoba https://bnn.go.id/kambuh-relapse; https://republika.co.id/berita, yeyentimalla & suryawati ghmj (global health management journal) 2022, vol. 5, no. 2 134 we made ourserves friends with jeremy, we were there, and engaged in deep conversations with him. jeremy, who was quiet, was encouraged to share his thought and feelings. we laughed together on many things; for example, when his mother gave him a little sum of money, jeremy jokingly said his mother was going through a monetary crisis. we also reached his family and we’re getting to know each other. jeremy’s mother was surprisingly a friendly and open person. she comes from a large family with 11 siblings; all of them live in the same city. jeremy rehabilitation program was completed in july 2018, but his family, especially his mother, refused jeremy to come home. jeremy then enrolled in training for workers whose tuition fee was seven million rupiah (approximately us dollars 475) as a preparation to work in panti. during an interview at panti, jeremy said that he wanted to devote his life to the panti. we provided the basic knowledge, tips and tricks on how to engage in emotional communication with the family. we also practiced the tips and tricks with them, to make the family in turn could sit together and freely talk about problems in a comfortable atmosphere. we emphasized that the main goal of family conversation is understanding, not agreement (bechtle, 2014; hendricks, 2009). when we were away, contact was made via whatsapp. in the beginning, we usually initiated the chatting, and after a while jeremy’s mother did). figure 3 jeremy (inzet) in wuling motors, with boss and other four months has passed. in november 2018, the family welcomed jeremy to come home. jeremy then started working at wuling motors, a car sales agency. jeremy to start the responsibility of managing his money. jeremy decided to buy a motorbike by an installment scheme, deducted from his monthly salary. his boss also trusted jeremy to deliver cars to a buyer living outside palangka raya. such a situation sometimes made jeremy’s mother worried and she would wait until the son getting home. her mother was supportive to jeremy, she prepared jeremy’s daily meals. 135 ghmj (global health management journal) 2022, vol. 5, no. 2 yeyentimalla & suryawati the family relationship improved. his mother accepted the situation, so did the two younger siblings. his stepfather treated jeremy and his younger siblings as his own kids. on september 10, 2020, jeremy (who was then 22), married a girl of his choice, anita, 18, y.o. the wedding receptions followed the health protocol of covid-19. jeremy and anita are loving each other. jeremy’s mother said the marriage would boost jeremy’s responsibility towards his wife, which would be great for jeremy. jeremy’s connection with his stepfather improved. jeremy quit working at wuling motors as an impact of covid-19 and worked with his stepfather as a builder. jeremy’s new family lived at the same house. jeremy no longer called his stepfather “uncle” it turned into “papa”. jeremy’s mother said the hard times in her family’s life have passed, and she was grateful to god. figure 4 jeremy with youngest sister, stepfather and younger brother figure 5 jeremy with youngest sister, mother and stepfather figure 6 jeremy married anita on september 10, 2020 figure 7 jeremy with anita, mother and stepfather yeyentimalla & suryawati ghmj (global health management journal) 2022, vol. 5, no. 2 136 to end the story, in jeremy’s recovery process from drugs, the benefits of the presence of professionals as friend are long-stated by goldstein and kanfer (1975). this is a form of relationship enhancement method, plays a role in influencing client learning behavior. from jeremy’s side, his strong will and the support of the whole make jeremy firm in continuing his drug-free life (friedman, et al., 2014; sillars, et al., 2004). this study result is in concordance with the finding of triple r project in european union that social reintegration is important from the first-day drug users to undergo re habilitation (the triple r project team, 2016). consent the photographed adults (identifiable) have given their consent for their pictures to be used in the dissemination and publication of this research. conflict of interest none. acknowledgments the author would like to thank you for the cooperation to jeremy and his family in palangka raya, central kalimantan province, indonesia. figure 8 jeremy was enthusiastically helping us mounting the banner of international seminar of poltekkes kemenkes palangka raya on october 22, 2020 137 ghmj (global health management journal) 2022, vol. 5, no. 2 yeyentimalla & suryawati references bechtle, m. (2014). how to communicate with confidence. jakarta: nafiri gabriel. friedman, m. m., bowden, v. r., & jones, e. g. (2014). family nursing: research, theory, and practices (5th ed.). jakarta: egc. goldstein, a. p., & kanfer, f. h. (1975). helping people change: a text box of methods. michigan university: pergamon press. hendricks, h. g. (2009). teaching to change lives. jakarta: gloria graffa. international narcotics control board. (2017). annual report 2016. retrieved from https://www.incb.org/documents/publications/annualreports/ar2016/english/ar2016_e_ebook.pdf mcvey, s., & quarles, m. (2013). helping others overcome addictions (1st ed.). eugene, oregon: harvest house publishers. shea, s. c. (1996). wawancara psikiatri. seni pemahaman (1st ed.; y. asih & m. ester, eds.). jakarta: penerbit buku kedokteran egc. sillars, a., canary, d. j., & tafoya, m. (2004). communication, conflict, and the quality of the family relationship. in a. l. vangelisti (ed.), handbook of family communication. mahwah, new jersey: lawrence erlbaum associates. triple r project team. (2016). triple r: rehabilitation for recovery and reinsertion. handbook on social reintegration of recovered drug users. retrieved from http://www.tripler-project.eu/publi/handbook-onsocial-reintegration-of-recovered-drug-users.pdf united nations. (1961). single convention on narcotic drugs. final act of the united nations conference for the adoption of a single convention on narcotic drugs, 44. https://doi.org/10.1017/s0020818300011620 wahlroos, s. (1995). family communication: the essential rules for improving communication and making your relationship more loving, supportive, and enriching. mc.graw-hill. -------https://fk.ugm.ac.id/reintegrasi-sosial-tanggulangi-bahaya-narkoba/, accessed october 14, 2020 -------https://bnn.go.id/kambuh-relapse/, accessed october 14, 2020 -------https://republika.co.id/berita/nasional/hukum/18/03/20/p5w2eo428-bnn-70-persen-pecandu narkobarelapse-setelah-rehabilitasi, accessed october 14, 2020 cite this article as: yeyentimalla, suryawati s. a new drug-free life: the essence of professional’s presence in drug survivor’s family. ghmj (global health management journal). 2022; 5(2):132-137. doi:10.35898/ghmj-52940 https://fk.ugm.ac.id/reintegrasi-sosial-tanggulangi-bahaya-narkoba/ https://bnn.go.id/kambuh-relapse/ https://republika.co.id/berita/nasional/hukum/18/03/20/p5w2eo428-bnn-70-persen-pecandu-%20%20narkoba-relapse-setelah-rehabilitasi https://republika.co.id/berita/nasional/hukum/18/03/20/p5w2eo428-bnn-70-persen-pecandu-%20%20narkoba-relapse-setelah-rehabilitasi https://doi.org/10.35898/ghmj-52940 cite this article as diartama aaa, suswaty s, priantoro w, sugiyanto, sudiyono, anwar mc, latifah l, santjaka a, amri f, mulyantoro dk. the design of radiology viewing box using charger system and potentiometer. global health management journal. 2017; 1(1): 10-4. global health management journal www.publications.inschool.id published by original research article the design of radiology viewing box using charger system and potentiometer anak agung aris diartama 1,*, susy suswaty 2, win priantoro 2, sugiyanto 1, sudiyono 1, m. choiroel anwar 1, leny latifah 1, aris santjaka 1, faisal amri 1, donny kristanto mulyantoro 1 1 postgraduate imaging diagnostic program, poltekkes kemenkes semarang, semarang health polytechnic, indonesia 2 poltekkes kemenkes jakarta ii, jakarta ii health polytechnic, indonesia *corresponding author. email: diartamaaris@gmail.com article info abstract article history: submitted 3 may 2017 accepted 22 june 2017 background: in the process of work to gain the maximum results, a radiologist needs a viewing box tool to read radiographs. therefore, the authors want to develop a viewing box tool, which in general the work if this tool resembles the factory manufactured tool. the viewing tool box made can adjust the intensity of the light produced. it uses batteries as a charger system, so that the viewing box can be used anywhere, especially areas that have not been reached by electricity. aims: this study aimed to create a viewing box tool by using a potentiometer system and charger system. methods: this study used applied research method by creating and using the design of viewing box tool by using a potentiometer and charger system. using a lux meter, the tool’s feasibility and the quality of potentiometer system were assessed by 15 respondents consisting of five radiologists and 10 radiographers who should fulfill the questionnaire form. results: the results of the questionnaire showed that 100% radiologist gave an a (excellent) and expressed that the viewing box tool created could be used properly and 90% radiographers provided an a (excellent) and expressed that the viewing box tool created could be used properly, while 10% radiographer gave a value of b (moderate). conclusion: the proposed viewing box tool could be used properly and obtained optimal results as a tool in reading radiographs. potentiometer system contained in the viewing box was very helpful in reading radiographs. keywords: viewing box radiology potentiometer charger © 2017 publications of yayasan aliansi cendekiawan indonesia thailand this is an open access following creative commons license deed – attribution-noncommercial-sharealike 4.0 international (cc by-nc-sa 4.0) introduction radiology installation is one of the supporting medical installations in establishing the diagnosis needed in various health facilities. indonesia is an archipelagic country and has remote areas far from adequate health care centers, especially the availability of radiology installation. currently the government has provided mobile radiology services to reach these areas, which of course have been granted permission to use mobile x-ray machine that has passed the conformity test (regulation of head of bapeten no. 9 of 2011). in indonesia, especially in remote areas many have not been reached by the electrical power supply [1]. in the work process of radiology installation, ionizing and non-ionizing radiation are using as http://publications.inschool.id/ mailto:diartamaaris@gmail.com http://inschool.id/ http://creativecommons.org/licenses/by-nc-sa/4.0/ 11 global health management journal, 2017, vol. 1, no. 1 energy sources. in the radiograph science, to obtain good quality and adequate radiographs, it is influenced by several factors, among others: the radiographic techniques, materials, equipment and techniques of darkroom/ processing. all of which is interrelated each other, so if one factor is ignored then the radiographic images produced will be inadequate. after passing through these stages then the operator will obtained a yield of radiographs, but radiographs are not the end of the radiodiagnostic examination process, without the written results or expertise from the radiologist then radiography process can be said to be redundant. in this case there is a need to implement quality control and quality assurance standards in viewing the radiographic images, to support the overall optimization of the radiography process [2] radiographer has a responsible to see the film to assess its suitability as a diagnostic support which is often referred to as the image quality. contrast, sharpness and the mean of density will be tested from each other and this is a quality that can be considered in accordance with the state of the displayed image. in general, the fewer the number of odd light, the better the detection analysis of a radiologist to read radiographs. the film with good quality is not necessarily better when viewed with the viewing box that does not meet the standards. therefore, the selection of good quality viewing box is indispensable when planning the radiology department. there should be a comprehensive quality assurance program for the viewing box to obtain good, consistent and informative image visualization [3]. the display of light intensity of the viewing box should be able to set in low and higher lighting so that the detection accuracy when viewing calcification in the glandular tissue can be seen clearly [4]. potentiometer is one type of resistor that the resistance value can be set according to the needs of electronic circuits or the needs of the user, it is often also used in the lamp brightness regulator circuit (light dimmer circuit) and the voltage regulator in the power supply (dc generator). structurally, the potentiometer consists of 3 terminal feet with a shaft or lever that function as the regulator. potentiometer as known as resistor with scroll connection which is made setting voltage divider [5]. the charger system used in the manufacture of viewing box tool uses an accumulator / accu. accumulator / accu is a device that can store energy (generally electrical energy) in the form of chemical energy. rechargeable batteries that are currently widely used are accu batteries (lead acid battery) and the type is lithium ion [6]. battery with accu type has a good performance quality, but it has a problem of a rather heavy weight. [7, 8]. based on the geographical location of indonesia that consists of the islands and there are still many areas that have not been reached by electricity, then to support radiological examination to the area, the authors made a viewing box tool by using a charger system to facilitate the radiologist in reading the results of x-ray everywhere though without the presence of direct electric current. viewing box tool is also equipped with a potentiometer that serves to adjust the intensity of light in the viewing box, so that the radiologist will be able to read the results of x-ray more optimally. methods this study used applied research method by creating and using the design of viewing box tool by using a potentiometer and charger system. the function test was performed by observing the objects being created. in order to test the effectiveness of the modified viewing box tool, then the tool function test experiment would be conducted at the laboratory of mathematics and natural science, university of udayana and in some hospitals during march 2009. the data collection process was carried out by tool test experiment to measure the color temperature of the x-ray viewing box by using lux meters and it was also tested in terms of effectiveness, both in function and other available supporting components in the viewing box [9]. the instrument used in this study was a questionnaire addressed to radiology doctors and radiographers. this questionnaire was used to obtain the data in order to test the function of the modified viewing box tool in accordance with the actual function. the points to be assessed include: feasibility of the viewing box tool to be used in accordance with its function, and the added benefits from the supporting components contained in the global health management journal, 2017, vol. 1, no. 1 12 viewing box. assessment indicator a meant good, b meant moderate and c meant less good. in designing the viewing box the authors needed tools and materials used in its manufacture, namely: electric drill, cable scissors, blade/cutter, mechanical pens, solder, tin solder, acrylic (black and white with 2 mm thickness), power supply, sandpaper, power cable, black duct tape, led (light emitting diode), glue gun, potentiometer, resistor (resistance), on-off switch, step-down transformer to lower the voltage of ac to dc voltage, dimmer light (inflows regulators), capacitors, diodes (1 ampere), relay, head sink, fuse, pcb board. as shown in figure 1. the process to make this tool was firstly by sketching on the surface of acrylic, in accordance with a box that will be created by using a mechanical pen, did the cutting and created holes for the placement of equipment/accessories required. then the acrylics were arranged/shaped that have been cut by using glue, thereby there were formed two boxes with a height of 45 cm, length of 37 cm, a width of 7 cm and a height of 45 cm, a length of 8 cm, height 7 cm. the rear part of the viewing box was set to be opened and closed in order to facilitate the preparation of electronic series, led lights and to simplify the tool repair at any time when the viewing box is damaged. figure 1 acrylic pieces were adhered by using glue as shown in figure 2. firstly, potentiometer electronic system was outside the box before being placed in the box. this was done to facilitate the string. then a series of led lights that will be used on a viewing box were arranged with a distance of between 2 cm-3 cm for each led (leds used here were as many as 288 pieces). figure 2 led lamps series in the viewing box for each led a resistance (resistor) of 220 ohm was provided in order to restrain the excess voltage that goes into the leds. after the series of leds and resistors was neatly arranged, then the series was attached in the box that has been made. when all the components have been set and neatly arranged in a box, then all of the series were connected/linked to each other. the film prop was made on the front side of the viewing box by using rubber materials or similar material. the final stage was combining the box with bolts on the both boxes. figure 3 modified viewing box by using potentiometer result the study was conducted from march to may 2009, to create a viewing tool box by using a potentiometer system. for viewing box lighting, the function test of the tool was conducted in the optical laboratory of mathematics and natural science faculty of udayana university. measurements were made by using lux meter and showed a mean of viewing box illumination of 220 lux. to know the resilience of the accu when the 13 global health management journal, 2017, vol. 1, no. 1 viewing box was started up until the lights of the viewing box led by the accu could not be used in reading the results of x-ray, it was measured using a stopwatch. it was obtained that viewing box results could live for 105 minutes and could be used up to 90 minutes in reading the results of x-ray. the function test of the viewing box was also conducted by using questionnaire addressed to 5 radiology specialists and 10 radiographers in some hospitals to assess the feasibility of viewing box tool when it was used to read radiographs, and to assess the available supporting components on a viewing tool box. as shown in table 1, 5 radiologists (100%) who provided assessment, all of them provided good on the feasibility of viewing box tools use for reading the results of x-ray photographs. 10 radiographers who provided assessment for the feasibility of viewing box use in reading radiographs, 9 radiographers (90%) provided an a (good) and 1 radiographer (10%) provided a value of b (moderate). the results also show 5 radiologists (100%) who were requested in assessing the potentiometer system contained in the viewing box, all radiologists marked an a on the supporting components contained in the viewing box. 10 radiographers who provided assessment for the benefits of supporting components contained in the viewing box, 9 radiographers (90%) provided an a (good) and 1 radiographer (10%) provided a value of b (moderate). grade in assessing tool’s feasibility in assessing the potentiometer and charger system system n % n % radiologist good 5 100 5 100 moderate 0 0 0 0 less 0 0 0 0 total 5 100 5 100 radiographer good 9 90 9 90 moderate 1 10 1 10 less 0 0 0 0 total 10 100 10 100 the study results showed that the light intensity of the viewing box has met the standard of 220 lux. the whole radiologists who were respondents in this study provided excellent on the assessment of the feasibility of the viewing box in reading the radiographs using charger system and potentiometer. whereas most radiographers who were respondents in the study provided excellent on the feasibility of the viewing box in reading the radiographs and using charger system and potentiometer. the potentiometer system allowed radiologists and radiographers to set the required light intensity. thus, viewing box can be used optimally in reading the radiographs, by using accu battery with charger system, the viewing box could be used without direct electric current. discussion radiology viewing box is an assisting tool for radiologist in reading the radiographs. to be able to assess the radiographs, feasible viewing box tool is required. most of the viewing boxes in hospitals, especially in indonesia have lighting system that cannot be set. in fact, a good viewing box is a viewing box whter ich the light intensity can be set lower and higher to produce high detection accuracy to view calcification in the glandular tissue clearly [4]. therefore, making a viewing box table 1. frequency distribution of the radiologist and radiografer in assessing the feasibility and the potentiometer and charger system of the proposed viewing box tools used for reading radiographs global health management journal, 2017, vol. 1, no. 1 14 tool with the light intensity that can be set is an appropriate solution. potentiometer is a three-terminal resistor with a sliding connection which form a voltage divider that can be tuned [5]. by using the potentiometer system, then light intensity on a viewing box can be adjusted as needed. this viewing box used led lights with evenly spread mounting in the box, so that the viewing box had an evenly spread light intensity. the materials used in the manufacture of viewing box in this study used acrylic material, while most of the viewing boxes in hospitals use ferrous materials. the fundamental difference that made the viewing box in this study was that is was easily moved because the basic material was lighter. with the potentiometer system on the viewing box created it is expected to assist radiologists in reading radiographs with optimal results. in general, the fewer the number of foreign light, the better the detection analysis of a radiologist to read the radiographs, so it is advisable to reduce light scattering in the eye in enhancing the performance capability of the radiologist (3). limitation in this study was the size of the viewing box that was still reserved for 1 big film size reading, so it is not possible to compare the two readings on big size x-ray films. accu battery of the viewing box could be used optimally for 90 minutes in reading the results of x-ray and must be recharged. conclusion based on the results obtained, in general the viewing box tool that was created could be used properly and obtained optimal results as a tool in reading radiographs. potentiometer and charger system on the viewing box is very helpful in reading radiographs because it allows to adjust the light intensity according to user needs and could be used everywhere without direct electric current. the advantages of the viewing box made, among others; it can be made with materials that are easy to get, lighter because it is made of acrylic, light intensity can be adjusted by using a potentiometer, could be used without direct electric current and the accu battery used here could be recharged. it is suggested that the viewing box should be maintained every 3 months by cleaning it and checking the electrical equipment and the fluorescence lamps. conflict of interests none declared. references 1. juwito a.f., pramonohadi s., haryono t. optimalisasi energi terbarukan pada pembagkit tenaga listrik dalam menghadapi desa mandiri energi di margajaya. jurnal ilmiah semesta teknika, vol 15, no1, 22-34. 2012 2. t nyathi, msc, an mwale, bsc, p segone, bmedsc, sh mhlanga, bsc, and ml pule, bmedsc. radiographic viewing condition at johannesburg hospital. biomed imaging interv j. 2008 apr-jun; 4(2):e17 3. mccarthy e1, brennan pc. viewing conditions for diagnostic images in three major dublin hospitals: a comparison with who and cec recommendations. br j radiol. 2003 feb;76(902):94-7 4. kimme-smith c1, haus ag, debruhl n, bassett lw. effects of ambient light and view box luminance on the detection of calcifications in mammography. ajr am j roentgenol. 1997 mar;168(3):775-8. 5. the authoritative dictionary of ieee standards terms (ieee 100) (edisi ketujuh ed.). piscataway, new jersey: ieee press. 2000. isbn 0-7381-2601-2 6. sahrul h, chandra l, mariah k, wahyu a. sintesis polianilin dan karakteristik kinerjanya pada sistem baterai asam sulfat. jurnal material dan energi indonesia. vol. 06, no 01 (2016) 20-26. 7. b. n grgur, a. zeradjanin, m gvozdenovic, m. d maksimovic, t. lj trisovic, b. z jugovic. electrochemical characteristic of rechargeable polyaniline/lead dioxide cell, j. of power source. vol. 217 (2012), p. 193-198 8. b. cheraghi, a. r fakhari, s. borhani, a. a entezami, chemical and electrohemical deposition of conducting polyaniline on lead, j. of electroanalytical chemistry, vol. 626, issues 1-2 (2009), p. 116-122 9. kepmenkes. pedoman kendali mutu (quality control) peralatan radiodiagnostik. keputusan menteri kesehatan republik indonesia nomor 1250/menkes/sk/xii/2009: jakarta. 2009 https://id.wikipedia.org/w/index.php?title=piscataway&action=edit&redlink=1 https://id.wikipedia.org/wiki/new_jersey https://id.wikipedia.org/wiki/international_standard_book_number https://id.wikipedia.org/wiki/istimewa:sumber_buku/0-7381-2601-2 the correlation of age, gender, heredity, smoking habit, obesity, and salt consumption with hypertension grade in cirebon, indonesia indonesian scholars’ alliance ghmj (global health management journal) 2019, vol. 3, no. 3 open access original research the 4th interna onal conference on applied science and health (icash 2019), 23-24 july 2019, faculty of graduate studies, mahidol university, thailand the correlation of age, gender, heredity, smoking habit, obesity, and salt consumption with hypertension grade in cirebon, indonesia alif hamzah* , uswatun khasanah, dini norviatin faculty of medicine, university of swadaya gunung ja , cirebon, indonesia *corresponding author’s email: hamzah.alif33@gmail.com abstract background: hypertension is one of the most global killer diseases that causes death. the world health organiza on es mated around 1.5 billion people in the world will be diagnosed with hypertension every year. the increasing incidences of hypertension in the world may be affected by several predictors including age, sex-linked, heredity, smoking habit, obesity, and salt consump on. this study has objec ve to examine those predictors to hypertension grade. methods: this research was used observa onal analy c method with cross-sec onal study. this study involved 136 respondents who came to kalijaga permai public health center, cirebon city. the variables were measured by microtoise, sphygmomanometer, stethoscope, scales, and ques onnaires. spearman correla on test and logis c regression test was analyzed for this study. results: 59.9% of respondents were in hypertension grade 1 and 54% of respondents were in high risk age. the bivariate results revealed that age, sex-linked, heredity, and salt consump on were sta s cally correlated with hypertension grade (p=0.001). however, smoking habit and obesity were not sta s cally correlated. mul variate analysis found that those who add extra salt were 3.3 mes more likely to have hypertension grade 2 and those in high risk age were 3.1 more likely to have hypertension grade 2 as well. compared with female and those who have nega ve heredity, male and posi ve heredity were 2.7 mes more likely to have hypertension grade 2. conclusion: salt consump on, age, sex-linked, heredity was significantly correlated with hypertension grade. salt consump on was a risk factors which has the highest impact. public health center should educate people about the recommenda on of daily salt intake to prevent the excessive intake that may affect hypertension. keywords: hypertension, smoking habit, obesity, salt consump on, age, gender, heredity received: 26 april 2019 reviewed: 27 may 2019 revised: 17 june 2019 accepted: 12 july 2019 doi: 10.35898/ghmj-33457 selec on and peer-review under responsibility of the scien fic commi ee and the editorial board of the 4th internaonal conference on applied science and health (icash 2019) © yayasan aliansi cendekiawan indonesia thailand (indonesian scholars’ alliance). this is an open-access following crea ve commons license deed a ribu on-noncommercial-sharealike 4.0 interna onal (cc by-nc-sa 4.0) 1. introduc on hypertension is one of the most global killer diseases that cause death in which the number of cases keeps increasing year after year (setyanda et al., 2015). the world health organization estimated that around 1.5 billion people in the world are diagnosed with hypertension disease every year (setyanda et al., 2015). hypertension is a “silent killer disease” that has symptoms which looks like another 138 mailto:hamzah.alif33@gmail.com https://dx.doi.org/10.35898/ghmj-33457 hamzah a et al. ghmj (global health management journal) 2019, vol. 3, no. 3 disease and shows different symptoms for every person. based from the indonesian survey sample registration system 2014, hypertension was ranked the fifth disease causing death of all ages next to stroke, heart-related disease, dm and tb with 5.3% (kemenkes ri, 2014). the national hypertension prevalence, referring to the indonesian baseline health research 2018, reached 8.4% (kemenkes ri, 2018). the hypertension prevalence in west java is greater than the national figure (kemenkes ri, 2018). the hypertension prevalence in cirebon itself reached 28.9% (kemenkes ri, 2018). meanwhile, community health center of kalijaga permai occupies the first rank of hypertension cases in cirebon with 90.63% in 2016 (dinas kesehatan, 2016). ninety-five percent people with hypertension did not know they got diagnosed as a primary or secondary type of hypertension (sulastri et al., 2012). several mechanisms that might contribute to the hypertension have been identified, but none of the theories expressly states the pathogenesis of hypertension (sulastri et al., 2012). the cases of hypertension in the world are affected by two types of risk factors, changeable risk factors such as obesity, salt consumption, stress, smoking habits and unchangeable risk factors such as age, gender, heredity, race (kemenkes ri, 2014). hypertension generally develops at the age of 36 45 years which is mainly due to reduced blood vessel elasticity (semet et al., 2016). it is in line with the results of research conducted in karanganyar regency using the case control design. when the age group of 25-35 years is compared with the age group of 36-45 years, it is proven that the latter group age is a risk factor for hypertension (sugiharto, 2007). on the contrary, novitaningtyas found that age did not have a significant effect on the hypertension grade (novitaningtyas, 2014). hypertension is closely related to physical activity (maharani, 2014). the research conducted by lina and tanti in hospital 45 kuningan shows the proportion of men suffering from primary hypertension was 71.9%. the statistical test results obtained are smaller than the significant numbers meaning that the risk of experiencing primary hypertension for men is 4.182 greater than that of women. however, the study by sofyan shows that sex variables were not related to stroke (sofyan et al., 2015). hypertension could be obtained from parents; therefore, the chance of being diagnosed by primary hypertension in a person will be quite large. a research carried out in karanganyar regency with a case control design shows that family history was proven to be a risk factor for hypertension (sugiharto, 2007). meanwhile, a study on the relationship between family history and hypertension by jane a. shows that there was no relationship between family history and hypertension (ratulangi et al., 2016). smoking is one of the health problems where the solution has not been found in indonesia. a study by yashinta octavian regarding the relationship of smoking to the grade of hypertension in men aged 35-65 years in the city of padang shows that hypertension is triggered by smoking time and type of cigarette (setyanda et al., 2015). in addition, a study renny fitriana about the risk factors for hypertension degrees in adolescents in the working area of the health center in the city of pekanbaru shows that there is no correlation with hypertension (ratulangi et al., 2016). obesity is excessive fat accumulation that occurs in the body area consisting of subcutaneous fat and intra-abdominal fat. based on demi sulastri’s research on hypertension research in the city of padang, there was a correlation between the cases of obesity and hypertension (sulastri et al., 2012). it is different from the study by andrew johanes ratulangi in bolaan district, north mangondouw, sowing that there was no correlation between blood pressure and obesity (ratulangi et al., 2016). sodium and potassium are the main cations in the body’s extracellular fluid which have the function of regulating the body’s fluid and acidic balance and play a role in nerve transmission and muscle contraction (atun et al., 2014). in a study conducted by listiyaningsih atun regarding the correlation between salt consumption and hypertension, the results show that high salt consumption can increase the risk of high blood pressure. the ratio of potassium sodium can’t increase the risk of high blood pressure (atun et al., 2014). on the contrary, a study by renny fitriani shows that salt consumption is not proven against the degree of hypertension (ratulangi et al., 2016). in a journal from the american physiology society, it was found that salt consumption was a factor that has a major influence on the cases of hypertension. this has been proven by the effect of an endogenous hormone that causes an 139 ghmj (global health management journal) 2019, vol. 3, no. 3 hamzah a et al. increase in the sympathetic system. in experiments conducted in mice, when mice were injected with endogenous hormone antibodies, a significant decrease in pressure occurred (blaustein et al., 2011). based on previous researches, there were still conflicting results about the correlation among hypertension risk factors. thus, in this study, we summarize risk factors that directly correlate age, sex-linked, heredity smoking habit, obesity, and salt consumption with hypertension grade in the community health center of kalijaga permai, cirebon, indonesia. 2. method this research used an observational analytic method with cross-sectional study. the sample size for the present study was calculated using slovin formula by taking prevalence of hypertension as 90.63% and permissible error as 5% with 95% confidence interval (dinas kesehatan, 2016). meanwhile, the minimum sample size was calculated as n = 136. consecutive sampling was used for sampling technique. inclusion criteria were patients who came to community health center of kalijaga permai with ≥140/90 mmhg and were diagnosed of having primary hypertension. exclusion criteria were patients who didn’t give a permission to be respondents and diagnosed by secondary hypertension. data was collected by the author with informed consent. authors did blood pressure measurement using sphygmomanometer and stethoscope, body mass index measurement using weight scale and microtoise, and age, sex type, smoking habit, salt consumption measurement using the questionnaire. high risk age included the respondents in age group of 36-year-old or older. low risk age included the respondents in age group of under 36-years-old, as seen on questionnaire (sugiharto, 2007). sex types were defined from a questionnaire based from their look (maharani, 2014). heredity was defined positive when the respondent has parents with a history of hypertension and it would be negative when the respondent has no parents with history of hypertension (sugiharto, 2007). current daily smoker was defined as those who were smoke cigarettes daily; light smoker only have 1 to 10 cigarettes a day, while medium to moderate smoker have more than 11 cigarettes a day (setyanda et al., 2015). obesity was classified using who international bmi classification: bmi < 18.5 was classified as ”underweight”; < 16.00, ”severe thinness”; 16.00–16.99, ”moderate thinness”; 17.00–18.49, ”mild thinness”; 18.50-24.99, ”normal range”; bmi ≥ 25.00, ”overweight”; 25.0-29.99, ”pre obese”; ≥30.00,  ”obese”; 30.00-34.99, ”obese class i”; 35.00-39.99, ”obese class ii”; and > 40.00, ”obese class iii.” (kemenkes ri, 2014) salt consumption was defined with scoring from the questionnaire. it was divided into two groups, adding amount of extra salt group and not adding amount of extra salt group. extra salt was defined as at least the score in salt consumption section is 4 or more. joint national committee on prevention, detection, evaluation, and treatment of high blood pressure (jnc 8) classification was used for hypertension. hypertension is defined as systolic bp level of ≥140 mmhg and/or diastolic bp level of ≥90 mmhg or being previously diagnosed as hypertensive by any health professional (bell et al., 2015). once the data have been collected, data will be proceeded by editing, coding, processing, tabulating, entering, and cleaning. it was analyzed with univariate statistics (distribution and percentage) to summarize the data. other statistical tests like spearman rho’s test were applied to find out correlation between the subjects. logistic regression was applied to identify the most impact risk factors for hypertension. the significance level of 0.05 was used in this statistical process. 3. results table 1 showed total of 137 study subjects were interviewed for the survey. out of these, 64 (46,7%) were female subject and 73 (53.3%) were male. the median age (±sd) of the study subjects was 33.0 140 hamzah a et al. ghmj (global health management journal) 2019, vol. 3, no. 3 (±11.9) years and for male and female it was 34.0 (±11.9) years and 35 (±11.8) years, respectively. majority of the study subjects has parents diagnosed by hypertension (56.2%). regarding at dietary salt intake, most of the subjects constantly add high amount off extra salt. only 13 samples (9.5%) experienced obesity and 33 samples (24,1%) has medium to moderate smoking habit. this cross-sectional community-based study identified prevalence of hypertension grade 1 and hypertension grade 2 in kalijaga permai public health center, which was 59.9% and 40.1%, respectively. table 1. characteris c of the respondents characteris cs number of respondents percentage age low risk 63 46 high risk 74 54 sex-linked female 64 46.7 male 73 53.3 heredity nega ve 60 43.8 posi ve 77 56.2 smoking habit not a smoker 73 53.3 light-smoker 31 22.6 medium to moderate-smoker 33 24.1 obesity nega ve 124 90.5 posi ve 13 9.5 salt consump on did not add amount of extra salt 65 47.4 add extra salt 72 52.6 hypertension level grade 1 82 59.9 grade 2 55 40.1 3.1 bivariate analysis the correlation of smoking habit, obesity, natrium consumption, age, sex-linked, and heredity towards hypertension level were analyzed using spearman correlation test with p<0.05. table 2. correla on of risk factors towards hypertension grades characteris cs hypertension p value r grade 1 grade 2 age low risk 57 17 0.001 0.380 high risk 25 38 sex-linked 141 ghmj (global health management journal) 2019, vol. 3, no. 3 hamzah a et al. female 58 17 0.001 0.367 male 26 38 heredity nega ve 48 12 0.001 0.453 posi ve 34 43 smoking habit not a smoker 45 35 0.224 0.105 light-smoker 23 8 medium to moderate-smoker 14 19 obesity nega ve 77 47 0.100 0.141 posi ve 5 8 salt consump on did not add amount of extra salt 53 12 0.001 0.420 add extra salt 29 43 total 82 55 table 2 shows that there are some correlations of age (p=0.001), sex-linked (p=0.001), hereditary (p=0.001), and salt consumption (p=0.001) with hypertension grade. grade 2 hypertension was more prevalent in the age group of 36–77 years, while grade 1 hypertension was prevalent in the group of under the 36 years. the rate of grade 2 hypertension was higher among males. positive family history of hypertension shows more chances to be diagnosed of having grade 2 hypertension. eating food with some extra salt was found to be risk factors for being hypertensive in this study. considering the rest, neither smoking habit (p=0.224) nor obesity (p=0,100) have a correlation with hypertension grade. 3.2 mul variate analysis the prevalence ratio of smoking habit, obesity, natrium consumption, age, sex-linked, and heredity with hypertension level was analyzed using logistic regression test with 95% ci. table 3. prevalence ra o of risk factors with hypertension grades characteris cs wald df sig. exp(b) 95% ci for exp(b) lower upper heredity 4.689 1 0.030 2.743 1.100 6.837 sex-linked 5.333 1 0.021 2.698 1.162 6.266 ages 7.068 1 0.008 3.141 1.351 7.303 salt consump on 6.603 1 0.010 3.247 1.322 7.975 constant 33.287 1 0.000 0.001 table 3 shows that salt consumption has the most impact risk factor with hypertension grade (p=0.010, pr=3.247, c.i.=95%) followed by age (p=0.008, pr=3.141), heredity (p=0.021, pr=2.743), and sex-linked (p=0.030, pr=2.698). salt consumption, age, heredity and sex-linked were significantly related to hypertension grades. being female, younger in age, and staying away from any kind of addiction could serve as protective factors against hypertension. 142 hamzah a et al. ghmj (global health management journal) 2019, vol. 3, no. 3 4. discussion indonesia is one of the developing countries with a rapid demographic and epidemiological transition. this cross-sectional community-based study identified prevalence of grade 1 hypertension and grade 2 hypertension in the community health center of kalijaga permai of 59.9% and 40.1%, respectively. in this study, age was found to be an important risk factor for hypertension (p=0.001). as one gets older, the prevalence of hypertension among both the sexes was found. similar findings were reported by a study in universitas diponegoro confirming that hypertension mostly develop between the age group of 36-45 year instead of the age group of 25-35 years. generally, hypertension will develop when the age reaches 36-years-old (sugiharto, 2007). as one gets older, the aorta and arteries walls will be stiffened and it contributes to the high prevalence of hypertension in the older age group (sugiharto, 2007). in this research, men exhibit higher prevalence of grade 2 hypertension than women (m: 53.3% and w: 46.7%) (p=0.001), respectively. similarly, a study by jangi p shows most men from 45-years-old got diagnosed with hypertension higher than women (jangid et al., 2015). men are suspected of having a lifestyle that tends to increase blood pressure compared to women. however, the prevalence of hypertension in menopause women increases because the estrogen increased high density lipoprotein to defend arteries from arthrosclerosis (maharani, 2014). our study shows that family history of hypertension is susceptible with increasing blood pressure (p=0.001). it will give more chances to a person diagnosed by hypertension. it is in line with the finding before. in a family history of affected individuals, there is an abnormality in the angiotensinogen gene that plays an important role in the process of producing angiotensin suppression substances (gunawan, 2007). another theory says it happens because of the problem in parasympathetic nerve activity (ambasari et al., 2013). our results show that adding some extra salts were found to be a risk factor for being hypertensive (p=0.001). the results show that it is the most impactful correlation between salt intake and hypertension (p=0.010, pr=3.247, c.i.=95%). some previous studies show that salt intake was positively related to hypertension (atun et al., 2014). in this new paradigm, high dietary salt raises cerebrospinal fluid [na+] through the na+-sensing circumventricular organs of the brain to increase sympathetic nerve activity (sna), a major trigger of vasoconstriction. plasma levels of endogenous ouabain (eo), and the na+ pump ligand elevated, as well. remarkably, high cerebrospinal fluid [na+]-evoked and locally secreted (hypothalamic) eo participates in a pathway that mediates the sustained increase in sna. this hypothalamic signaling chain includes aldosterone, epithelial na+ channels, eo, ouabainsensitive α2 na+ pumps, and angiotensin ii (ang ii). the eo increases, hypothalamic ang-ii type1 receptor and nadph oxidase and decreases neuronal nitric oxide synthase protein expression. the aldosterone-epithelial na+ channel-eo-α2 na+ pump-ang-ii pathway modulates the activity of brain cardiovascular control centers that regulate the bp set point and induce sustained changes in sna (blaustein et al., 2011). smoking remains to be one of the biggest problems in indonesia. who confirmed in 2007 that indonesia reached the top 5 most smokers in the world (setyanda et al., 2015). this study indicates the negative correlation between tobacco use and hypertension (p=0.224). it is supported by other studies such as (ratulangi et al., 2016). however, there are other studies with contradictory findings (green et al., 1986; lee et al., 2001). for instance, some researchers have reported lower blood pressure levels found among smokers compared to former smokers and increases in blood pressure after smoking cessation. the results from a male steel workers’ follow-up have revealed that the rate of hypertension among continuous smokers was lower than never-smokers and ex-smokers. as a result, it is still unclear to what extent cigarette smoking is a risk factor for the development of hypertension (green et al., 1986; lee et al., 2001; narkiewicz et al., 2005; oncken et al., 2001). there was negative correlation between increasing bmi and increasing rate of hypertension (p=0,100), which was consistent with other studies (ratulangi et al., 2016). however, there are other studies with 143 ghmj (global health management journal) 2019, vol. 3, no. 3 hamzah a et al. contradictory findings. obesity is associated with increased morbidity and mortality due to hypertension, diabetes, dyslipidemia, and cardiovascular and renal diseases. obesity clearly induces hypertension. the mechanism by which obesity directly causes hypertension is under investigation. activation of the sympathetic nervous system (sns), the amount of intra-abdominal and intra-vascular fat, sodium retention leading to increase in renal reabsorption, and the renin-angiotensin system, are considered to have important functions in the pathogenesis of obesity-related hypertension, a chronic medical condition in which the blood pressure is persistently at >140/90 mmhg but not at the normal level which is defined as 100–140 and 60–90 mmhg for systolic and diastolic pressure, respectively (jiang et al., 2016). in obese patient, there is a desire striving to keep healthy. this study has several limitations. obesity was measured only by body mass index without measuring abdominal circumference; thus, there was an opposite result on relation between increasing bmi and hypertension. smoking was measured only by current smoking behavior (status classification: non-smokers, current smokers and former smokers; cigarette consumption classification: light smokers, heavy smokers and so on) to analyze the effects of smoking on health without knowing the cigarette types. salt consumption was not measured in an objective way using tablespoon. all of these limitations can be overcome by changing the questionnaire. for the future, study on salt consumption as the impactful risk factor could be developed. tablespoon measurement could be used to know how much salt one eats on a daily basis since this study shows that salt consumption was the most impactful subject among the other and this study takes times. 5. conclusion from the discussion, it can be concluded that salt consumption, age, sex-linked, and hereditary have significant correlation with hypertension grades; in addition, salt consumption has the highest impact (p=0.010, pr=3.247, c.i.=95%) among the other risk factors found in the community health center of kalijaga permai, cirebon. for future study, it is recommended to provide another study on salt consumption correlation with hypertension grade by an objective measurement. acknowledgments the authors would like to thank to all participants for participating in this study. conflict of interest there is no conflict of interest. references ambasari, r. p., sarosa, h., et al. 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(2012). hubungan obesitas dengan kejadian hipertensi pada masyarakat etnik minangkabau di kota padang. majalah kedokteran andalas, 36(2):188–201. cite this article as: hamzah a, khasanah u, norviatin d. the correlation of age, gender, heredity, smoking habit, obesity, and salt consumption with hypertension grade in cirebon, indonesia. ghmj (global health management journal). 2019; 3(3):138-145. doi:10.35898/ghmj-33457 145 http://www.depkes.go.id/download.php?file=download/pusdatin/infodatin/infodatin-hipertensi.pdf http://www.depkes.go.id/download.php?file=download/pusdatin/infodatin/infodatin-hipertensi.pdf http://www.depkes.go.id/resources/download/info-terkini/materi_rakorpop_2018/hasil%20riskesdas%202018.pdf http://www.depkes.go.id/resources/download/info-terkini/materi_rakorpop_2018/hasil%20riskesdas%202018.pdf https://sains.kompas.com/read/2016/05/18/211900923/waspadai.hipertensi.saat.hamil.dan.menopause https://sains.kompas.com/read/2016/05/18/211900923/waspadai.hipertensi.saat.hamil.dan.menopause introduction method results bivariate analysis multivariate analysis discussion conclusion cite this article as iskandar fn, suwondo a, santoso b. tactile-kinesthetic stimulation to gain weight and reduce the length of stay care for premature baby at public hospitals of semarang, indonesia. global health management journal. 2019; 3(1):25-30. global health management journal www.publications.inschool.id published by original research article issn 2580-9296 (online) tactile-kinesthetic stimulation to gain weight and reduce the length of stay care for premature baby at public hospitals of semarang, indonesia freya nazera iskandar 1,*, ari suwondo 2, bedjo santoso 3 1 postgraduate applied science midwifery program, poltekkes kemenkes semarang, indonesia. 2 faculty of public health, diponegoro university, semarang, indonesia. 3 postgraduate applied science health program, poltekkes kemenkes semarang, indonesia. *corresponding author. email: freyanazera@gmail.com article info abstract article history: received 06 september 2018 reviewed 13 september 2018 received in revised form 24 october 2019 accepted 26 february 2019 background: premature babies are susceptible to a variety of health problems in early of their lives, thus, management of premature care should be designed to optimize the growth and development, with no more cost extension. the management of premature care by nonpharmacological treatments becomes popular nowadays, and applied in the hospital unit care, including the tactile-kinesthetic stimulation (tks) and kangaroo mother care (kmc). aims: this study is to present the effect of tactile-kinesthetic stimulation (tks) on weight gain and reduction length of stay care for premature babies, and to compare the results with the standard kangaroo mother care (kmc) given at the hospital care unit. methods: the study used a quasi-experimental design with pretest-posttest with a control group. a total of 32 premature babies was equally divided to a control group given a standard kmc procedure and an intervention group receiving the tks. sampling was done using a consecutive sampling method where the low birth weight infants were selected from two public hospitals in semarang of indonesia, with consent from the parents. data was then analyzed by a repeated measure anova, general linear model and mann-whitney test to find the significant mean difference at p value less than 0.05. results: the data shows that the babies’ weight significantly increased day by day only if the premature neonates received tactile-kinesthetic stimulation, gained 148.75 gram only 3 days after the initial measurement. however, from this study we noted that the premature babies’ weight at the control group provided only with kangaroo mother care slightly decreased at 35.69 gram at the third day of observation. in average, premature babies receiving tks need only 3 days before return home, while if receiving the standard kmc the preterm babies required 5 days in the hospital care. conclusion: not only effective to gain the weight, giving tactile-kinesthetic stimulation to the low birth weight baby shorter the length of stay in the hospital unit care. it suggests that the tks intervention will provide good result in maintaining the weight of the low birth weight baby and will reduce the costs of staying in the hospital unit care. keywords: tactile-kinesthetic stimulation kangaroo mother care low birth weight length of stay care premature baby © 2019 publications of yayasan aliansi cendekiawan indonesia thailand this is an open-access following creative commons license deed – attribution-noncommercial-sharealike 4.0 international (cc by-nc-sa 4.0) introduction the conditions in the premature babies often lead to the occurrence of mortality and pain in babies [1]. the 2017 world health organization’s report noted, of 4.5 million premature babies died over the globe, there are 675,700 cases found in indonesia, or at the 5th rank after india, china, nigeria and pakistan [2]. a recent report from the perinatology room of krmt wongsonegoro hospital recorded that, of 1,608 babies were born premature and http://publications.inschool.id/index.php/ghmj/index http://publications.inschool.id/ http://inschool.id/ http://publications.inschool.id/index.php/ghmj/index mailto:freyanazera@gmail.com http://inschool.id/ http://creativecommons.org/licenses/by-nc-sa/4.0/ global health management journal, 2019, vol. 3, no. 1 26 iskandar et al. global health management journal. 2019; 3(1):25-30 low birth weight (lbw) in semarang in 2017, there were 335 cases found in this study site [3]. premature babies have been indicated with non-mature rudimentary organ function and others conditions led to experience adverse effects three times greater than those born at term [4]. as results, the preterm neonates face difficulty to adjust to their life outside the uterus which causes the baby having many disorders [5]. for example, the premature infant oral motor intervention on feeding progression led the premature babies to barely gain weight, and it will affect the premature babies will stay longer in the hospital [6, 7]. thus, it is a need to provide properly care to the premature babies including the more efficient good handling and optimal management which can improve the growth and development of premature babies. kangaroo mother care (kmc) is a standard operation procedure provided by the hospital for the premature birth and it is found to effectively improve the babies’ growth and development and the physiology and welfare of premature babies; however, the care is less efficient in the process of reducing the length of stay in the hospital [8]. this study proposes tactile-kinesthetic stimulation (tks) as a non-pharmacological treatment alternative that can help in the process of adaptation of preterm to the extrauterine environment [9], and known to shorter the length of hospital stay and lower the cost of hospital care [10]. tactile-kinesthetic stimulation (tks) presents benefits to brain development, reduces stress reflected in lower serum cortisol levels, increases weight, decreases pain response, improves digestion, lower energy expenditure, increases temperature in preventing hypothermia, stables the neonates’ rate breathing, improves the preterm’ behavior related to their physical health, and increases the maturation of electroencephalographic activity, visual function, neurological development, and motor [8]. this typical massage is a healing method using energy transferred from providers’ hand, generating warmth to the recipient's body and has a fairly specific effect in maturation and activity of the premature babies’ sympathetic nervous system. a recent literature review orchestrates advantages of massage in improving the behavior and physiological state of the premature infants [11]. this stimulation therapy is in the form of additional care that functions not to replace pharmacological treatment but must be carried out together with a hospital care treatment plan [12, 13]. this study will define how effective the tactile-kinesthetic stimulation (tks) on weight gain and reduction length of stay care for premature baby, compares to kangaroo mother care (kmc). methods this study employed a quasi-experiment pretest-posttest with a control group. the focused population consisted of all stable premature babies and allowed to return home, and met the inclusion criteria; born at age <37 weeks with weight 1,500-2,500 grams and body temperature 36.5 37.5 0c, and based on medical records babies who did not have congenital abnormalities, complications such as anemia, rds, intracranial hemorrhage, apnea marked by blue baby skin, and pulling of the chest wall. those who receiving oxygen therapy or indicated with dehydration are excluded from the group. there were 32 premature neonates selected using a consecutive sampling method in may to june 2018, from two public hospitals in semarang; krmt wongsonegoro regional hospital and ungaran district hospital. the babies were then equally divided into two groups, a control group receiving the standard procedure of kangaroo mother care (kmc) and the intervention group acquiring with tactile-kinesthetic stimulation (tks). the procedures and the research design used in this study have been approved by the health research ethics commission on may 03, 2018, with number 128/kepk/poltekkes-smg/ec/2018. the trained health providers accompanied with hospital nurses deliver the tactile-kinesthetic stimulation (tks) twice a day for 3 days, at morning and evening, for 15 minutes. in the first 5 minutes tactile stimulation was given with the supine baby positioned, 2 x 5 times with 6 repetitions, starting from the head, shoulders, back, legs and arms. for the next 5 minutes, the kinesthetic stimulation was given with the position of the baby prone, 2 x 5 times with 6 repetitions of each movement, both hands and feet. the last 5 minutes, the baby in supine position and received tactile stimulation, as like given at the first 5 minutes. kangaroo mother care (kmc) was given for 1 hour a day for 3 days, by placing the baby, skin-by-skin contact, directly to the mother's chest. after that the baby is held directly by the mother for 1 hour in one action. kmc is applied to the control group because kmc treatment has been included in the standard routine care for the premature babies who are already allowed to return home. measurements on weight gain were carried out before and after treatment. measurements on the first morning were carried out by measuring body weight before being given tks action, then after the measurement the baby was given tks action which lasted for 15 minutes. then in the afternoon tks care was given and continued measurement of body weight afterwards. on the second day, the tks action will continue to be given as the first day and the measurements will be carried out in the afternoon after the tks is given. and on the third day, the 27 global health management journal, 2019, vol. 3, no. 1 iskandar et al. global health management journal. 2019; 3(1):25-30 tks action is still given like the first or second day and the measurement of body weight is still done in the afternoon after giving tks. whereas, the measurement on the variable length of stay is to assess the duration of treatment of premature babies measured when babies are given treatment until premature babies are allowed to go home or until hospital care is completed. baby’s weight was measured before tks and kmc given to the neonates as the pre day, and the day after (post) observed from the day 1, day 2, and day 3. the study also recorded the time of baby be allowed to return home after the birth, indicated as length of stay care. the data was then analyzed using the repeated measure anova test and general linear model after be noted the data was normally distributed. a mann-whitney test was performed to indicate the significant mean difference of body weight and length of stay care between the control and intervention group. table 1. overview of premature babies weight gain and length of stay (n=32) variables intervention (n=16) control (n=16) mean sd mean sd weight gain (gram) pre post day 1 post day 2 post day 3 delta 2125.63 2125.63 2179.56 2274.38 148.75 221.42 221.42 231.61 238.58 20.58 2150.31 2150.00 2135.25 2114.62 35.69 205.75 205.51 207.06 205.34 11.56 length of stay care (day) post 3.00 1.18 5.00 1.21 results overeview of premature babies weight gain and length of stay table 1 orchestrates the weight and length of stay in hospital unit care of the premature babies receiving the kangaroo mother care (control group) and tactilekinesthetic stimulation (intervention group). the data shows that the babies’ weight increased gradually day by day only if the premature neonates received tks, gained 148.75 gram only 3 days after the initial measurement. however, from this study we noted that the premature babies’ weight at the control group provided only with kmc slightly decreased at 35.69 gram at the third day of observation. no wonder why the preterm babies at control group need more time to stay at the hospital unit care compared to those who received the tks intervention. in average, premature babies receiving tks need only 3 days before return home, while if receiving the standard kmc the preterm babies required 5 days in the hospital care. the result shows that the average length of stay care in the intervention group, where the preterm received the tks, was shorter than the control group. the average length of stay care in the intervention group was 3 days with a minimum of 3 days and a maximum of 6 days. meanwhile, the average length of stay care in the control group is 5 days with a minimum duration of 3 days and a maximum of 7 days. will the tactile-kinesthetic stimulation present significant difference to the weight gain? table 2 presents the mean difference and indicates the parametric statistical tests of premature neonates’ body weight in the intervention and control group between two indicated time using mann-whitney test, and overall group (repeated measure anova). interestingly, we found that the tks increases the weight, however, the standard kmc provided at the hospital presents the negative result to the weight gain. we noticed that almost no difference observed from pre and post day 1 while the highest difference found if compared the pre and post day 3. the statistical analysis indicates the mean difference between the weight gain between the control and intervention group was significant (p value = 0.001). from the results, we noticed that a least one group generates significant weight gain. table 2. the difference in the average weight of a premature babies observation time weight gain (gram) p value mannwhitney test intervention control delta delta prepost day 2 prepost day 3 post day 1post day 2 post day 1post day 3 post day 2-post day 3 53.93 148.75 53.93 148.75 94.81 15.06 35.68 14.75 35.37 20.62 0.001 0.001 0.001 0.001 0.001 p value repeated measure anova 0.001 by a post hoc bonferroni test, we found that if compared to the result from pretest before tks was applied, the highest mean difference was observed at the post day 3, and the difference was significant (p value = 0.046), as shown in table 3. table 3. effect of giving premature babies tactile kinesthetic stimulation to weight gain observation time p value post day 1 post day 2 post day 3 0.749 0.573 0.046 general linear model pos hoc bonferroni global health management journal, 2019, vol. 3, no. 1 28 iskandar et al. global health management journal. 2019; 3(1):25-30 table 4. effect of giving premature babies tactile kinesthetic stimulation to the length of stay care variables group delta p value intervention control length of stay 3 days 5 days 2 days 0.033 mann-whitney test table 4 shows that the length of stay care of the premature babies in control and intervention group is significantly different (p value = 0.033). in average, the premature babies received tks required 2 days shorter to stay at hospital care unit compared to those provided with a standard kmc. discussion the process of increasing body weight observed in the intervention group is more optimal than in the control group. the body weight of premature babies who received the tkc (intervention group) increased 53.93 grams at the first day, 94.82 grams at the second day, and 148.75 at the third day. the results of the study are in accordance with the existing theory that the weight gain of premature babies per day ranges from 15-30 grams so that when viewed in a period of 3 days to 90 grams so that in this study the weight gain of premature babies was 58.75 grams [14]. meanwhile, in the control group on the first day decreased by 15.06 grams, 20.62 grams at the second, and 35.68 grams at the third day. this is in line with the theory that the weight of a premature baby will experience a normal decline on the first day to the third day of 6-8% of body weight at birth while a full-term baby has a decrease of 5% [15]. the baby's weight loss is caused by insufficient breastfeeding, lack of calorie intake, decreasing fluid volume due to dehydration, declining the gastrointestinal motility, and the fluid loss when evaporation of the skin, through respiration, kidney and gastrointestinal, and experienced to urine and faecal fluid loss about 3-10% [16, 17]. weight gain occurs due to the provision of kinesthetic tactile stimulation (tks). this process is a touch action given to the baby as an effort to care for premature babies using certain techniques that provide great benefit to the process of growth and development of the baby, both physically and emotionally [18]. the growth process affects the weight gain while in the progression process it stimulates the effective sucking and swallowing reflexes, thus, it can affect the development process of the baby's intelligence more optimally. consequently, the coverage of breast milk received by the baby is more and more effective [19]. the kinesthetic-tactile stimulation (tks) given to the baby is in the form of sensory touches that will be processed in the brain's hypothalamus and mediated by the skin to produce positive brain waves in the form of beta endoprin release which can improve the process of growth and development of the baby so that the mechanism of food absorption is better in the digestive system baby [20, 21]. babies given tactile kinesthetic stimulation will experience an increasing of vagus nerve tone (brain nerve 10) which will lead to an increase in the level of absorption enzyme gastrin, insulin or igf-1 (insulin like growth factor 1) which results in better food absorption, thus, the breast milk production of mother increased and the baby will feel hungry quickly and will breastfeed more often. with this condition, the baby's body weight increases more than babies who do not get kinesthetic tactile stimulation [22]. from the result, we acknowledge that tactile kinesthetic stimulation is effective in increasing the weight of premature babies compared to the treatment of kangaroo mother care (kmc), however, the kmc is also effective in anticipating excessive baby weight loss. this kmc is one method in the management of premature and low birth weight (lbw) baby care. thus, all hospitals may require to implemente this method. the two public hospitals in this study have implemented this method and met the standard operating procedure (sop), however, not all babies received this application. the analysis on the length of stay care variable is based on the length of treatment given to the two groups. the duration of treatment both in the intervention group and in the control group was not determined, so that the treatments have been given according to the condition of each premature baby or it can be seen from the achievement of the premature baby health during hospitalization from the condition of weight gain or the condition of the signs vital baby in a stable limit. from the present study, the average length of stay care of premature babies in the intervention group was 3 days while in the control group reached 5 days. it can be concluded that there was a difference in the duration of treatment between the intervention group and the control group. based on the observations made during the research, the long stay of treatment between premature babies with one another is significantly different. this can be caused by differences in the acceptance of the condition of each baby's body [23]. in general, premature babies are allowed to go home or finish their treatment period when they meet several indicators of the improvement of baby's condition, such as strong suction power, the ability to swallow, heavy body increases more than body weight at birth and stable vital signs [24]. the attainment of premature baby health affects the cost of hospitalization funds, if the stay care is longer, it will need higher cost 29 global health management journal, 2019, vol. 3, no. 1 iskandar et al. global health management journal. 2019; 3(1):25-30 [25]. in addition, tks can improve premature baby’s growth and development to be more optimal and reduce hospital stay [26]. looking at the result, it was found in this study that the intervention group given tactile-kinesthetic stimulation had shorter treatment period than the control group where kangaroo mother care (kmc) has been provided. this research is in accordance with the theory developed by mendes et. al. in 2008, which states that tks in low birth weight babies can reduce the length of stay in hospital [23]. this finding is also inforced by a theory by abdallah (2013) that explains that tks has a large positive effect on premature babies including gaining the body weight, decreasing the pain response, improving the baby’s digestion, and decreasing the energy expenditure, temperature rise, positive effect on heart rate variability [8]. thus, this study encourages hospitals to provide tactile kinesthetic stimulation for the premature babies with a purposes to the better baby condition and a decrease of cost by shorter the length of stay in the hospital unit care. conclusion giving premature babies tactile-kinesthetic stimulation (tks) is effective in increasing weight of the low birth weight baby and decreasing the length of stay care in the perinatology room of the hospital. the study acknowledges that the kinesthetic-tactile stimulation given to the premature babies was more effective in shortening the treatment period about 2 days faster than those received kangaroo mother care (kmc). this finding can be recommended, among others for health workers, which tks can be used as treatment care as sop (standard operating procedures) in treating premature babies in a hospital catalog and can be used as routine daily care in addition to kmc because it can optimize growth and development, especially in the process of weight gain. this tks study was not carried out in conjunction with kmc, but was carried out separately in each treatment group so that the researcher had not been able to measure the advantages obtained if done together. conflict of interests no conflict of interests declared in the study. references 1. gleason ca, juul se. avery's diseases of the newborn e-book: elsevier health sciences; 2017. 2. world health organization. preterm birth 2017. available from: http://www.who.int/mediacentre/factsheets/fs363/en/. 3. the perinatology room of krmt wongsonegoro hospital. the incidence of cases in the perinatology room of krmt wongsonegoro hospital. semarang city2017. 4. hockenberry mj, wilson d, rodgers cc. wong's essentials of pediatric nursing-e-book: elsevier health sciences; 2016. 5. priyono y. merawat bayi tanpa baby sitter (caring for babies without baby sisters): media pressindo; 2010. 6. hurlock eb. developmental psychology : an approach throughout the life span . edition 5 ( dra. istiwidayanti & drs. soedjarwo . translate ). jakarta: penerbit airlangga; 2008. 7. lessen bs. effect of the premature infant oral motor intervention on feeding progression and length of stay in preterm infants. advances in neonatal care. 2011;11(2):129-39. 8. abdallah b, badr lk, hawwari m. the efficacy of massage on short and long term outcomes in preterm infants. infant behavior and development. 2013;36(4):662-9. 9. massaro a, hammad t, jazzo b, aly h. massage with kinesthetic stimulation improves weight gain in preterm infants. journal of perinatology. 2009;29(5):352-7. 10. ahmed rg, suliman gi, elfakey wa, salih km, elamin ei, ahmed wa, et al. effect of tactile kinesthetic stimulation on preterm infants’ weight and length of hospital stay in khartoum, sudan. saudi medical journal. 2015;36(2):196. 11. ayuningrum ld, astriani m, editors. the effect of massage and music therapy for premature infants: a literature review. proceedings of the international conference on applied science and health; 2017. 12. mohamadzadeh a, karbandi s, esmaily h, basiry m. effect of tactile-kinesthetic stimulation on weight gaining of preterm infants. 2009. 13. ramada nco, almeida fda, cunha mldr. therapeutic touch: influence on vital signs of newborns. einstein (são paulo). 2013;11(4):421-5. 14. lissauer t, fanaroff aa, miall l, fanaroff j. neonatology at a glance: john wiley & sons; 2015. 15. berk laura e. child development ninth edition. illinois state university: pearson; 2015. 16. chawla d, agarwal r, deorari ak, paul vk. fluid and electrolyte management in term and preterm neonates. the indian journal of pediatrics. 2008;75(3):255. 17. greenbaum la. pathophysiology of body fluids and fluid therapy. behrman re, kliegman rm jenson hb, textbook of pediatrics. 2004;1:210-4. 18. diego ma, field t, hernandez-reif m. preterm infant weight gain is increased by massage therapy and http://www.who.int/mediacentre/factsheets/fs363/en/ global health management journal, 2019, vol. 3, no. 1 30 iskandar et al. global health management journal. 2019; 3(1):25-30 exercise via different underlying mechanisms. early human development. 2014;90(3):137-40. 19. nasir m. rahasia kecerdasan anak (the secret of children's intelligence). pt kompas media nusantara: jakarta. 2010. 20. aliabadi f, askary rk. effects of tactile–kinesthetic stimulation on low birth weight neonates. iranian journal of pediatrics. 2013;23(3):289. 21. roesli u. massage guidelines for premature babies and infants aged 0 3 months. jakarta trubus agro wijaya. 2007. 22. field t, diego m, hernandez-reif m, dieter jn, kumar am, schanberg s, et al. insulin and insulinlike growth factor 1 (igf-1) increased in preterm neonates. journal of developmental and behavioral pediatrics: jdbp. 2008;29(6):463. 23. mendes e, procianoy r. massage therapy reduces hospital stay and occurrence of late-onset sepsis in very preterm neonates. journal of perinatology. 2008;28(12):815. 24. neonatalogi service guidelines. in: krmt wongsonegoro hospital sc, editor. 2018. 25. manktelow b, draper e, field c, field d. estimates of length of neonatal stay for very premature babies in the uk. archives of disease in childhood-fetal and neonatal edition. 2010;95(4):f288-f92. 26. rangey ps, sheth m. comparative effect of massage therapy versus kangaroo mother care on body weight and length of hospital stay in low birth weight preterm infants. international journal of pediatrics. 2014. knowledge, attitudes, and hiv/aids risk behaviors of myanmar migrant workers in thailand ghmj (global health management journal) 2022, vol. 5, no. 2 indonesian scholars’ alliance open access photo essay politeknik kesehatan kemenkes palangka raya: health forum and international seminar the new normal : creating a pleasant virtual communication a documentation of calcaneus region diabetic foot care: wound healing during outpatient treatment ester inung sylvia department of nursing, poltekkes kemenkes palangka raya, indonesia *corresponding author’s email: esterinung@gmail.com; ester.inung@polkesraya.ac.id doi: 10.35898/ghmj-52937 selection and peer-review under responsibility of the scientific committee and the editorial board of the annual health forum and international seminar of the politeknik kesehatan kemenkes palangka raya © yayasan aliansi cendekiawan indonesia thailand (indonesian scholars’ alliance). this is an open-access following creative commons license deed attribution-noncommercial-sharealike 4.0 international (cc by-nc-sa 4.0) mrs. antik is a mother of 2 teenage daughters, aged 45 years. in 2019, the client opened a food stall which has been the main source of income for the family since her husband passed away in 2016. however, with a wound on her right heel, the family's source of income stopped, she was unable to sell. the client expressed her concern to her brother-in-law whether the wound could heal because she had a history of diabetes mellitus since 10 years ago. his brother-in-law also tried to help facilitate finding a place and who could treat further wounds. the first information was provided by the client's brother-in-law via short message on whatsapp by sending a photo depicting the condition of the wound on the client's right heel. this information is followed up with a home visit. the client told the early history of the incident involving her feet. the problem began in early july 2020, when wood chips got into the client's right leg which she tried to remove with the help of a needle. a few days later her leg became red, swollen and very painful. the client went to the clinic but the wound did not heal for a week. because this condition did not go away, the client went to a doctor and was then referred to the hospital. the results of the examination at the hospital were that the client must immediately undergo debridement surgery to clean the wound. for one week the client was hospitalized and then treated with outpatient treatment for the wound. in wound healing, there are several things that must be considered and this will greatly determine the wound healing processes which are: 1) wound bed preparation, 2) cleaning, 3) debridement, and 4) dressing. the data obtained during the assessment also determines the appropriate course of actions. the results of the assessment when treating the client for the first time on august 5, 2020, obtained results: blood pressure 120/70 mmhg, breath rate 22 x/minute, pulse rate 86 x/minute, gds 210 mg/dl, 8 units of novorapid insulin therapy and lavemir 4 unit, the condition of the client's extensive wound encircling the right calcaneus area is shown in figure 1. the wound area is 5x15 cm, grade 2, namely deep ulcers, penetration to the ligaments and muscles, but does not hit the bone or there is no abscess, slough (+), exudate (+), necrotic (+), hyperemia (+), odor (+). mailto:esterinung@gmail.com mailto:ester.inung@polkesraya.ac.id https://doi.org/10.35898/ghmj-52937 117 ghmj (global health management journal) 2022, vol. 5, no. 2 sylvia ei figure 1. the condition of mrs. antik's wound during the assessment 05 august 2020 the first treatment for a wound is wound bed preparation (wbp), which is a wound base preparation. the wound bed preparation is a concept that emphasizes a holistic and systematic approach to evaluate and remove obstacles so that the wound healing process can run normally (falanga, 2004). the goal of wbp is to create a good wound environment by minimizing exudate, reducing bacterial colonies, removing dead tissue, ensuring good vascularity in the wound so as to support the wound healing process (cavanagh, 2005). wound bed preparation is carried out by debridement. debridement removes slough, namely yellow necrotic tissue which is a soft material consisting of dead cells, sticking to and covering the wound. slough can inhibit wound healing so the right therapeutic agent can optimize wound healing effectively. clean the wound using sodium chloride solution. this fluid is isotonic, does not cause allergies so it does not interfere with the wound healing process. cleaning the wound is done by washing and swabbing it. debridement is done by removing the necrotic tissue. the dressing of choice in client care is an occlusive dressing. occlusive dressing is a type of dressing that maintains the wound environment in an optimal state. when changing the dressing, you will see necrotic/ slough tissue decay with a clean wound bed. the type of dressing used with the client's wound condition on august 5, 2020, was hydrogel as the primary dressing, foam absorbent as a secondary dressing. hydrogel is an autolytic debridement that provides hydration to create a moist atmosphere and will trigger the granulation process. the secondary dressing used to cover the wound was a foam absorbent which has function to absorb exudate and provide moisture to the wound. the wound treatment of antik's mother was carried out every 2 days. the results of treatment with occlusive dressings were that the hyperemia began to diminish and disappear. then the wound bed became clean and red indicating reduced slough and the growth of healthy granulation tissue. to support the acceleration of wound healing, the client was advised not to do excessive activities that used their feet as support. this aimed to reduce the load pressure on the feet (off-loading). excessive load on the wound area would damage the granulation tissue that began to grow and ultimately hinder the wound healing process. off-loading has been shown to accelerate wound healing (bus, et al, 2008). there are four groups of off-loading methods commonly used in clinical practice, which are: o casting techniques, o use of special shoes, o surgical off-loading techniques, and o alternative off-loading simple off-loading recommended to the client was an alternative off-loading which was using crutches while walking. the improvement achieved by the treatment described can be seen in figure 2. sylvia ei ghmj (global health management journal) 2022, vol. 5, no. 2 118 figure 2. condition of the wound after 16 days of treatment on the 24th day of treatment, the client's wound condition was completely cleaned from slough (figure 3). the granulation tissue appeared red and began to rise from the wound bed. granulation tissue is connective tissue that contains many capillaries, red in color, looks like a pile of marbles. over time the epithelialization process begins. epithelial tissue that is silvery white or pink begins to grow from the edges of the wound and covers the granulation tissue. figure 3.the condition of the wound on the 24th day on the 41st day treatment, 80% epithelialization closed the wound (figure 4 a). the wound continued to be cleaned with normal saline and covered with foam absorbent dressings, and on the 50th day the epithelialization was 100% closed. (figure 4 b). figure 4. (a) the wound on day 41 closed 80%, (b) the wound on day 50 closed complete 119 ghmj (global health management journal) 2022, vol. 5, no. 2 sylvia ei health educations which were given at the completion of healing: 1. the clients are encouraged to use soft footwear both inside and outside the home. this aimed to prevent recurring injury to vulnerable wound sites. the recommended footwear was a sloop style shoe. (datak, g., & sylvia, e. i; 2021) 2. after every shower in the morning and evening, the client checked the feet and soles using a mirror aid to identify recurrent wounds. 3. if the wound is still on the leg, immediately seek treatment at the nearest health agency. 4. continue to carry out good management of diabetic management (diet, exercise, drug therapy, independent blood sugar checks and regularly following diabetic education. (sylvia, e. i., & munikaire, e.; 2018) summary: o patients with diabetes are vulnerable to infection and poor healing after injury. o wound care using the steps and techniques described can achieve healing over time. o post healing care instructions are an important part of successful treatment o photos of the wound healing process are a good way to document the effects of treatment and provide a record for the health care team. such photos can also be used to encourage patients with new wounds to work hard to obey care instructions figure 5 education on the use of footwear and mrs. antik is ready to open her food stall again consent the informants (identifiable) photographed have given their consent for their pictures to be used in the publication of this research. conflict of interest none. sylvia ei ghmj (global health management journal) 2022, vol. 5, no. 2 120 acknowledgments the authors wish to thank mrs. antik and my student christie. references effectiveness of footwear and off loading interventions to prevent and heal foot ulcersand reduce plantar pressure in diabetes:a systematic review. diabetes/metabolism research and reviews, 162-180. cavanagh, p. r., lipsky, b. a., bradbury, a. w., & botek, g. (2005). treatment for diabetic foot ulcers. the lancet vol 366, 1725-1735. datak, g., & sylvia, e. i. (2021). edukasi dengan media booklet dan audiovisual terhadap pengetahuan keluarga tentang perawatan luka kaki diabetes. syntax literate; jurnal ilmiah indonesia, 6(10), 4995-5005. sylvia, e. i., & munikaire, e. (2018). health education for diabetes patients in consumption of oral hypoglycemic drugs (oho). health notions, 2(2), 297-300. falanga, v. (2004). wound bed preparation: science (p.2). london: published by medical education. fitria, e., sylvia, e. i., & datak, g. (2019, august). health literacy and diabetes risk factors score. in proceedings of the international conference on applied science and health (no. 4, pp. 641-646). cite this article as: sylvia ei. a documentation of calcaneus region diabetic foot care: wound healing during outpatient treatment. ghmj (global health management journal). 2022; 5(2):116-120. doi:10.35898/ghmj-52937 https://doi.org/10.35898/ghmj-52937 microsoft word 4. accepted original, mita agustina, 70-75.docx cite this article as agustina m, santoso b, sudirman. gargling with aloe vera extract is effective to prevent the ventilator-associated pneumonia (vap). global health management journal. 2018; 2(3): 70-5. global health management journal www.publications.inschool.id published by original research article issn 2580-9296 (online) gargling with aloe vera extract is effective to prevent the ventilator-associated pneumonia (vap) mita agustina 1,*, bedjo santoso 2, sudirman 2 1 postgraduate applied science program in nursing, poltekkes kemenkes semarang, semarang, indonesia. 2 poltekkes kemenkes semarang, semarang, indonesia. *corresponding author. email: mitaagustus84@gmail.com article info abstract article history: received 25 august 2018 reviewed 30 august 2018 received in revised form 22 october 2018 accepted 31 october 2018 background: long-term use of a mechanic ventilator may cause ventilatorassociated pneumonia (vap) infection, nosocomial pneumonia that occurs after 48 hours in patients using mechanical ventilation either through the endotracheal tube or the tracheostomy tube. to prevent the occurrence of vap, antiseptic liquid (mouthwash) such as chlorhexidine 2% maybe recommended. however, gargling using chlorhexidine may also cause allergies, thus, aloe vera extract could be an alternative. aims: the purpose of this study was to determine the effectiveness of aloe vera extract as mouthwash to prevent the occurrence of ventilator-associated pneumonia. methods: this research is a quasi-experiment case-control study with a preposttest control group design. the sample size in this study was 30 respondents who were equally distributed into two groups; intervention group was administered using aloe vera extract, while chlorhexidine was practiced for the control group. to determine the occurrence of vap, clinical pulmonary infection score (cpis) for ventilator-associated pneumonia was measured on the first day of intubation and the fourth day, enumerated by nurses in the emergency room. cpis is a set of indicators comprised of temperature, leucocyte, trachea secretion, oxygenation (pao2/fio in mm hg), and thorax photo. cpis value below than five will be regarded non-vap, while cpis scored 6-9 will be diagnosed as vap. results: oral hygiene with aloe vera extract was able to prevent the occurrence of vap (p-value = 0.001), but there was no significant difference between the control group and intervention in the cpis component temperature, leukocytes, tracheal secretions, fio2, and the thoracic component. conclusions: oral hygiene with aloe vera extract effectively prevented the occurrence of ventilator-associated pneumonia (vap) compared to chlorhexidine. keywords: aloe vera extract ventilator-associated pneumonia clinical pulmonary infection score © 2018 publications of yayasan aliansi cendekiawan indonesia thailand this is an open-access following creative commons license deed – attribution-noncommercial-sharealike 4.0 international (cc by-nc-sa 4.0) introduction a mechanical ventilator is a set of airway aid to maintain ventilation and oxygen administration for a long time [1]. the use of ventilator will cause infectious disease, one of which is ventilatorassociated pneumonia (vap). vap is an inflammation of the lungs (pneumonia) caused by the use of a ventilator for a long time in patients [2, 3]. vap is pneumonia nosocomial that occurs after 48 hours in patients with the help of mechanical 71 global health management journal, 2018, vol. 2, no. 3 ventilation either through the endotracheal tube or tracheostomy tube [4]. the incidence of vap in patients who received mechanical ventilation was around 22.8% and accounted for 86% of cases of nosocomial infection [5]. previous studies reported the occurrence of vap ranged between 36.8 to 42 percent with 50 to 80 percent fatalities [6, 7]. most of vap incidence occurred among patients with ventilator who required antibiotics, suction, hand washing, changes in sleeping position, and oral hygiene to prevent oral decontamination. studies found, antiseptics is more recommended that antibiotics considering the risk of resistance of vapcausing bacteria [8, 9]. according to the institute for healthcare improvement (ihi), antiseptic liquid recommended for oral hygiene is chlorhexidine 2%. nevertheless, long-term use chlorhexidine may also cause side effects namely tooth discoloration, restoration, and mucous membranes increased calculus formation, taste disturbances, burning sensation, and mucosal irritations [10]. the negative effects most patients complain of chlorhexidine is the appearance of stains on the teeth, mouth and cheek mucosa after 2 weeks of use. in addition, gargling using chlorhexidine can also cause irritation to the oral mucosa, burning sensation, and changes in taste perception [11]. aloe vera has been proven as an alternative substance for mouthwash in patients with ventilator exposure. it contains active components which include anthraquinone, aloesin, aloin, aloeemodin, aceman nan, saponin, sterols, amino acids, minerals, aminoglycosides, and enzymes that beneficial for health. antibacterial activity of aloe vera inhibits bacterial growth, both gram-positive and grambacteria negative. aloe vera also has antimicrobial power in staphylococcus aureus, pseudomonas aeruginosa, candida albicans, klebsiella pneumonia, enterococcus faecalis, and micrococcus luteus [12]. the use of aloe vera as an antiseptic for oral hygiene has been done in mice and in vitro animals but has never been done to humans directly. in a study conducted by pandey, that ethanol extract from aloe vera produced a greater growth inhibition zone (29-30mm) than water extract (3-4mm) against organisms including enterococcus bovis and staphylococcus aureus 14. based on the description above, the study aims to find out the effectiveness of gargling with aloe vera extract in patients with ventilator in preventing the occurrence of vap. methods the study uses a case-control study with a pre-posttest design with a sample size of 30 respondents which equally divided into case and control group. sample is ventilator-associated pneumonia patients with endotracheal tube tracheostomy in 3 general hospitals in central java of indonesia, namely rsud dr. loekmono hadi kudus (12 samples), rsa raa soewondo pati (10 samples), and rsud dr. soetrasno rembang (8 samples), who were selected consecutively from the population. patients with hivaids and previous history of pneumonia were excluded from the study. the intervention group was administered to gargling twice a day using 10 ml aloe vera extract as mouthwash, while the control group used 10ml chlorhexidine 2%. to determine the occurrence of vap, clinical pulmonary infection score (cpis) for ventilator-associated pneumonia was measured on the first day and the fourth day of intubation, enumerated by nurses in the emergency room. cpis is a set of indicators comprised of temperature, leucocyte, trachea secretion, oxygenation (pao2/fio in mm hg), and thorax photo. cpis value below than five will be regarded non-vap, while cpis scored 69 will be diagnosed as vap. procedures performed in this research received approval from health research ethic commission of politeknik kesehatan kemenkes semarang on march 29th, 2018 with number 040/kepk/poltekkes-smg/ec/2018. results table 1 shows homogeneous data variations between the intervention and the control group (p value >0.05). data found that the majority of respondents were elderly, aged more than 65 years (40%). generally, respondents in the intervention group are older than those in the control group. of 30 participants, 16 respondents were male (53.3%). while intervention group was dominated by male, the control group was mostly comprised of females. from medical diagnosis data, most respondents having chf medical diagnoses (26.7%). although there was a slight difference on the diagnosis, however, most of respondents in both groups are suffered from chf. about 13 percent of males also diagnosed with stroke hemorrhagic and head injury, while about a fourth of female diagnosed with pulmonary edema. moreover, the majority noted staying at the hospitals for 4 and 5 days, while only 1 patient stayed for 6 days. global health management journal, 2018, vol. 2, no. 3 72 table 1. respondents’ characteristics (n=30) characteristics total case control p value n % % % age 36-45 46-55 56-65 > 65 7 5 6 12 23.3 16.7 20 40 13.3 6.7 33.3 46.7 33.3 26.7 6.7 33.3 0.682 gender male female 16 14 53.3 46.7 66.7 33.3 40.0 60.0 0.478 medical diagnosis chf head injury pleural effusion chronic renal failure hepatomegaly pulmonary edema post-surgery sepsis stroke hemorrhagic stroke nonhemoragic preeclampsia 8 3 1 3 1 5 2 1 3 2 1 26.7 10 3.3 10 3.3 16.7 6.7 3.3 10 6.7 3.3 26.7 13.3 6.7 6.7 6.7 6.7 6.7 6.7 13.3 6.7 0 26.7 6.7 0 13.3 0 26.7 6.7 0 6.7 6.7 6.7 0.856 length of stay 4 days 5 days 6 days 15 14 1 50 46.7 3.3 53.3 46.7 0 46.7 46.7 0.353 table 2. mean difference of cpis components before and after oral hygiene in intervention and control groups (n=30) cpis components intervention control p value** mean difference (±sd) p value* mean difference (±sd) p value* temperature 0.773±0.846 0.002 0.5±0.240 0.001 0.138 leukocytes -1.853± 10.180 0.492 -0.85 ±2.210 0.157 0.713 oxygenation pao2/fio2 -43.190±143.640 0.262 -32.66± 139.750 0.381 0.840 tracheal secretions -0.667± 0.258 0.317 0.067± 0.798 0.739 0.089 thorax photo 0.670± 0.488 1.000 0.20 ± 0.414 1.000 0.011 * peer t-test comparing the mean value before and after treatment of each group; **independent t-test comparing the mean difference between the intervention and control group table 3. total cpis score before (pretest) and after (post-test) mouthwash administration (n=30) group total cpis score p value pretest post-test intervention 4.07±1.100 3 ±1.195 0.001 control 3.87 ±1.246 3.53±1.187 0.465 73 global health management journal, 2018, vol. 2, no. 3 table 2 shows that temperature was the only component of cpis that has a significant difference after the administration of mouth wash. other cpis components such as leukocyte, oxygenation, tracheal secretion and thorax photo showed no difference counted on the first (pretest) and fourth day (post-test) of observation. as shown in table 3, after the administration of aloe vera extract (intervention group) and chlorhexidine 2% (control group), there was a significant difference on the mean cpis score in the intervention group with p-value 0.001 whereas in the control group, there was no significant changes (p-value of 0.465). clinical assessment after the administration of mouthwash in the intervention groups ranged from 0 to 5 which means aloe vera extract prevents the occurrence of vap. discussion congestive heart failure (chf) is one of the cardiovascular system diseases in which the conditions on the cardiovascular system are closely related to the respiratory system where the heart is unable to pump blood in sufficient quantity to maintain smooth circulation. consequently, blood builds up and extra pressure that causes fluid to accumulate into the lungs. when the lungs have lost function, it requires a breathing apparatus such as a mechanical ventilator [13]. one of the factors causing the occurrence of vap was the use of an extended breathing apparatus [14]. strict monitoring and supervising the maintenance of vap bundle are required to reduce the incidence of vap infection [15]. the respondents of the study were fitted with mechanical ventilators only for 4 days because the respondent is ready to breath without assistance. weaning is carried out to avoid side effects due to ventilator installation, shorten the length of stay, and reduce the cost of care. the finding of the study indicated that aloe vera extract reduces body temperatures. prior the intervention, there was no significant difference of temperatures between intervention and the control group (p value = 0.252). the administration of aloe vera extract effectively reduced the body temperatures of patients in the intervention group (p value <0.05). according to kowalak, an increase in temperature occurs when the infectious agent enters the body. an increase in temperature will help fight infection because many microorganisms cannot live in high temperature environments. if the body temperature rises too high, the body's cells can be damaged [13]. there was no significant difference of leucocyte counts between the intervention and the control group (p value > 0.05). leukocytes are white blood cells that form blood components. white blood cells function to help the body fight various infectious diseases as part of the immune system. the body reacts to the entry of pathogenic microorganisms by increasing the number and type of white blood cells. the inflammatory response that occurs after 48 hours of trauma shows a risk of the appearance of vap [16]. in this study, reduction in the number of leukocytes was higher in the control group. however, it should be noted that the increased leukocytes is one form of the body's defense against microorganisms due to the installation of a ventilator. gargling with aloe vera extract twice a day can maintain the cleanliness of the upper cavity of the patient so as to minimize the proliferation of pathogenic germs in it. according to augustyn, the mucosal injury due to intubation and a decrease in the body's ability to filter and moisturize the air in the airways causing disruption of mechanisms clearance from cilia in cleansing. the presence of et will provide a place for bacteria to enter the trachea. the next condition of these things will increase mucus production and secretion. there was no significant difference of secretory component between intervention and control group. aloe vera as an antiseptic against several bacteria in the oral cavity allows reducing the number of secretions in the trachea which will naturally produce excess secretions which can affect the ventilation and oxygenation processes so that they can increase pao2 / fio2 to patients with ventilators mechanical [16]. the mean oxygenation of the intervention group was greater than the control group although there was no significant difference with a p value > 0.05. research by wang suggests that chest radiographs have a deficiency in diagnosing pulmonary consolidation because changes in radiographic features can be affected by positive end-expiratory pressure (peep) in a fraction of inspiring oxygen in the use of ventilators mechanical. one lung disease causing infiltrates pneumonia which causes the lungs to become inflamed and filled with fluid. chest x-ray is a major investigation to diagnose pneumonia by finding a radiological picture of an infiltrate. the diagnosis of vap is most often based on the presence of a new or progressive infiltrate in chest x[5, 14]. global health management journal, 2018, vol. 2, no. 3 74 there is no significant difference in cpis score that describes the incidence of vap between groups. the occurrence of vap in the control group with chlorhexidine, showed that none of the respondents experienced vap, because the content of chlorhexidine was capable of killing vap-causing bacteria. however, the administration of aloe vera extract to intervention group showed that there were no respondents who experienced vap with reference to cpis scores. aloe vera consists of antimicrobial aminoglycosides which have the ability to kill germs. saponin and aminoglycoside compounds will diffuse on bacterial cell walls. this process takes place continuously in an aqueous atmosphere and will be forwarded to the ribosome which produces protein and will then cause the breakdown of protein bonds of bacterial cells. aloe vera gel has many properties and is unique with great medicinal value and very few side effects. therefore it is definitely recommended in the treatment of numerous oral mucosal diseases [17]. aloe vera can be used as mouthwash to prevent plaque stomatitis and gingivitis, because the inhibitory power of aloe vera is able to kill gram positive and negative bacteria, and aloe vera is a safe, natural material and no side effects. according to ihi in patients with mechanical ventilators other than ett, decreased consciousness, and loss of cough reflexes, microorganisms can develop because of the presence of dental plaque biofilms due to lack of or loss of mechanical functions namely chewing and reduced or even absence of saliva which can minimize biofilm development in the tooth. dental plaque can be a reservoir for potential respiratory pathogens that cause vap [18]. aloe vera also serves as an effective as chlorhexidine in reducing plaque and gingivitis [19]. medium concentration of the aloe vera extract in the study shows that the effect size of aloe vera extract is better than the honey solution which has an effect size of 0.18. hexadol gargle is effective in preventing the occurrence of vap, but hexadol gargle with a value size of 3.46 but has a disadvantage that should not be given to patients who are allergic to hexetidine. chlorhexidine is oral hygiene recommended by ihi, but the fda has issued a rule for every chlorhexidine manufacturer to attach a warning label about allergies [20]. although the results if the study showed a positive indication of aloe vera extract, limitation of the study also should be addressed. a selection bias could be a threat since most of sample in the case or intervention group are older than sample in the control group. moreover, unequal proportion of males-females which actually has different risk of vap should also be considered for further research and investigation. conclusion gargling with aloe vera extract effectively prevents the occurrence of a ventilator-associated pneumonia (p value = 0.001) compared to chlorhexidine. aloe vera extract can be used as an alternative antiseptic to maintain oral hygiene of ventilator-attached patients in preventing ventilator-associated pneumonia. conflict of interests the authors declare no conflict of interest. references 1. iwan purnawan s. mengelola pasien dengan ventilator mekanik. 1 ed. bogor: rekatama; 2010. 2. smeltzer scb, b.g. buku ajar keperawatan medikal bedah. 8 ed. jakarta: egc; 2001. 3. saragih rj, amin z, sedono r, pitoyo cw, rumende cm. prediktor mortalitas pasien dengan ventilator-associated pneumonia di rs cipto mangunkusumo. ejournal kedokteran indonesia. 2014. 4. tohirin a. pengaruh oral hygiene menggunakan hexadol gargle dalam meminimalkan kejadian vap di icu rsud tugurejo: perpusnwu.web.id/karyailmiah/documents/4846.pdf; 2016. 5. augustyn b. ventilator-associated pneumonia risk factors and prevention. critical care nurse. 2007;27(4):32-9. 6. rahmawati fa, leksana e. angka kejadian pneumonia pada pasien sepsis di icu rsup dr. kariadi semarang (the incidence of pneumonia on patients with sepsis at icu rsup dr. kariadi semarang). jurnal kedokteran diponegoro. 2014;3(1). 7. cm r. pola resistensi kuman penyebab vap di rscm tahun 2006-2007. jakarta: universitas indonesia; 2008. 8. lev a, aied as, arshed s. the effect of different oral hygiene treatments on the occurrence of ventilator associated pneumonia (vap) in ventilated patients. journal of infection prevention. 2015;16(2):76-81. 75 global health management journal, 2018, vol. 2, no. 3 9. japoni a, vazin a, davarpanah ma, ardakani ma, alborzi a, japoni s, et al. ventilator-associated pneumonia in iranian intensive care units. the journal of infection in developing countries. 2011;5(04):286-93. 10. majidah d. daya antibakteri ekstrak daun seledri (apium graveolens l.) terhadap pertumbuhan streptococcus mutans sebagai alternatif obat kumur. 2014. 11. puspita k. pengaruh chlorhexidine gluconate 0,12% terhadap kejadian vap (the effect of chlorhexidine gluconate 0.12% on vap incidence). tidak diterbitkan skripsi denpasar: fakultas kedokteran gigi universitas mahasaraswati denpasar. 2014. 12. kayum na. the comparison of effectivity between red ginger (zingiber officinale var rubrum) and aloe vera mouthwash formulae in the growth of staphylococcus aureus. padang: universitas andalas padang; 2015. 13. kowalak jp, welsh w, mayer b. buku ajar patofisiologi. jakarta: egc. 2011. 14. indonesia pdp. penyakit paru obstruktif kronik pedoman diagnosis dan penatalaksanaan di indonesia. jurnal jakarta. 2003. 15. maria e, permanasari vy, editors. the implementation of ventilator-associated pneumonia bundle (vap) in the icu of eka hospital, pekanbaru. proceedings of the international conference on applied science and health; 2018. 16. dunham cm, chirichella tj. attenuated hypocholesterolemia following severe trauma signals risk for late ventilator-associated pneumonia, ventilator dependency, and death: a retrospective study of consecutive patients. lipids in health and disease. 2011;10(1):42. 17. nair gr, naidu gs, jain s, nagi r, makkad rs, jha a. clinical effectiveness of aloe vera in the management of oral mucosal diseasesa systematic review. journal of clinical & diagnostic research. 2016;10(8):1-7. 18. hutchins k, karras g, erwin j, sullivan kl. ventilator-associated pneumonia and oral care: a successful quality improvement project. american journal of infection control. 2009;37(7):590-7. 19. jain s, rathod n, nagi r, sur j, laheji a, gupta n, et al. antibacterial effect of aloe vera gel against oral pathogens: an in-vitro study. journal of clinical & diagnostic research. 2016;10(11):41-4. 20. food u, administration d. fda drug safety communication: fda warns about rare but serious allergic reactions with the skin antiseptic chlorhexidine gluconate. 2017. predisposing factors related to four anc visits (k4) on tm iii pregnant women at danurejan i primary health center of yogyakarta indonesian scholars’ alliance ghmj (global health management journal) 2020, vol. 4, no. 1 open access original research linda yulyani* , menik sri daryanti predisposing factors related to four anc visits (k4) on tm iii pregnant women at danurejan i primary health center of yogyakarta faculty of health science, universitas ’aisyiyah yogyakarta, indonesia. *corresponding author’s email: linda.yulyani13@gmail.com abstract background: pregnancy may cause problems or become a complica on at any me. however, complica ons of pregnancy and childbirth can be prevented by regular antenatal care (anc) visits. four anc visits (k4) are indicators used to assess the quality of health services for pregnant women. na onally, performance indicators for the coverage of four anc visits (k4) on pregnant women in 2014 did not reach the target. various factors may contribute to an unsuccessful four anc visit (k4) of pregnant women. the objec ve of the study is to inves gate factors related to four anc visits (k4) on tm iii pregnant women at the danurejan i primary health center of yogyakarta. methods: it is an analy c observa onal study design with a cross-sec onal approach. the sample was taken by accidental sampling as many as 30 tm iii pregnant women. results: the result of this study shows that only two factors have a significant rela onship with four anc visits (k4), which are maternal age (p value=0.000) and parity (p value=0.000). meanwhile, educa on level (p value=0.155) and occupa on (p value=0.210) have no correla on with four anc visits k4. conclusion: it can be concluded from this study that the maternal age and parity are the predisposing factors related to the four anc visits (k4). as a result, it is clear that promo on and preven on efforts such as health educa on about mature age at marriage and improving family planning programs are essen al to increase four anc visits (k4). keywords: pregnancy; predisposing; four anc visits received: 5 june 2020 reviewed: 18 july 2020 revised: 24 july 2020 accepted: 28 august 2020 doi: 10.35898/ghmj-41496 © yayasan aliansi cendekiawan indonesia thailand (indonesian scholars’ alliance). this is an open-access following crea ve commons license deed a ribu on-noncommercial-sharealike 4.0 interna onal (cc by-nc-sa 4.0) 1. introduc on maternal mortality rate (mmr) is an indicator that is sensitive to the quality and accessibility of health care services in a region (kemenkes ri, 2015a). world health organization (who) mentioned that in 2015, maternal mortality around the world was estimated at 303,000 people or around 216 / 100.000 live births. mortality and morbidity in women during pregnancy and childbirth are major problems in developing countries because mmr mostly occurs in developing countries by 99% (manuaba, 2010). indonesia is one of countries included in developing countries. nowadays, indonesia even included as one of the 10 largest contributors of mmr in the world, where these 10 countries contribute around 59% of all maternal mortality (who, 2015). based on the results of the 2012 indonesian demographic health survey (idhs) and the 2010 population census, mmr in indonesia was recorded at 359 per 100.000 live births. mmr turned out to be deviating from the expected trend. the trend of mmr from 1992 to 2007 tended to fall, but in 2012, it actually increased (wijaya, 2013). the causes of maternal mortality known from the past until nowadays tend to have no shift. the 27 mailto:linda.yulyani13@gmail.com https://dx.doi.org/10.35898/ghmj-41496 ghmj (global health management journal) 2020, vol. 4, no. 1 yulyani l and daryan ms direct causes of maternal mortality are hemorrhage (28%), eclampsia (24%) and infection (11%). meanwhile, some of the indirect causes of maternal mortality are chronic energy deficiency (ced) (37%) and anemia in pregnancy (40%). combined with the presence of ”4 too” and ”3 late”, which are too young, too old, too often, too many children to become pregnant and too late to reach the health care facilities, late of getting a help in giving birth and too late to recognize the danger signs of pregnancy and childbirth (kemenkes ri, 2010). various efforts have been conducted to reduce mmr, including the safe motherhood program that has been implemented in indonesia since 1997. to achieve the goals of millennium development goals (mdgs) and the indonesia strategic plan for long-term development by 2015, the policy known as making pregnancy safer (mps) was made (kemenkes ri, 2015b). at the end of 2015, through the united nations general assembly (un), a new global commitment was created known as sustainable development goals (sdgs) (hoelman et al., 2015). sdgs is a new development agreement to replace mdgs and it will end in 2030. sdgs contains 17 goals and 169 targets. maternal and child health problems themselves included in the third goal, whereby in 2030, the target is to reduce the mmr until below 70/100.000 live births. to achieve this target is certainly not easy as reflected in the past experiences of mdgs failures. it requires more active role of local and district governments to achieve sdgs goals, as we already know that the local governments are closer to their citizens and are the spearhead of public service providers including the maternal and child health service programs (hoelman et al., 2015). health services for pregnant women in each region are implemented by providing antenatal care for at least four times during pregnancy. the minimum time distribution is once in the first trimester (0-12 week gestation), once in the second trimester (12-24 week gestations), and twice in the third trimester (24 weeks gestation to delivery). this standard is used as a k4 assessment indicator (kemenkes ri, 2015a). the k4 indicator is an indicator to see the frequency that refers to the trimester period in applying antenatal care (kemenkes ri, 2010). it was also explained in the minister of health of the republic of indonesia (kemenkes) regulation no. 741/menkes/per/vii/2008 concerning minimum health service standards in each district/city. it is stated that one of the health services measurement is the coverage of k4 visits by 95% (kemenkes ri, 2008). nationally, the k4 indicator in 2014 has not reached the target of the ministry of health strategic plan which only 86.7% of 95% target (kemenkes ri, 2015b). meanwhile, the coverage of the k4 indicator in yogyakarta province in 2015 was 92.68%, a slight decrease from the previous year (92.81%). although the coverage of the k4 indicator in yogyakarta province from year to year tends to be stable, it still cannot reach the target of 95% (dinkes kota yogyakarta, 2016). the results of a study conducted by priani in 2012 showed that there are several factors that influence the regularity of pregnant women on doing antenatal care, including predisposing factors such as the average age of pregnant women 21-35 years (74.4%), the level of high school education (54.9%), no occupation (82.9%), a little parity (78%), high knowledge (76.8%), and negative attitudes (61%). enabling factors including low income (63.4%), the short distance of residence (63.4%), good media of information (52.4%). however, the reinforcing factor is husband’s support (90.2%) (priani, 2012). the data obtained from the yogyakarta health profile in 2016, show that the first contact with a health care provider in trimester i (k1) was 100% while the k4 was 91.78%. it shows the disparity between k1 and k4 that is still high (8.21%). danurejan i primary health center ranked the third lowest rank in terms of k4 indicator by 84% in 2015 after previously at the first lowest rank of 68% in 2014. although it was increased, the disparity between k1 and k4 in danurejan i primary health center was still quite high, which was 26% (dinkes kota yogyakarta, 2016). therefore, the aim of this study is to investigate the predisposing factors related to k4 visits on pregnant women at the danurejan i primary health center in yogyakarta. 28 yulyani l and daryan ms ghmj (global health management journal) 2020, vol. 4, no. 1 2. method this study is an observational analytic study with a cross-sectional approach. the cross-sectional approach is a research design by measuring or observing variables at the same time (hidayat, 2014). in this case, the characteristic identification of the mother with k4 visits is conducted at the same time. the population in this study was all pregnant women in the working area of danurejan i primary health center. the sample was taken based on accidental sampling technique with inclusion and exclusion criteria, which are a tm iii pregnant women with 28-36 weeks gestation, carrying the maternal and child health (mch) handbook. the previous anc was applied in the working area of danurejan i primary health center, and willing to become respondent of the study. there were 30 tm iii pregnant women included in this study. mch handbook and checklist were used as the data collection tools, both for the independent and dependent variables. data collection in this study was conducted by the researcher directly through making direct observations to look for things to be examined by looking at the mother’s mch handbook when the mother carried out antenatal care in the third trimester (hidayat, 2014). 3. result and discussion 3.1 frequency distribu on of respondents’ characteris c table 1. characteris c of respondents no characteris c n % 1 age 1 = not at risk (20-35 years old) 23 76.7 2 = at risk (<20 or >35 years old) 7 23.3 2 parity 1 = low (≤ 2) 19 63.3 2 = high (≥ 3) 11 36.7 3 educa on level 1 = high (≥ d3) 6 20.0 2 = low (sd-sma) 24 80.0 4 work status 1 = do not have a job 18 60.0 2 = have a job 12 40.0 5 k4 visits 1 = fits the standard 22 73.3 2 = do not fit the standard 8 26.7 the data in table 1 above shows that the majority of respondents, as many as 22 out of 30 respondents (73.3%) have fit the standard of k4 visits. k4 visits that are considered as fit the standard are the antenatal care visits which at least 1 time in the first trimester, 1 time in the second trimester and at least 2 times in the third trimester. the results of the study show that most of the respondents have not at risk of age (20-35 years). in addition, there are 11 pregnant women who have high parity (36.7%) with ≥3 children. from this study, it is also found that the majority of respondents (60%) have no job or become housewives and have an elementary (sd)-senior high school (sma) education level (80%). 29 ghmj (global health management journal) 2020, vol. 4, no. 1 yulyani l and daryan ms thus, domestic work is not included in the type of occupation, because what is meant by work in this study is in terms to earn money or salary to meet the necessities of lives. 3.2 correla on between age and k4 visits table 2. the correla on between age and k4 visits at danurejan i primary health center no age k4 visits total pvfit the standard do not fit the standard n % n % n % 1 not at risk 21 70.0 2 6.7 23 76.7 0.000 2 at risk 1 3.3 6 20.0 7 23.3 total 22 73.3 8 26.7 30 100 age really determines maternal health status. women considered at high risk if they become pregnant before 20 years or above 35 years old. age under 20 years is considered to have a risk of complications that are closely related to women’s reproductive health. meanwhile, if it is over 35 years, it is also at high risk due to the decline of reproductive function, and maternal mortality which is higher in women who are pregnant at the risky age (padila, 2014). furthermore, age also can affect a person’s thoughts and mindset. the more mature a person will also develop the strength of their thought. thus, they will have better knowledge as a result of the experience and the maturity of her soul (cholifah and putri, 2016). at the age of 20-35 years, pregnant women will tend to check their pregnancy more regularly because they still feel that pregnancy checks or antenatal care are very important. meanwhile, those aged <20 years tend to not really understand the importance of regular antenatal care and those aged> 35 years tend to be indifferent to antenatal care because they feel that they have had quite good experience, when in fact both of these age groups should routinely check their pregnancy to the health services because of the high risk of pregnancy and childbirth (pongsibidang and abdulah, 2013). therefore, this should be a particular concern to both health workers and especially pregnant women themselves, to prevent pregnancy at a risky age. for example, the efforts to promote the maturing age at marriage, so that women will not get pregnant and give birth when they are still too young age. in addition, it is also necessary to strengthen family planning services to prevent pregnancy when women reach the age of 35. it should become a particular concern to both health care providers and especially pregnant women. regular antenatal care is the way to monitor the development of a pregnancy and also to recognize various abnormalities. hence, it could be ensured that the pregnancy will run well and the labor also can be planned properly to ensure the safety of the mother and baby, and to avoid various complications such as preterm birth, low birth weight (lbw), and etc. (nimi et al., 2016). the results of statistical analysis as outlined in table 2 show that there is a significant correlation between maternal age and k4 visit, with p-value=0.000 (<α = 0.05). it is in line with the research conducted by putri et al. (2015) which stated that there is a relationship between the age of pregnant women and anc compliance at suruh primary health center, semarang regency. another research by hidayatun mukaromah (2014) also revealed the same result, that there was a relationship between maternal age and four times antenatal care visits (k4) (hidayatun mukaromah, 2014). the same result was also shown in a study conducted by simkhada et al. (2008), who showed that age was a factor related to the utilization of antenatal care services. in accordance with the lawrence green’s theory in notoatmodjo (2010), age is one of the predisposing factors behind the behavior change that provides rational thinking or motivation for an 30 yulyani l and daryan ms ghmj (global health management journal) 2020, vol. 4, no. 1 activity, as well as a factor that facilitates the occurrence of people’s behavior. in other words, age has an influence on maternal behavior in utilizing and fit the standard of antenatal care visits (k4). 3.3 the correla on between parity and k4 visits table 3. the correla on between parity and k4 visits at danurejan i primary health center no parity k4 visits total pvfit the standard do not fit the standard n % n % n % 1 low 18 60.0 1 3.3 19 63.3 0.000 2 high 4 13.3 7 23.3 11 36.7 total 22 73.3 8 26.7 30 100 parity is one of the predisposing factors that influences mother’s behavior of using health care services. in this case, the four times antenatal care visits (k4) (notoatmodjo, 2010). parity is the condition of a mother who has given birth to one or more fetus, the higher the parity, the higher the maternal mortality. even though, the risk of high parity actually can be reduced or prevented by the family planning program, because most pregnancies at high parity are unplanned (padila, 2014). the experience of previous pregnancy influences the motivation of mother to conduct the antenatal care visit. the primigravida pregnant women think that they need more information about pregnancy because they do not have experience of pregnancy before. they are more anxious than multigravida, so the primigravida will utilize more antenatal care services compared to multigravida. multigravida tends to feel that they have more knowledge and experience than primigravida. while in fact, each pregnancy is different so the conditions would be different (sari et al., 2015). in fact, the experience of pregnancy and childbirth that the mothers have experienced would not be enough and could not guarantee the current pregnancy is running normally. pregnancy and childbirth that occur in mothers with high parity are directly proportional to the risks that threaten the well-being condition of both mother and fetus (saifuddin, 2010). the results of statistical analysis in table 3 show that there is a significant relationship between maternal parity and k4 visits, with p-value=0.001 (<α = 0.05). the same results of the study conducted by sari and indriani (2014) also stated that there was a relationship between parity or the number of children with k4 visits. the result of this study is also supported by a study conducted by agustina (2015) and sriwahyu (2013) which explained that there was a significant relationship between parity with the standard of antenatal care visits at least 4 times during pregnancy until 36 weeks gestation. a research conducted by pell et al. (2013) also revealed that parity has a complex influence on initiatives to conduct anc visits, for instance, due to the ignorance about the signs and symptoms of pregnancy, primigravida will have more effort to find a place to examine and conduct anc earlier. the results of this study show that pregnant women with low parity more likely to conduct k4 visits. pregnant women who have low parity (≤ 2) feel that pregnancy is still a new and very interesting thing. the curiosity about the development of their pregnancy from month to month makes the mother owns high motivation to check her pregnancy regularly (padila, 2014). different from pregnant women who have high parity (≥ 3), they tend to feel that they have enough experience in handling pregnancy. due to that reason, they have low motivation to check their pregnancy and meet the k4 visits which is the standard of antenatal care visit during pregnancy. it emphasizes that parity influences the anc visits and even for the first anc of pregnant women (agha and tappis, 2016). 3.4 the correla on between maternal educa on level and k4 visits 31 ghmj (global health management journal) 2020, vol. 4, no. 1 yulyani l and daryan ms table 4. the correla on between maternal educa on level and k4 visits at danurejan i primary health center no educa on level k4 visits total pvfit the standard do not fit the standard n % n % n % 1 low 6 20.0 0 0 6 20.0 0.155 2 high 16 53.3 8 26.7 24 80.0 total 22 73.3 8 26.7 30 100 based on the data on table 4 above, it is found that all pregnant women who have high education level (20%) have done k4 visits and met the standards. meanwhile, there were 8 pregnant women who have a low education level (elementary-high school) (26.7%) that have not done k4 visits as a standard of antenatal care visit. basically, indonesia recognizes three levels of education that are basic education, secondary education, and higher education. basic education includes elementary school/its equal and junior high school/its equal. secondary education is a high school /its equal (notoatmodjo, 2010). based on this theory, it is known that the majority of pregnant women in this study have secondary education or lower. however, secondary education cannot be categorized as higher education because higher education is obtained through tertiary institutions with at least a diploma degree. according to notoatmodjo (2010), the level of formal education influences differences in knowledge and decisions. education determines people’s knowledge and insight. the behavioral change provided through counseling is more easily accepted by people with higher education than those with low education. cholifah and putri (2016) also said the same thoughts that the level of education can increase women’s access to information, increase the ability to accept the new health concepts and have the balanced interaction between health care providers and the client. the education level that a mother has can affect the awareness of utilizing health care facilities. heredia-pi et al. (2016) who conducted research on antenatal care in mexico also revealed that the probability of adequate antenatal care was higher in women with high education and socioeconomic level. the results of the study in table 4 also show that pregnant women who have a higher education level (20%) have conducted the k4 visits according to the standard. it is consistent with the theory of notoatmodjo (2010) and cholifah and putri (2016) regarding the level of education that it influences pregnant women in conducting antenatal care visits. however, pregnant women with a low education level also have done k4 visits according to the standard with a fairly large percentage of 53.3%. based on the result of statistical analysis, it is obtained the p-value=0.155 (>α =0.05), which means that there is no relationship between maternal education level and k4 visits. the results of this study are not in line with the concept of padila (2014), which stated that the role of mothers with low education levels is more resigned, giving up circumstances without any efforts to improve their destinies. they ignored various important signs and symptoms that can cause dangerous conditions because they considered it as normal. the result of this study is also not in line with the research conducted by wulandari and ariesta (2015), which argued that there is a significant relationship between maternal education level and the completeness of antenatal care (k4). however, this study is in line with some previous studies, such as the study conducted by sarminah (2012), which stated that there is no significant relationship between education level and the completeness of antenatal care visits. the same result was also expressed by sari and indriani (2014) that there was no meaningful relationship between mother’s education level and k4 visits. the results of the cross-tabulations in table 4 show that all pregnant women with high education levels have had k4 visits in accordance with the standards. it is indicates a positive relationship, 32 yulyani l and daryan ms ghmj (global health management journal) 2020, vol. 4, no. 1 that highly educated mothers have higher knowledge and motivation to conduct regular pregnancy checks. the results of statistical analysis show that there is no significant relationship between maternal education level and k4 visits (p-value=0.155). it is might be influenced by the presence of cells with a ”zero value” on cross-tabulation. moreover, there are many other factors that also involved. for instance, a pregnant woman who has low education, but it is also the first pregnancy to her, so it will make her more likely to have regular antenatal care, due to the high curiosity about the development and condition of her pregnancy. in line with the theory of lawrence green in notoatmodjo (2010), many other factors also encourage pregnant women to have regular antenatal care visits, including maternal age, parity, and also support from family. 3.5 the correla on between maternal work status and k4 visits table 5. the correla on between maternal work status and k4 visits at danurejan i primary health center no work status k4 visits total pvfit the standard do not fit the standard n % n % n % 1 do not have a job 15 50.0 3 10.0 18 60.0 0.210 2 have a job 7 23.3 5 16.7 12 40.0 total 22 73.3 8 26.7 30 100 the maternal occupation considered in this study refers to the work outside or inside the house except for domestic work, in terms of getting money and supporting the family income. working mothers will have less time to check their pregnancy and spend more time to work. however, mothers who do not work will have plenty of time to check their pregnancy (notoatmodjo, 2010). work affects the respondent’s ability to spare their time to visit health care facilities for antenatal care. housewives tend to have more spare time than working mothers (marullyta and pudjirahardjo, 2013). table 5 above shows that there are 15 people (50.0%) of pregnant women who do not work and have k4 visits according to the standards. meanwhile, only 23.3% of working pregnant women that meet k4 visits in accordance with the standards. it means that the status of not working can support the mother for antenatal care visits and meet the minimum standard of 4 times antenatal care visits. however in this study, there was no statistically significant relationship between maternal employment status and k4 visit. the results of the statistical analysis presented in table 5 show that there is no significant relationship between maternal employment and k4 visits in pregnancy, with a p-value=0.210 (>α=0.05). the result of this study is in line with the results of research conducted by lumempouw et al. (2015) which shows that there is no relationship between maternal employment and the completeness of antenatal care visits (k4). similar results were also stated in the studies of cholifah and putri (2016), sarminah (2012) and sari and indriani (2014), which showed that there was no meaningful relationship between maternal employment and the regularity or completeness of antenatal care visit (k4). research conducted by onasoga et al. (2012) in nigeria also found that there was no relationship between maternal employment and visits to use anc services during pregnancy. from the results of this study, researchers argue that as one of the predisposing factors that facilitate health behaviors, maternal employment does affect the mother’s opportunity to make the antenatal care visit. however, it does not mean that all working mothers lose their opportunity for regular antenatal care visits. various other factors revealed by notoatmodjo (2010), such as age, parity, fam33 ghmj (global health management journal) 2020, vol. 4, no. 1 yulyani l and daryan ms ily support, and distance also become factors that enable mothers to conduct antenatal care visits complies with standard (k4). as in this study, pregnant women who work but are supported by high education, mature age and moreover if this pregnancy is the first pregnancy that has been expected, the mother will have a strong motivation to apply routine antenatal care visits. conversely, for pregnant women who do not have job, but if the pregnancy is a high-risk pregnancy such as high parity, there is a possibility of mothers to feel that they have enough experience which tends to cause the lack of motivation to check their pregnancy routinely. therefore, it means that the minimum four times antenatal care (k4) will not be achieved. in addition to age, parity, education, and employment factors, there is also a cultural factor that can be a barrier to achieving the k4 target. for example, there is a culture of the community when the pregnancy is near to the delivery time, the pregnant women will return to their hometowns because they want to give birth and feel comfortable when close to their parents. besides that, some pregnant women also frequently move around from one health care facility to another for a pregnancy check. in the end, this will have an impact on non-optimal recording and reporting (direktorat kesehatan keluarga, 2018). conclusion based on the results of this study, it can be concluded that age (p-value=0.000) and parity (p-value = 0.000) are the predisposing factors that significantly related to k4 visits, but education (p-value=0.155) and occupation (p-value=0.210) are the predisposing factors that have no relation with k4 visits on tm iii pregnant women at danurejan i primary health center in yogyakarta. therefore, it requires encouraging and preventive efforts to be able to increase k4 visits of pregnant women, such as health education efforts about maturing age at marriage and efforts to improve family planning programs in order to prevent risky pregnancy. future studies are expected to be conducted with a larger sample size and different epidemiological approaches. conflict of interest the authors have disclosed no conflict of interest, financial or otherwise. references agha, s. and tappis, h. 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(2015). hubungan pendidikan dan umur ibu hamil dengan kelengkapan pemeriksaan kehamilan (k4). jurnal obstretika scientia, 2(2):159–178. 35 http://www.pdpersi.co.id/peraturan/permenkes/pmk7412008.pdf http://www.pdpersi.co.id/peraturan/permenkes/pmk7412008.pdf http://www.akbidmuhammadiyahmadiun.ac.id/backsite/file_download/pedoman-pws-kia.pdf http://www.akbidmuhammadiyahmadiun.ac.id/backsite/file_download/pedoman-pws-kia.pdf https://www.depkes.go.id/resources/download/pusdatin/profil-kesehatan-indonesia/profil-kesehatan-indonesia-2014.pdf https://www.depkes.go.id/resources/download/pusdatin/profil-kesehatan-indonesia/profil-kesehatan-indonesia-2014.pdf http://lontar.ui.ac.id/file?file=digital/20296280-s-sarminah.pdf http://lontar.ui.ac.id/file?file=digital/20296280-s-sarminah.pdf https://www.who.int/reproductivehealth/publications/monitoring/maternal-mortality-2015/en/ https://www.who.int/reproductivehealth/publications/monitoring/maternal-mortality-2015/en/ https://www.infodokterku.com/index.php/en/98-daftar-isi-content/data/data-kesehatan/219-angka-kematian-ibu-tahun-2012 https://www.infodokterku.com/index.php/en/98-daftar-isi-content/data/data-kesehatan/219-angka-kematian-ibu-tahun-2012 ghmj (global health management journal) 2020, vol. 4, no. 1 yulyani l and daryan ms cite this article as: yulyani l and daryanti ms. predisposing factors related to four anc visits (k4) on tm iii pregnant women at danurejan i primary health center of yogyakarta. ghmj (global health management journal). 2020; 4(1):27-36. doi:10.35898/ghmj-41496 36 introduction method result and discussion frequency distribution of respondents’ characteristic correlation between age and k4 visits the correlation between parity and k4 visits the correlation between maternal education level and k4 visits the correlation between maternal work status and k4 visits cite this article as pradnyani pe, putra igne, astiti nlep. knowledge, attitude, and behavior about sexual and reproductive health among adolescent students in denpasar, bali, indonesia. global health management journal. 2019; 3(1):31-39. global health management journal www.publications.inschool.id published by original research article issn 2580-9296 (online) knowledge, attitude, and behavior about sexual and reproductive health among adolescent students in denpasar, bali, indonesia putu erma pradnyani 1,3, i gusti ngurah edi putra 2,3, ni luh eka purni astiti 3 1 faculty of public health, airlangga university, indonesia. 2 institute for population and social research, mahidol university, thailand. 3 kisara (kita sayang remaja) ippa bali chapter, indonesia. *corresponding author. email: ediputra.ign@gmail.com article info abstract article history: received 26 october 2018 reviewed 08 january 2019 received in revised form 25 february 2019 accepted 28 february 2019 background: adolescent sexual and reproductive health (srh) problems remain an important public health issue in many developing countries, such as indonesia. therefore, assessing srh knowledge, attitude, and behavior among adolescents are worth considering for public health intervention purpose in order to reduce their vulnerability to srh problems. aims: this study aimed to assess srh knowledge, attitude, and behavior among adolescent students in denpasar, bali, indonesia. methods: this was a cross-sectional school-based study conducted in denpasar, bali, indonesia from july to september 2016. this study applied multi-stage random sampling to recruit 1,200 students out of 24 junior, senior, and vocational high schools. variables in this study consisted of socio-demographic characteristics, knowledge, attitude, and behavior related to srh. data were analyzed using descriptive analysis and cross-tabulation to identify proportion differences. results: regarding knowledge on srh, students had less knowledge on a reproductive process (10.1%) and reproductive risk (11.4%), but half of them knew about the sexually transmitted infections (stis) and hiv&aids (55.6%) and almost all had sufficient knowledge on puberty (90.7%). meanwhile, few students argued that several sexual behaviors can be performed before getting married, such as kissing and hugging (48.9%), petting and oral sex (18.7%) and sexual intercourse (vaginal sex) (13.8%). out of 1,200 adolescent students, 880 (73.3%) reported for have ever been in dating with someone. among adolescent dating, few students reported for an experience of petting (14.3%), oral sex (9.8%), vaginal sex (6.5%), and anal sex (2.6%). conclusion: adolescent students in denpasar, bali, had a low level of sufficient knowledge in some srh aspects, a few students reported for permissive attitude and performed premarital sexual behaviors. therefore, providing comprehensive sexuality education (cse) is worth considering to improve knowledge and appropriate skills in order to prevent risky sexual behavior among adolescents. keywords: sexual and reproductive health (srh) adolescents students knowledge attitude sexual behavior © 2019 publications of yayasan aliansi cendekiawan indonesia thailand this is an open-access following creative commons license deed – attribution-noncommercial-sharealike 4.0 international (cc by-nc-sa 4.0) introduction in many developing countries, including indonesia, the high population of adolescents without adequate development of information, technology, and facilities can lead to adolescent’s problems. one of those problems which currently needs a lot of attention is risky sexual behavior. the national figure from the indonesia demographic and health survey in 2012 showed that 33.3% of females and 34.5% of males aged 15-19 years old have started dating before 15 years old [1]. meanwhile, the finding from riset kesehatan dasar (the national health research) in 2010 found that some http://publications.inschool.id/index.php/ghmj/index http://publications.inschool.id/ http://inschool.id/ http://publications.inschool.id/index.php/ghmj/index mailto:ediputra.ign@gmail.com http://inschool.id/ http://creativecommons.org/licenses/by-nc-sa/4.0/ global health management journal, 2019, vol. 3, no. 1 32 pradnyani et al. global health management journal. 2019; 3(1):31-39 adolescents aged 10-24 years old had premarital sexual experience [2]. in addition, indonesian adolescents have been documented with carrying a high risk sexual behavior since the protected sex among them was at very low level [3]. to respond this problem, some previous study suggested to provide comprehensive sexual and reproductive health (srh) education [3, 4]. in many setting in indonesia, adolescents face difficulties to access the srh information and services. even though they are supported by health law no. 36/2009, article 72 which stated that everyone has rights to obtain information, education, and counseling about reproductive health [5], the implementation is far away from the expectation. the socio-cultural in indonesia places the reproductive health matters as taboo and sensitive issues and its discussion is viewed as private realm. not surprisingly then, this condition contributes to insufficient knowledge regarding srh and risky sexual behavior among indonesian adolescents [6]. risky sexual activity among adolescents would certainly increase the risk of being infected with stis and hiv, as well as, unintended pregnancy [7]. as one of the provinces in indonesia, adolescents in bali are also vulnerable to srh consequences due to lack of access to srh information and services since srh discussion is viewed as inappropriate for unmarried people. moreover, their vulnerability is also due to bali as a well-known tourism place which contributes to the acculturation process of overseas-cultures in terms of interpersonal relationship pattern among adolescents [8]. not surprisingly then, there is an increasing acceptance among balinese adolescents of premarital sex, even the pregnancy among unmarried couples can be accepted as long they commit to get married soon [9]. indonesian planned parenthood association (ippa) of bali chapter reported that 29.3% of 1,225 unwanted pregnancy cases in 2015 came from young people (1024 years) whereas adolescents (15-19 year) contributed to 7.7% of 1,162 sti sufferers [10]. a previous study conducted among senior high school students at 10th and 11th grade in denpasar found that 29 students (4.26%) have performed premarital sexual intercourse (1.44% of females and 3.19% of males) [11]. in order to provide more insights related to srh among adolescents in denpasar, bali, this study aimed to assess knowledge, attitude, and behavior about srh among adolescents in denpasar, bali, indonesia. methods population and sample a cross-sectional school-based study was conducted by kisara (kita sayang remaja =we love youth), ippa of bali chapter from july to september 2016. the population of this study was adolescents from junior, senior, and vocational high school in denpasar, bali with an inclusion criterion that students were in schools and willing to participate in this study at the time of survey. adolescent students were selected as samples in this study because they can represent the adolescents in community, particularly in geographical area of denpasar. as the most developed area, the rates of school-age adolescents who did not attend schools due to underprivileged economic status might be identified at very low level. therefore, recruiting adolescent students in this study can estimate the srh situation among school-age adolescents properly. the sample size was determined using the formula for a population proportion with assumptions: 95% confidence interval; 50% as the anticipated population proportion; and 5% of absolute precision, making a minimum sample size of 385 students. however, to increase generalizability, we decided to collect 400 students from each level of education (junior, senior, and vocational high school), resulting in a total sample of 1,200 students, as representative of the sampling population. this study employed a multi-stage cluster random sampling to recruit students from the selected population. first, 24 schools were selected through cluster probabilistic selection, stratified by four sub-districts of denpasar and school levels (junior high school, senior high school, and vocational high school) as well as grouped into private and public school, resulting in an equal number of students obtained with different school levels and types of school. second, two classes were picked using a simple random sampling from the selected schools in denpasar, and then, systematic random sampling was used to recruit 25 students from each class. data were collected through a self-administered questionnaire and set to be anonymous to ensure confidentiality and reduce bias. prior the data collection, we have explained the study’s purpose to the students, and written informed consent from students has been obtained. in addition, teachers supervised the data collection process and they approved the study as students’ guardian. variables and data analysis variables in this study consisted of four main groups, such as socio-demographic characteristics, knowledge, attitude, and behavior related to srh. more than one questions were used to measure knowledge, attitude, and behavior. moreover, data were analyzed descriptively to present distribution of variables in this study. chi-square test was employed to identify the proportion differences by sociodemographic characteristics with significance level (α) at 0.05. 33 global health management journal, 2019, vol. 3, no. 1 pradnyani et al. global health management journal. 2019; 3(1):31-39 table 1. sociodemographic characteristics of adolescent students in denpasar, bali (n=1,200) variables n % age ≤ 15 years old > 15 years old 369 831 30.8 69.2 sex female male 724 476 60.3 39.7 current educational level junior high school senior high school vocational high school 400 400 400 33.3 33.3 33.3 types of school public/state school private school 600 600 50.0 50.0 results table 1 shows that the average age of students in this study was nearly 16 years and more than half aged 16 years and more (69.2%) with the majority were female students (60.3%). meanwhile, the same number of students were obtained from three different school levels and two types of school. the knowledge on srh was measured by 63 questions, grouped into four main sections of knowledge: puberty (8 questions), reproductive process (9 questions), reproductive risk (4 questions), and stis and hiv&aids (42 questions). those who could answer correctly at least a half of total questions were classified into sufficient knowledge. table 2 clearly presents that more than 90% of students had sufficient knowledge on puberty whereas only one out of ten students had good enough knowledge on reproductive process (10.1%) and reproductive risk (11.4%). meanwhile, only a half of the students had sufficient knowledge on stis and hiv&aids (55.6%). based on cross-tabulation of each aspect of knowledge with sociodemographic characteristics, it showed that students aged > 15 years old and female students had significantly higher knowledge on puberty and sti and hiv&aids. while junior high school students had the lowest proportion of sufficient knowledge on puberty and stis, including hiv&aids, vocational high school students appeared with the lowest sufficient knowledge on reproductive process. meanwhile, those in public schools had higher proportion of sufficient knowledge on puberty, but the smaller proportion on reproductive risk. table 3 presents the attitude of adolescents regarding preferred time for sexual behavior. most of the students argued that sexual behavior should be performed after getting married. meanwhile, others argued that the following sexual behaviours can be performed before getting married such as kissing and hugging (48.9%), petting and oral sex (18.7%) and sexual intercourse (vaginal sex) (13.8%). based on age, adolescents aged > 15 years old were consistent to approve all premarital sexual behaviors at higher proportion compared to those aged 15 years and less. moreover, male students were more permissive to agree that petting, oral sex, and sexual intercourse could be performed before getting married. junior high schools students were observed with the lowest percentage of the acceptance of premarital sexual behaviors. in addition, adolescents’ approval of some premarital sexual behaviors was found higher among private-schooling adolescents. table 2. sexual and reproductive health knowledge among adolescent students in denpasar, bali (n=1,200) sociodemographic characteristics sufficient knowledge on puberty n (%) reproductive process n (%) reproductive risk n (%) stis and hiv&aids n (%) total 1,088 (90.7) 121 (10.1) 137 (11.4) 667 (55.6) age (χ2) 9.81*** 0.99 0.32 43.04*** ≤ 15 years old 320 (86.7) 42 (11.38) 45 (12.20) 153 (41.46) > 15 years old 768 (92.4) 79 (9.51) 92 (11.07) 514 (61.85) sex (χ2) 14.20*** 0.00 0.24 11.52*** female 675 (93.2) 73 (10.1) 80 (11.1) 431 (59.5) male 413 (86.7) 48 (10.1) 57 (12.00) 236 (49.6) current educational level (χ2) 17.51*** 8.62* 5.06 62.18*** junior high school 343 (85.8) 49 (12.3) 52 (13.0) 160 (40.0) senior high school 370 (92.5) 46 (11.5) 51 (12.8) 266 (66.5) vocational high school 375 (93.8) 26 (6.5) 34 (8.5) 241 (60.3) types of school (χ2) 20.84*** 2.07 10.09*** 0.76 public/state school 567 (94.50) 53 (8.83) 51 (8.50) 326 (54.33) private school 521 (86.83) 68 (11.33) 86 (14.33) 341 (56.83) *p<0.5; **p<0.01; ***p<0.001 global health management journal, 2019, vol. 3, no. 1 34 pradnyani et al. global health management journal. 2019; 3(1):31-39 table 3. adolescent students’ attitude toward sexual behavior in denpasar, bali (n=1,200) sociodemographic characteristics adolescents’ approval of premarital sexual behaviors kissing, hugging, touching n (%) petting and oral sex n (%) sexual intercourse n (%) total 587 (48.9) 224 (18.7) 166 (13.8) age (χ2) 48.25*** 20.04*** 5.59* ≤ 15 years old 125 (33.9) 41 (11.1) 38 (10.3) > 15 years old 462 (55.6) 183 (22.0) 128 (15.4) sex (χ2) 2.41 38.83*** 26.56*** female 341 (47.1) 94 (13.0) 70 (9.7) male 246 (51.7) 130 (27.3) 96 (20.2) current educational level (χ2) 61.64*** 25.37*** 13.82** junior high school 140 (35.0) 45 (11.3) 42 (10.5) senior high school 251 (62.8) 100 (25.0) 76 (19.0) vocational high school 196 (49.0) 79 (19.8) 48 (12.0) types of school (χ2) 0.003 4.30* 13.54*** public/state school 294 (49.0) 98 (16.3) 61 (10.2) private school 293 (48.8) 126 (21.0) 105 (17.5) *p<0.5; **p<0.01; ***p<0.001 figure 1. sexual behaviors among adolescent students in denpasar, bali out of 1,200 students in this study, 880 respondents (73.3%) have been reported for have ever been in dating with someone. figure 1 describes the sexual activities among the adolescents dating. it shows that among adolescent dating in this study, hand in hand, hugging, and kissing on the check was the common behaviour among couples. meanwhile, few students reported for an experience of petting (14.3%), oral sex (9.8%), vaginal sex (6.5%), and anal sex (2.6%). figure 2 presents the proportion differences of sexual behaviors by sociodemographic characteristics. it showed that sexual behaviours were more common among adolescents aged >15 years old, males, senior high school students, and private-schooling adolescents. based on figure 3, condom use among adolescent students who were sexually active in denpasar was low. only one out of five sexually active students reported for “always” using condom for vaginal sex (19.3%) from 57 students, and anal sex (21.7%) from 23 students. in addition, shown at figure 4, it informs age at first sex among adolescent students who have performed oral, vaginal or anal sex. out of 98 students, 1% reported for sexual debut at 11 years old whilst the majority had their first sex at age 15 years (43.9%) and 16 years (34.7%). 2.6% 6.5% 9.8% 14.3% 17.6% 20.9% 35.6% 58.3% 68.0% 88.1% adolescents dating hand in hand hugging kissing on the cheeck kissing on the mouth touching on body touching on genital petting oral sex vaginal sex anal sex 35 global health management journal, 2019, vol. 3, no. 1 pradnyani et al. global health management journal. 2019; 3(1):31-39 discussion this study found that srh knowledge varied by domain. adolescents in this study were more knowledgeable related to puberty rather than other aspects. puberty is an inevitable process and first sign of their adolescence life. it is understandable then, they are more likely to look for or receive more information related puberty at first-stage of the adolescent period before other srh information is equipped [12]. adolescents can obtain puberty-related information from their parents and they might be taught about puberty at schools. it is supported by findings from a previous study that 75.2% students had sufficient knowledge level about puberty, while 84.2% stated that they received first information from parents whereas teachers contributed to 18.1% as a source of information [13]. in indonesia, puberty information is formally delivered by teachers at school in some sections of biology subject. however, it does not rule out the possibility that students also can receive information from various media and also the results from information sharing with peers that contributed to their knowledge on puberty. based on sociodemographic characteristics, older students, females, senior high school students, public-schooling students had higher knowledge of puberty. older age of students is directly proportional to a higher educational level that might contribute to the exposure of puberty information. meanwhile, due to the earlier onset of puberty symptoms among females, they want to be informed on srh matters for menstruation preparedness [14]. in addition, the different internal culture and social environment between public and private schools might influence the adolescents’ knowledge. the low level of knowledge’s aspect on reproductive process reflects a lack of understanding of adolescents related to the process of how pregnancy occurs. it also indicates that many adolescents might assume that having sexual intercourse once will not cause pregnancy. as a finding among their counterparts that 50.9% girls believed that they would not get pregnant in her first sexual encounter [15]. similarly, information about reproductive risk/consequences was poorly known by adolescents in denpasar. it also denotes that adolescents were less knowledgeable related to unintended pregnancy and abortion-related information. figure 2. sexual behaviors by sociodemographic characteristics among adolescent students in denpasar, bali global health management journal, 2019, vol. 3, no. 1 36 pradnyani et al. global health management journal. 2019; 3(1):31-39 a previous study also confirmed that 46% of respondents were aware of the fact that the natural herbs and 45.5% considered herbs as a better option for abortion [16]. even though school curricula provides several subjects where students can rely on information related to srh, such as biology, religion, sport science, and budi pekerti (character science), in fact, those subjects commonly only cover general information of srh and its topic in each subject is limited in some sections. meanwhile, moderate-level of hiv&aids and sti knowledge among students might be due to hiv&aids information has been delivered by teachers at schools or through students’ participation in extracurricular activities, such as kelompok siswa peduli aids dan narkoba/kspan (students’ group with awareness of aids and drugs) and pusat informasi dan konseling remaja/pik-r (adolescent center for information and counselling) [17]. both of kspan and pik-r are organized by appointed teachers in schools where the materials or activities not only can be led by teachers, but also health personnel from public health centers, regional health office, or ngos who are concerns on this issue can take part as speakers. however, during the implementation, teachers commonly collaborate with two main organizations as the initiators for those extracurricular activities, such as bali aids commission for kspan and national family planning board of bali for pik-r. students who have interest in activities offered by those extracurricular can participate. moreover, the core activities are intended to develop peer educators who help non-members of those activities to receive appropriate information. it is important to note, however, both extracurricular activities place a lot attention on hiv&aids information, but limited information related to other types of stis is provided. therefore, adolescents in denpasar might not be exposed with sufficient sti-related information. awang’s study in 2014 confirmed that male adolescents did not know other types of stis, except for hiv&aids and syphilis [18]. in another setting, a survey conducted among school-going adolescents found that 60.2% had good knowledge on hiv&aids whereas 34.1% and 5.7% students were in moderate and poor knowledgelevel categories, respectively [19]. moreover, this study found that females, students aged > 15 years old, senior or vocational high school students were more knowledgeable on stis and hiv&aids. similar to previous explanation that older students or with higher educational level tend to receive more information, supported by findings from a previous study that older adolescents aged 15–19 years were more likely to know about aids than their younger counterparts [20]. regarding the attitude, few students argued that kissing and hugging; petting and oral sex; and sexual intercourse can be performed before getting married. it may be due to the acculturation process between foreigners’ and natives’ cultures occurred in bali that play important roles to the adolescents’ acceptance of premarital sex [8]. moreover, during the puberty period, the level of curiosity and sexual intention reach a peak, followed by any misconception related to reproductive process and consequences, in which, turns to permissive attitude towards sexual behavior. with these kinds of responses, it is logical to assume that students in denpasar might potentially perform premarital sex, as well as, risky sexual behavior. a study in nepal conducted by bhatta found that high proportion of students (32.4%) who agreed for premarital sex was in line with high prevalence of premarital sex (25%) [21]. moreover, older, male, or senior high school students, as well as, those in private schools were in a higher acceptance of premarital sexual behaviors. focusing on sex, this study is similar to a previous study which found that males were more likely to have a permissive attitude toward sex. it may be due to gender figure 3. condom use among sexually active adolescent students in denpasar, bali 37 global health management journal, 2019, vol. 3, no. 1 pradnyani et al. global health management journal. 2019; 3(1):31-39 norms in the indonesian context where females are expected to maintain their virginity, but it is not strongly applied for males [22]. this study also highlighted the sexual activities among adolescents who have been dating with someone with a few of them reported for having sexual intercourse. similar to a previous study in denpasar which found that 4.26% of the school adolescents have performed premarital sexual intercourse [11]. moreover, characteristics of adolescents who had higher proportion of engagement in premarital sexual behavior were in line with those who more approved premarital sex, indicating key prioritize for intervention. in addition, risky sexual behaviour e.g., low condom use among adolescent students was also well-documented in denpasar, bali. surprisingly, only one out of five sexually-active students reported for "always" using condom for vaginal sex (19%), and anal sex (22%). these percentages are slightly lower than the national figure of condom use prevalence which was about 25% among male adolescents aged 15-24 years old [3]. with low consistency for protected sex, it indicates that adolescent students in denpasar carry high risk of being infected with stis, hiv&aids, and unintended pregnancy. low condom use might be related to the socio-cultural context of indonesia where contraceptive tools are not acceptable for unmarried people. as a consequence, the restricted access to both srh information and services especially condoms transforms to barriers as underlying reasons for unprotected sex. in addition, condom use in fact, seems to be highly linked with trust and more intimate relationship and hence, its negotiation can become extremely difficult [23, 24]. the findings of this study suggested to clarify any misconceptions related to srh among adolescent students in denpasar, bali such as false beliefs in reproductive process and consequences. even though schools seem supporting the delivery of srh information through the presence of some subjects and extracurricular activities, the coverage of given information was not satisfactory. for school subjects formally taught by teachers, the lessons related srh are limited in terms of duration and frequency and those depend on teachers’ willingness to what extent the srh-related information should be provided. in most situations, srh information provided by teachers mostly covers physical-anatomy of reproductive organs and it counts less than 10 percent of total meetings [25]. meanwhile, for extracurricular activities, kspan focus on providing materials related to hiv&aids, drugs, and stis whereas information related to age maturation of marriage, drugs, hiv&aids, and sexuality is strongly attached in pik-r’s activities. both of those extracurricular activities are commonly arranged once a week depending on schools’ situation and policy. obviously, we note some weaknesses, such as low coverage of other aspects of information such as reproductive process and consequences/risk and also the duration for providing srh information is quite lacking. more importantly, necessary skills and efficacy to make informed decisions are not prioritized in both extracurricular activities. providing comprehensive sexuality education (cse) is worth considering among adolescents to equip them with reproductive and sexual health and rights, gender equality, and knowledge and skills for hiv prevention in order to be able in making informed decisions [26]. nowadays, the kisara ippa of bali chapter as one of the pioneers of srh program among adolescents in denpasar figure 4. age at sexual debut among sexually active adolescent students in denpasar, bali 1.0% 0.0% 4.1% 6.1% 43.9% 34.7% 8.2% 2.0% 11 12 13 14 15 16 17 18 age (years old) global health management journal, 2019, vol. 3, no. 1 38 pradnyani et al. global health management journal. 2019; 3(1):31-39 has started implementing cse in some schools in denpasar in collaboration with related stakeholders such as education regional office and health regional office of denpasar city. to date, even though there is no formal evaluation of this implementation, cse in many settings is promising to delay sexual debut and prevent risky sexual behavior among adolescents [27, 28]. in denpasar, cse implementation is integrated to the school curricula. appointed teachers in some subjects have been trained about the use of cse module developed by rutgers wpf prior to providing cse materials routinely as part of the discourse in some subjects (natural science/biology, religion, sports science, and guidance and counseling). with this implemented program, it obviously increases the coverage of srh information, as well as, the frequency and duration of information delivery. furthermore, cse implementation is not limited to the school settings, but it is supported by public health centers which align with their existing adolescent health program. there is a collaboration between teachers and health providers to refer adolescents with srh problems to seek for help in public health centers and also to create private space for adolescents in discussing srh matters. therefore, expanding the number of schools that adopt cse is substantial to increase the access to srh information and services among adolescents in denpasar. more importantly, according to findings of this study, cse implementation should target adolescent students with low srh knowledge, higher acceptance of premarital sexual behaviors, and have engaged in sexual behaviors. younger adolescents or junior high school students in particular, should be equipped with sufficient knowledge and appropriate skills as soon as possible in order to be able in making informed decisions and prevent themselves from adverse srh outcomes. moreover, compared to public schools, students in private schools should be prioritized for intervention. there are several limitations noted for this study. first, the findings relied on descriptive statistics so that information related factors associated with srh knowledge, attitude, and behavior were not deeply discussed. second, the selfreported of srh behavior might be prone to bias due to social desirability. however, that potential bias can be reduced by the anonymous and self-administered questionnaires. moreover, other variables were not collected in this study, such as sources of srh information since previous study found that peers at school and mass media were perceived to the main sources among adolescents [29]. in addition, the sociocultural and religious factors are not identified in this study that can help explain the nature of adolescents in balinese context. therefore, future studies need to take the limitations of this study into consideration. conclusions school-going adolescents in denpasar, bali had low level of knowledge on some srh aspects, particularly related to reproductive process and risk. in addition, some of the adolescents had the permissive attitude for premarital sex, as well as, a few of them reported for having sexual debut and unprotected sex. hence, providing cse is the promising solution so far to enhance their knowledge and skills in making informed decisions, including preventing risky sexual behavior. cse implementation should target adolescents of which had lower srh knowledge, permissive attitude of sexual behavior and had premarital sex experiences. conflict of interests authors declared that there is no conflict of interest. acknowledgments authors thank to kisara of ippa bali chapter who provided funding support for this study. in addition, authors gratefully acknowledge national unity and politics board of denpasar, education regional office of denpasar and also head master in all selected schools who gave permission for this study. references 1. statistics indonesia (badan pusat statistik-bps), national population and family planning board (bkkbn), kementerian kesehatan (kemenkes-moh), icf international. indonesia demographic and health survey 2012. jakarta, indonesia: bps, bkkbn, kemenkes, icf international; 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27(2): 2049–66. doi: 10.1177/1010539513475655. 28. kirby d, ecker n. international technical guidance on sexuality education: an evidence-informed approach for schools, teachers and health educators. paris, france: united nations educational, scientific and cultural organization; 2009. 29. muhwezi ww, anne rk, cecily b, herbert m, doris k, sheri b, knut ik. perceptions and experiences of adolescents, parents and school administrators regarding adolescent-parent communication on sexual and reproductive health issues in urban and rural uganda. reproductive health.2015;12(110):1-16. combination of polyethylene terephthalate nesting and prone position at the standard box care to the vital signs and length of stay on the low birth weight babies indonesian scholars’ alliance ghmj (global health management journal) 2020, vol. 4, no. 1 open access original research meli deviana1* , noor pramono2 , ari suwondo2 combination of polyethylene terephthalate nesting and prone position at the standard box care to the vital signs and length of stay on the low birth weight babies 1postgraduate applied science program in midwifery, poltekkes kemenkes semarang, semarang, indonesia. 2poltekkes kemenkes semarang, semarang, indonesia. *corresponding author’s email: meli.deviana@gmail.com abstract background: the use of nes ng and prone posi on condi oned low birth weight (lbw) babies as the mother’s womb that helped in the development of physiological func ons and achieve physiological func on stability. this study aims to test the effec veness of designed nes ng with polyethylene terephthalate materials and the posi on of prone with standard care using a box of baby warmers for the length of stay which is observed from the achievement of the stability of vital signs on lbw. methods: this is a quasi-experimental design study with non-equivalent control group design. the study popula on was all lbw treated in the perinatal room with a sample of 36 lbw selected consecu vely from newborns at rsud raa soewondo pa and rsud dr. r. soetrasno rembang. results: the combina on of nes ng polyethylene group with posi on prone achieved faster vital signs stability and shorter dura on of treatment compared to the control group with p = 0.001 for temperature, respira on and oxygen satura on. conclusion: the combina on of polyethylene terephthalate nes ng and prone posi on is effec ve to reduce the dura on of treatment and achieving the stability of vital signs of low birth weight infants. this interven on can be used as lbw care during hospital and home care. keywords: nes ng, posi on prone, polyethylene tread, length of stay, baby vital signs received: 25 august 2018 reviewed: 10 september 2018 revised: 28 june 2020 accepted: 28 june 2020 doi: 10.35898/ghmj-41269 © yayasan aliansi cendekiawan indonesia thailand (indonesian scholars’ alliance). this is an open-access following crea ve commons license deed a ribu on-noncommercial-sharealike 4.0 interna onal (cc by-nc-sa 4.0) 1. introduc on newborn babies experience very rapid environmental changes, from intrauterine to extrauterine maternal environment. a significant difference between intrauterine and extrauterine conditions requires the baby to adapt, which becomes more difficult in high-risk infants such as lbw (erb and berman, 2009; hockenberry and wilson, 2018). problems that often arise in the process of adaptation occur in the respiratory, neurology, cardiovascular, hematological, gastrointestinal, kidney and thermoregulation system as lbw infants are very susceptible to hypothermia due to the thin fat reserves under the skin and the immaturity of the heat-regulating center in the brain (trihono et al., 2013). therefore, lbw infants requires a longer time for hospital care than newborns with normal weight. the process of the long duration of treatment can increase morbidity and require higher maintenance costs (khashu et al., 2009; shapiro-mendoza et al., 2006; tomashek et al., 2006; artana, 2016). lbw infants can adapt as well as term newborns if given the environment and needs and treatments that resemble the condition in the womb (trihono et al., 2013; world health organization and 21 mailto:meli.deviana@gmail.com https://dx.doi.org/10.35898/ghmj-41269 ghmj (global health management journal) 2020, vol. 4, no. 1 deviana m et. al. others, 2004). various programs in nidcap are carried out to support the process and development of premature and lbw infants, including nesting and developmental positioning (efendi and rustina, 2013). nesting is the use of tools shaped like conditions in the mother’s womb that aim to maintain the baby’s flexy position. although various forms of nesting have been applied in hospitals, improper design can interfere the baby’s comfort during sleeping and may affects the respiratory stability, pulse and infant oxygen saturation (irva et al., 2016). in addition to nesting, the position of the baby has an effect on the stability of the physiological and neurological functions of the baby (kahraman et al., 2018). although the position of supine creates more pain and distress score than other positions, however, any potential adverse effects can be corrected or prevented through the use of support positioning. prone positioning provides effective support for the development of neuromuscular and improve hand to mouth activities and comforts the premature or lbw infants (comaru and miura, 2009; eichenwald and stark, 2008). this study aims to test the effectiveness of designed nesting using polyethylene terephthalate material and prone position with standard care using a box of baby warmer. the polyethylene terephthalate material was chosen considering its ability as thermal conductor in preserving temperature for the lbw newborns. the nesting was designed to maintain the newborns in her/his flexy position which beneficial in avoiding thermal lost and to provide the comfort in order to establish a stable respiratory system. the prone position maintains the newborn’s head in a lower position than her/his feet to regulate better oxygen saturation to the brain. the vital signs are observed to determine the duration of hospitalization for lbw infants. 2. method this was a quasi-experimental with nonequivalent control group design. the treatment group received a combination of nesting polyethylene terephthalate and prone position whereas the control group were given standard care for lbw infants with baby warmers. a total of 36 lbw newborns treated in perinatal room of raa soewondo pati hospital and dr. r. soetrasno rembang who were selected consecutively and divided into two groups equally. the study was conducted between may 8, 2018 to june 31, 2018. pre-test was conducted by measuring the temperature, pulse, respiration rate and oxygen saturation during one minute respiratory. intervention was given for 20 minutes for four days during hospitalization. post-test was conducted to measure the similar vital signs of the newborns. axilla body temperature was measured using calibrated digital thermometer and expressed in celsius, ranged from 36.5 to 37.5℃ to be defined as normal temperature. calibrated oximetry was used to measure pulse and oxygen saturation; defining 120-160 pulse, 30-60 respiratory and 95-100% oxygen saturation per minute as normal. as respiration rate and oxygen saturation were not normally distributed and all variables in each group were homogeneous, wallis test was employed to test the differences of observed variables between intervention and control group while wilcoxon test was practices to compare the difference outcomes in each group. 3. result statistical test results showed that there was a significant difference of temperature before and after given a combination of nesting polyethylene terephthalate position prone at lbw on the first day of treatment with a significance value of 0.001 and an average increase of 0.2ºc (table 1). there was no significant difference between the pulses before and after given a nesting combination of polyethylene terephthalate prone position in lbw with a value of p = 0.183 and a decrease in the mean pulse of 2 times / minute. the results showed the average pulse frequency experienced a slight decrease. however, the results of the statistical analysis show that there is no significant difference between 22 deviana m et. al. ghmj (global health management journal) 2020, vol. 4, no. 1 the decrease in the mean pulse frequency. polyethylene terephthalate material and prone position provided a significance difference on the vital signs of the newborns, shown by a p-value of 0.001 and a decrease in the average respiration 3 times/minute. it also affected oxygen saturation of lbw infants (p= 0.001), evidenced by an average increase in oxygen saturation by 0.2%. table 1. body temperature, pulse, respira on and oxygen satura on of lbw on days i, ii, iii, iv day temperature **p-valuecombina on 1 control mean±sd min-max *p value mean± sd min-max *p value day i 36,6± 0,09 36,5-36,8 0,000 36,6± 0,13 36,5-37,0 0,003 0,001 day ii 36,8± 0,08 36,7-37,0 0,968 36,6± 0,14 36,537,0 0,014 0,119 day iii 36,8± 0,00 36,8-36,8 0,102 36,7± 0,19 36,637,1 0,107 0,642 day iv 36,9± 36,936,9 36,7± 0,00 36,736,7 0,317 0,632 pulse day i 145± 4,50 140-156 0,355 141± 2,15 140-148 0,270 0,242 day ii 144± 2,09 140-148 0,485 142± 2,59 140148 0,591 0,089 day iii 142± 1,00 142-144 0,141 143± 2,27 140146 0,564 0,269 day iv 140± 140140 147± 1,41 146148 0,180 0,325 respira on day i 47± 3,85 4056 0,001 42± 2,74 4048 0,856 0,001 day ii 43± 2,10 4048 0,002 42± 2,33 4048 0,084 0,136 day iii 43± 1,91 4246 0,414 43± 2,27 4048 0,623 0,433 day iv 40± 4040 43± 4,24 4046 1,000 0,325 oxygen satura on day i 96± 0,85 9598 0,000 96± 1,61 36,5-37,0 0,004 0,001 day ii 99± 0,85 97-100 0,001 98± 1,36 36,537,0 0,005 0,001 day iii 100± 0,00 100-100 0,083 98± 1,36 36,637,1 0,008 0,085 day iv 100± 100100 * wilcoxon test **test kruskal wallis among the newborns in the control group, the temperature changes before and after being given the heating box method showed that there was a significant difference between the temperature before and after being given the heating box at lbw with a significance value of 0.001 with an average increase in temperature of 0.1ºc . nevertheless, there was no difference in the pulse, respiration and oxygen saturation before and after the newborns were placed in the baby warmer box. the results confirmed that the combination group was more effective in achieving temperature stability, respiration and oxygen saturation than the control group on the first day. 4. discussion the combination of nesting with polyethylene terephthalate material and the position of prone affect the vital signs such as temperature, pulse, respiration and oxygen saturation in lbw infants. as lbw has an unstable body temperature and tends to experience hypothermia (temperature <36.5°c), nesting with polyethylene terephthalate materia as a good thermal conductor can maintain temperature stability. the prone position also reduced the probability of heat loss because it lower the body’s metabolism and reduce the amount of heat loss. in the prone position, the baby faced the blanket or 23 ghmj (global health management journal) 2020, vol. 4, no. 1 deviana m et. al. bed to prevent excessive air exposure and allow a decrease in heat loss through the radiation process. the results correspond to previous studies with 3 lbw subjects given nesting, infants experienced an average increase in body temperature on the third day after being given interventions with a temperature of 36.7°c (hegner, 2003; bayuningsih, 2011). the process of changing the pulse rate is influenced by changes in heart rate to stimuli caused by the sympathetic nervous system and parasympathetic nerves. sympathetic stimulation can increase the speed of the heart rate such as when the body is awake or anxious, while parasympathetic stimulation can reduce the speed of the pulse as in a calm sleep condition (als, 1986; aylott, 2006). the baby’s pulse rate is different when sleeping calmly and awake. the baby’s pulse tends to decrease when in a calm sleep state. in this study the pulse rate decreased to 142 times/minute, wherein this phase the baby was in a state of calm sleep. during this calm sleep phase there is a decrease in peripheral vascular tone and arterial blood pressure, decreased pulse frequency, dilatation of skin blood vessels, sometimes increased gastrointestinal activity, and muscles are experiencing a complete resting state (guyton and hall, 1990). while this study obtained a lower pulse frequency after being given an intervention because at the time of intervention the respondent was in a slow wave sleep condition, the results are similar to research conducted on premature infants in comparing pulse frequency with nesting and prone position, which showed that there was no significant difference between pulse frequency and nesting and prone position, with p values of 0.087 and 0.236 (kahraman et al., 2018). the mean respiration in this study decreased 4 times per minute (normal respiration in infants is 30-60 times per minute) as many babies with lbw need supplemental oxygen and ventilatory assistance. however, the position of prone in the baby can increase tidal lung volume, lung development and breathing become more regular (maynard et al., 2000). nesting that gives a sense of comfort provides a stimulus to the hypothalamus which can release corticotropin-releasing factor (crf) and also endorphins that can provide a sense of calm in the baby which causes a change in respiratory rate (gouna et al., 2013). when the lbw infants are in a comfortable condition and relax, the breathing pattern will become regular and will experience a decrease when in the calm phase of sleep (hockenberry and wilson, 2018; zen, 2018). the findings of the study revealed that there were significant differences in oxygen saturation values between nesting positions and prone positions with an average increase of 96% oxygen saturation. this results similar to previous studies on the state of organ immaturity in lbw infants that may cause the newborns to have an oxygen saturation level below 90% (bayuningsih, 2011). the results of other studies also explained that there was a significant difference between oxygen saturation and the prone position (maynard et al., 2000). the use of baby box warmers affected the duration of hospitalization that was measured by the changes in the newborns’ temperature, pulse, respiration and oxygen saturation. the result corresponds with previous study that found there was a linear relationship between temperature and power (setyaningsih and wahyunggoro, 2015). baby boxes with lights as heating are one of the essential components that must be present to provide warmth to the baby. in infants with less birth weight and premature babies, an increase in body temperature will increase metabolism in the body and will affect the need for increased oxygen consumption (pantiwati, 2010). the results of the study explained that the use of baby boxes with heating lamps significantly affected the baby’s body temperature but did not affect respiration and frequency (ng et al., 2017; pfohl and uphold, 1991). the difference in the effectiveness of the combination of nesting polyethylene terephthalate and position-prone affected the duration hospitalization, observed from the achievement of temperature, pulse, respiration and oxygen saturation in lbw. previous research conducted on the effect of use nesting on lbw showed that there was a significant decrease in the duration of treatment with an average duration of treatment for 5 days (hendricks-muñoz et al., 2002). other study suggest that the position of prone with nesting facilitation greatly affects the improvement of oxygen saturation, lung development, chest wall development and decreased incidence of apnea in premature infants (picheansathian et al., 2009). different studies related to the prone position in lbw and preterm in24 deviana m et. al. ghmj (global health management journal) 2020, vol. 4, no. 1 fants with oxygen saturation showed a decrease in pulse frequency and respiratory frequency (zen, 2018). the results of the study on the position of the baby explained that the position of prone decreases the respiratory frequency and increases oxygen saturation in infants and produces better analgesic effects than position supine. the results of research on nesting use in lbw by observing impromptu movements in infants and evaluating posture and movement in infants who do not use nesting whereas infants with nesting experience a lower incidence of impending movements compared to infants who do not use nesting (ferrari et al., 2007). conclusion the combination of nesting polyethylene terephthalate and position is prone more effectively applied to achieve temperature stability, respiration and oxygen saturation at lbw and reduce the duration of treatment. conflict of interest there is no conflict of interest. nothing to disclosure. references als, h. 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(2013). pelayanan kesehatan anak terpadu. departemen ilmu kesehatan anak fkui-rscm. world health organization and others (2004). low birthweight: country, regional and global estimates. zen, d. (2018). pengaruh nesting terhadap perubahan fisiologis dan perilaku bayi prematur di perinatologi rumah sakit umum daerah tasikmalaya. jurnal kesehatan bakti tunas husada: jurnal ilmu-ilmu keperawatan, analis kesehatan dan farmasi, 17(2):357–374. cite this article as: deviana m, pramono n, suwondo a. combination of polyethylene terephthalate nesting and prone position at the standard box care to the vital signs and length of stay on the low birth weight babies. ghmj (global health management journal). 2020; 4(1):21-26. doi:10.35898/ghmj-41269 26 https://dx.doi.org/10.1053/j.semperi.2006.02.002 https://dx.doi.org/10.1053/j.semperi.2006.02.003 introduction method result discussion   cite this article as  bernolian n, sjaaf ac. the evaluation of early initiation breastfeeding implementation  in dr. mohammad hoesin hospital of palembang, indonesia: complaints and barriers.  global health management journal. 2017; 1(2): 53‐60.    global health management journal  www.publications.inschool.id  published by  original research article issn 2580-9296 (online) the evaluation of early initiation breastfeeding implementation in dr. mohammad hoesin hospital of palembang, indonesia: complaints and barriers nuswil bernolian 1,*, amal c. sjaaf 2 1 obstetrics and gynecology department of dr. mohammad. hoesin hospital palembang 2 faculty of public health, universitas indonesia *corresponding author. email: nuswilbernoli@gmail.com article info abstract article history: submitted 17 april 2017 accepted 28 october 2017 background: early initiation of breastfeeding (eib) is a worldwide health demand of both mother and child. eib programme implementation is the duty and responsibility of all health care practitioners, ranging from executive staff and manager, which haven’t runs well in dr. mohammad hoesin hospital. aims: to identify opportunities and challenges of hospital management in running the eib programme in obstetric department of dr. mohammad hoesin hospital. methods: in this cross sectional study, all of birth mothers and health professionals were included. samples were selected by purposive sampling. data was obtained from the questionnaires which have been tested for validity and reliability. results: our study found disintegration of eib implementation between the managerial and implementer staff. most of eib implementers (29 doctors and 14 midwives) stated that eib was already done well but complained of low level of maternal eib knowledge and lack of eib practice support from hospital manager. while managerial staff (n = 12) blaming the eib implementers worked attitude for this issue. most patients (51,3%) performing eib, while majority of no eib group had abdominal delivery (p = 0,003) and complained that no eib policy in operating room. conclusion: at dr. mohammad hoesin hospital, eib implementation faces challenges in managing the hospital, such no eib policy in operating room, majority of patients are obstetric referral case with complication and unfit for eib, managerial staff knowledge of eib differ greatly, low socialization of eib regulations and other elements of implementation, patient’s level of knowledge, disintegration between the manager and executive staff causing ambiguity in the implementation of the eib, and the lack of supervision of eib implementation in the field. keywords: early initiation breastfeeding implementation evaluation hospital management complaints barrier this article is an extension of a selected paper “the evaluation of early initiation breastfeeding practice in dr. mohammad hoesin hospital palembang” published in proceedings of the international conference on applied science and health (no. 1, february 2017). © 2017 publications of yayasan aliansi cendekiawan indonesia thailand this is an open access following creative commons license deed – attribution-noncommercial-sharealike 4.0 international (cc by-nc-sa 4.0) introduction early initiation of breastfeeding (eib) is the natural process that allowed baby to feed itself, at least in the 1st hour of the life [1]. babies are given the opportunity to obtain colostrum along eib process [2]. colostrum is the white blood cells and antibody-containing immunoglobulin a (iga), which very important for resistance to infection, intestinal growth, infant survival, as well as create a protective layer for baby's immature intestines [1,3]. early initiation of breastfeeding is crucial in preventing newborn deaths which greatly contribute to mdg’s objective in lowering neonatal mortality rate [4]. however, in fact, the national rate global health management journal, 2017, vol. 1, no. 2  54      of eib is still low, only 34.5% [5]. to increase the value of such coverage, there should be an effort to take advantage of opportunities and overcome the challenges of eib implementation [6]. in dr. mohammad hoesin hospital, eib programme has become a procedure that must be implemented for hospital management. although there is a standard procedure, but its implementation was very poor. eib was given just a few minutes after the mother gave birth spontaneously. the newborn is immediately taken from her mother for body weight and length measurement. eib also never happened in the setting of caesarean section (cs) mother because the baby was considered a high-risk infant and should have neonatal management immediately. this eib implementation gap has lasted for years without any evaluation and refinement, which encourage the writer to evaluate its problems from the dimension of patients, executive staff (doctor, midwife, and nurse), and manager’s points of view. methods study design was cross sectional, consists of three groups of sample (patients, executive staff, and manager) which minimal sample size of the first two groups was calculated with lemeshow formula proportioned by each population size (n = 37, n = 43 respectively), while total sampling was done in manager group whom govern the eib policy (n = 12). all subjects were selected by purposive sampling. data was taken primary by a selfstructured contingency questionnaire, rated valid and reliable by cronbach test, to be filled out by the subjects, and secondary from medical record for tracking the pregnancy and labor history in patient group. univariate analysis was performed to calculate the frequency distribution and the proportion of each sample group characteristics. bivariate data was analyzed to determine the relationship between reinforcing factors (knowledge, attitude, behaviour, barrier, and support) and eib implementation, chi-square or fisher exact test for category variable and mannwhitney u test for continues variable. result characteristics of patients the characteristics of patients in both of groups (eib vs non eib) were similar. in both of groups, the subject majority aged 21-35 years (age of reproduction), live in the urban city, high educated, and multiparous. they both also showed high knowledge and good attitude characteristic, received good support and less eib barrier, altough no significant relationship was found between these demographic data and reinforcing factors with eib implementation (table 1). patients’ complaints to eib mode of delivery was one significant risk factor of poor eib implementation, where cs women mostly could not implement the eib (p = 0.003) (table 1). half of respondents (50%) from the group eib (-) complained that eib is unable to performed in operating room and delivery room is less feasible, others stated education about eib which was given by doctor or midwive were remain unclear, and complained of low policy socialization (figure 1). figure 1. patient’s complaint to eib* * note: a respondent can give more than one complaint 55                                 global health management journal, 2017, vol. 1, no. 2        table 1. demographic characteristic and reinforcing factors of patient group. variables eib (+) (n = 19) eib (-) (n = 18) p value n % n % age <20 year 20-35 year >35 year 1 13 5 5.3 68.4 26.3 1 12 5 5,6 66,7 27,8 0,994€ living urban area rural area 13 6 68.4 31.6 12 6 66,7 33,3 0,909§ education low educated high educated 7 12 36.8 63.2 7 11 38,9 61,1 0,802§ occupation housewife not housewife 15 4 78.9 21.1 16 2 88,9 11,1 0,660§ parity nulliparous multiparous grandemultiparous 7 11 1 36.8 57.9 5.3 4 14 0 22,2 77,8 0 0,341€ mode of delivery vaginal abdominal 18 1 94.7 5.3 9 9 50 50 0,003§ rr = 0,056 (0,006 – 0,509) knowledge high moderate low 9 4 6 47.4 21.1 31.6 8 8 2 44,4 44,4 11,1 0,186€ mean + sd score 10.63 + 3.68 12 + 2.249 0.041* attitude good bad 15 4 78.9 21.1 15 3 83,3 16,7 1,000§ mean + sd score 11.68 + 2.24 11.7222 + 2.94669 0.814* behaviour supporting eib not supporting eib 18 1 94.7 5.3 9 9 50 50 0,003§ rr = 0,056 (0,006 – 0,509) mean + sd score 3.73 + 0.99 2.0556 + 1.69679 0.002* support good bad 19 0 100 0 18 0 100 0 -£ mean + sd score 8.47 + 0.77 8.6667 + 0.59409 0.115* policy good bad 4 15 21.1 78.9 4 14 22,2 77,8 1,000§ mean + sd score 2.63 + 1.30 2 + 1.97037 0.103* barrier low high 18 1 94.7 5.3 18 0 100 0 -£ mean + sd score 9.79 + 2.02 9.7222 + 1.60167 0.330* § fisher exact test, 95% ci € chi square test, 95% ci * mann-whitney u test, 95% ci £ p-value can not be calculated global health management journal, 2017, vol. 1, no. 2  56      characteristics of hospital staff doctors in executive staff group have more advance age, higher education and knowledge about eib compared with midwives in the same group. high majority of doctors and midwives showing a good attitude and practice towards eib implementation, but deplore the policy which didn’t support eib implementation (table 2). while no significant differences were found in eib reinforcing factors (knowledge, attitude, practice, policy and barriers) both in doctors group and in midwives group. table 2. demographic characteristic and and reinforcing factors of executive staff group. variable midwive (n = 14) doctor (n = 29) p age 28.36+2.4 30.55+2.94 0.020* education less than diploma diploma bachelore master 0 (0%) 14 (100%) 0 (0%) 0 (0%) 0 (0%) 0 (0%) 29 (100%) 0 (0%) <0.001€ eib implementation running well bad 12 (85.7%) 2 (14.3%) 19 (65.5%) 10 (34.5%) 0.279§ knowledge about eib good moderate bad 9 (64.3%) 5 (35.7%) 0 (0%) 28 (96.6%) 1 (3.4%) 0 (0%) 0.01€ rr = 0.64 (0.007-0.625) mean + sd 12.57 + 1.55 13.41+ 1.38 0.79* eib attitude pro contra 14 (100%) 0 (0%) 29 (100%) 0 (0%) -£ mean + sd 6 + 0 5.83+ 0.47 0.178* eib practice good bad 14 (100%) 0 (0%) 27 (93.1%) 2 (6.9%) 1.000§ mean + sd 4 + 0 3.86+ 0.52 0.326* eib policy supported not supported 5 (35.7%) 9 (64.3%) 13 (44.8%) 16 (55.2%) 0.409§ mean + sd 3.64 + 1.39 3.27+ 1.58 0.463* eib barrier high barrier low barrier 6 (42.9%) 8 (57.1%) 12 (41.4%) 17 (58.6%) 1.000§ mean + sd 8.14+ 1.61 8.07+ 1.73 0.894* § fisher exact test, 95% ci € chi square test, 95% ci * mann-whitney u test, 95% ci £ p-value can not be calculated hospital staffs’ complaints to eib study result in executive staff found that eib has generally been implemented properly. but eib problems emerge from several factors: less recognition and support from hospital toward eib, unavailability of eib in cs patient, and low maternal knowledge are major complaints of doctors regarding eib implementation; the patient's condition, unavailability of eib in cs patient, low maternal knowledge, and less of socialization are midwife complaints regarding eib implementation as shown in figure 2. respondents suggested to improve hospital support through the socialization of policy; improving patient education not only given to maternity patients, but also in pregnant patients; and implement eib in operating room. 57                                 global health management journal, 2017, vol. 1, no. 2        figure 2. the doctor and midwive’s complaints to eib* * note: a respondent can give more than one complaint managements’ evaluation to eib implementation there were 58,33% (7 of 12) managerial stated that eib implementation in dr. mohammad hoesin hospital is still poor. all of whom were specialist doctors and had worked for more than one decade, while managerial who stated that eib implementation had run well comprise of room manager and head of medical unit, as in table 3. this rise a question, “do the stakeholder will give the honest disadvantageous answer ?”. the present study found that there were no significant differences in demographic characteristic and reinforcing factors (knowledge, attitudes, practices, support, policies, and barriers) in this group. table 3. eib evaluation by top managerial variables good eib implementation (n = 5) poor eib implementation (n = 7) p value n % n % age 49.4 + 6.84 55.71 + 4.27 0.076* occupation specialist doctor nursing manager 2 3 40 60 7 0 100 0 0.061§ position director head of department head of study programme head of installation head of emergency room head of delivery ward head of operating room 2 0 0 1 1 1 0 40 0 0 20 20 20 0 1 2 3 0 0 0 1 14.3 28.6 42.9 0 0 0 14.3 0.160€ length of work <5 year 5-10 year >10 year 2 1 2 40 20 40 0 0 7 0 0 100 0.061€ § fisher exact test, 95% ci € chi square test, 95% ci * mann-whitney u test, 95% ci global health management journal, 2017, vol. 1, no. 2  58      figure 3. distribution of eib barrier in managerial group* * note: a respondent can give more than one answer figure 3 shows barriers of eib practice mentioned by managerial group. the work attitude is the greatest obstacle in implementing eib. this “working attitude” such as less time to supervise and provide an opportunity for mothers to do eib, the midwive is too rush in taking the newborn from the mother. but when we did a crosscheck on the barriers, it was known to have its own reasons such as patient condition (uncooperative, medical conditions that unfit for eib), unavailability of eib in cs patient, low maternal knowledge, no eib policy socialization. this research obtains disintegration pattern between the two sides leading to the unproperly implementation of eib in our hospital. discussion the study was conducted from november to december 2016 enrolling 37 postpartum mothers, 43 executive staff (14 midwives and 29 medical residents), as well as 12 managerial staff. the rate of eib in our hospital is 51,4%. these results were still far below the target of health people 2010, which is about 75% [7]. we found significant differences in the mode of delivery affecting the eib implementation, which cs group did not implement eib the most. this gives a hint that one of the obstacles of eib implementation is cs patients don’t get the opportunity to carry out eib. study held by doung et al. found the probability risk of post cs mother for not having exclusive breastfeeding is 18,52 [8]. chandrasekhar in west nepal stated normal delivery has 7,6 times opportunity to have eib than cs patient [9, 10]. an early study by rowe-murray and fisher (2002) in hobbs (2016), found that babies born via c-section were less likely to be have skin-to-skin contact immediately after birth and were more likely not to have attempted breastfeeding within the first 24 h post delivery [11]. hobbs et al, stated the delays in breastfeeding initiation accompanying c-section delivery are associated with maternal/infant separation, reduced suckling ability, decreased infant receptivity, and insufficient milk supply, which are predictive of shortened breastfeeding duration [11], while khanal et al (2015) stated that effect of anaesthesia, caesarean procedure, maternal tiredness, reduced maternal alertness and inadequate maternal skills to initiate breastfeeding are some of the reasons for delayed breastfeeding among caesarean births [12]. performing eib after cs requires many requisitions. the stability of mother and baby condition, appropriate operation room temperature, the availability of warmer, assistance from neonatology, and mother should fully awake may be needed to performing safe eib. dr. mohammad hoesin is a tertiatry level hospital which most of it handling difficult referral cases, no exception in obstetric case. this makes a cs the most frequent mode of delivery done in complicated obsteric patient. although this reason may explain the majority cause of low rate eib implementation after 59                                 global health management journal, 2017, vol. 1, no. 2        mergency cesarean section patients, the same also happened in elective cesaren section. the most logic and acceptable reason for this gap is the absence of eib policy in cesaeran setting, as mentioned by executive staff group. however, contradictory statements were arise from the managerial side, by stating the eib policy had been enacted for years. the fact that neither patients nor executive staff aware of this regulation show us the poor eib policy socialization among executive staff and patients. interestingly, in managerial group, the knowledge and awareness about eib were varied greatly, which indicate socialization once again seems to be a major obstacle not only at the level of the patient and executive staff, but also the managerial level. in addition, there is a discrepancy between the managerial (good eib managerial group vs poor eib managerial group) shown by contradictive answer in the existance of eib policy (25% didn’t know if eib policy exist), monev system (only 33,3% state monev system is exist), and eib program indicator (only 41,6% state eib program indicatior is exist). this is interesting because actually all of them should know and understand about eib policy. these discrepancies may occur as a result of unproper eib policy not only in patients but up to managerial level. the last but not least, this study found that executive staffs’ “working attitude” were poor, which disputes by managerial and patient, such as less time to supervise and provide an opportunity for mothers to do eib, the midwive is too rush in taking the newborn from the mother. from other sides, when we did a crosscheck on the barriers, there was no significant difference between attituted and practice of eib in executive staff group, and had their own reasons such as patient condition (uncooperative, medical conditions that unfit for eib), unavailability of eib in cs patient, low maternal knowledge, no eib policy socialization. no statistically significant differences were found in all group’s demoraphics (except knowledge in patients group) and reinforcing factors, showing that either respondents who implement eib or respondents who do not implement eib have similiar human behaviour model, and those factors do not related with the good or bad of eib implementation. this also shows us that eib socialization might be the main culprit of this problem, and root cause analysis are needed to clarify the main cause of this problem. the opportunitiy of eib implementation is affected by medical condition of mother and fetus, method of delivery, hospital support, eib policy socialization, and patient’s level of knowledge. there are so many challenges for dr. mohammad hoesin hospital to implement eib, such as no eib policy in operating room, the majority of patients are obstetric referral case with complication so that the mother's condition is often unfit for eib, knowledge of the managerial about eib differ greatly, low socialization about regulations and other elements of the eib implementation. there is also disintegration between the manager and executive staff causing ambiguity in the implementation of the eib and the lack of supervision of eib implementation in the field. this is the first study that evaluated eib practices and explored issues at various levels provider in the setting of dr. mohammad hoesin hospital. the research included a questionnaire with closed and open questions based on a model of human behavior (health believe model and malcolm bridge model) so that it covers the majority of human behavior dimension and makes it possible to analyze each of the behavior. the weakness of this study is its design, whih was cross-sectional, and the researchers did not evaluate the objectivity respondent’s answer with direct assess practices in dr mohammad hoesin hospital. we had tried to minimize this weakness by doing cross-checking at all provider levels to reach conclusion. we also use a questionnaire that may not necessarily include all issues that may exist in the field, however the researchers tried to minimize this bias by open label question. conclusion the rate of eib in dr. mohammad hoesin hospital from november-december 2016 is 51.3%. the opportunity of eib implementation is affected by medical condition of mother and fetus, method of delivery, hospital support, eib policy socialization, and patient’s level of knowledge. while the global health management journal, 2017, vol. 1, no. 2  60      challenges, such as no eib policy in operating room, frequent complicated maternal condition lead the impossible to perform eib, managerial knowledge about eib differ greatly, low eib socialization, disintegration between manager and implementer staff causing ambiguity in the implementation of the eib, and the lack of supervision of eib implementation in the field. from this study results, for the hospital management, we suggest to perform a better socialization of eib policy by the hospital staff, informative education about eib to the patients, the new policy of eib in the operating room, and the eib integrated service system. further research needs to be done with a single variable based on the problem issues summarized in this study, so it can focus to evaluate the eib problems with more valid study design and bias control, also with a larger number of samples. unintegrated eib service raised misunderstanding issue in both providers. it requires an effort to solve the problem by round table discussion among providers to formulate an integrative mechanism that benefits all parties whom related with eib practice. acknowledgements the author thank prof. dr. amal chalik sjaaf, ph.d. who provided insight and expertise that greatly assisted the research. author would also like to show gratitude to the management and all health practitioner, especially in obstetrics and gynecology division, of dr. mohammad hoesin hospital for their cooperation as precious subject and source of information of this study. conflict of interests author have not conflict of interest. references 1. saleha s. midwifery care in the puerperium. jakarta: salemba medika; 2009. 2. edmond km, zandoh c, quigley ma, etego sa, et al. delayed breastfeeding initiation increases risk of neonatal mortality. pediatrics. 2006;117(3):3.80-6. 3. bigelow a, gillis de, alex m. breastfeeding, skin to skin contact and mother infant interactions over infant first three months. infant mental health j. 2014;35(1):51-62. 4. aprillia y. analysis of early initiation of breastfeeding and exclusive breastfeeding socialization to midwife in klaten district, indonesia. semarang: diponegoro university; 2014 5. bergstrom a, okong p, ransjo a. immidiate maternal thermal response to skin-to-skin care of newborn. acta paediatr. 2009;5:655–8. 6. bappenas. a road map to accelerate the achievement of the millennium development goals in indonesia. jakarta. 2010. 7. guidelines for breasfeeding initiation and support [guideline]. massachusetts: department of public health bureau of family health and nutrition; 2008. 8. helda. early initiation of breastfeeding (eib) increase exclusive breastfeeding in infants who born in m. yunus hospitals and private practice midwife (ppm): analysis of survival in bengkulu city period july 2010 june 2011. epidemiology science graduate program of the faculty of public health. depok: university of indonesia; 2009 9. emmanuel a. a literature review of the factors that influence breastfeeding: an application of the health believe model. int j nursing health sci. 2015;2(2):28-36. 10. chezem j. breastfeeding attitudes among couples planning exclusive breastfeeding or mixed feeding. breastfeeding med. 2012;7(3):155-61. 11. hobbs aj, mannion ca, mcdonald sw, brockway m, tough sc. the impact of caesarean section on breastfeeding initiation, duration and difficulties in the first four months postpartum. bmc pregnancy and childbirth. 2016; 16:90 12. khanal v, scott ja, lee ah, karkee r, binns cw. factors associated with early initiation of breastfeeding in western nepal. int. j. environ. res. public health 2015, 12, 9562-74. cite this article as lwin kz, putra igne. mothers' knowledge of the causes and prevention associated with diarrhea among under-five children in hlaing thar yar township, yangon, myanmar. global health management journal. 2018; 2(3): 76-83. global health management journal www.publications.inschool.id published by original research article issn 2580-9296 (online) mothers' knowledge of the causes and prevention associated with diarrhea among under-five children in hlaing thar yar township, yangon, myanmar khaing zar lwin 1,2,*, i gusti ngurah edi putra 1,3 1 institute for population and social research, mahidol university, thailand. 2 karuna mission social solidarity (kmss), yangon, myanmar. 3 center for public health innovation (cphi), faculty of medicine, udayana university, indonesia *corresponding author. email: lwin.khinezar11@gmail.com article info abstract article history: received 29 august 2018 reviewed 31 august 2018 received in revised form 08 september 2018 accepted 21 october 2018 background: diarrhea among under-five children remains a major public health problem in developing countries, such as myanmar. its complications contribute to the worse health outcomes as well as increase the child mortality in myanmar. hlaing thar yar was recognized as a township with the highest incidence of diarrhea in yangon region. aims: this study aimed to identify the association of mother’s knowledge on diarrhea with the diarrheal disease among under-five children in hlaing thar yar township, yangon, myanmar. methods: this was a cross-sectional study by collecting primary data in the hlaing thar yar township of yangon, myanmar from november to december 2016. about 277 records of mothers and their under-five children have been collected through multistage random sampling. a dependent variable in this study was the occurrence of diarrhea among under-five children whilst independent variables consisted of socio-demographic characteristics of parents and five domains of mother’s knowledge on diarrhea. data were analyzed by using univariate, bivariate and multivariate analysis. results: this study found that a half (53.43%) of under-five children suffered diarrhea within two weeks prior to the survey. based on multivariate analysis by controlling all socio-demographic factors, two out of five domains of mother’s knowledge showed significant association. an increased one score of mother’s knowledge on causes and prevention of diarrhea contributed to decrease the likelihood of diarrheal disease by 37% (or=0.63; 95%ci=0.44-0.90) and 27% (or=0.73; 95%ci=0.54-0.99), respectively. conclusions: this study confirmed that the knowledge of mothers on causes and prevention of diarrhea appears to have important effects on the occurrence of diarrhea among the under-five children. therefore, health promotion program with an emphasis on providing information related to diarrhea causes and prevention is worth to enhance mother’s knowledge and their ability to prevent diarrhea among under-five children in hlaing thar yar township, yangon. keywords: diarrhea under-five children mothers’ knowledge causes and prevention myanmar © 2018 publications of yayasan aliansi cendekiawan indonesia thailand this is an open-access following creative commons license deed – attribution-noncommercial-sharealike 4.0 international (cc by-nc-sa 4.0) introduction diarrhea is the second leading cause of death among under-five children. it is estimated that 525,000 under-five children die because of diarrhea every year [1]. not surprisingly then, the incidence of diarrhea among under-five children remains a major public health issue in lowand middleincome countries which plays important role as a key driver to child mortality [2]. in developing countries, nearly http://publications.inschool.id/index.php/ghmj/index http://publications.inschool.id/ http://publications.inschool.id/index.php/ghmj/index http://inschool.id/ mailto:lwin.khinezar11@gmail.com http://inschool.id/ http://creativecommons.org/licenses/by-nc-sa/4.0/ 77 global health management journal, 2018, vol. 2, no. 3 half of the babies delivered within a year, they did not pass their first birthday mainly due to pneumonia, diarrhea and malnourishments [3]. similar to the situation in myanmar as developing country, the main direct causes of death among under-five children continue to be diarrhea, acute respiratory infection, and malaria, exacerbated by underlying malnutrition contributing to 50% of total deaths [4]. ministry of health reported that 7.7 % of the total deaths among under-five children in myanmar were caused by diarrhea [5]. according to the report from multiple indicator cluster survey in myanmar, the prevalence of diarrhea in last two weeks accounted for 6.7% among children under five years old in 2010 [6]. diarrhea is one of the seasonal diseases in myanmar which commonly occurs in rainy and summer seasons. the reported number of diarrhea cases in yangon as the populous region in myanmar increased from 11,016 in 2011 to 13,919 in 2013 [7]. hlaing thar yar is one of the townships in yangon, myanmar which comprises 20 wards, 18 villages under 9 village tracts [8]. the total population of hlaing thar yar was 687,867, consisting of 322,862 males and 365,005 females and 70.1% of population settled in urban area [9]. concerning the housing condition, 68% of the total houses in hlaing thar yar township were made from bamboo, 12% were timber house, 6% were with brick foundation, and the remaining were bungalow [9]. under-five mortality rate in hlaing thar yar township was quite high compared to other townships in yangon. a study conducted by united nations human settlements programme (un-habitat) in 2013, found that hlaing thar yar township was the highest incidence in yangon for the diseases related to poor environmental conditions and lack of water and sanitation facilities (diarrhea, dysentery, malaria, and tuberculosis). this township was also designated as the highest prevalence of diarrhea of among all townships in yangon [10]. with several complications of diarrhea among underfive children, it obviously impacts to their physical development. moreover, dehydration caused by severe diarrhea is one of the major causes of child mortality in myanmar [11]. a study in pakistan found that children who suffered diarrhea during the last one year were more likely to become malnutrition than children who did not suffer diarrhea [12]. indeed, diarrhea is a preventable disease, but the inadequate knowledge of mother as the one who mainly takes care children and their improper approach towards the prevention, care, and management of diarrhea lead to the high likelihood of diarrhea among children as well as its mismanagement [13]. a previous literature from india showed that only 44% of mothers knew that the diarrhea can be prevented [14]. given to those issues, it is necessary for mothers to have relevant information on diarrhea in order to prevent diarrhea as well as have adequate management for children with diarrhea. the prevalence of diarrhea in hlaing thar yar township is the highest one compared to other townships in yangon. to our knowledge, no study has been conducted to reveal factors associated with the occurrence of diarrhea among under-five children in hlaing thar yar township. in the context of myanmar, mothers play a major role in taking care children which implies that their knowledge on diarrhea might contribute to the occurrence of diarrhea among under-five children and hence, it needs to be assessed. mothers' knowledge is one of the possible predictors of diarrheal disease among under-five children. the comprehensive knowledge on diarrhea might play an important role in the decision-making and action among mothers related to diarrhea prevention for their children. therefore, this study was intended to examine the association between mothers’ knowledge on diarrhea with diarrheal disease among under-five children in hlaing thar yar township, yangon, myanmar. methods population and samples this was a cross-sectional study by collecting primary data in hlaing thar yar township, yangon, myanmar from november to december 2016. the population of this study was children aged under-five years old with an inclusion criterion that mother can be interviewed at the time of survey. sample for this study was calculated based on the formula for two population proportions with an assumption 95% confidence interval (ci), 80% power, 45% as the proportion of diarrhea among under-five children from previous study (p2) [3], and 30% (15% lower than p2) as the estimation of diarrhea among under five children where their mothers have good knowledge on diarrhea (p1), resulting in a minimum samples of 256 married women with under-five children. this study successfully collected 277 samples through multistage random sampling procedure, consisting of 1) selecting four wards and three villages from the 20 wards and 18 villages in hlaing thar yar township by cluster global health management journal, 2018, vol. 2, no. 3 78 random technique and 2) selecting a number of households from selected wards and villages through simple random sampling by using a sampling frame of household data from township administrative department. mothers who had under-five children were interviewed to document their sociodemographic characteristics, knowledge on diarrhea, and the diarrhea occurrence of their last under-five child. a self-designed and pretested structured questionnaire was employed. in addition, written informed consent was obtained before face-to-face interview. the variables for this study, diarrhea was defined as one of the followings: passage of three or more loose watery motion, more than usual loose watery motion, a single large watery motion in a day, or mother’s assessment that her child passed more frequent liquid stools. the dependent variable in this study was the occurrence of diarrhea in two weeks prior to the survey in order to minimize recall bias and that recall period has been used in several surveys [6, 11]. independent variables consisted of socio-demographic characteristics of parents and five domains of mother’s knowledge on diarrhea as presented by following conceptual framework (figure 1). those indicators of knowledge developed in this study followed the indicators presented in who report [1, 15]. there are five domains of knowledge, consisting of knowledge on causes, symptoms, complications, management, and prevention of diarrhea. the number of questions used to measure knowledge varied by domain, such as 3 items for a domain on causes, 5 items for symptoms, and 4 items for each domain on complications, management, and prevention. each item was scored one for a given correct answer. furthermore, the score of each domain was summed up with the maximum score is equal to the total number of questions. a high score of a particular domain approaching the maximum value reflects high level of knowledge on that domain. statistical analysis data were analysed descriptively to present data distribution of variables. moreover, chi-square test and independent sample t-test were used for bivariate analysis purpose. meanwhile, binary logistic regression analysis was performed for multivariate analysis in order to examine the effects of sociodemographic characteristics and knowledge of mother toward the occurrence of diarrhea among under-five children. odds ratio (or), 95% confidence interval (ci) or and p-value were reported in this study. figure 1. conceptual framework showing association between independent variables and the occurance of diarrhea results table 1 shows the percentage distribution of sociodemographic characteristics of respondents. nearly 80% of the mothers completed secondary and higher education and 42.96% of them reported as full-time housewife at the time of survey. regarding husband’s characteristics, 78.70% completed secondary and higher education and they worked in odd job (37.55%), company (35.74%), and run small owned business (26.71%). more than half of couples lived in the house with brick foundation (58.12%) and did not own the house (59.21%). regarding the monthly income, about a half of the couples had income more than 150,000 kyats (51.62%). importantly, this study found that more than a half (53.43%) of under-five children experienced diarrhea in past two weeks. in d e p e n d e n t v a ri a b le s socio-demographic characteristics education level of mother occupational status of mother education level of father occupational status of father home condition home ownership monthly income dependent variable occurrence of diarrhea knowledge on diarrhea knowledge on causes of diarrhea knowledge on symptoms of diarrhea knowledge on complications of diarrhea knowledge on management of diarrhea knowledge on prevention of diarrhea 79 global health management journal, 2018, vol. 2, no. 3 table 1. respondents’ distribution (n=277) variables n % education level of mother no education and primary 56 20.22 secondary and higher 221 79.78 occupational status of mother employed 158 57.04 unemployed 119 42.96 education level of father no education and primary 59 21.30 secondary and higher 218 78.70 occupational status of father odd job 109 39.35 small owned business 70 25.27 staff at private company 98 35.74 house condition condo/bungalow 62 22.38 brick foundation 161 58.12 timber house 54 19.49 house ownership yes 113 40.79 no 164 59.21 monthly income ≤ 150,000 kyats 134 48.38 > 150,000 kyats 143 51.62 occurrence of diarrhea no 129 46.57 yes 148 53.43 table 2 exhibits the mothers’ knowledge on causes of diarrhea. there were three main causes of diarrhea used in this study which included eating unclean food, eating food with fly infestation, and drinking unclean water. about 91.34% of the mothers were aware that unclean food can cause diarrhea and 67.51% knew the diarrhea can be caused by taking fly infested food, and less than a half (45.85%) of them were aware on drinking unclean water can cause diarrhea. results present the mother’s knowledge on symptoms of diarrhea. the symptoms during suffering diarrhea consisted of child drinks liquid eagerly, dry tear when child is crying, child’s skin becomes normal slowly when punching the skin of forehead and abdomen and child shows sunken eye. among these symptoms, 94.58% of the mothers knew the symptom of dry tear when baby is crying and 77.62 % were aware on the sunken eye during when child is suffering diarrhea. if related to mother’s knowledge on complications of diarrhea, most of the mothers understood that malnutrition and dehydration are the complications of diarrhea, accounting for 83.39% and 76.53%, respectively. unfortunately, the majority did not know that shock and convulsion are also the severe complications of diarrhea. table 2. mothers’ knowledge on diarrhea (n=277) mothers’ knowledge to % causes of diarrhea unclean water 45.85 fly infestation to food 67.51 unclean food 91.34 total score (mean ± sd) 2.05 ± 0.87 symptoms of diarrhea drinking liquid eagerly 52.35 sunken eye 77.62 when pinching abdominal skin, it reaches normal slowly 31.77 when pinching forehead skin, it reaches normal slowly 3.61 dry tear when baby is crying 94.58 total score (mean ± sd) 2.60 ± 0.80 complications of diarrhea malnutrition 83.39 dehydration and loss of mineral salt 76.53 shock 5.05 convulsion 5.42 total score (mean ± sd) 1.71 ± 0.77 managements of diarrhea drinking ors 97.83 drinking coconut 13 drinking gruel 27.44 taking fresh food 23.83 total score (mean ± sd) 1.62 ± 0.78 prevention of diarrhea washing hand before handle of food 91.34 covering food to prevent flies blown 78.34 drinking water sterilized by boiling 61.01 washing hand after going toilet 70.40 total score (mean ± sd) 2.60 ± 1.07 regarding the first management of diarrhea at home prior to hospital visit as presented by table 2, about 97.83 % of the mothers were aware that their child needs to drink oral rehydration solutions (ors) as an important treatment of diarrhea. meanwhile, less than a half of them knew that taking fresh food, drinking gruel, and coconut water are also the treatment of diarrhea at home. considering to the mothers’ knowledge in preventing the diarrhea, the majority of the mothers believed that the occurrence of diarrhea can be prevented through some approaches such as global health management journal, 2018, vol. 2, no. 3 80 washing hand before handling food (91.34%), covering food to prevent flies blown (78.34%), and drinking sterilized boiling water (61.01%), whereas only 29.60% of mothers knew that washing hand after using toilet can prevent diarrhea. the total score (mean ± sd) of each domain of mothers’ knowledge in table 2 indicates the mothers acknowledge the symptomps of diarrhea and how to prevent. however, mothers may need more knowledge in managing the diarrhea and how to deal with the complications. the statistical analysis (table 3) acknowledges there were seven variables included such as educational level and occupational status of the couples, house condition, house ownership status, and monthly average income. however, no statistically significant association between socio-demographic characteristics with diarrheal disease among under-five children was found. as shown in table 4, this present study found that all domains of knowledge were found significantly associated with occurrence of diarrhea. mothers with no child suffering diarrhea in last two weeks had significantly higher level of knowledge on causes, symptoms, complications, management, and prevention of diarrhea. table 3. association between socio-demographic characteristics and the occurrence of diarrhea (n=277) variables occurrence of diarrhea chi-square test p-value no (%) yes (%) education level of mother 0.0006 0.981 no education and primary 26 (46.43) 30 (53.57) secondary and higher 103 (46.61) 118 (53.39) occupational status of mother 1.1561 0.282 employed 78 (49.37) 80 (50.63) unemployed 51 (42.86) 68 (57.14) education level of father 0.0197 0.889 no education and primary 27 (45.76) 32 (54.24) secondary and higher 102 (46.79) 116 (53.21) occupational status of father 0.0281 0.986 odd job 51 (46.79) 58 (53.21) small own business 32 (45.71) 38 (54.29) staff at private company 46 (46.94) 52 (53.06) house condition 1.0567 0.590 condo/bungalow 31 (50.00) 31 (50.00) brick foundation 76 (47.20) 85 (52.80) timber house 22 (40.74) 32 (59.26) house ownership 0.0085 0.927 yes 53 (46.90) 60 (53.10) no 76 (46.34) 88 (53.66) monthly income 0.3358 0.562 ≤ 150,000 kyats 55 (41.04) 79 (58.96) > 150,000 kyats 74 (51.75) 69 (48.25) table 4. association between mother’s knowledge on diarrhea and the occurrence of diarrhea knowledge on diarrhea occurrence of diarrhea t-test p-value no (mean ± sd) yes (mean ± sd) causes of diarrhea 2.29 ± 0.80 1.84 ± 0.87 4.43 <0.0001 symptoms of diarrhea 2.74 ± 0.83 2.48 ± 0.74 2.71 0.0071 complications of diarrhea 1.81 ± 0.64 1.61 ± 0.85 2.09 0.0377 management of diarrhea 1.72 ± 0.96 1.53 ± 0.56 2.01 0.0457 prevention of diarrhea 2.89 ± 1.05 2.35 ± 0.85 4.31 <0.0001 81 global health management journal, 2018, vol. 2, no. 3 table 5. binary logistic regression of factors associated with the occurance of diarrhea variables model i model ii model iii or 95% ci p-value or 95% ci p-value or 95% ci p-value socio-demographic characteristics education level of mother no education and primary reference reference secondary and higher 1.46 0.12 18.22 0.771 1.40 0.10 20.64 0.804 occupational status of mother employed reference reference unemployed 1.40 0.84 – 2.33 0.196 1.51 0.87 2.59 0.140 education level of father no education and primary reference reference secondary and higher 0.64 0.05 – 7.87 0.727 0.70 0.05 10.01 0.793 occupational status of father odd job reference reference small own business 1.08 0.56 – 2.09 0.821 1.70 0.82 3.52 0.150 staff at private company 1.36 0.61 – 2.11 0.686 1.21 0.63 2.34 0.570 house condition condo/bungalow reference reference brick foundation 0.99 0.53 – 1.83 0.968 0.90 0.47 1.74 0.761 timber house 1.17 0.51 – 2.64 0.713 0.99 0.41 2.38 0.979 house ownership yes reference reference no 0.89 0.53 – 1.48 0.645 0.88 0.51 1.52 0.644 monthly income ≤ 150000 reference reference > 150000 0.61 0.36 – 1.04 0.068 0.59 0.33 1.06 0.078 knowledge on diarrhea causes of diarrhea 0.65 0.46 0.91 0.013 0.63 0.44 0.90 0.012 symptoms of diarrhea 0.82 0.56 1.20 0.308 0.80 0.54 1.19 0.276 complications of diarrhea 1.12 0.76 1.66 0.567 1.09 0.73 1.61 0.680 management of diarrhea 1.03 0.72 1.49 0.855 0.93 0.63 1.38 0.732 prevention of diarrhea 0.73 0.54 – 0.98 0.034 0.73 0.54 0.99 0.046 lr chi square (df) 5.75 (9) 25.73 (5) 33.48 (14) pseudo r-square 0.0150 0.0672 0.0875 discussion this study found a half (53.43%) of the under-five children in hlaing thar yar township suffered diarrhea within two weeks preceding the survey. this finding is almost similar to the result of a baseline survey conducted by world vision myanmar in hlaing thar yar township in 2012 which found that nearly half (45%) of under-five children suffered diarrhea in one month prior the survey [3]. obviously, different sampling and data collection procedure, assessment, and inclusion criteria of samples might play important roles for the differences. it is important to note that the prevalence of diarrhea among underfive children in hlaing thar yar township was very high compared to other country’s settings, such as in banten, indonesia of 18.9% [16] and in gujarat, india of 35.3% [17]. the high prevalence of diarrhea in hlaing thar yar township might be due to poor hygienic conditions and inadequate of water and sanitation facilities [10]. beyond those existing environmental factors that are well-known to contribute to diarrhea occurrence, this study attempts to identify the association between mother’s knowledge of diarrhea with diarrheal disease among under-five children in hlaing thar yar township. based on multivariate analysis after controlling all socio-demographic of parents and household, two domains of knowledge, namely knowledge on causes and prevention of diarrhea were associated with diarrheal disease among under-five children. both domains of knowledge play an important role as global health management journal, 2018, vol. 2, no. 3 82 preventive factors since those declined the likelihood of diarrhea. similarly, other previous studies also confirmed the same findings. a study conducted in west ethiopia found that not knowledgeable mothers of causes, transmission, and prevention of diarrhea were more likely to have children experiencing diarrhea in last 15 days by 3.62 times [18]. in addition, another study also supports this finding where poor level knowledge of mothers on causes and prevention of diarrhea was associated with high odds of diarrhea among infants, reported by a study in nigeria [19]. it is understandable then, mothers who had a higher knowledge about causes and prevention of diarrhea, they were more likely to prevent diarrheal disease among children. being knowledgeable of causes and prevention of diarrhea leads mothers to have good practices in terms of feeding their children as well as eliminating transmission of diarrhea. meanwhile, other domains of knowledge showed insignificant association, such as knowledge on symptoms, complications, and management. those types of knowledge might be not strong factors associated with mother’s prevention acts of diarrhea, but they are more related to diarrheal management practices for children who are suffering from diarrhea. findings from this study suggested that enhancing knowledge of mothers related to causes and prevention of diarrhea is worth considering to prevent diarrheal diseases among under-five children in hlaing thar yar township. an advocacy can be addressed to the authorized persons of public health department at district level in order to develop health promotion program aiming to increase mother’s awareness and skills of diarrhea prevention in hlaing thar yar township. moreover, health care providers from rural health center and sub-rural health center play important roles in health promotion program to educate and provide information to mothers and other family members about diarrhea and its prevention acts. this efforts to decrease diarrhea prevalence is in line with a vision of the global action plan for pneumonia and diarrhea (gappd) which aims to eliminate pneumonia and diarrhea-related deaths by 2025, by accessing universal prevention and treatment. therefore, an investment in a program which provides comprehensive knowledge on diarrhea helps mothers to avert diarrhea. in addition, mothers also need to be equipped with adequate management skills for children with diarrhea in order to avoid unexpected complications and mortality. it should be noted however, level of knowledge and awareness might be not sufficient to prevent diarrheal disease [20]. a massive improvement of environmental quality such as adequate supply of clean water and sanitation facilities should be taken into account as a way to create enabling condition for diarrhea prevention. conclusion the prevalence of diarrhea among under-five children in hlaing thar yar township was quite high. the occurrence of diarrhea among under-five children was significantly associated with mothers’ knowledge on causes and prevention of diarrhea. therefore, a health promotion program should be designed to enhance mother’s knowledge on causes and prevention of diarrhea in order to prevent the diarrheal disease. furthermore, it impacts positively on the health status of children that can reduce morbidity and mortality among children. conflict of interests authors declared that there is no conflict of interest. references 1. world health organization. diarrhea disease fact sheet. geneva: world health organization. 2017. retrieved from: http://www.who.int/news-room/factsheets/detail/diarrhoeal-disease [accessed: 28/07/2018] 2. fischer wc, perin j, aryee m, boschi pc, black r. diarrhea incidence in lowand middle-income countries in 1990 and 2010: a systematic review. bmc public health. 2010; 12(220). 3. world vision myanmar. knowledge, attitude and practice (kap) survey: maternal and child health (from miracle to reality) project: baseline report. world vision myanmar: yangon; 2012. 4. myint sys. myanmar's child mortality still highest in region: myanmar time; 2012. retrieved from: https://www.mmtimes.com/national-news/3113myanmar-s-child-mortality-still-highest-in-regionunicef.html [accessed: 28/07/2018] 5. ministry of health (moh) health, myanmar. study on causes of under-five mortality. myanmar: moh myanmar; 2012. 6. ministry of national planning and economic development, ministry of health (moh). myanmar. myanmar multiple indicator cluster survey 2009 2010 final report. ministry of national planning and economic development and moh myanmar: nay pyi taw; 2011. 83 global health management journal, 2018, vol. 2, no. 3 7. aung ww, okada k, mathukorn nu, natakuathung w, sandar t, oo nat, aye mm, hamada s. cholera in yangon, myanmar, 2012–2013. emerging infectious diseases. 2015; 21(3):543-544. 8. district administrative department. hlaing thar yar township profile data. north yangon, yangon region, myanmar: mimu; 2017. 9. department of population. the 2014 myanmar population and housing census. yangon region report. census report volume 3 – l. nay pyi taw, myanmar: ministry of immigration and population; 2015. 10. united nations human settlements programme (unhabitat). baseline assessment report. yangon. myanmar: un-habitat; 2013. 11. department of population, myanmar, united nations population fund (unfpa). country report on 2007 fertility and reproductive health survey. nay pyi taw, myanmar: department of population, myanmar, unfpa; 2009. 12. agha a, younus m, kadir mm, alir s, fatimi z. eight key household practices of integrated management of childhood illnesses (imci) amongst mothers of children aged 6 to 59 months in gambat, sindh, pakistan. journal of pakistan medical association. 2007; 57(6): 288-293. 13. rehan sh, gautam k, gurung k. kap of mothers regarding diarrhea. indian journal of prevention and social medicine. 2003; (34): 1-6. 14. rao a, jadhav j, ranganath ts, dsouza l. awareness regarding diarrhea, its prevention, and oral rehydration therapy among mothers of under-five children in urban slums of bengaluru. international journal of medical science and public health. 2015; 4(8):1086 – 1089. 15. world health organization. childhood pneumonia and diarrhea. geneva: world health organization; 2013. 16. rohmawati n, allesio p, lertmaharit s. factors associated with diarrhea among children under five years of age in banten province, indonesia. journal of health research. 2012; 26(1): 31-34. 17. seksaria sa, sheth mk. maternal knowledge and practices towards sanitation and their relationships with occurrence of diarrhea in children. international journal of public health science. 2014; 3(3): 206-212. 18. nigatu m, tadesse a. knowledge, perception, and management skills of mothers with under-five children about diarrheal disease in indigenous and resettlement communities in assosa district, western ethiopia. journal of health population and nutrition. 2015; 33(1):20-30. 19. dairo md, ibrahim tf, salawu at. prevalence and determinants of diarrhea among infants in selected primary health centers in kaduna north local government area, nigeria. pan african medical journal. 2017; 28(109). 20. ansari m, mohamed i, ravi s. a survey of mothers’ knowledge about childhood diarrhea and its management among a marginalized community of morang, nepal. australasian medical journal. 2011; 4(9):474–479.   cite this article as  hoang tn, pham dt. associated factors to attitudes and perceptions toward hiv/aids:  a study of ethnic minorities in buon ma thuot city, dak lak province, vietnam. global  health management journal. 2017; 1(2): 37‐42.    global health management journal  www.publications.inschool.id  published by  original research article issn 2580-9296 (online) associated factors to attitudes and perceptions toward hiv/aids: a study of ethnic minorities in buon ma thuot city, dak lak province, vietnam thang nghia hoang *, duoc tho pham tay nguyen institute of hygiene and epidemiology, buon ma thuot, dac lak, vietnam *corresponding author. email: nghiathang2k5@gmail.com article info abstract article history: submitted 9 october 2017 accepted 28 october 2017 background: in central highland of vietnam, number of hiv infected people in the highlands region was 2,869, with 654 cases of aids. there are very few researches on hiv/aids, especially, research in community. the ethnic minority populations are the source of differences from other regions of in the country. negative attitude and misperception toward hiv/aids are remaining among this group. aims: this study aims to illustrate attitude and perception towards hiv/aids among ethnic minority in buon ma thuot city and determine factors related to attitude and perception towards hiv/aids in this population. methods: we performed a cross-sectional survey of collected from 810 ethnic minority aged 15-49 in buon ma thuot city, vietnam in 2012. face-to-face interviews were conducted to collect information regarding hiv knowledge, hiv perception and attitude towards people living with hiv/aids (plwha). the mean score was calculated. multivariate analysis performed to analyze the influence of socio-demographic, hiv information sources and hiv knowledge on attitudes and perception towards hiv/aids. results: we identified that the mass media channel has been used as hiv information resource (92.8%); however, the respondents received hiv information through mass media channels had lower perception and attitude towards hiv/aids. the multivariate analysis showed that the socioeconomic-demographic characteristic, hiv information, and hiv knowledge significantly associated with perception and attitude towards hiv/aids. the findings highligh the hiv information provided by health officers, who are ethnic minorities, had more effectiveness of improving attitude towards people living with hiv/aids (plwha) in the premise community (p<0.05). conclusion: based on these data, we recommend improving quality of hiv message through mass media channel with adequate hiv information combine with social messages. besides, combination of the role of multichannel mass media and health officers is needed to improve the perception and attitude towards hiv/aids among ethnic minorities. keywords: perception attitude ethnic minorities hiv/aids © 2017 publications of yayasan aliansi cendekiawan indonesia thailand this is an open access following creative commons license deed – attribution-noncommercial-sharealike 4.0 international (cc by-nc-sa 4.0) introduction hiv / aids pandemic is one of the major impact to the world. every year, millions of people died of aids. it is a major challenge to public health issue over the world. hiv / aids does not only affect human health but also security, economic, social, and development of the human race. since the global health management journal, 2017, vol. 1, no. 2   38      discovery of hiv in 1981 until 2011, 34 million of population are infected hiv in the world. an estimated 0.8% people from aged 15-49 years were living with hiv. aids has killed more than 1.7 million people (a 24% decrease compared to 2005) and 2.5 million people newly infected hiv [13]. according to the report of the organization on hiv/aids of the united nations in 2006, less than 50% of people infected worldwide understand of hiv/aids. general knowledge about the transmission and prevention was not high [5]. since 2001, after having been relatively stable for several years, the hiv infection in eastern europe and central asia began increased in the late 2000s.  in many countries in asia, hiv epidemics started with the virus spreading rapidly among people who inject drugs and sex workers [12]. the hiv prevalence spreading in high risk groups but can risk transmission to population. for example, an estimate of 35% of people living with hiv in asia and the pacific are women. the majority of women living with hiv in the region received infections from their intimate partners. in vietnam, the coverage of hiv knowledge improving program runs almost in all provinces through mass media and peer educator. yet, there are differences in knowledge, attitude and perception toward hiv/aids disease in different education groups, region groups, age groups, and ethnic groups. in particular, the discrimination and stigma are still barriers to the hiv prevention programmes in all provinces [7]. after more than 20 year fighting with hiv/aids, vietnam has achieved some effectiveness but still has many challenges in the future. in 2012, the number of hiv cases still alive is 210,703 cases, aids patients alive is 61,699 cases and 63,372 deaths due to aids [14]. in central highland of vietnam, in 2012, number of hiv infected people in the highlands region was 2,869, with 654 cases of aids. in this region, there are very few researches on hiv/aids, especially, research in community [14]. the lack of investment from foreign organizations for hiv/aids prevention program remains a challenge. the ethnic minority populations are the source of differences from other regions of in the country. negative attitude and misperception toward hiv/aids among this group are still high. to improve the perception and attitude towards hiv/aids among ethnic minorities, it is important to reduce the spread of hiv in minority communities. this study aims to illustrate attitude and perception toward hiv/aids among ethnic minority in buon ma thuot city and determine factors related to attitude and perception towards hiv/aids in this population. results are expected to provide some recommendations for the future hiv intervention programs. methods the cross-sectional study was conducted in buon ma thuot city, dak lak province, one of provinces in central highland, vietnam. this study selected 810 households from 30 clusters includes population of several ethnic minorities (eđe, m’nong, tay, muong, nung and others) aged 1549. the respondents were selected one by one, corresponding with 810 households. the questionnaire forms were designed base on national indicators for monitoring and evaluation in hiv/aids prevention by vietnam authority of hiv/aids control and modify with ethnic minorities. all respondents were interviewed by this questionnaire. hiv knowledge was measured based on six items including causes of hiv/aids disease and knowledge about hiv medication to prolong life of people living with hiv/aids. the hiv knowledge score are computed according to these six items range from 0-6. the perception towards plwha was measured according to 22 items. these items are mentioned on the perception about the ways to the prevention, recognize the high risk group (female sex workers, man who have sex with man, and people who inject drug), and recognize behavior with high risk of hiv infection and rejecting hiv misperception. the perception toward hiv/aids scores are computed by these 22 items range form 0-22. the attitude toward plwha was measured according to 16 items that mentioned on the attitude about caring towards plwha, who are member of family and neighbors, the attitude stigma and discrimination towards plwha. the attitude towards plwha scores are computed by these 16 items range from 0-16. 39                                 global health management journal, 2017, vol. 1, no. 2        this study used descriptive statistics to investigate the situation regarding attitudes and perceptions toward hiv/aids among ethnic minorities. for multivariate analysis, the binary logistic regression has been used to determine the association between each independent variable and the dependent variable. the perception towards hiv/aids, attitude toward plwha and hiv knowledge were computed as score variables range from low level to high level. results characteristics of respondents among 810 respondents aged 15-49, 39.0% aged 35-49, 35.6% aged 15-24, and 25.4% aged 25-34. there are more females (56.2%) along with ede ethnics higher than other ethnic minorities (69.6% and 30.4%, respectively). more than half the respondents had secondary school and higher than secondary, 30.0% and 30.2%, respectively. the majority (68.3%) is single. the common occupation is farmer (69.1%), over fifteen percent (15.7%) of respondents did not work. most of respondents had middle income (89.5%). the large proportion of respondents can read (79.4%) and write (77.2%) vietnamese language. the common hiv information sources is mass media channels (92.8%) such as: television, newspapers, and posters etc. the mean of hiv knowledge 2.0 (± sd 1.5), ranging from no hiv knowledge (score is 0) to high hiv knowledge (score is 6). perception towards hiv/aids as shown in table 1, the mean of the perception towards hiv/aids score is 14.6 (±sd5.4). in additions, the perception towards plwha score ranges from the lowest perception with misperception towards hiv/aids (score is 0) to high perception with reject perception towards hiv/aids (score is 22). the highest score of perception towards hiv/aids demonstrate in respondents aged 15-24 (16.4), followed by those aged 25-34 (14.6) and lowest among respondents aged 35-49 (13.0), respectively. the respondents with no educational level demonstrated the lowest mean score of perception toward plwha (9.3 and highest mean score in higher than secondary group (18.2). different occupation also indicates different mean score of perception towards hiv/aids. labors have the lowest mean score of perception towards hiv/aids (11.7) and officers demonstrated the highest mean score of perception (18.9). especially, not working persons also demonstrated high mean score of perception (17.4). better economic status corresponds with higher mean score of perception towards hiv/aids. the highest mean score of perception is shown in those with highest income group (18.0) and lowest in lowest income group (8.9). the respondents who can read and write vietnamese language indicates higher mean score of perception towards hiv/aids (15.6 and 15.7, respectively) compared with respondents who cannot read nor write (10.7 and 10.9, respectively). table 1. mean score of perception and attitude scores by the socio-demographic characteristics variables mean score (n=810) perception attitude age 15-24 16.4 11.2 25-34 14.6 10.2 35-49 13.0 9.5 sex male 14.3 10.4 female 14.8 10.3 ethnicity ede 15.6 10.6 others 12.3 9.6 education level illiterate 9.3 8.6 primary school 12.8 8.8 secondary school 15.0 10.7 higher than secondary school 18.2 12.1 marital status single 14.2 10.0 married 15.5 10.9 occupation farmer 13.8 9.7 labor 11.7 10.6 officer 18.9 12.9 not working 17.4 11.8 others 16.4 11.4 income low income 8.9 9.1 middle income 15.0 10.3 high income 18.0 13.2 read vietnamese can read vietnamese 15.6 10.6 cannot read vietnamese 10.7 9.1 write vietnamese can read vietnamese 15.7 10.8 cannot read vietnamese 10.9 8.8 global health management journal, 2017, vol. 1, no. 2   40      surprisingly, as shown in table 2, the lowest mean score of perception towards hiv/aids is found among respondents who reported received hiv information through mass media (15.6) and highest among respondents receiving hiv information from other sources (17.9) such as family having hiv-positive persons, from friends, etc. table 2. mean score of perception and attitude towards plwha by sources of hiv information sources mean score (n=810) perception attitude mass media 15.6 10.5 health officers 17.2 11.6 others 17.9 11.7 however, the full model after controlling for socioeconomic-demographic characteristics and source of hiv information, hiv knowledge is significantly and positively associated with perception towards hiv/aids. all sources of hiv information have strongly significant association with perception towards hiv/aids. as for socioeconomic-demographic characteristics, most are statistically significant, except age, sex, and ability to read and write vietnamese. the other ethnic minorities had higher negative perception, compared with the ede ethnic. this model explained only 67% of the variability (data not shown). attitude towards hiv/aids the mean of score of attitude towards plwha is 10.3 (±sd 4.1). the total of attitude towards plwha score range from the lowest attitude with stigma and discrimination towards plwha (score is 0) to high attitude with no sigma and discrimination towards hiv/aids (score is 16). follow the same pattern as perception, orchestrated in table 1, the mean score of attitude is highest among those aged 15-24 (11.2), lowest among those 35-49 (9.5), not different between males and females (10.4 and 10.3 respectively), and slightly higher among ede ethnic (10.6) than others ethnic (9.6), and among married people (10.9) than the singles (10.0). the mean score of attitude is higher among the more educated. the mean score of attitude towards plwha is highest among those with higher than secondary school (12.1) and lowest among the illiterates (8.6). similar to perception, mean score of attitude varies across types of occupation. farmers show the lowest mean score of attitude towards plwha (9.7), while officers the highest (12.9). higher income corresponds with higher attitude towards plwha. the highest income group indicates the highest mean score of attitude towards plwha (13.2) and lowest in the lowest income group (9.1). in additions, higher mean score of attitude towards plwha is also shown among respondents with ability to read and write vietnamese language (10.6 and 10.8, respectively) compared to their counterparts (9.1 and 8.8, respectively). similarly, as shown in table 2, the respondents who received information through mass media demonstrated the lowest mean score of attitude towards plwha (10.5), while those respondents who received hiv information through others sources have the highest mean score of attitude (11.7), though respondents receiving information through health officers have only slightly lower mean of score of attitude (11.6). the full model, when all socioeconomicdemographic characteristics, source of hiv information, and hiv knowledge are simultaneously included, three variables are significant, hiv knowledge, source of information, education. higher hiv knowledge is significantly associated with positive attitude towards plwha. however, this model explained only 17% of the variability (data not shown). discussion these community-based survey results provide overall picture of perception and attitude towards hiv/aids. findings from this current analysis will be useful for communication programmes and monitoring and evaluating hiv/aids prevention programmes, in ethnic minority communities. this study results found that the socioeconomic demographic, but age, sex, ability to read and write had relationship with perception towards hiv/aids. it is consistent with findings is similar with the finding in bangladesh [4]. in recent years, the education system provide information towards hiv/aids through small section, especially in secondary school. therefore, 41                                 global health management journal, 2017, vol. 1, no. 2        those who had secondary school had higher perception than no education group, the higher secondary and primary school are not significantly associated with perception towards hiv/aids. this findings is consistent with the findings of study in bangladesh, where they also found that respondents with secondary school or above was more likely awareness towards hiv/aids [4]. the mass media is a common source on hiv prevention programmes (92.8%). the hiv/aids information on prevention and transmission were provided through the tv, newspapers, radio, magazines, poster. this finding is consistent with the finding of the study in bangladesh, where they found that the mass media like the radio and tv are the primary sources of hiv/aids information [10]. this study showed all the hiv information sources had strong relationship with perception towards hiv/aids. but the study also found that the respondents who received hiv information though mass media had lower perception in comparison with health officers and other sources includes family had hiv-positive persons, friends. most important is that the hiv/aids prevention had low effectiveness due to socio-cultural barriers. the hiv information in the mass media only provided some information about hiv prevention without enough details of hiv information for better understanding. therefore, the local health government think that it is unsuitable to promote hiv knowledge and perception towards hiv/aids directly, as the community will not accept it. from that reason, the hiv information was provided through the health officers in the village, meeting and community activities. this finding is consistent with the study in india [1]. the hiv knowledge is also a determinant of perception towards hiv/aids. the results show a positive significant relationship between the perception towards hiv/aids and hiv knowledge. the ethnic minorities, those who had high perception will be reject misperception towards hiv/aids. the results reflect the effective of hiv knowledge was improved in minority communities through the hiv communication programmes. the results consistent with previous studies [9, 11]. in generally, the study found that while the most of socioeconomic-demographic characteristics is not significantly relationship with attitude towards plwha, education level shows its significant with attitude. the results show that the respondents who had secondary school or higher are significantly related to high attitude towards plwha. the difference study showed that the educated ethnic who had education at higher level, have higher attitude towards plwha [2, 15]. the significantly relationship between education and attitude towards plwha represent the effectiveness of hiv prevention programmes through the activities providing the hiv information over time. besides, as the discussion above also indicates that education level at higher level had more perception towards hiv/aids, which may be lead to high attitude towards plwha among ethnic minorities. the findings also found that the hiv information sources provided by health officers had significantly positive relationship with attitude towards plwha. the findings shows the limitation and socio-culture barriers of hiv intervention to improve attitude towards plwha. the hiv message on hiv communication is only providing the ways of hiv prevention, this is not enough details to have better understanding towards hiv/aids. on other hand, the health officers are usually ethnic minorities living in community, who had advantage to provide hiv information by the visiting home and village activities. the result is consistent with the other study, where the hiv information sources had significantly relationship with attitude towards hiv-infected persons [6]. the result found that the hiv information had strong positive relationship with attitude towards plwha. those who had higher hiv knowledge related to higher attitude towards hiv-infected persons. this is one of important factors that affects changes to the attitude towards hiv-infected persons and reject the stigma towards hiv/aids. to improve the attitude towards plwha in ethnic minority communities needs to improve the hiv knowledge and quality of hiv information sources. the finding is consistent with the other studies [1, 3, 8, 11, 15]. these study shows that those who had higher level of hiv knowledge are more significantly related to empathy attitude towards plwha. global health management journal, 2017, vol. 1, no. 2   42      conclusion this study concludes that the common hiv information sources is the mass media channel (92.8%). however, respondents who received hiv information through mass media channels had lower perception and attitude towards hiv/aids than those received from the local health provider, or even other sources. this shows that the limitations of hiv communication campaign through mass media channels in ethnic minorities. this study also indicates that the most of socioeconomic-demographic characteristic is a factor related to perception towards hiv/aids. the hiv knowledge as well as exposure hiv information sources affects their perception towards hiv/aids. education level is one of socioeconomic-demographic related to attitude towards plwha. the hiv information provided by the health officers, who are ethnic minorities had more effectiveness of improving attitude towards plwha in community. the hiv knowledge also contributes an important role in improving the attitude towards plwha among ethnic minority. since the information sources can increase the perception towards hiv/aids. the future hiv/aids programmes need to improve the quality of hiv messages through mass media channel with adequate hiv information combine with social messages. besides, the combination roles between multichannel mass media and health officers is needed. the mass media are most effective when it is used in combination with interpersonal interaction. it can be proposes as solution for sociocultural barriers in hiv prevention among ethnic minorities. conflict of interests none declared. references 1. agrawal, h. r. knowledge of and attitudes to hiv/aids of senior secondary school pupils and trainee teachers in udupi district, karnataka, india. tropical child health.1999; 19(2), 143-149. 2. elsadig, y. m. knowledge and attitudes of population towards hiv/aids in four states, sudan. sudan journal of medical sciences. 2011; 6(2), 125130. 3. gao, x. w. effectiveness of school-based education on hiv/aids knowledge, attitude, and behavior among secondary school students in wuhan, china. plos one. 2012; 9. 4. hasan, a. h. influence of socio-demographic factors on awareness of hiv/aids among bangladeshi garment workers. springerplus, 2013; 2, 174. 5. kraus, s. j. aids in 2010 “the global anh regional epidemic anh response” unaids regional support steam for asia and pacific. unaids. 2010. 6. li l, r.-b. m. mass media and hiv/aids in china. journal health communication. 2009;14(5), 424438. 7. ministry of health vietnam. declaration of commitment on hiv and aids adopted at the 26th united nations general assembly special session in june 2001 hanoi, march 2010: reporting period: january 2010 – december 2011. hanoi: ministry of health vietnam. 2012. 8. naim nur. turkish school teachers’ knowledge and attitudes toward hiv/aids. croat medical. 2012; 53(3), 271-277. 9. naing, c. m. hiv/aids-related knowledge, attitudes and perceptions: a cross-sectional household survey. southeast asian j trop med public health. 2010; 952-960. 10. shafiqurrahman, m., & lutforrahman, m. media and education play a tremendous role in mounting aids awareness among married couples in bangladesh. aids research and therapy. 2007; 4(10). 11. tavoosi, a., & azadeh zaferani, a. e. knowledge and attitude towards hiv/aids among iranian students. bmc public health. 2004; 4(17), 14712458. 12. unaids. hiv in asia and the pacific: getting to zero. joint united nations program on hiv/aids (unaids). 2011. 13. unaids. global report: 2012 unaids report on the global aids epidemic. joint united nations program on hiv/aids. 2012 14. vaac. vietnam: hiv prevention programme report vietnam. vietnam athority of hiv/aids control .2012. 15. wang, g. k. association of knowledge of hiv and other factors with individuals’ attitudes toward hiv infection: a national cross-sectional survey among the japanese non-medical working population. plos one. 2013; 8(7). cite this article as ulkhasanah me, hadisaputro s, pujiastuti rse. the effect of chocolate consumption (theobroma cacao l.) on level of blood cholesterol and triglyceride in hypertension patients at jatiroto health center, indonesia. global health management journal. 2019; 3(1):20-24. global health management journal www.publications.inschool.id published by original research article issn 2580-9296 (online) the effect of chocolate consumption (theobroma cacao l.) on level of blood cholesterol and triglyceride in hypertension patients at jatiroto health center, indonesia muzaroah ermawati ulkhasanah*, suharyo hadisaputro, rr. sri endang pujiastuti postgraduate applied science program in nursing, poltekkes kemenkes semarang, semarang, indonesia. *corresponding author. email: muzaroahermawati29@gmail.com article info abstract article history: received 25 august 2018 reviewed 04 september 2018 received in revised form 23 february 2019 accepted 26 february 2019 background: hypertension is influenced by lifestyle factors such as high fat intake which has the potential for high blood cholesterol level. cocoa products, which are rich sources of flavonoids, have been shown to reduce blood pressure and the risk of cardiovascular disease. aims: the purpose of this research is to examine the dark chocolate consumption in decreasing the level of blood cholesterol and triglyceride in hypertension patients. methods: this research is a quasi-experiment study with pre and post and control group design. there were thirty two (32) hypertensive patients selected from jatiroto health center in june-july 2018 using a random sampling technique. the respondents were then divided to (1) a control group where patients were prescribed to a popular non-pharmacological therapy simvastatin and (2) an intervention group where the respondents were prescribed with simvastatin and also received an additional dark chocolate 60gr/day (given twice a day, each 30gr) for 15 days. a spectrophotometer glycerol phosphate oxidase (gpo-pod) with 546 nm wavelength was employed to measure the levels of blood cholesterol and triglyceride. the significant mean difference between pre and posttest, and the changes between control and intervention group were defined by statistical analysis t-test. results: this study acknowledged that the prescribed simvastatin alone presents a significant contribution to decrease the cholesterol level at 14.40 point (p value = 0.041), however, the generic is not enough to deliver a significant effect to the decrease of triglyceride level in the hypertension patients (p value = 0.361). a great contribution to the depression of cholesterol and triglyceride level in the hypertensive respondent was observed if simvastatin prescription was combined with a provision of 60 gram dark chocolate, respectively to the level of 57.06 and 38.41 mg/dl with p value = 0.001. the addition of dark chocolate in the simvastatin prescription will significantly reduce the blood cholesterol level (p value = 0.020), but not really effective to reduce the triglyceride (p value = 0.560). conclusion: the findings suggest that giving dark chocolate to the hypertensive patients who receive simvastatin prescription will decrease the cholesterol and triglyceride levels greater than the consumption of simvastatin drugs alone. keywords: dark chocolate simvastatin hypertension cholesterol triglyceride © 2019 publications of yayasan aliansi cendekiawan indonesia thailand this is an open-access following creative commons license deed – attribution-noncommercial-sharealike 4.0 international (cc by-nc-sa 4.0) introduction hypertension is a non-communicable disease and is indicated by the increasing of systole blood pressure ≥140 mmhg and diastole blood pressure ≥90 mmhg. world health organization (who) estimated 24% of male and 20.5% of female adults worldwide suffered from hypertension [1]. unhealthy life style such as poor diet and lack of physical activity has been identified as the risk factors of ncds [2-4]. high unsaturated fat intake affects the development of elevated blood cholesterol levels as the benchmark for the incidence of http://publications.inschool.id/index.php/ghmj/index http://publications.inschool.id/ http://inschool.id/ http://publications.inschool.id/index.php/ghmj/index http://inschool.id/ http://creativecommons.org/licenses/by-nc-sa/4.0/ 21 global health management journal, 2019, vol. 3, no. 1 ulkhasanah et al. global health management journal. 2019; 3(1):20-24 clinical cardiovascular disease. the buildup of cholesterol in the blood results in thickening of the walls of the arteries and reduced elasticity of blood vessels. as a consequence, blood flow requires high pressure in passing through narrow blood vessels. the impact that occurs if this condition is not addressed immediately will result in cardiovascular disorders [5]. studies have documented the behavioral intervention as the most cost-effective treatment for ncds instead of medicine [6-8]. dietary modifications that increase the intake of vegetables, fruit, and grains and decrease the intake of saturated fats and refined sugars are recommended for hypertensive patients with high blood cholesterol levels [9] beside physical activity [10, 11]. cocoa products, which are rich sources of flavonoids, have been shown to reduce blood pressure and the risk of cardiovascular disease. regular consumption of cocoa flavanol-containing chocolate bars can significantly lower serum total and ldl cholesterol levels [12] as dark chocolate contains saturated fat and is a source of dietary calories [13]. the mechanism of how dark chocolate may reduce cholesterol are lacking in clinical settings, but several studies have shown that flavones have been shown to stimulate the production of endothelial nitric oxide, causing blood vessels to dilate and thus lowering blood pressure [9]. dark chocolate consumption has also been suggested to have lipid modifying effects, decreasing total and low density lipoprotein cholesterol levels and increasing high density lipoprotein cholesterol levels. this study aims to compare the effect of drug combined chocolate treatment to chocolate treatment only in reducing blood cholesterol level among hypertension patients. methods this was a quasi-experimental study with pre-test and post-test design with a control group design. the population in this study was all hypertensive patients who were treated at the jatiroto health center, indonesia. random sampling technique was practiced to assign patients into 2 groups with criteria of inclusion as follows: 1) having hypertension with systole ≥130 mmhg, and diastole ≥85 mmhg; 2) total cholesterol level above 200 mg/dl; 3) were not under other treatment; and 4) willing to participate in the study. hypertension patients with obesity, diabetes mellitus, and arthrosclerosis and kidney disorders were excluded from the study. patients in the intervention group were administered with simvastatin with an additional dark chocolate 60gr/day (given twice a day, each 30gr) for 15 days, while patients in the control group only received simvastatin as the prescription. blood cholesterol level was measured by trained health officers where the patients were asked to not taken any food (fasting) 8 hours before blood sample taken. the day before any medication taken by the respondents, counted as pretest. after the measurement for the pretest data, the patients were asked to take their medication as prescribed by doctor which at the intervention group they were asked to consume 60gr/day dark chocolate twice a day. at the day 15, patients at the control and the intervention group were invited for blood lipid profile determination (cholesterol and triglyceride), counted as posttest. a spectrophotometer glycerol phosphate oxidase (gpopod) with 546 nm wavelength was employed to measure the levels of blood cholesterol and triglyceride where the interpretation of lipid status was following the classification from national cholesterol education program adult panel iii (ncep-atp iii): cholesterol and triglyceride levels were considered high if measured more than 239 and 199 mg/dl [14]. dependent t-test was employed to analyze the mean difference level of the blood lipid profile before and after treatment, while independent t-test was practiced to observe the results between groups. the procedures, research design and the study preparations have been approved prior the sampling and measurement, by the health research ethics commission of semarang health polytechnic on june 21st, 2018, with number 463/kepk/poltekkes-smg/ec/2018. table 1. frequency distribution of respondent’s characteristics characteristics intervention (n=17) control (n=15) p value f % f % age 26-45 3 17.6 2 13.3 0.791 46-65 11 64.7 11 73.3 >65 3 17.6 2 13.3 sex male 7 41.2 7 46.7 0.592 female 10 58.8 8 53.3 hypertension history yes 7 41.2 8 53.3 0.592 no 10 58.8 7 46.7 bmi underweight 2 11.8 0.041 normal 6 35.3 12 80.0 pre obese 8 47.1 3 20.0 obese 1 5.9 severe obese global health management journal, 2019, vol. 3, no. 1 22 ulkhasanah et al. global health management journal. 2019; 3(1):20-24 results there is no significance difference in the respondents’ age between the intervention and a control group. most of the respondents in both groups are adult aged between 46-65 years old, with a very low proportion of younger and oldest adult. there is a slight difference in the proportion of male/female where female respondents are slightly higher than their male counterparts. more respondents in the control group had hypertension history (53 versus 41 percent) compared to the intervention group. the body mass index (bmi) was categorized into 5 groups; underweight (≤ 18.4), normal (18.5-24.9), pre obese (2529.9), obese (30-39.9) and severe obese (>40). while most respondents in control group are categorized normal, only 35 percent in intervention group had a normal body mass index (bmi). with 47 percent of respondents in the intervention group was categorized as pre-obese, the interpretation of the results should be made with cautions. table 2. cholesterol level (mg/dl) in the intervention and control group variable intervention (n=17) control group (n=15) mean ± sd range mean ± sd range pre 250.18±31.08 204-298 236.00±24.2 207-271 post 193.12±43.55 98-260 222.40±30.5 178-278 table 2 shows the cholesterol levels of patients in both group. prior to the intervention, blood cholesterol level of respondents in the intervention group was higher compared to their counterparts in the control group (250 versus 236 mg/dl), which means, all patients are above the normal level (200 mg/dl). after the provision of simvastatin with an additional dark chocolate 60gr/day (given twice a day each 30gr) for 15 days, the blood cholesterol level of respondents in the intervention group decreased significantly to 193 mg/dl whereas respondents in the intervention group who did not received dark chocolate treatment slightly decreased into 222 mg/dl. table 3. blood lipid profile (cholesterol and triglyceride) before and after treatment at the control and intervention group blood lipid profile pretest-post test p value control intervention cholesterol (mg/dl) difference -14.40 ± 24.83 -57.06 ± 41.50 0.020 p value 0.041 0.001 triglyceride (mg/dl) difference -23.47 ± 96.10 -38.41 ± 38.98 0.560 p value 0.361 0.001 from a paired t-test, as shown in table 3, this study noticed that the prescribed simvastatin alone presents a significant contribution to decrease the cholesterol level at 14.40 point (p value = 0.041), however, the generic is not enough to deliver a significant effect to the decrease of triglyceride level in the hypertension patients (p value = 0.361). a great contribution to the depression of cholesterol and triglyceride level in the hypertensive respondent was observed if simvastatin prescription was combined with a provision of 60 gram dark chocolate, respectively to the level of 57.06 and 38.41 mg/dl with p value = 0.001. from an independent t-test, it showed that there is a significant difference of blood cholesterol between intervention and control group with a p value of 0.020, however, the mean difference of triglyceride is not significant at the control group (p value > 0.05). it means that the addition of dark chocolate in the simvastatin prescription will significantly reduce the blood cholesterol level, but not really effective to reduce the triglyceride. discussion the present study found, the generic simvastatin prescribed to the hypertension patients slightly decreased the blood lipid profile. a higher depression of cholesterol and triglyceride level was observed at the intervention group where the patients received the simvastatin with the provision of dark chocolate. although patients in the control group also experienced a slight decrease in the cholesterol level, however, the chocolate addition helped the reduction of cholesterol level of patients in the intervention group further. the results of this study corresponds with the previous studies in evaluating the intake of 50 grams of chocolate against the lipid profile in hypertension which showed a decrease in the average total cholesterol level [15]. dark chocolate which contained flavonoids has been proven helpful in reducing levels of 3-hydroxy-3-methylglutaryl-coa (hmg coa) reductase which later causes a decrease in cholesterol levels in the blood [16]. dark chocolate with flavonoid-rich also improved endothelial function after regular consumption for 30 days [17]. the changes in triglyceride level will only be significant if the hypertensive patients who received simvastatin prescription also adding dark chocolate to their daily consumption. the findings in line with the previous study which acknowledged the popular non-pharmacological therapy, simvastatin, decreased the triglyceride level in blood, however the changes was not significant [18]. however, if compared to the level in control and intervention group, the 2-week additional consumption of 60 gram dark chocolate, doubled from the previous study 23 global health management journal, 2019, vol. 3, no. 1 ulkhasanah et al. global health management journal. 2019; 3(1):20-24 by muniyappa et. al. [19], is still not effective to reduce the triglyceride. flavonoid compounds which are polyphenol derivatives capable of reducing plasma total cholesterol levels by inhibiting cholesterol absorption by the intestine and increasing the reaction of bile acid formation from cholesterol and then secreted through feces. phenol and polyphenols play a role in reducing the secretion of lipoproteins found in the liver and intestines and reduce the process of cholesterol esterification resulting in a decrease in cholesterol ester levels where cholesterol esters are the main formation component of psychometric and vldl [20]. the activity of lipoprotein lipase will also decrease the level of triglyceride. antioxidants are able to dissolve in water and work very effectively as a deterrent to the process of lipid peroxidation in the plasma. in addition, it helps the hydroxylation reaction in the formation of bile acids thereby increasing cholesterol excretion and decreasing total cholesterol levels in the blood [20]. polyphenol compounds affect the rate of increase in blood cholesterol levels by inhibiting the increase in total cholesterol levels by a mechanism to inhibit the activity of the enzyme hmg coa reductase which plays an important role in the biosynthesis of cholesterol [21, 22]. conclusion this study concluded that the prescribed simvastatin alone presents a significant contribution to decrease the cholesterol level, however, the generic is not enough to deliver a significant effect to the decrease of triglyceride level in the hypertension patients. a significant contribution to the depression of cholesterol and triglyceride level in the hypertensive respondent was observed if simvastatin prescription was combined with a provision of 60 gram dark chocolate per day for 15 days. the findings recommend the provision of dark chocolate to the hypertensive patients who received simvastatin prescription in their medication to significantly reduce the blood cholesterol level, but not really effective to reduce the triglyceride. conflict of interests no conflict of interests involved in the study. references 1. world health organization. world health statistics 2010: world health organization; 2010. 2. islam sms, purnat td, phuong nta, mwingira u, schacht k, fröschl g. non‐communicable diseases (ncds) in developing countries: a symposium report. globalization and health. 2014;10(1):81. 3. miranda jj, kinra s, casas jp, davey smith g, ebrahim s. non‐communicable diseases in low‐and middle‐income countries: context, determinants and health policy. tropical medicine & international health. 2008;13(10):1225-34. 4. peasey a, bobak m, kubinova r, malyutina s, pajak a, tamosiunas a, et al. determinants of cardiovascular disease and other non-communicable diseases in central and eastern europe: rationale and design of the hapiee study. bmc public health. 2006;6(1):255. 5. naue sh, doda v, wungouw h. hubungan kadar kolesterol total dengan tekanan darah pada guru di smp 1 dan 2 eben haezar dan sma eben haezer manado. jurnal e-biomedik. 2016;4(2). 6. world health organization. global action plan for the prevention and control of noncommunicable diseases 2013-2020: world health organization; 2013. 7. popkin bm. global nutrition dynamics: the world is shifting rapidly toward a diet linked with noncommunicable diseases–. the american journal of clinical nutrition. 2006;84(2):289-98. 8. popkin bm, horton s, kim s, mahal a, shuigao j. trends in diet, nutritional status, and diet-related noncommunicable diseases in china and india: the economic costs of the nutrition transition. nutrition reviews. 2001;59(12):379-90. 9. zomer e, owen a, magliano dj, liew d, reid cm. the effectiveness and cost effectiveness of dark chocolate consumption as prevention therapy in people at high risk of cardiovascular disease: best case scenario analysis using a markov model. bmj. 2012;344:e3657. 10. hallal pc, andersen lb, bull fc, guthold r, haskell w, ekelund u, et al. global physical activity levels: surveillance progress, pitfalls, and prospects. the lancet. 2012;380(9838):247-57. 11. lee i-m, shiroma ej, lobelo f, puska p, blair sn, katzmarzyk pt, et al. effect of physical inactivity on major non-communicable diseases worldwide: an analysis of burden of disease and life expectancy. the lancet. 2012;380(9838):219-29. 12. allen rr, carson l, kwik-uribe c, evans em, erdman jr jw. daily consumption of a dark chocolate containing flavanols and added sterol esters affects cardiovascular risk factors in a normotensive population with elevated cholesterol. the journal of nutrition. 2008;138(4):725-31. 13. tokede o, gaziano j, djousse l. effects of cocoa products/dark chocolate on serum lipids: a metaanalysis. european journal of clinical nutrition. 2011;65(8):879. 14. evaluation expert panel on detection. executive summary of the third report of the national cholesterol education program (ncep) expert panel on detection, evaluation, and treatment of high blood cholesterol in global health management journal, 2019, vol. 3, no. 1 24 ulkhasanah et al. global health management journal. 2019; 3(1):20-24 adults (adult treatment panel iii). jama. 2001;285(19):2486. 15. nogueira ldp, knibel mp, torres mrsg, neto jfn, sanjuliani af. consumption of high-polyphenol dark chocolate improves endothelial function in individuals with stage 1 hypertension and excess body weight. international journal of hypertension. 2012;2012:9. 16. sudarma v, sukmaniah s, siregar p. efek cokelat hitam terhadap nitrit okside serum dan tekanan darah pada subyek prehipertensi (the effect of dark chocolate to serum nitric oxide levels and blood pressure in prehypertension patients). acta med indones-indones j intern med. 2011;43(4):224-118. 17. balzer j, rassaf t, heiss c, kleinbongard p, lauer t, merx m, et al. sustained benefits in vascular function through flavanol-containing cocoa in medicated diabetic patients. journal of the american college of cardiology. 2008;51(22). 18. nogueira ldp, knibel mp, torres mrsg, nogueira neto jf, sanjuliani af. consumption of highpolyphenol dark chocolate improves endothelial function in individuals with stage 1 hypertension and excess body weight. international journal of hypertension. 2012;2012:1-9. 19. muniyappa r, hall g, kolodziej tl, karne rj, crandon sk, quon mj. cocoa consumption for 2 wk enhances insulin-mediated vasodilatation without improving blood pressure or insulin resistance in essential hypertension. the american journal of clinical nutrition. 2008;88(6):1685-96. 20. listianasari y, dirgahayu p, wasita b, nuhariawangsa amp. efektivitas pemberian jus labu siam [sechium edule] terhadap profil lipid tikus [rattus novergicus] model hiperlipidemia (the effectiveness of squash [sechium edule] juice administration on the lipid profile of hyperlipidemia model-rat [rattus novergicus]). penelitian gizi dan makanan. 2017;40(1). 21. havsteen b. the biochemistry and medical significance of the flavonoids. . elsevier2002. 22. muflikhatur s, murwani h. perbedaan pengaruh antara ektrak dan rebusan daun salam (eugenia polyntha) dalam pencegahan peningkatan kadar kolesterol total pada tikus sprague dwely. journal of nutrition college. 2014;2(1):142-9.   cite this article as  macnab aj, mukisa r, mutabazi s, steed r. engaging schools in diagnosis and treatment  of malaria: evidence of sustained impact on morbidity and behavior. global health  management journal. 2017; 1(2): 43‐52.    global health management journal  www.publications.inschool.id  published by  original research article issn 2580-9296 (online) engaging schools in diagnosis and treatment of malaria: evidence of sustained impact on morbidity and behavior andrew j macnab 1,2,*, ronald mukisa 1,3, sharif mutabazi 3, rachel steed 4 1 stellenbosch institute of advanced study, wallenberg research centre at stellenbosch university 7600 stellenbosch, south africa. 2 university of british columbia, vancouver, canada. 3 health and development agency, uganda. 4 hillman medical education fund, vancouver, canada. *corresponding author. email: ajmacnab@gmail.com article info abstract article history: submitted 21 april 2017 accepted 4 october 2017 background: in low and middle income countries (lmics) teachers send home children found sick in class devolving subsequent care to parents; where malaria is endemic, morbidity is high as the most parents fail to access who-endorsed rapid diagnostic testing (rdt and prompt treatment with artemisinin combination therapy (act). consequently malaria is the principal reason a child misses school; so, we trained teachers to use rdt to evaluate all sick pupils and give act promptly to those positive. aims: pre, intra and post intervention evaluation of impact of using the who health promoting school (hps) model to empower teachers to provide rdt and act and engage and inform pupils about malaria in 4 schools in rural uganda. methods: documenting duration of absence from school as a surrogate measure for morbidity and change in children’s knowledge and reported behaviors regarding malaria. preintervention (year 1) baseline evaluation of days of absence and children’s malaria knowledge/behavior; intervention (year 2) trained teachers administered rdt in all sick children and treated those positive with adt; post-intervention (end of year 3) after schools independently continued rdt/act and education on malaria. results: pre-intervention <1:5 pupils had basic knowledge about malaria (caused by mosquitos; can be prevented; requires rapid diagnosis and prompt medication). in year 1: 953 of 1764 pupils were sent home due to illness. mean duration of absence was 6.5 (sd 3.17) school days. in year 2: 1066 of 1774 pupils were sick, all had rdt, 765/1066 (68%) tested positive and received act; their duration of absence fell to 0.59 (sd 0.64) school days (p<0.001). by year 2 all children knew the signs and symptoms of malaria and had essential epidemiological knowledge. twelve months post intervention the universality of this knowledge had been sustained and the whole-school focus on malaria continued. children reported better health, more consistent attendance and improved academic achievement, and had become proactive in prevention strategies; 6% fewer tested positive for malaria; and key health knowledge was being passed to new pupils. conclusion: teacher administered rdt/act reduced child morbidity from malaria significantly; essential knowledge was generated and new health practices acquired that changed behaviors. our who hps model is applicable to other lmics where malaria is endemic and morbidity high keywords: health promoting schools malaria school-based intervention teachers this article is an extension of a selected paper “teachers as agents of change: school-based diagnosis and treatment of malaria positively impacts child morbidity” published in proceedings of the international conference on applied science and health (no. 1, february 2017). © 2017 publications of yayasan aliansi cendekiawan indonesia thailand this is an open access following creative commons license deed – attribution-noncommercial-sharealike 4.0 international (cc by-nc-sa 4.0).   global health management journal, 2017, vol. 1, no. 2  44      introduction in many low and middle income countries (lmics) worldwide malaria is the main reason a school-aged child will die and the principal reason why a child will be absent from school [1,2]. teachers recognize that the duration of malaria-related absence, frequency of absence due to repeated infection, residual malaise from sub-optimal treatment and temporary or permanent neurological complications of falciparum malaria can all compromise a child’s potential to learn [3-5]. the burden of disease from malaria morbidity and mortality is greatest among children in low resource settings. the world health organization (who) advocates early, accurate diagnosis of malaria and prompt, effective and affordable treatment within 24 hours of the onset of illness [6]. validated measures to do this exist, but health resources to diagnose and treat malaria are scarce in most lmics, especially in rural and low resource communities, and to date diagnostic and treatment measures have not been made available in schools. a diagnosis of malaria based on history and examination alone is difficult to make because symptoms are not specific; a lack of knowledge about appropriate treatment and limited access to care also contribute to morbidity and mortality [7]. hence, there is an urgent need for the simple, accurate and inexpensive diagnostic testing tools and effective therapeutic agents that now exist to be made available at a community level [8]. the combined use of rapid diagnostic test kits (rdt) to diagnose malaria and prompt administration of a locally effective therapeutic agent such as artemisinin combination therapy (act) in those who test positive has improved both diagnostic accuracy and treatment efficacy. rdt kits are now available in many countries and the feasibility of using them in rural clinics without laboratory facilities has been demonstrated [9, 10]. but deployment of rdt and act has been slow, especially in low resource settings as the engagement of the population necessary to spread the knowledge that this approach is effective and empower rural communities to use them has been missing [8]. although rdt and act use is recommended by who, training low cadre health care workers, including school staff, in their use has not occurred. malaria rdts provide a diagnosis in minutes by detecting the presence of malaria parasites in human blood. rdt kits vary, but the principles of how they work are similar [11]. most are for individual use and include a lancet to obtain blood from a finger-prick. a drop of blood from a sick patient is put onto a reagent strip to test for the presence of specific proteins (antigens) produced by malaria parasites. if malaria antigens are present, they bind to the dye-labeled antibody reagent in the kit, creating a colour change in the results window. the sensitivity and specificity of rdts is good enough for them to replace conventional testing for malaria [12]. who recommends acts as the first-line therapy for p. falciparum malaria worldwide [13, 14]. originally sourced from the natural herb artemisinin can now be made synthetically. acts combine artemisinin which kills the majority of parasites in a few hours, with a longer half-life partner drug of a different class which eliminates the remaining parasites in a single fixed-dose tablet. benefits of genuine acts include high efficiency, fast action, few adverse effects, low cost and the potential to lower the rate at which resistance emerges and spreads [13]. care must be taken in the choice of preparation in lmics as counterfeit products with little or no efficacy are widespread. since 2006 we have established health promoting school (hps) using the who model in rural uganda to deliver low cost health education in schools [15]. we learned from teachers that absence from school due to malaria is high, and on investigation found that most children sent home due to febrile illness do not then get taken to a clinic for diagnosis and treatment by their parents; reasons for this include the distance to a clinic, cost, and lack of awareness that care is important. hence, as a logical and medically expedient response, we designed a trial where diagnosis and treatment using rdt/act would be provided in schools by trained volunteer teachers to address the challenge and burden of malaria amongst children in rural resource-poor settings. 45                                 global health management journal, 2017, vol. 1, no. 2        the hypothesis was that with engagement of teachers to provide school-based rapid diagnostic testing, all sick children normally just sent home with presumed infectious illness would be screened for malaria using rdt and those who tested positive given act, and as a result child morbidity due to malaria would improve, as measured by a significant reduction in days absent from school. a secondary benefit anticipated was that children’s knowledge about malaria would increase and that changes in their behavior would occur particularly related to prevention and treatment. methods this was a community outreach health education project conducted in 4 newly established health promoting schools by the health and development agency (heada) uganda. heada is a nongovernmental agency funded by the hillman medical education fund to implement comprehensive health education, treatment and support programs in western uganda [16]. the project followed the principles of participatory action research and incorporated related process to promote participation and achieve trust in the communities engaged [17]. the full protocol and sequence for community engagement has been described previously [16]. the teachers in the schools and leaders in the community were central to this intervention. teachers and heada staff held public forums to inform and engage members of the community. these included presentations with question and answer sessions where teachers explained how absence from school due to malaria was having a negative impact on the education of a large number of children. the community came to understand that the current practice of sending children home who were sick was problematic, as although many were assumed to have malaria, once home their parents often did not take any action to get a diagnosis or treatment. also because many children were absent for a week or two due to illness, and then often remained unwell for days or even weeks after they returned, so consequently were unable to benefit fully from being back in school. current knowledge about the benefits of interventions available to help prevent, diagnose and treat malaria and the practicalities of delivering them were explained; particularly the use of rdt kits in government clinics for prompt diagnosis and importance of early treatment with act. when community leaders (teachers and elders) subsequently chose a school-based intervention to address malaria absenteeism heada coordinated discussions to facilitate implementation. these included establishing if teachers would invest the time to take the training required, be prepared to sustain a school-based program, and perform testing involving collection of blood from a finger prick. teachers in the schools then invited parents to participate in community-wide sessions which allowed dialogue regarding the process and the obtaining of consent; no parents wanted their child excluded. each school signed an agreement to follow the co-developed action protocol for a trained teacher to evaluate all children identified as sick who would normally be sent home, conduct the rdt and administer act in those positive. the teachers in the 4 schools were orientated on the action protocol by heada staff who then visited each school weekly during the project to support the teachers, collect data sheets documenting the pupils absent from school and the sick, tested and treated children and deliver supplies (rdt kits, act medication, and sharps boxes for used blood lancets and biohazard bags for safe waste disposal. ninety km separated the 4 schools; a motorcycle and fuel costs were included in the budget. in year one the protocol included data collection on all sick pupils sent home and subsequently absent. absence for reasons other than presumed infectious illness was excluded. heada trained the teachers who volunteered to conduct rdt and administer act in one day interactive workshops supervised by a physician and run by two trained laboratory staff and two nurses. instruction included: how to evaluate a child for a presumed infectious illness; the theory and practice for conduct of rdt and administration of act; record keeping; needle safety and waste disposal techniques [16]. practical competency was evaluated and a refresher course given in year two. the rdt kits used were: malaria ag pan/pf malaria test kits ‘malarascan’ (zephyr biomedical systems) which targets hrp2 and pan global health management journal, 2017, vol. 1, no. 2  46      aldolase of plasmodium falciparum and other less common plasmodium species (p. vivax, and p. ovale); sensitivity (96.3%) and specificity (98%) are high [16]. in year two the protocol added rdt screening by teachers of all children identified as sick and treatment of those testing positive for malaria with act [18]. a single dose act preparation was used to ensure a full course of treatment was completed; this was to avoid the potential for partial treatment bias if any of the five additional doses that would have had to be given at home were missed had a conventional 3 day 12 hourly regimen been used. the act given was arco (artemisininnapthoquine) (midas care uganda, ltd). the drug was taken with milk or juice to aid tolerance under teacher supervision. children were observed for at least 1 hour for side effects; the protocol called for another dose to be given if vomiting occurred [16]. throughout the 2 year intervention heada and the schools maintained community-based dialogue to sustain the school-based action and promote new knowledge and behavioral change community wide. in the schools classroom education was added to increase knowledge and develop practices and behaviours to benefit the children in the context of malaria. a pre-assessment of children’s knowledge and behaviors related to malaria preceded new hps activities; assessment was repeated for comparison early in the intervention year; and again 12 months post-intervention when the schools were operating the rdt/act program independently. result four primary schools (classes primary 1-7) were engaged in geographically separate low resource settings in south western uganda [16]. table 1 shows pupil enrollment (1764 in year one and 1774 in year two) and demographic data, and the impact on absence from school comparing year one (preintervention) and year two (intervention). community-based dialogue (may – september 2013) led to the collaborative decision to introduce school-based teacher-administered rdt and act to address absence from school due to malaria. statements made by head teachers included: a) “this is exactly what we need, testing and treating malaria at school. we are ready to collaborate”. b) “our children suffer from fever and malaria, but we send them home where they are given local herbs and paracetamol. malaria affects children’s brains and ability to learn; it is a great opportunity for us to be trained to prevent this from continuing to happen”. c) our teachers are enthusiastic about being involved in testing and treating children after they have undergone training. our school board chairman has endorsed the idea. we are grateful for this initiative” [16]. logistic planning, baseline assessment and teacher training (september 2013 august 2014 in year one) and was followed by action/intervention with ongoing evaluation (september 2014 august 2015 in year two). this allowed a 2 year evaluation where pre and post intervention data were collected over comparable 3 term periods during 2 consecutive school years, recognizing the seasonal nature of malaria. knowledge and awareness about malaria causation, transmission, prevention, diagnosis and management amongst the children was assessed in classroom sessions. pre-intervention less than 20% of the children knew mosquitos transmitted malaria, the role of bed nets in prevention, how malaria can be diagnosed and why prompt and effective treatment is important. by early year two virtually all children had this knowledge, and understood how infection would make them feel unwell and how to access diagnosis and treatment. questionnaires established that all teachers (except one) wanted training to do rdt for malaria and administer act. all agreed to take on the additional work of evaluating sick children and follow the action protocol. to provide the 2 trained teachers the 4 schools asked for to conduct the duties required (one as primary evaluator and one as a back-up) eleven volunteers were trained over 2 years; their performance and a refresher course evaluation confirmed all retained the necessary knowledge and practical competency. we also identified that for the majority of sick children sent home in year one with symptoms compatible with malaria parental management was not in keeping with who recommendations [6]. only 26% were taken for clinic-based diagnostic and/or anti-malarial treatment measures and the 47                                 global health management journal, 2017, vol. 1, no. 2        majority (42%) were only given an anti-pyretic (e.g. paracetamol/tylenol); other care included local herbal remedies (19%), being taken to church (8%), or to a traditional healer (6%) [18]. children identified by their classroom teachers as being sick and needing to be sent home using the school’s regular criteria numbered 953 in year one (pre-intervention) and 1066 in year two (intervention). these 1066 were evaluated by a trained teacher and an rdt performed; 715/1066 (67.5%) tested positive and all 715 of them received immediate treatment at school with a single dose act preparation (artemisinin-napthoquine). table 1. study demographics and diagnostic, treatment and absenteeism data for the 4 participating schools: year 1 indicates pre-intervention, while year 2 shows data after intervention by teachers using rdt and act. modified from mukisa et al., 2016 [16] variables year 1 year 2 children age-years gender m/f 1764 5-13 49/51% 1774 5-13 49/51% schools 1 2 3 4 1 2 3 4 children at each school 412 451 189 712 422 451 189 712 children found to be sick at school 953 1066 sick/per school 221 200 218 314 263 201 300 302 sick/per term term 1 term 2 term 3 56 127 80 27 97 77 55 135 110 70 133 99 sick: sent home 953 sick: tested rdt 1066 sick: rdt +ve for malaria term 1 term 2 term 3 total 715 27 92 49 20 74 57 28 68 106 35 98 62 sick: rdt +ve treated with act term 1 term 2 term 3 total 715 27 92 49 20 74 57 28 68 106 70 133 99 absence (days) sick sent home total (mean) 6.5 (3.2) 6.2 6.5 6.7 6.6 2.55 (3.35) p < 0.001 2.4 2.8 3.0 2.5 absence (days) sick sent home rdt positive malaria 0.59 (0.64) p < 0.001 0.49 0.66 0.72 0.48 absence (days) sick sent home rdt negative 4.62 (3.54) p < 0.001 4.1 6.1 4.5 3.8 the mean duration of absence in children sent home with a presumed infectious illness in year one was 6.5 school days from onset of illness to return to class. in year two mean duration of absence overall decreased to 2.55 days (p <0.001), and fell to 0.59 days in the 715 children rdt positive for malaria who were treated immediately with act (p < 0.001). in those rdt negative duration of absence global health management journal, 2017, vol. 1, no. 2  48      was 4.62 days. many treated children felt well enough to ask to return to class within hours of receiving act, and consequently had no days when they were absent from school. overall, absence from school was reduced by 60.8% during this teacher-driven intervention. if the same percentage of children sent home in year one had malaria as were diagnosed using rdts in year two this would equate to 1358 cases in 1775 children over the 2 years a malaria incidence rate of 79% across the 4 schools. no adverse events occurred in the context of rdt screening and no adverse reactions resulted from administration of the single dose act preparation which was well tolerated. no children died from malaria during the intervention year. post-intervention the consensus in the community was that participating children had derived both health and educational benefits from having schoolbased rdt/act provided by teachers. also, that new knowledge was now resulting in behavioral change over how suspected malaria was managed in the broader community. it was agreed that teachers in the 4 schools would continue to offer rdt/act, but via a modified intervention where rdt positive children would now be given a conventional and 3 day act regimen as the cost was less. knowledge transfer was also extended beyond the community to engage the health ministry. repeat evaluation after the schools had maintained the program independently for one year indicated that the whole-school focus on malaria continued, school children still had comprehensive knowledge about malaria and that community commitment to prevention and altered care practices had been sustained. children reported better health, more consistent attendance and improved academic achievement, they were also passing key health knowledge to new pupils and had become proactive in prevention strategies. overall, 6% fewer now tested positive for malaria. discussion teachers can be effective agents for change in the context of malaria. this community-based health promotion intervention has confirmed the feasibility of school-based rdt kit use by teachers to screen children for malaria, and the efficacy of accurate diagnosis combined with prompt treatment with act at school. amongst sick primary school children who would otherwise just have been sent home 67.5% tested positive for malaria and received act. subsequently, many felt well enough to choose to go back to class rather than be sent home, presumably because their malaria was diagnosed soon after symptoms developed, promptly treated and the act rapidly cleared their blood of parasites [19]. for these children, their duration of absence from diagnosis to return to class fell 60.8% when compared to the duration of absence overall in the pre-intervention cohort sent home with a presumed infective illness from more than a week (6.5 school days) to < 1 day. knowledge and awareness related to malaria also improved among the children, and behaviours related to malaria management and prevention in the broader community also showed evidence of change. children now knew how malaria was caused, the symptoms that suggest infection, that prompt diagnosis and effective treatment are available and the importance of both, and parents had learned that malaria can be rapidly diagnosed and there are benefits from early treatment. importantly, re-evaluation post intervention, when the schools had been maintaining the program independently for one year, indicated that the schools’ focus on malaria continued, children’s knowledge was retained and the community was still committed to practices to promote diagnosis and treatment. children reported better health, more consistent attendance and improved academic achievement, and had become proactive in prevention strategies. the change in parental attitudes and behavior is significant as this was a low resource rural setting where prior to this schoolbased initiative, less than a third of febrile children sent home from school received management for malaria that met who recommendations for prompt, accurate diagnosis and comprehensive treatment within 24 hours of the onset of illness [6]. although use of school-based rdt and act by appropriately trained teachers is a novel approach to managing malaria in children our findings are broadly in agreement with previous findings in uganda related to rdt kit and act use. importantly, studies indicate that kits can be 49                                 global health management journal, 2017, vol. 1, no. 2        stocked and used appropriately outside formal health facilities [20], and that training comparable to ours enables individuals without a health care background to use them reliably [21, 22]. while the overall incidence and number of deaths from malaria are decreasing worldwide the disease is still a major cause of mortality and morbidity especially among children [11, 13]; 50% of deaths occur in school-aged children [3], up to 50% of preventable school absenteeism is due to malaria [1], and there is the potential to reduce morbidity and achieve educational benefits as infection with plasmodium falciparum is associated with permanent loss of cognitive and fine motor function in children where diagnosis is delayed and/or treatment is sub-optimal [23, 24]. fernando et al. have reported that an attack of even uncomplicated malaria causes significant short term impairment of cognitive performance, with impairment persisting for around two weeks and appearing to be cumulative with repeated attacks [25]. hence, where teachers are engaged to provide school-based intervention with rdt/act, there is the potential worldwide for child morbidity to be reduced and educational benefits achieved. this approach is relevant even where efforts to promote preventive measures exist, as in many developing countries < 50% of households own a mosquito net and most children do not sleep under insecticide treated nets. as our intervention took place in 4 geographically separated rural schools in low resource communities, and all children identified to be sick with a presumed infectious illness were included, we believe our results and the benefits we describe can be generalized to other areas with a similar endemic setting for malaria. hence, our model of school-based diagnosis and treatment is probably applicable worldwide, provided rdt kits and treatments appropriate for the locally endemic strains of malaria are used [18], and has global relevance as malaria remains the most prevalent parasitic disease that affects human beings worldwide. it is endemic in 108 countries, with >3 billion people estimated to be at risk, among whom the burden of disease is highest or children in low resource communities [24]. this initiative using rdt/act is an example of health promotion that successfully integrates technology and health care policy. it is effective, affordable and easy to use, and has the potential to reduce malaria transmission within communities, because each treated individual’s malaria episode will be shorter, less severe, and hence less likely to result in mosquito-borne transmission to others [13, 19]. the reduction by 6% in the number of infected children when the schools were re-evaluated probably reflects this. however, to date the ‘missing link’ in the rdt/act equation has been the lack of social engagement to make test kits and treatment accessible to rural populations [8]; but now deploying rdt/act through school-based programs offers a logical solution to the burden of malaria and lack of diagnostic and treatment capacity in resource poor settings, and is an approach that our initiative indicates is both feasible and effective. the cost and cost-benefit of rdt/act are relevant to their deployment; the cost of acts especially has been identified as a potential barrier to scale up of initiatives that use them [8, 22]. our cost for rdt was about us$ 0.50 per kit. we chose to use a relatively expensive (us$ 2.2) single dose act formulation to eliminate any partial treatment bias during our evaluation phase. now a conventional 3 day 6 dose act preparation is being used which is considerably cheaper (us$ 1.0). who has always placed community participation at the centre of ‘health for all’ strategies [26]. it was the school teachers in the community who identified the burden malaria was causing on children’s education; they co-developed a realistic school-based ‘action’, and their ongoing active participation was integral to the success of the intervention. this teacher-driven initiative to address absence from school due to malaria morbidity is an example of the type of innovative, content specific, school-based intervention called for by the who commission on social determinants of health to support health behaviors and empower young people to take control of their lives [27]. teachers have also successfully administered a number of other health programs in schools in lmics which have been proved to be both valuable and cost-effective, including nationwide anti-helminth treatment in uganda [28], provision of intermittent anti-malarial therapy in kenya [29, 30] and prophylactic chloroquine in sri global health management journal, 2017, vol. 1, no. 2  50      lanka [31, 32]; cost-benefit analysis shows that health program delivery costs can be reduced by having teachers implement care [33]. we recognize limitations in what we report. principally that we chose absence from onset of illness to return to school as the outcome measure as a surrogate for malaria morbidity. also, that we can only compare year two data from the rdt positive and act treated children with year one data from the cohort where infectious illness was presumed, but the actual number of malaria cases is unknown. this is because it was not feasible to follow each child sent home for parental care in the community during year one to establish if a diagnosis of malaria was made, and if so what treatment resulted. however, the >10 fold difference in the duration of absence strongly suggests benefit from the school-based rdt/act initiative we trialed. the burden of illness from malaria in these 4 rural schools was significantly reduced; 67.5% of sick children who would otherwise just have been sent home were accurately diagnosed and promptly treated as per who guidelines, in a community where the majority would not have been taken for appropriate care by their parents based on documented pre-intervention behavior. in addition to the improvement in malaria morbidity evident from reduced duration of absence, it is likely that in the longer term the learning potential and educational outcomes of children managed with school-based rdt/act will also improve. while children diagnosed and treated in this initiative missed less school as they recovered quickly, it is also probable that they recovered more completely and with fewer, or no long term consequences. malaria in uganda is predominantly caused by plasmodium falciparum. this infection is known to be associated with brain related consequences, especially when treatment is delayed, incomplete or absent, and functional impairment occurs that involves all cognitive spheres: language, attention, memory, visuospatial skills and executive functions [5, 24, 28, 34, 35]. it should also be stated that, although not directly measured, our belief is that this project has also broadened community knowledge about malaria, probably because the initiative was co-developed and collaboratively delivered by the communities where the 4 schools were located. if so, this is a secondary benefit of importance. prior research has identified that improved health knowledge and health-related behaviors are often evident in the community as a whole where comprehensive school health promotion programs are delivered [36, 37]. importantly, even though rdt kit use and act provision in schools has not happened previously, this is the approach to malaria diagnosis and treatment recommended by who and endorsed by many governments worldwide. the low complexity and diagnostic reliability of rdt and efficacy and reliability of act invite their use by personnel without formal medical training. and, as malaria remains a priority area for governments, aid foundations, health care providers and educators worldwide [11, 13, 27, 38, 39] novel and effective avenues for enhancing intervention are constantly being sought. because schools are being used increasingly as platforms for delivering simple, safe and cost-effective health interventions, and our school-based rdt/act model is a feasible and effective means of reducing child morbidity due to malaria, we suggest this teacher-driven approach is applicable in low resource settings worldwide where morbidity from malaria is high. conclusion rdt/act use by teachers as a school-based health practice is novel and reduced child morbidity from malaria significantly. our model of engaging and training teachers represents a community empowerment approach applicable to other lowresource settings worldwide where malaria is endemic and morbidity high. in addition to being simple to implement and low cost this model uses who endorsed testing and treatment and is in keeping with the call by the who commission on social determinants of health for innovative school-based interventions to tackle health challenges faced by young people. acknowledgements this project was funded by the hillman medical education fund (hmef), canada, and we gratefully acknowledge the teachers, parents and 51                                 global health management journal, 2017, vol. 1, no. 2        children who participated. a.m and r.m thank the stellenbosch institute for advanced study for their invitations to work at the wallenberg research centre in stellenbosch. conflict of interests none declared. references 1. brooker 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hygiene. 2001;69(6):582-88. 35. birbeck gl, molyneux me, kaplan pw, seydel kb, chimalizeni yf, kawaza k et al. blantyre malaria project epilepsy study (bmpes) of neurological outcomes in retinopathy positive pediatric cerebral malaria survivors: a prospective cohort study. lancet neurology. 2010;9(12):1173-81. 36. macnab aj, gagnon fa. stewart d. health promoting schools: consensus, challenges and potential. health education. 2014;114(3):17085. 37. tang kc, nutbeam d, aldinger c, st leger l, bundy d, hoffmann am et al. schools for health, education and development: a call for action. health promotion international, 2009;24(1):68-77. 38. world health organization regional office for africa. health promotion strategy for the african region. sixty-second session, who regional office for africa, 2013. final report document afr/rc62/9 2013; 58-62. 39. brooker s, clarke s, snow rw, bundy dap. malaria in african schoolchildren: options for control. transactions of the royal society of tropical medicine and hygiene. 2008;102:30405. microsoft word 4. accepted review, hafizh muhammad noor, 32-36.docx cite this article as noor hm. potential of carrageenans in foods and medical applications. global health management journal. 2018; 2(2): 32-6. global health management journal www.publications.inschool.id published by review issn 2580-9296 (online) potential of carrageenans in foods and medical applications hafizh muhammad noor institute of nutrition, mahidol university, thailand. *corresponding author. email: noor.hafizh@gmail.com; noor.hafizh-12@fpk.unair.ac.id article info abstract article history: received 19 january 2018 reviewed 10 may 2018 received in revised form 10 june 2018 accepted 27 june 2018 background: carrageenans, the polysaccharides obtained by extraction of certain species of red seaweeds (rhodophyceae), have been widely used in both food industry and medical applications because of their excellent physical functional properties that are used as gelling, thickening and stabilizing agent. several studies showed biological properties of carrageenans such as antiviral, anticoagulant, antitumor, antioxidant, anti-inflammatory and immunemodulatory activity. aims: this study is to bring a short overview of the potential of carrageenans in foods and medical applications based on their biological activities. methods: this short overview used relevant works and articles examined that collected through several electronic database including pubmed, science direct, springer link and google scholars for the years 1991-2018 with full text in english. results: this study is an alternative approach that is necessary in order to present the potential of carrageenans in foods and medical applications.the advantages of carrageenans as a food additive and pharmaceutical formulation lie on their high availability, low cost, and low induction of resistance. conclusion: this review suggested that carrageenans are suitable to be applied in many kinds of food products as gelling and thickening agent with their antioxidant potency as well as medical applications such as pharmaceutical formulations in drug delivery and experimental medicine. however, more comprehensive studies on toxicity and side effect of carrageenans are necessary. keywords: carrageenan antiviral antitumor antioxidant food and medical application © 2018 publications of yayasan aliansi cendekiawan indonesia thailand this is an open-access following creative commons license deed – attribution-noncommercial-sharealike 4.0 international (cc by-nc-sa 4.0) introduction polysaccharides from some seaweeds have been reported to possess biological activity of potential medical value, including carrageenan [1]. carrageenans are gel forming and viscosifying polysaccharides, which are obtained by extraction of certain species of red seaweeds (rhodophyceae) [2]. carrageenans are split into six basic forms based on their chemical classification: kappa (κ)-, iota (ι)-, lamda (λ)-, mu (µ)-, nu (ν)and theta (θ)[3]. carrageenans are composed of a linear galactose backbone with a varying degree of sulfatation between 15% and 40% [2]. carrageenans are formed by alternate units of ɗ-galactose and 3,6-anhydrogalactose (3,6-ag) joined by α-1,3 and β1,4glycosidic linkage and they have an average relative molecular mass well above 100 kda [4]. carrageenans have the eu additive e-number e407 or e407a, which e407a contains amount of cellulose [4]. the acceptable daily intake (adi) of carrageenan is 0-75 mg/kg bw and the concentration in food products ranges 0.005-2.0% by weight [5]. 33 global health management journal, 2018, vol. 2, no. 2 carrageenans have been used both in food and nonfood products. in terms of food industry, carrageenans are used as gelling, thickening and stabilizing agent because of their excellent physical functional properties [3]. carrageenans are used in yogurt, sauces, jellies, chocolate-milk, frozen desserts, cottage cheese and many other products [2]. carrageenans have been considered as safe and become a constituent of many food products for many years. it was confirmed in 2001 at the 57th meeting of the joint food and agriculture organization of the united nations world health organization expert committee in food additive (jecfa) and only degraded carrageenans were associated to adverse health effects, which should not be consumed [6]. in the non-food industry, carrageenans have been used for cosmetics, pharmaceutical formulations and experimental medicine [4]. carrageenan has been used for enhancing agent for controlled drug release and prolonged retention in drug delivery [7]. much research in recent years has focused not only on food applications but also on medical applications. there are several biological properties of carrageenans such as antiviral activity, anticoagulant activity, antitumor activity, antioxidant activity, antiinflammation and immunomodulatory activity that might bring more benefits in medical applications. numerous experiments have established that carrageenan has promising potential to be developed as therapeutic agents due to their in vivo and in vivo activity. although there were a lot of study about biological activities of carrageenans, few researchers have addressed the potential of carrageenans in foods and medical applications based on their biological activities. an alternative approach is necessary in order to present the potential of carrageenans in foods and medical applications. regarding to these widely function, the aim of this review article is to bring a short overview of the potential of carrageenans in foods and medical applications based on their biological activities. methods the materials of this review were collected on december 2017 to january 2018 through 4 electronic database: pubmed, science direct, springer link and google scholars for the years 1991-2018 with full text in english. there are many biological properties of carrageenans including antiviral activity, anticoagulant activity, antitumor activity, antioxidant activity, anti-inflammation and immunomodulatory activity, which are the most common effect of carrageenans as food additive or application in medical purpose. only relevant works and articles examined were included. the potential of carrageenans as an antiviral carrageenans as food additive in many products have beneficial effect including antiviral activity. carrageenans are considered a good alternative for preventing a wide range of disease, mainly caused by enveloped viruses [8]. the advantages lie on their high availability, low cost and low induction of resistance. the antiviral activity of carrageenan can be influenced using depolymerization [9]. carrageenans have antiviral activity against human papillomavirus (hpv) [10, 11], herpes simplex and dengue virus [12]. kappa-, iotaand lambdacarrageenans have a potent inhibitory effect on replication of hepatitis a virus (hav) in the human hepatoma cell line plc/prf/5, which are no cytotoxic effects with concentration up to 200 µg/ml [13]. another study suggest that carrageenan might serve as an effective topical hpv microbicide [14]. carrageenan oligosaccharides and its sulphated derivatives present good inhibitory actions on antiinfluenza a virus (iav) in vitro and in vivo [15]. iota-carrageenan inhibits a step in virus replication subsequent to viral internalization but prior to the onset of late viral protein synthesis [16]. another study suggests that iota-carrageenan nasal spray appears to be a promising treatment for safe and effective treatment of early symptoms of common cold caused by virus [17]. carrageenan nasal spray in virus can be an effective treatment of common cold in children and adults [18]. inhibition of viral cytopathology and antigen expression was also detached to the presence of the carrageenans [19]. on another case, κ/β-carrageenan extracted from tichocarpus crinitus possesses antiviral activity against tobacco mosaic virus (tmv), which inhibits tmv infection in detached tobacco leaves at early stages [20]. carrageenan, especially κ/β-carrageenan extracted from tichocarpus crinitus, may be regarded as a promising preparation for plant protection against viruses [21]. the κ/β-carrageenan from tichocarpus crinitus has another antiviral activity against potato virus x (pvx) infection in the leaves of datura stramonium l, that shows the potential of carrageenans as antiviral [22]. global health management journal, 2018, vol. 2, no. 2 34 biological activity of carrageenans in edema study some carrageenans showed a reduced anticoagulant activity only at concentration that were considerably higher than the ic50 [23]. a study about quantitative evaluation of inflammation demonstrated that iota and lambda carrageenans have higher inflammatory potential than do kappa-carrageenans [24]. this study induced paw edema using kappa, iota and lamdacarrageenans in saline solution into the hind paw male wistar rats. the histological analysis in paw edema suggests that lamda and iota carrageenans showed major cellular infiltration in relation to kappa-carrageenan [24]. kappa/iota carrageenan possessed for the potential anticoagulant activity, which was extremely strong in low concentration [25]. anticoagulant activity of carrageenans depends on the monosaccharide composition of polysaccharides, number, position and distribution of sulphate groups along galactan chain [25]. the study by yermak et al. (2012) showed hybrid kappa/beta-carrageenan has fairly high activity independent on concentration. position of sulfate groups shows the biggest impact on both the anticoagulant activity and the cell proliferation [26]. sulfation at c2 of 3,6-anhydro-α-ɗ-galp and c6 of βɗ-galp increased the anticoagulant activity [27]. another theory suggests that the ability to influence on the cytokine production by human cells is greatly dependent on concentration and structure of polysaccharides [25]. carrageenan has been used on some in vivo studies. the study by matsumoto et al. (2015) demonstrated the anti-inflammatory activity of linezolid and other anti-mrsa agents using the carrageenan-induced rat paw edema model. however, further studies are needed on the molecular mechanisms underlaying these anti-inflammatory activities [28]. another studies suggest that kappa-carrageenan oligosaccharide may have some biological activity for preventing the process of some central nervous system disease [29]. the study by yermak et al. (2012) suggest that all types of carrageenans induced the secretion of antiinflammatory il-10 in dose-dependent manner. the immunomodulation activity of carrageenans depends on the composition of polysaccharides including their position, number and distribution of sulphate groups along galactan chain [25]. another factor that might be the key factor is the basic structure of the carrageenan [30]. the potential of carrageenans as antitumor carrageenans as a food additive have some benefits such as antitumor activity. carrageenan has effect to cancer cells that could possibly be developed into a tumor cell-specific anticancer agent [31]. antitumor mechanism of carrageenans were relevant to their inhibitory activity of tumor cells directly and activating immunocompetence of the body. however, the exact mechanisms should be achieved through more other experiments [32]. chemical modification of carbohydrate can lead to differences in their biological activities where sulfation of carrageenan oligosaccharides will enhance the antitumor effect and boost the antitumor immunity [33]. carrageenan oligosaccharides exert its antitumor effect by promoting the immune system [30]. the degraded λ-carrageenan could add the antitumor activities and improve the immune-competence damages [32]. molecular weight of carrageenans had notable effect on the activities [34]. another studies suggest that the antitumor activity of carrageenan oligosaccharides may be due to their recognition or interaction with the tumor-specific molecules [35]. the anti-tumor activity of the sulfonated oligosaccharide is related to its antioxidant activity, immunological regulation and inhibition of tumor metastasis [36]. furthermore, there needs further investigation in term of anti-tumor mechanism, relationship between structure and biological activity remain to be elucidated and the exact correlation between molecular weight and antitumor activity. carrageenans as a food additive with antioxidant activity carrageenans have potential as an antioxidant which is widely used in the food industry [1] as gelling and stabilizing agent [37]. algal polysaccharides have beneficial effect as antioxidant with respect to the inhibition of superoxide radical formation [1]. the inclusion of antioxidant-rich polysaccharides, especially carrageenan, or other fractions will probably prevent the oxidative deterioration of food. current studies about application of carrageenan on food suggest that carrageenans have antioxidant activity. kappa-carrageenan oligosaccharides were applied to increase shelf-life of frozen shrimps during 120 days of frozen storage and their antioxidant 35 global health management journal, 2018, vol. 2, no. 2 affected on myofibrillar protein in peeled shrimp (litopenaeus vannamei) [38]. as an antioxidant, carrageenan has potential application as a photoprotective agent in addition to just being used as an excipient [39]. the antioxidant activity of carrageenans depend on their structural composition and the extraction method used [40]. conclusion some studies showed biological properties of carrageenans including antiviral, anticoagulant, antitumor, anti-inflammatory and immunomodulatory activity that can be appropriate in medical applications. the advantages lie on their high availability, low cost and low induction of resistance. it is suggested that carrageenans are suitable to be applied in many kinds of food products as gelling and thickening agent with their antioxidant potency as well as medical applications such as pharmaceutical formulation in drug delivery and experimental medicine. however, all of these potentials need to be approved by further studies that focused on the each biological activity of carrageenans after applied in food products or medicines. moreover, comprehensive studies on toxicity and side effect of carrageenans are necessary. conflict of interests the author declares that the author has no conflicts of interest. 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lambda-carrageenans from chondrus ocellatus. pharmacol res. 2004;50(1):47-53. 35. yuan h, song j. preparation, structural characterization and in vitro antitumor activity of kappa-carrageenan oligosaccharide fraction from kappaphycus striatum. journal of applied phycology. 2005;17(1):7-13. 36. haijin m, xiaolu j, huashi g. a κ-carrageenan derived oligosaccharide prepared by enzymatic degradation containing anti-tumor activity. journal of applied phycology. 2003;15(4):297-303. 37. usov a. structural analysis of red seaweed galactans of agar and carrageenan groups. food hydrocolloids. 1998;12(3):301-8. 38. zhang b, fang cd, hao gj, zhang yy. effect of kappa-carrageenan oligosaccharides on myofibrillar protein oxidation in peeled shrimp (litopenaeus vannamei) during long-term frozen storage. food chem. 2018;245:254-61. 39. thevanayagam h, mohamed sm, chu w-l. assessment of uvb-photoprotective and antioxidative activities of carrageenan in keratinocytes. journal of applied phycology. 2014;26(4):1813-21. 40. rafiquzzaman s, ahmed r, lee jm, noh g, jo g-a, kong i-s. improved methods for isolation of carrageenan from hypnea musciformis and its antioxidant activity. journal of applied phycology. 2016;28(2):1265-74. microsoft word 2. accepted original, mohamat iskandar, 57-62.docx cite this article as iskandar m, mardiyono, rumahorbo h. the effectiveness of discharge planning and range of motion (rom) training in increasing muscle strength of nonhemorrhagic stroke patients. global health management journal. 2018; 2(3): 57-62. global health management journal www.publications.inschool.id published by original research article issn 2580-9296 (online) the effectiveness of discharge planning and range of motion (rom) training in increasing muscle strength of nonhemorrhagic stroke patients mohamat iskandar 1,*, mardiyono 1, hotma rumahorbo 2 1 postgraduate applied science program in nursing, poltekkes kemenkes semarang, semarang, indonesia. 2 poltekkes kemenkes bandung, indonesia *corresponding author. email: mohamatiskandar@gmail.com article info abstract article history: received 25 august 2018 reviewed 01 september 2018 received in revised form 23 october 2018 accepted 31 october 2018 background: non-hemorrhagic stroke patients experience hemiparesis, an improper handling results in joint contractures. discharge planning combined with a range of motion (rom) training given to patients and their families are expected to improve muscle strength in patients after returning from the hospital. aims: this study is to identify the effectiveness of discharge planning in increasing muscle strength. methods: this is a quasi-experimental study with a pre-posttest design. a total of 34 respondents were selected by cluster random sampling technique, from raa soewondo pati general hospital of pati, central java, indonesia. the respondents were divided equally into two groups; an intervention group (n = 17) was given a discharge planning program together with stroke information and range of motion (rom) training while the control group (n = 17) received a standard discharge planning available in the hospital. further, muscle rating scale (mrs) was employed to assess the muscle strength on the 2nd, 7th, and 14th day after discharge planning presented to the nonhemorrhagic stroke patients. results: this present study clearly acknowledges the standard discharge planning program available in the hospital improve the muscle strength of the upper and lower extremity in the nonhemorrhagic stroke patients just 2nd day after the care (pretest), and the significant improvement was observed until the day 14. moreover, combining the care with rom training at the intervention group faster the recovery and the muscle strength improved significantly at the 7th day and continue increase at the day 14. looking to the muscle strength since the 2nd day to the day 14, respectively the muscle strength of upper and lower limb at the control group improved at the point of 0.588 and 0.882, while at the group received the rom training reached the value of 1.472 and 1.412. conclusions: the rom training combined to the current discharge planning program will faster the muscle strength recovery of the nonhemorrhagic stroke patients. this research provide insight how family plays important role to the success in monitoring the rehabilitation and recovery progress. keywords: discharge planning range of motion (rom) training nonhemorrhagic stroke patients muscle strength © 2018 publications of yayasan aliansi cendekiawan indonesia thailand this is an open access following creative commons license deed – attribution-noncommercial-sharealike 4.0 international (cc by-nc-sa 4.0) introduction stroke, according to world health organization (who), is a permanent clinical sign due to disruption of blood circulation to the brain which lasts about 24 hours or more and can cause acute brain disorders and even death without apparent symptoms other than vascular, which can happen anytime and anyone and global health management journal, 2018, vol. 2, no. 3 58 can cause paralysis and even death. stroke are defined into two types, namely ischemic stroke and hemorrhagic stroke. about three-quarters of strokes are caused by ischemia or infarction and a quarter is due to hemorrhagic disease and nearly 83% of patients have an ischemic stroke [1, 2]. in 2010, nearly 17 million people in the world suffered this disease, while in the united states every year around 800,000 people experience varied stroke and recurrent strokes and this disease becomes a leading cause of disability [3]. in 2013, indonesia national stroke prevalence reached to 8.3%, while the prevalence in central java hit 7.6% [4]. at the study population, in raa soewondo pati hospital, the number of stroke patients increases every year while in 2016 there were 809 stroke patients, with an average visit of about 67 patients each month. after 6 months, patients with stroke will experience an impact of 50% hemiparesis, 30% barely walk without any assistant, 46% cognitive deficits, 35% symptoms of depression, 19% aphasia, 26% depending on activities of daily life [5]. the worst case, the patients may suffer paralysis, in which patients cannot move normally, and the recent study shows 35% of hemorrhagic stroke patients suffer irreversible paralysis, and 20-25% of them unable to walk without help while 65% barely use their hands for daily life activities [6]. in providing the treatment, attention should be concerned on rehabilitation measures, prevention of complications and recurrent strokes, thus the patients can return to meaningful activities [7]. in addition to providing rehabilitation measures, promotive and preventive measures are needed in order to prevent recurrent complications and strokes with the provision of discharge planning [8]. the range of motion (rom) training is a form of exercise in the rehabilitation process for the stroke patients, and it presents positive results both physically and psychologically in preventing the disability in the stroke patients, thus, the quality of life can increase [9]. compare to other therapy in a nursing care, rom training is relatively more effective, easy to be applied and considered with low cost. a study from mawarti and farid orchestrate the rom application towards acute stroke patients, given two times per day in seven consecutive days, was following with a muscle strength improvement [10]. nevertheless, the current stroke patients in hospital were only given the rom two times of a week. as result, the treatment was ineffective in increasing the muscle strength or even declining. the patients and their family need to know about the disease process, find out how to handle it and the continuity of care in the rehabilitation phase and adaptation that is arranged in a discharge planning [11]. family is effective and responsible for fast stroke recognition and response, and to reduce the risk of disability [12]. discharge planning aims to empower and maximize the potential of patients to live independently by means of support and resources that are in the family [13]. therefore, through the proper discharge arrangment which contains stroke information together with rom can improve the rehabilitation progress effectively in home. at the study site of raa soewondo pati general hospital of pati, central java, indonesia, the discharge planning program providing to the stroke patients at the nursing care unit is limited to routine activities in the daily visit or patient returns, including in providing information of time control, medication and some required lifestyle changes. the rom rehabilitation is only given twice a week and it also takes a particular time because physiotherapy was only done in the hospital. as the consequences, the patient experienced some void for a long time to come back to physiotherapy, thus, the progress of improving the muscle strength in the post-stroke patients was very slow or none at all even decreased. the nursing care with the provision of discharge planning must be carried out optimally so that patients and families who suffer a stroke can care for family members by providing information about strokes and rehabilitation (rom exercises). thus, when the families return home, they will be able to care the patients by providing rom training that expects improvement to the patient's muscle strength, or at least there is no complication occurred. this study aims to analyze the effectiveness of discharge planning on increasing muscle strength in patients with non-hemorrhagic stroke" in raa soewondo pati general hospital in pati, central java, indonesia. methods this is a quasi-experiment employed a pretest-posttest design with control group. the population in this study were 59 nonhemorrhagic stroke patients with a sample size of 34 nonhemorrhagic stroke patients selected room at raa soewondo general hospital, pati, central java, indonesia. in this study, the sampling technique was carried out by means of cluster random sampling based on treated room, where the participants from gading i and gading ii room were recruited as the intervention group, while the respondents from dahlia and flamboyan as the control group. the inclusion criteria used in this study 59 global health management journal, 2018, vol. 2, no. 3 were: stroke patients treated after 24 hours in the treatment room, compositional awareness based on glasgow coma scale (gcs) assessment 13-15, family members aged 18-60 years old, minimum family education at high school, willing to be a respondent by signing informed consent. family members recorded with health problems or in a critical condition, or refused to continue will be excluded from the study. table 1. respondents’ characteristics characteristics control (n=17) intervention (n=17) total p value n % n % n % age 0.521 40-54 8 47.1 5 29.4 13 38.2 55-64 6 35.3 5 29.4 11 32.4 65-75 2 11.8 4 23.5 6 17.6 >76 1 5.9 3 17.6 4 11.8 gender 0.550 male 9 52.9 7 41.2 16 47.1 female 8 47.1 10 58.8 18 52.9 education 0.098 no school 5 29.4 14 82.4 19 55.9 elementary school 10 58.8 3 17.6 13 38.2 junior high school 2 11.8 2 11.8 occupation 0.269 laborer 2 11.8 4 23.5 6 17.6 farmer 13 76.5 12 70.6 25 73.5 entrepreneur 2 11.8 1 5.9 3 8.8 risk factor 0.001 hypertension 17 100 14 82.4 31 91.2 dm 0 0 3 17.6 3 8.8 attack frequency 0.002 the first time 17 100 15 88.2 32 94.1 >1 0 0 2 11.8 2 5.9 admission time 0.118 <6 hour 14 82.4 12 70.6 26 76.5 >6 hour 3 17.6 5 29.4 8 23.5 hemiparesis 0.550 right 10 58.8 8 47.1 18 52.9 left 7 41.2 9 52.9 16 47.1 intervention group received discharge planning which contains stroke information and rom training while control group received the standard discharge planning program available in the hospital. at the day before treatment (pretest) and the 7th and 14th day of treatment (posttest), the muscle strength and joint contractures of the extremities of the patient were assessed in the hospital during the period of rehabilitation control. before participation, the respondents were given oral and written consent. the research designs and procedures of this study have been approved by ethical commission of politeknik kesehatan kemenkes semarang (semarang health polytechnic), no. 132/kepk/poltekkes-smg/ec/ 2018, on may 3rd, 2018. medical research council (mrc) scales, consisting of 6 levels, have been performed by the registered and trained nurse to measure the muscle strength by following the standard procedure. to measure the muscle strength, the patients were asked to be in a recumbent potition. in measuring the extremities superior, the patients were asked to lift their weaker hand (left hand for right-handed patient) then the scoring was done from zero (no movement was global health management journal, 2018, vol. 2, no. 3 60 observed until five (muscle fully contracted normally). in measuring the muscle strength of the extremities inferior, the patients were asked to lift their weaker leg (left leg for right-handed patient) then the nurse scored from zero (no movement was observed) until five (muscle fully contracted normally). the measurement of joint contractures was performed with a goniometer by the same nurses. patients and their family were briefly explained to the daily rom monitor sheet before filling the form. statistical analysis used in this study was general linear model (glm) and post hoc to find the difference of muscle strength before and after intervention post-test i (day 7) and post-test ii (day 14) as well as the mean difference between the intervention group and control group. results as shown in table 1, most of the patients were in age group 40-54 years old and 55-64 years old (38.2% and 32.4%). there was no sifnificant difference between intervention and control group in age. based on gender, there were more females than males in all respondents. the data of education also shows that more than a half of all respondents had no education (55.9%), while the other 38.2% and 11.8% finished their elementry school and junior high school, respectively. based on occupation data, most of the respondents were farmer (73.5%) and the least was entrepreneur (8.8%). based on the characteristic data, more patients in control group have hypertension history, compared to the intervention group. interestingly, no patient in control group experienced stroke more than 1 time and had diabetes mellitus. in intervention group, while 14 patients had record having hypertension complication and 3 patients with dm complication; among them, 15 patients claim experienced stroke for the first time and 2 patients recorded with stroke more than one time attack. table 2 shows that there was no significant difference between intervention group and control group in upper and lower extremity muscle strength at. these results confirm that both group had the same base status prior the treatment. furthermore, after the administration of intervention and control, the significant improvement was appeared in fourteenth day of upper extremety measurement between intervention and control group (p value = 0.003) but not in lower extremity measurement as shown in table 3. table 4 orchestrates the muscle strength improvement at the control and the intervention group, comparing the value (as the mean difference) before the treatment given (pretest) and day 7 (posttest i) and day 14 (posttest ii) after the assessment. repeated anova analysis considers the significant mean difference. the results show that the patients at the control and intervention group experienced strength muscle improvement both the upper and lower extremity. table 2. muscle strength of upper and lower extremities in the control group (n=17) and intervention groups (n = 17) before the intervention given (pretest) muscle strength type iii sum of squares mean square f p value upper extremity 5.186 5.186 3.677 0.064 lower extremity 1.657 1.657 0.726 0.400 table 3. muscle strength of upper and lower extremities in the control group (n=17) and intervention groups (n = 17) before intervention (pretest) and at the 7th and 14th day after the treatment (post-test) muscle strength intervention (n=17) control (n=17) p value mean sd mean sd upper extremity pretest 1.88 0.781 1.82 0.728 0.822 post-test i (day 7) 2.47 0.624 2.12 0.781 0.155 post-test ii (day 14) 3.35 0.862 2.41 0.870 0.003 lower extremity pretest 1.65 0.862 1.59 0.939 0,850 post-test i (day 7) 2.29 0.849 2.18 1.015 0.716 post-test ii (day 14) 3.06 0.899 2.47 1.007 0.082 61 global health management journal, 2018, vol. 2, no. 3 table 4. muscle strength improvement (mean difference) of the upper and lower extremity of the stroke patients at the control group (n=17) and intervention groups (n = 17) before intervention (pretest) and at the 7th and 14th day after the treatment (post-test) muscle strength intervention control mean difference p value mean difference p value upper extremity ∆ pre-post test i 0.588 0.011 0.294 0.060 ∆ pre-post test ii 1.471 0.000 0.588 0.004 ∆ post i-post test ii 0.882 0.000 0.294 0.060 lower extremity ∆ pre-post test i 0.647 0.000 0.588 0.010 ∆ pre-post test ii 1.412 0.000 0.882 0.000 ∆ post i-post test ii 0.765 0.000 0.294 0.060 interestingly, discharge planning program combined with stroke information and rom training given to the stroke patients in the intervention group results with significant improvement of the muscle strength at the upper extremity (0.588). the results show the rom training may faster the upper limb improvement only 7 days after the program (p value = 0.011) while at the control group with no rom training the improvement can be observed after 14 days. the muscle strength improvement of the upper and lower extremity even can be observed until the 14 days at the both groups, however, significant improvement can be observed at the intervention group. discussion stroke can cause the decrease of muscle strength, thus, the discharge planning is important to the stroke patients in increasing the muscle strength. in this study muscle strength was measured three times, pre-test on the second day of treatment, post-test i on the seventh day of treatment and post-test ii on day fourteenth day of treatment. table 2 shows that there was no significant difference in upper limb muscle strength (p-value = 0.064) and lower extremity (p value = 0.4) between intervention group and control group. in table 3 shows that there was a significant difference in upper extremity muscle strength in post-test two (fourteenth day) measurements (p value = 0.003) between intervention and control group. moreover, muscle strength improvement between pre and the two post tests in intervention group were significantly different while in control group was only appeared between pre and post test one (table 4). stroke patients will experience a decrease of the strength of the limb muscles due to hemiparesis. hemiparesis at one side of the body is often found in stroke patients after hemiplegia. the most common manifestation of hemiparesis is a decrease in muscle strength. muscle strength is closely related to the neuromuscular system. namely how much the ability of the nervous system to activate the muscles to contract. thus, the more muscle fibers are enabled, the greater the strength produced by the muscle [14]. in theory, if the muscles including the extremity muscles are not trained especially on clients who experienced gross motor function impairment in a certain period of time, the muscle will lose its motor function permanently. this happens because the muscles are usually in a state of immobilization. limitations of mobilization affect the client's muscles through loss of endurance, reduced muscle mass, atrophy and decreased stability. other influences from the limitations of mobilization are disorders of calcium metabolism and impaired joint mobilization. immobilization can affect muscle and skeletal function. as a result of protein breakdown in the muscle, the consumer experiences a loss of body mass that forms part of the muscle. therefore a decrease in muscle mass is not in a position to maintain activity without increasing fatigue. muscle mass decreases due to unused metabolism and muscle. if immobilization continues and the muscles are not trained, there will be a continuous decrease in mass. the decrease in the mobilization and movement resulting in large musculoskeletal damage with its main pathophysiological changes is atrophy which required immobilization and bed rest. the decrease in the stability occurs due to loss of endurance, decreased muscle mass, atrophy and actual joint abnormalities so that clients are unable to move continuously and are at risk for falls [15]. bestowing discharge planning can improve functional status and reduce the risk of recurrence in ischemic stroke patients and to provide health education to patients and their families. this health education including the knowledge about signs, symptoms and global health management journal, 2018, vol. 2, no. 3 62 risk factors for stroke as efforts to prevent the occurrence of spasmodic attacks [16]. the rom exercises twice a day for 7 days can increase muscle strength in the upper extremities [17]. this study supports the previous research [10] orchestrating the provision of rom exercises twice a day in stroke patients increase muscle strength effectively after the 2nd day. conclusions discharge planning providing to the stroke patients in the control and intervention group effectively increased upper and lower limb muscle strength. this present study notice the rom training given at the intervention group increase muscle strength higher than the value at the control group. the statistical analysis even shows that the increasing at the day 14 was significant only at the intervention group. moreover, muscle strength improvement between pre and two post tests in intervention group were significantly different while in control group was only appeared between pre and post test one. as health workers, especially nurses, of course will deal with the problem of returning non-hemorrhagic stroke patients who experience limb weakness. interestingly, a recent review summarizes results from many studies showing treatments given to stroke patients at a stroke unit will generate better outcomes [18]. discharge planning can motivate nurses to realize the importance of knowledge and skills in caring for families who suffer strokes with limb weakness. the results of this study prove that giving discharge planning with rom training to patients and families can increase limb muscle strength in non-hemorrhagic stroke patients. in the implementation of discharge planning a nurse must have expertise in assessment, and coordinate, have expertise in communicating and realizing the resources that exist in the community so that a nurse must have knowledge, attitudes and skills in planning nursing care. conflict of interests none declared. references 1. patricia gonce morton df, carolyn m hudak, barbara m gallo. keperawatan kritis 2011. in: pendekatan asuhan holistik [internet]. jakarta: penerbit buku kedokteran egc. 2. misbach j, harmani k. stroke mengancam usia produktig: www.medicastore.com; 2017 [cited 2017 25 november]. 3. westerlind e, persson hc, sunnerhagen ks. return to work after a stroke in working age persons; a sixyear follow up. plos one. 2017;12(1):e0169759-e. 4. ri kk. riset kesehatan dasar (riskesda). jakarta: badan penelitian dan pengembangan kesehatan; 2013. 5. kelly-hayes m, beiser a, kase cs, scaramucci a, d’agostino rb, wolf pa. the influence of gender and age on disability following ischemic stroke: the framingham study. journal of stroke and cerebrovascular diseases.12(3):119-26. 6. dobkin bh. rehabilitation after stroke. new england journal of medicine. 2015;352(16):1677-84. 7. harsono ed. kapita selekta neurologi. yogyakarta: gadjah mada university press; 2009. 8. almborg a-h. perceived participation in discharge planning and health related quality of life after stroke: hälsohögskolan; 2008. 9. tseng cn, chen cch, wu sc, lin lc. effects of a rangeofmotion exercise programme. journal of advanced nursing. 2007;57(2):181-91. 10. mawarti h. f. pengaruh latihan rom (range of motion) pasif terhadap peningkatan kekuatan otot pada pasien stroke dengan hemiparase [rom exercise influence (range of motion) passive to increase muscle strength in stroke patients with hemiparase]. journal eduhealth. 2012;2(2). 11. mackenzie a, perry l, lockhart e, cottee m, cloud g, mann h. family carers of stroke survivors: needs, knowledge, satisfaction and competence in caring. disability and rehabilitation. 2007;29(2):111-21. 12. sudirman h, yuliyanti c, sari ai, editors. effectiveness of ‘fast’stroke campaign for fast stroke recognition and response: a systematic review. proceedings of the international conference on applied science and health; 2018. 13. hankey gj. stroke. the lancet. 2017;389(10069):64154. 14. smeltzer&bare, brunner&suddart. buku ajar keperawatan medikal bedah. jakarta: egc; 2008. 15. potter ap, perry, a. fundamental of nursing. 4, editor. missouri: mosby-year book, ink; 2009. 16. pemila u, sitorus r, hastono sp. penurunan risiko kambuh dan lama rawat pada klien stroke iskemik melalui rencana pemulangan terstruktur. jurnal keperawatan indonesia. 2010;13(3):187-94. 17. rhestifujiayani e, huriani e, muharriza m. comparison of muscle strength in stroke patients between the given and not given range of motion exercise. 2015. 2015;5(2):13. 18. hartono w, darmawan es, editors. stroke care: stroke unit versus non stroke unit. proceedings of the international conference on applied science and health; 2018. knowledge, attitudes, and hiv/aids risk behaviors of myanmar migrant workers in thailand ghmj (global health management journal) 2022, vol. 5, no. 2 theresia, sylvia & datak open access photo essay politeknik kesehatan kemenkes palangka raya: health forum and international seminar the new normal: creating a pleasant virtual communication family care and reproductions health for teens: applying 8 family functions during the transition growth yoan agnes theresia*, ester inung sylvia, gad datak department of nursing, poltekkes kemenkes palangka raya, indonesia *corresponding author’s e-mail: rvllackerman@gmail.com doi: 10.35898/ghmj-52942 selection and peer-review under responsibility of the scientific committee and the editorial board of the annual health forum and international seminar of the politeknik kesehatan kemenkes palangka raya © yayasan aliansi cendekiawan indonesia thailand (indonesian scholars’ alliance). this is an open-access following creative commons license deed attribution-noncommercial-sharealike 4.0 international (cc by-nc-sa 4.0) “as the spearhead of national development, sometimes teenagers are required to be perfect. what people don’t even know is that sometimes we teenagers also have stories to tell. share a laugh and be cheerful, that’s what we are. in the end, life is not about being perfect but how we want to learn and grow together. it’s okay, you are not alone, we are always there for you“. those are words i thought of when i saw teenagers. in the world, it is estimated that the youth group is 1.2 billion, or 18% of the world's population (who, 2014). you really can imagine how much '1.2 billion is. but before that, let's talk about who a teenager is. adolescence is a period where the transition from childhood to adulthood, which includes all the developments, experienced in preparation for entering adulthood. these changes in development include physical, psychological, and psychosocial aspects (pusdatin kemenkes ri, 2015). figure 1. election of ambassadors in the youth community mailto:rvllackerman@gmail.com https://doi.org/10.35898/ghmj-52942 theresia, sylvia, & datak ghmj (global health management journal) 2022, vol. 5, no. 2 144 exactly like the picture of the two teenagers above, you can see that they are certainly different from when they were still a kid. growth has occurred rapidly, even including psychosocial. figure 1 shows two teenagers, participating in an ambassador event for the youth community in indonesia, palangka raya, to be precise, last october. they fill their adolescence with productive activities. yes, like the thoughts that always crossed my mind in the first paragraphs, teenagers will not be alone. an example is the presence of teenagers in the youth community ambassador, which aims to provide counseling to other teenagers about how to behave, how to build a future, and how to build a prosperous family. adolescents are the spearhead of national development; therefore teenagers need to carry out productive activities. but it is not enough just from productive activities, the quality of teenagers is also determined by their families. how the family can provide a basic understanding to adolescents before they face the world outside to avoid reproductive health problems. according to the ministry of health of republic indonesia (1988) defines family as: "the family is the smallest unit of society which consists of the head of the family and several people who gather and live under one roof in a state of interdependence". the smallest unit means everything that underlies everything. without guidance, teenagers can fall into a dark hole called reproductive health problems. three problems are often encountered in adolescents; there are early marriage, premarital sex, and drug abuse. for information, i quote from unicef (2019) that the number of early marriages in indonesia is second place in asean. there are more than one million underage women who are married at a young age. early marriage, sex before marriage, and drug abuse will affect their reproductive health. why? there are a lot of bad effects that we get from these three reproductive problems. start from pregnancy problems such as preeclampsia, placenta previa, fetal death, and childbirth problems such as maternal mortality. this happens because the growth of the reproductive organs has not yet matured. premarital sex also has the same effect, one of which is the transmission of sexually transmitted diseases among adolescents, including hiv. drug abuse will make a person desperate to do anything to get that item; this is the forerunner to damage the social function and personality of a teenager apart from the negative effects that we know from drug abuse. then what should the family do to prevent this happen? apply these 8 family functions: 1. functions of religion; a family is a place where religious values are given, taught, and practiced. here, parents play a role in instilling religious values as well as giving religious identity to children. a family that succeeds in applying religious values through example in everyday life can provide a strong foundation for each member of the family. 2. functions of compassion; since the baby was born, since then he has known love. the feeling of being loved is very important for a child because one day he will grow up to be someone who can love too. this will be an asset for all family members to foster a sense of compassion in a wider context and be able to reduce the emergence of seeds of hostility and anarchism in society. 3. functions of protection; ideally, a family is capable of being a place where its members feel safe and secure. therefore, no matter how bad the conflict that occurs in the family, avoid acts of verbal or physical violence, discrimination, and coercion of the will. 4. function of social and culture; a family also has an important role in introducing children to the sociocultural values that exist in society. manners are highly respected, with various kinds of norms, customs, and manners that apply in society. it is from family members that children can learn how to behave towards older people and learn what is appropriate and inappropriate in their culture. in this case, the family must also be wise in filtering socio-cultural conditions with the needs of children in this advanced era. if socially and culturally tend to allow children to marry at an early age, it is the family who has to consider and find other alternative solutions. 5. reproductive function; one of the goals of most humans to have a family is to have offspring. through a legal marriage, the family becomes an entity capable of producing the next generation of the nation. early sex education and respect for the opposite sex need to be instilled in the family. ghmj (global health management journal) 2022, vol. 5, no. 2 theresia, sylvia, & datak 145 6. function of education; the family is the first place a child learns to socialize with other people, parents, and siblings. in the family, the education process is accepted for the first time by the child. all of this is caused by the intensive interactions that occur so that the educational process occurs naturally and effectively. 7. economic function; the economic condition of a family usually affects family harmony. therefore, teaching children to save money and foster an entrepreneurial thing will make them financially smart. 8. environmental function; an environmentally friendly lifestyle can be realized if it is instilled in the family early on. likewise, the habit of caring about the environment, such as neighbors and society in general. cultivate nature by loving the environment, not wasting electricity, clean water, and food, and also make it a habit to dispose of garbage in its place from an early age, because only from nature do we exist. and you can take a look at this picture. what a happy big family gathering on the wedding procession. the ideal age for marriage suggests for an adult is 21 years old for a woman and 25 years old for a man (bkkbn,.2018). figure 2. large families at weddings with the ideal age (my sister wedding) so by applying these eight family functions, we will achieve the highest state of reproductive health for our teens. and what was it all done for? is it to achieve the goals of all nations in preparing to enter an era of demographic bonus that will only occur once in the history of a nation? the demographic bonus is a condition in which the productive age is more than the non-productive. with qualified teenagers, they will turn their demographic bonus into a golden generation. especially in indonesia, it is called 'indonesia emas tahun 2045' “love your family, love your teenager, and love the future of your nation” figure 3 shows the teenagers who become a winner of a teenager’s ambassador. in our society, it is perceived an idea how a teenager should be. reach the highest goals, rich in knowledge, and then form a happy family that can avoid adolescents from reproductive health problems. theresia, sylvia, & datak ghmj (global health management journal) 2022, vol. 5, no. 2 146 figure 3. teenagers who achieved achievements and avoided the triad of krr problems as a manifestation of caring for the future of adolescents, i have been a resource person for reproductive health education for adolescents. it’s all started with my election in the same event as the teenager in the first photo as an ambassador for peers (figure 4). figure 4. providing education about adolescents and prosperous families from there i learned to find out the health status of the world’s population, one of which was by participating in an international congress (figure 5). there i found teenagers of the same age and saw for themselves the characteristics of youth from various countries. participants at that time were from indonesia, the philippines, nigeria, japan, and america. ghmj (global health management journal) 2022, vol. 5, no. 2 theresia, sylvia, & datak 147 figure 5. international health congress in st. petersburg paul philippines, 2018 figure 6 is also one of the things teenagers can do to carry out anti-substance abuse movements, including tobacco and tobacco products such as cigarettes. figure 6. commemorating world no tobacco day, 31 may 2018 consent the adults (identifiable) photographed have given their consent for their pictures to be used in the dissemination and publication of this research. theresia, sylvia, & datak ghmj (global health management journal) 2022, vol. 5, no. 2 148 conflict of interest none. references bkkbn. (2019). jurnal keluarga berencana, 4(2), 1-161. departemen kesehatan republik indonesia. (1998). konsep keluarga. fitriyani p, dkk. (2020). pengaruh religiusitas terhadap perilaku seks pranikah remaja di prodi d-iii kebidanan jurusan kebidanan poltekkes kemenkes medan. poltekkes kemenkes medan. kementerian kesehatan republik indonesia. (2015). pusat data dan informasi. united nations children funds. (2019). progress for children: a report card on adolescents, number 10. who. (2014). world health statistic. cite this article as: theresia yo., sylvia ei., datak g. family care and reproductions health for teens: applying 8 family functions during the transition growth. ghmj (global health management journal). 2022; 5(2): 143-148. doi:10.35898/ghmj-52942 https://doi.org/10.35898/ghmj-52942 knowledge, attitudes, and hiv/aids risk behaviors of myanmar migrant workers in thailand ghmj (global health management journal) 2022, vol. 5, no. 2 indonesian scholars’ alliance open access photo essay politeknik kesehatan kemenkes palangka raya: health forum and international seminar the new normal: creating a pleasant virtual communication the first international seminar poltekkes kemenkes palangka raya: a journey full of meaning yeyentimalla 1 *, agnescia clarissa sera 1 , doni marisi sinaga 2 1 committee of health forum and international seminar of poltekkes kemenkes palangka raya 2 global health management journal, yayasan aliansi cendekiawan indonesia thailand (indonesian scholars‟ alliance) *corresponding author’s e-mail: yeyentimalla@polkesraya.ac.id doi: 10.35898/ghmj-52945 ©yayasan aliansi cendekiawan indonesia thailand (indonesian scholars’ alliance). this is an open-access following creative commons license deed attribution-noncommercial-sharealike 4.0 international (cc by-nc-sa 4.0) figure 1 celebration of the 19 th anniversary of poltekkes kemenkes palangka raya and the first conference poltekkes kemenkes palangka raya in collaboration with indonesian scholars‟ alliance and global health management journal (ghmj) successfully held the first international seminar on november 9, 2020. the seminar which took place online in the midst of the raging coronavirus disease 2019 (covid-19) pandemic raised the theme “the new normal: creating a pleasant virtual communication”. five speaker from four countries namely prof andrew j. macnab (canada), sr. merceditas o. ang, spc (philippines), eva berthy tallutondok, m.sc. (taiwan), dr. yeyentimalla (poltekkes kemenkes palangka raya, indonesia), and prof. sri suryawati (universitas gadjah mada, indonesia) synergizes to convey ideas on how to create fun virtual communication actors. during the pandemic, we do not communicate face-to face, but instead switch to communication using technological devices and chating application, including whatsapp and facebook messenger, the most preferred chatting applications by indonesian citizens. adequate understanding is needed to be able to communicate with other people virtually where messages are conveyed well and at the same time happy. mailto:alfeusmanuntung@gmail.com https://dx.doi.org/10.35898/ghmj-52945 https://inschool.id/ https://publications.inschool.id/index.php/ghmj/index https://publications.inschool.id/index.php/ghmj/index yeyentimalla, sera, & sinaga ghmj (global health management journal) 2022, vol. 5, no. 2 166 the international seminar committees worked based on the decree of the director of poltekkes kemenkes palangka raya number hk. 02.03/1.1/5237/2020 dated july 21, 2020. we may see the pandemic situation is an opportunity for the possibility to hold seminars online at lower costs. if not, bringing in speakers from three countries other than indonesia is very expensive. funds allocated for this seminar are limited. so, the committee activates the existing network and optimizes it to achieve the goal of holding an international seminar. institutionally, poltekkes kemenkes palangka raya already has a cooperation agreement (c.q. memorandum of understanding) with the indonesian scholars‟ alliance in thailand and st. paul university philippines (spup). with indonesian scholars alliance, we were co-hosting their last event before lock down, 4th international conferences on applied science and health (widyastari et al., 2019), and two papers from our institution have been selected and included to their precious publication: determinants of prediabetes on teenagers in palangka raya city (sylvia & ardiyani, 2019) and critics on policy of soy-based infant formula in indonesia: compared to australian and new zealand food standards (sera, 2019). the journey to the seminar in about four months presents a variety of emotions with negative and positive valences. for example, how to create a seminar participant and photo essays registration website with an inexperienced committee and communication is done virtually. in many ways we argued loudly. this level of difficulty is quite high. virtual communication is different from face-to-face. we have to be more selective with words because intonation and gesture are absent in communication via whatsapp and facebook messenger. we optimize virtual communication right before we teach it to seminar attendees! this is so much fun! pandemic may isolate our body, not our ideas. figure 2. a meeting before midnight, discussing the details of conference publication we still have little experience holding international events, so we are open to help from friends from the indonesian scholars‟ alliance. together with doni marisi sinaga, who is familiarly called bang doni, we arranged the procedure for a photo essay competition, which will later be published in the global health management journal (ghmj) with prof. andrew j. macnab acted as editor in chief for the ghmj. we believe recording the seminar results and inviting scholars to contribute their idea is the best way to transfer knowledge in our field (macnab, 2018b). thanks to their experience in conducting several conferences, and 167 ghmj (global health management journal) 2022, vol. 5, no. 2 yeyentimalla, sera, & sinaga selecting the high promising papers, we believe summarizing a seminar or conference, will share the knowledge and experience the young investigators to the broader audience (macnab, 2017). we held several meetings in the zoom room with bang doni and on d-1 with seminar speakers. we view that the strong family atmosphere is very conducive to the holding of the seminar. we build on and appreciate all the good that comes our way. figure 3. the flyer of seminar international of poltekkes kemenkes palangka raya the international seminar was held on monday, november 9, 2020, to coincide with the 19th anniversary of the founding of the poltekkes kemenkes palangka raya. in accordance with the health protocol during the covid-19 pandemic, the online committee from home and from their respective workspaces does not gather in one room. seminar participants attended the zoom room after previously registering through the website, there were 1055 people. they consisted of students, lecturers, and the general public who came from several provinces in indonesia. other countries that are the origin of the yeyentimalla, sera, & sinaga ghmj (global health management journal) 2022, vol. 5, no. 2 168 participants are malaysia, taiwan, thailand, australia, and germany. the seminar was covered by leading newspaper in central kalimantan province namely kalteng pos, youtube channel of st. paul university philippines (spup), and facebook of indonesian scholars‟ alliance live broadcast simultaneously. even though the event conducted online, however, for those gathering at the venue are required to follow the standard protocol for covid-19 prevention (figure 4). figure 4 the master of ceremony: retno ayu hapsari the photo essays registration period received an enthusiastic response from colleagues at the poltekkes kemenkes palangka raya and other institutions. the two moderators, agnescia clarissa sera and syam‟ani, proudly lead the events and handle the presentation time (figure 5). agnes, the committee secretary, moved to contact them. agnes' mission succeeded in getting prof. andrew j. macnab as the editor-in-chief of global health management journal (university of british columbia; figure 6a) and sr. merceditas o. ang as president of st. paul university (figure 6b). yeyen, the chairman of the committee, contacted speaker from taiwan and indonesia, and also ventured to be one the speakers. this courage has the support of eva berthy tallutondok (figure 6c) and prof. sri suryawati (figure 6d), both of whom had been teachers for yeyen in the past. while with prof. sri suryawati we often discuss technical seminars. figure 5. two moderators: agnescia clarissa sera and syam‟ani 169 ghmj (global health management journal) 2022, vol. 5, no. 2 yeyentimalla, sera, & sinaga (a) (b) (c) (d) figure 6. the invited keynote speaker: (a) prof. andrew j. macnab (canada), (b) merceditas o. ang, spc (philippines), (c) eva berthy tallutondok (taiwan), and (d) prof. sri suryawati (indonesia) at the end of the registration period, 32 photo essays obtained. the details are 16 photo essays from the department of nursing, 9 photo essays from the department of midwifery, and 7 photo essays from the department of nutrition. on november 9, 2020, after the seminar was over, 9 photo essays winners from 9 categories were announced directly by the head of the global health management journal, prof. j. macnab, online from canada, and been published at the global health management journal as 2022‟s special edition, following the standard guidelines for photo essays (macnab, mukisa, & stothers, 2018). in the end of the conference, dr. linda w. fanggidae distributed the questionnaire link for improvement in the future (figure 7). as scientists, health providers and educators, even as students, we must see the opportunity of translating policy into practices. we may need to identify “what works and why”, and take this very first international seminar poltekkes kemenkes palangka raya as a media to share our knowledge, and ultimately the „gold standard‟ to aim for is publication in a peer reviewed journal. the most direct route from research to policy is usually to look at issues of direct interest to policy makers. and when you do this, the best way to begin is to review what research has been done globally that you can apply locally, and use this as the basis for investigating the problem you want to focus on in your area (macnab, 2018a). https://publications.inschool.id/index.php/ghmj/issue/archive https://publications.inschool.id/index.php/ghmj/issue/archive yeyentimalla, sera, & sinaga ghmj (global health management journal) 2022, vol. 5, no. 2 170 figure 7. a questioner: dr. linda w. fanggidae from kupang, indonesia the international seminar was over, leaving a feeling of capability and confidence in our hearts. we turned out to be able to carry out an international standard activity and gain the trust of partners. our network was getting stronger and wider. we love this seminar journey that reveals our potential. hopefully, we will meet again in the future. acknowledgments thank you to all members of the health forum and international seminar (hfis) poltekkes kemenkes palangka raya. highest appreciation to the five speakers: prof. andrew j. macnab; sr. merceditas o ang, spc; dr. yeyentimalla; eva berthy tallutondok, m.sc.; prof. sri suryawati. proud to be friends with colleagues from the indonesian scholars' alliance. may our friendship last! references macnab, a. j. (2017). promoting global health innovation: on the need for global health care solutions in the spirit of the international conference on applied science and health (icash). ghmj (global health management journal), 1(1), 1-3. macnab, a. j. (2018a). global health: challenges and opportunities of translating policy into practice. paper presented at the proceedings of the international conference on applied science and health. macnab, a. j. (2018b). knowledge transfer of advances in applied health and science. ghmj (global health management journal), 2(2), 17-18. macnab, a. j., mukisa, r., & stothers, l. (2018). the use of photo-essay to report advances in applied science and health. ghmj (global health management journal), 2(2), 44-47. sera, a. c. (2019). critics on policy of soy-based infant formula in indonesia: compared to australian and new zealand food standards. ghmj (global health management journal), 3(3), 152-158. sylvia, e. i., & ardiyani, v. d. (2019). determinants of pre-diabetes on teenagers in palangka raya city. ghmj (global health management journal), 3(3), 117-123. widyastari, d. a., sinaga, d. m., wibowo, c. p., rahman, p. a., noor, h. m., sondang, d., . . . viniriani, m. a. (2019). the international conferences on applied science and health (icash): efforts and commitments in translating research results into policy and practices, for a better society. ghmj (global health management journal), 3(3), 79-83. cite this article as: yeyentimalla, sera ac., sinaga dm. the first international seminar of poltekkes kemenkes palangka raya: a journey full of meaning. 2022; 5(2):165170. doi:10.35898/ghmj-52945 https://doi.org/10.35898/ghmj-52945 alcohol consumption and current situation of drinking risk level among university students in mandalay region indonesian scholars’ alliance ghmj (global health management journal) 2019, vol. 3, no. 3 open access original research the 4th interna onal conference on applied science and health (icash 2019), 23-24 july 2019, faculty of graduate studies, mahidol university, thailand alcohol consumption and current situation of drinking risk level among university students in mandalay region yadanar aung1* , yin thet nu ou1 , nanda myo aung wan2 , bo bo nyan3 , aung pyae phyo1 , le le win1 1department of medical research, ministry of health and sports, myanmar 2na onal drug abuse control program, department of medical services, ministry of health and sports, myanmar 3university of medicine (mandalay), mental health department,ministry of health and sports, myanmar *corresponding author’s email: yadanaraung@mohs.gov.mm abstract background: in myanmar, alcohol consump on among university students had been recognized as a major public health concern. a cross-sec onal study was done to inves gate drinking alcohol and risk level assessment using the alcohol use disorder iden fica on test (audit) and examined the reasons of alcohol uses and types of beverage preference consumed. methods: the two universi es from three districts in mandalay region were randomly selected, from which 976 students (stra fied by academic year and sex) were contributed in self-administered ques onnaire. results: the mean age at first drinking alcohol among the par cipants was 16.36±0.15 years with range of 16 to 19 years. the drinking risk level assessment using the audit test, nearly half of the par cipants 48.7% were abstainers and 86 (8.8%) were high risk drinkers while 28 (2.9%) had alcohol dependency. among those, 57.8% had experiences of alcohol drinking and the favorite beverage of the university students who drink alcohol was beer. binary logis c regression analysis indicated that gender, smoking habit and living situa on for drinking were significant predictors of alcohol consump on among university students. the results found out that living separately with parents and smoking habits were important factors for drinking alcohol with sta s cally significant at 95% confidence level. conclusion: it provided evidence-based findings for knowing the alcohol consump on risk level among university students to prevent social depriva on and health risk behaviors. findings from this study indicate a need for law governing, strictly prohibits the sale of alcohol directly or indirectly to those under the age of eighteen years. the alcohol interven on program can be helpful in modifying behaviors change communica on in health promo on of university students. keywords: alcohol consump on, audit test, drinking risk level, university students and binary logis c regression received: 12 april 2019 reviewed: 18 june 2019 revised: 25 june 2019 accepted: 8 july 2019 doi: 10.35898/ghmj-33453 selec on and peer-review under responsibility of the scien fic commi ee and the editorial board of the 4th internaonal conference on applied science and health (icash 2019) © yayasan aliansi cendekiawan indonesia thailand (indonesian scholars’ alliance). this is an open-access following crea ve commons license deed a ribu on-noncommercial-sharealike 4.0 interna onal (cc by-nc-sa 4.0) 95 mailto:yadanaraung@mohs.gov.mm https://dx.doi.org/10.35898/ghmj-33453 ghmj (global health management journal) 2019, vol. 3, no. 3 aung y et al. 1. introduc on worldwide, drinking alcohol was the seventh-leading risk factor for early death and among the aged group of 15 to 49 years old, alcohol consumption was tied to 4 percent of female deaths and 12 percent of male deaths in 2016 (world health organization, 2018). according to an ongoing, large-scale ontario survey conducted by the toronto-based centre for addiction and mental health in 2015, 39 per cent of high-school students reported drinking in the previous year (giesbrecht et al., 2004). the rate of drinking, unsurprisingly, goes up as students’ age. most of the teenagers insisted that the peer pressure to drink has largely evaporated. the world health organization (who) reported in 2014 that worldwide alcohol consumptions was 6.2 liters of pure alcohol consumed per person aged 15 years or older and 16.0% drinkers aged 15 years or older engage in heavy episodic drinking (world health organization, 2014). at the same time, alcohol per capita of myanmar nations (above 15 years of age) consumption (in liter of pure alcohol) was 0.7 compared to 3.5 in south east asia region (world health organization, 2004). in recent years there had been widespread public concern with the alcohol consumption of teenagers. interesting in this issue, there was a still lack of evidence and it had been brought about mainly to concerns the problems of alcohol drinking among adolescents’ university students and their social and health risks. in myanmar, the prevalence of current alcohol used among students (i.e., drinking at least one drink containing alcohol on one or more of the past 30 days) was 1.4% in year 2007 according to global school-based student health survey-gshs reported current alcohol use in grade 8,9,10 and 11 students (page and danielson, 2011). a variety of medical problems, including cardiovascular diseases, liver cirrhosis was highly related to alcohol drinking. alcohol use and abuse also contributed to injuries, and violence in the united state was high by historical standards and high relative to other developing countries except myanmar (thakker, 1998). when compared to older adults, teenagers and young adults were particularly at risk for diminishing school performances. the prevalence of harmful use of alcohol was increased in young adults and notably high 66.4% in university students at ireland (davoren et al., 2015). the consequences of alcohol consumption in earlier life deteriorated the emotional, physical and psychological development, then higher chanced to occur the alcohol-related health problems. the consumption of alcohol could be expected to have a negative impact on class activities both directly through its potential impact on cognitive ability and indirectly through its impact on study habits. the average number of drinks consumed per drinking occasion significantly increased the probability of skipping a class and the level of alcohol consumption was varied by religion, living situation and parental drinking behavior (powell et al., 2004). therefore, controlling for the potential harmful behaviors of alcohol consumption and drinking risk level assessment among university students was a key importance finding to build up the brighter future of young populations. additionally, the government could not regulate the evidence-based policy to reduce the impact of hazardous alcohol consumption among university students in myanmar. thus, the aim of this study was an attempt to examine the risk level of alcohol consumption by using the alcohol use disorder identification test (audit) and assess the reasons for drinking among university students in myanmar, with particular living situation and gender differences. though there were a few studies that had assessed the association between alcohol consumptions and social consequences among university students that could apply alcohol prevention program, to our knowledge this type of research had not yet been undertaken in universities. 2. method study design and participants: a cross-sectional analytical study was conducted using an anonymized, self-administered questionnaire to obtain information from students in six universities located in mandalay, meikhtila and kyaukse districts which had the highest number of university students from 96 aung y et al. ghmj (global health management journal) 2019, vol. 3, no. 3 different areas of upper myanmar. the two universities were randomly selected from each district. students were sampled at the age range of 16-19 years using a proportional probability to size (pps) sampling. individual student was recruited from the chosen universities using stratified simple random sampling (stratified by academic year and sex). as the prevalence of university students regarding alcohol consumption was unknown, assumed the proportion of students who drink alcohol to be 50%; delta as 0.05 and 95% confidence interval. then, was attempted to obtain the required number of samples was 792 and accounted 20% for non-response rate and dropped out rate, 158. thus, the estimated total sample for this study was 950 then proportionately divided by six universities from three districts, the respondents from one university were 160 students. the descriptive analysis was firstly done in 976 after excluding the missing values. variables and measurements: current situation of drinking alcohol was dependent variable while the independent variables composed three sections in questionnaires (1) the respondents’ background characteristics section, (2) risk level assessment: the alcohol use disorders identification test, audit (section 2), and (3) alcohol consumption practices and the reasons of alcohol drinking (section 3). audit test developed by the who (babor et al., 2001) was assessed using scoring system based on 10 questions with 40 points which were coded as a total of 40 scores and then calculated to define the drinking risk levels such as abstainers (0 score), low risk drinkers (1-7 scores), high risk drinkers (8-15 scores) and dependence (16-40 scores) according to audit classification. tobacco use, current betel chewing practices, previous experiences related alcohol drinking and living situation (with parents/guardians or without) were measured using a yes/no question. the other covariates included sociodemographic characteristics of the participants. procedure: after co-ordination meeting with rectors of universities, lecturers, assistant director (adolescent health program manager) and township medical officer (tmo-adolescent health team), the data was collected in the classrooms at university campus. getting voluntary consents to participate through a self-administered questionnaire, was completed individually by each student. each participant was informed of the purpose of the study by four trained data collectors and that the data was kept in a completely confidential and anonymous manner. the time necessary for completion of the questionnaire was approximately 30 minutes. ethics: this study was approved by the ethics review committee of department of medical research, ministry of health and sports, myanmar (erc number: 016917) ethics/dmr/2018/021 data analysis: after an initial descriptive analysis, a classification of risk level assessment in scoring audit test was carried out by calculating the scores. in the case of correlation in categorial variables, chi-square tests were used along with the calculation of coefficients. finally, a logistic regression analysis was performed to estimate the associated odds ratios for different variables on the binary outcomes of drinking (yes/no). data entry was done using epidata 3.02 software and descriptive analysis was performed by stata version 15.1 for mac software. 3. results 3.1 background characteris cs a total of 976 university students participated in the study. the mean age at first drinking alcohol among the participants was 16.36 ± 0.15 years with range of 16 to 19 years (table 1). table 2 showed the background characteristics of the participants as five hundred and thirty (54.3%) students were males, 45.3% were females and only 0.4% were not responded their gender or lgbt. only a very small number of participants 0.4% were not declared their gender status or lesbians, gays, bisexuals and transgenders (lgbt). about 95.3% of respondents were buddhist and 2.5%, 1.2, 0.6% and 0.4% of respondents were christian, islam, hindu and others respectively. notably, two-third of the participants 89.4% were burma and minority (<1%) were shan, chinese, kachin, chin, rakhine and kayin. the vast majority of the participants (898 out of 976) were fresher students and the rests 78 students were repeater. most of them were involved in physical and social activities at school (or) school per97 ghmj (global health management journal) 2019, vol. 3, no. 3 aung y et al. formances and only 7.2% were not attended the classes regularly. over half of the participants 60.8% were not lived with parents or guardians and the rests lived in their parents’ home. among those participants, 13.8% were current smokers and 6.7% were betel chewers. a considerable proportion of their parent’s history of drinking 40.7% had father only. nearly 60% of their parents did not drink any kind of alcohol beverage on previous history. table 1. mean age of par cipants and mean age at first drinking alcohol (n = 976) name of the variables mean ± sd age in years of par cipants 18.46±0.05 age at first drinking alcohol 16.36±0.15 table 2. background characteris cs of university students (n = 976) characteris cs name of variables n % gender male 530 54.3 female 442 45.3 lgbt or no response 4 0.4 religion buddhist 930 95.3 hindu 6 0.6 chris an 24 2.5 islam 12 1.2 others 4 0.4 educa on status fresher 898 92.1 repeater 78 7.9 performed physical/social ac vi es yes 680 69.7 no 296 30.3 class a endances absent one me per week 332 34.0 absent one me per month 150 15.4 more than one me per month 289 29.6 not more than 10 mes per year 135 13.8 never / regularly a end the classes 70 7.2 living situa on not with parents/guardians 593 60.8 with parents/guardians 383 39.2 level of life sa sfac on low (sad) 50 5.1 medium (normal) 532 54.5 high (enjoy/happy) 394 40.4 tobacco use/current smoking yes 135 13.8 no 841 86.2 current betel chewing yes 65 6.7 no 911 93.3 parents history of drinking both of them 23 2.3 father only 397 40.7 mother only 1 0.1 none of them 555 56.9 98 aung y et al. ghmj (global health management journal) 2019, vol. 3, no. 3 total 976 100.0 3.2 drinking risk level assessment using the alcohol use disorder iden fica on test (audit) table 3 showed the alcohol consumption and risk level of drinking was expressed according to the audit test in scoring system. there was total score of 40 in audit test, it contained ten questions with 40 multiple answers that every answer marked one score. nearly half of the participants 48.7% were abstainers and 86 (8.8%) were high risk drinkers while 28 (2.9%) had alcohol dependency. table 3. drinking risk levels assessment according to audit test (n = 976) types of drinkers n (%) abstainers (0 score) 475 48.7 low risk drinkers (1-7 score) 387 39.6 high risk drinkers (8-15 score) 86 8.8 dependence (16-40 score) 28 2.9 total 976 100.0 3.3 alcohol consump on situa on and favorites types of beverages the total of 976 university students were participated in responding the drinking habit. among those, 564 students (male = 375, female = 185, lgbt =4) had experiences of alcohol drinking and/or drank at least one time in the past and 412 students (male = 155, female = 257) had never tried to drink alcohol in figure 1. (pearson chi2(2) = 85.4496, pr = 0.000) yes 57.8% no 42.2% figure 1. drinking habit of the par cipants (n = 976) the favorite beverage of the university students who drink alcohol was beer followed by wine, toddy, cocktail, whisky and the least percentage of beverages was rum shown in (figure 2). most of them (338) students drank for the reason of relaxation and (293) drank because of peer pressure. the emotional reasons “sadness” and happy “for fun” were the same numbers of percentage for the drinkers. the group “social reasons” included heart broken, family problems, relationships status, fresher welcome parties and drinking as regard of social life events. and then, curiosity mean that test the taste of alcohol was the third common reason and 33 students drank because they like the alcohol and drank without having any reason (figure 3). the table 4 showed the experiences and feelings of the university students who drink alcohol. among those having experiences of drinking alcohol, only 95 students drank a reason of breaking up with their boyfriends or girlfriends. after drinking, 19.7% of students who drank alcohol had ever happened memory loss (blackout). while drinking, 6.7% of those had ever flighted and 18.3% had ever ignored the classes because of drinking. at the same time, the percentage of the students 99 ghmj (global health management journal) 2019, vol. 3, no. 3 aung y et al. beer wine toddy cocktail whisky others vodka/tequila rum 37.4 29 11.7 7.7 5.7 4.3 3 1.3 figure 2. types of beverages favorited by par cipants (n = 564) relaxa on peers curiosity for fun sadness social preference 59.9 51.9 25 20.9 20.9 19.7 5.9 figure 3. reasons for drinking among students who drank alcohol who felt guilty was 30.5% and 25% were always able to stop drinking when they would like to quit drinking. the total 141 students who decided to stop drinking but 119 (84.4%) were achieved to follow their decision (table 4). table 4. experiences and feelings of university students who drink alcohol (n = 564) feelings and prac ces n yes/no (%) was your drinking ever a reason to lose a rela onship? 95 yes 16.8 469 no 83.2 do you ever drink to get drunk? 167 yes 29.6 397 no 70.4 have you ever happened memory loss a er drinking? (blackout) 111 yes 19.7 453 no 80.3 have you ever skipped or missed classes because of drinking? 103 yes 18.3 461 no 81.7 do you ever feel guilty about your drinking? 172 yes 30.5 392 no 69.5 are you always able to stop drinking when you want to? 141 yes 25.0 423 no 75.0 total 594 100.0 100 aung y et al. ghmj (global health management journal) 2019, vol. 3, no. 3 among those who decided to stop drinking (n=141) if you decided to quit, s ll availabel to avoid alcohol yes 84.4 119 no 15.6 22 3.4 logis c regression analysis in the logistic regression analysis, gender, religion and parents’ history of drinking as the frequency distribution was less than five in numbers of some categories in those three independent variables. so, drop off those variables but recoded gender as two categories (male and female) to analyze a binary logistics regression model. in the model of logistic regression (table 5), gender, living situation of the university student and smoking habit had a statistically significant effect on drinking practice. all the predictors variables were negatively associated with the dependent variable except only one independent variable (education status) had positive association with drinking. if the university students were repeater, holding other variables constant, there would be 1.2 times more likely to drink alcohol compared to fresher students. the female students were 63% less likely to drink than male and if the students lived with their parents at home, holding other variables constant, 55% decreased the chance of drinking alcohol than those who did not live with their parents. in the factor of school activities (participation/involved =1), the students did not involve in school activities were 23% lower chance of drinking alcohol at the significant level of 0.112. the students feeling happy had 32% lower odds (or = 0.68) while feeling normal in life satisfaction had 36% lower odds (or = 0.64) of drinking habit compared with those who were felt sad (p = > 0.05). when a student did not smoke, the probability of drinking would be decreased 88% than who smoked (p = < 0.001) while not used of smokeless tobacco, not chewing betel had 52% lower odds (or = 0.48) at the significant level of 0.147. when a father of the students had a history of alcohol drinking, the student drinking habit chance also 1 time increased. table 5. logis c regression coefficient and odds ra os (n=966) characteris cs variables coefficient or (95%) p value gender male (ref) 1.00 female -0.98 0.37 (0.28-0.51) 0.000 religion buddhist (ref) 1.00 hindu -0.27 0.77 (0.13-4.64) 0.772 chris an 0.35 1.42 (0.55-3.67) 0.474 islam -2.20 0.11 (0.01-0.91) 0.041 educa on status fresher (ref) 1.00 repeater 0.18 1.20 (0.68-2.12) 0.539 school ac vi es yes (ref) 1.00 no -0.26 0.77 (0.56-1.06) 0.112 a endances absent 1 class/week (ref) 1.00 absent 1 class/month -0.07 0.93 (0.60-1.44) 0.748 > 1 class/month 0.21 1.24 (0.85-1.79) 0.262 not > 10 classes/month -0.46 0.63 (0.40-1.00) 0.046 regularly a end classes -0.86 0.42 (0.23-0.77) 0.005 living situa on without guardians (ref) 1.00 with parents -0.80 0.45 (0.33-0.61) 0.000 life sa sfac on low/sad (ref) 1.00 101 ghmj (global health management journal) 2019, vol. 3, no. 3 aung y et al. medium/normal -0.44 0.64 (0.30-1.37) 0.254 high/happy -0.39 0.68 (0.31-1.46) 0.322 smoking yes (ref) 1.00 no -2.14 0.12 (0.05-0.26) 0.000 betel chewing yes (ref) 1.00 no -0.74 0.48 (0.18-1.30) 0.147 parents history both of them (ref) 1.00 father only 0.01 1.01 (0.36-2.83) 0.989 none of them -0.43 0.65 (0.23-1.81) 0.406 constant 4.58 97.21 (18.78-503.15) 0.000 log likelihood = -544.98859; lr chi2 (17) = 226.42; prob > chi2 = 0.0000; pseudo r2 = 0.172 3.5 calcula on of probability of drinking alcohol among university students when concentrate on gender, smoking and living situa on in the following figures 4, the graphs that could be seen adjusted proportional probability when comparing probability to drink alcohol between smoking habit and living situations of the students when concentrating on their gender. when the statistically significant independent variables (gender, smoking and living situation) were set up with margins command in stata version 15.1 and figured out with the graphs. figure 4. probability of drinking alcohol when concentrate on gender, smoking and living situa ons of the university students the probabilities of getting chance of drinking alcohol among university students was higher chance in male when compare to female. at the same time, if the male students who did not live with their parents or without guardians and have a habit of smoking, the probability of drinking alcohol was more chance than those of female students. thus, the results found out that living separately with parents and smoking habits were important factors for drinking alcohol with statistically significant at 95% confidence level. 4. discussion this descriptive study had been crucial in understanding the alcohol consumption risk levels assessments on adolescents university students. ideally, alcohol consumption, reasons for drinking, types of beverages preference, socio-economic and environmental conditions would be the factors association with current situation of drinking risk level. the teenagers and adolescent university students 102 aung y et al. ghmj (global health management journal) 2019, vol. 3, no. 3 often engaged in health risk behaviors, resulting in unintended social deprivation, negative impacts on class activities and school performances. this research mainly focused on assessment of risk level of drinking alcohol applied audit test. the university students who reported drinking alcohol as a means of enjoying with students’ lives and relaxation. as a nature of teenagers, they had peers’ pressure to practice the habit of drinking alcohol (abbey et al., 1993; macarthur et al., 2017). this was tended to be sociable drinkers more alcohol when their friends drank any types of alcohol beverages at the social gatherings (supski et al., 2017). these results clarified the importance of concurrently reflecting personal drives for drinking alcohol and the extent to which individuals’ life perceptions related to these motives for drinking. the hazardous alcohol consumption (hac) among university students in ireland shown that 65.2% in male and 67.3% in female that was assessed audit test and more likely to account smoking and drug use (davoren et al., 2015) that was higher percentage of drinking risk level relative to this study. in that ireland study, self-reported information in classrooms were conducted with the undergraduates. the current situation of drinking risk level assessments among university students in england shown that 61% were high risk drinkers on the audit and 10% with apparent dependence (heather et al., 2011). the results obtained in this present study shown, firstly that expanding the sampling frame to first year students age ranged between 16-19 years of age leads to a downward adjustment in the mean age at first drinking alcohol to significantly earlier ages than those found in twantay township among youths. those participants were recruited from community and only 9.2% of the youths were university level education and this study can be seen consistent finding in father drinking practices of participants had positive association with their drinking habit (phyo, 2016). the university students in this study who had experiences of alcohol drinking and/or drank at least one time in the past was 57.8% that was higher percentage of the 15-24 years old medical students consumed alcohol 34.5% and compared with community youths 47.1% in myanmar (sakamoto, 2010). regarding the associations of drinking habit, it has been observed that the percentage of adolescents who did not smoke and did not have a practice of betal-chewing was less likely to drink alcohol beverages than those who smoked and chewed the betals. the practices of bad habits could be explained by a generic fact and that related with individual way of perceptions on awareness of health-related consequences of smoking, betel chewing and drinking alcohol beverages. the same associations was found out in the study of alcohol consumption among adults males in urban area of thanlyin township, yangon region (oo et al., 2015). and also the smoking habit was significantly related to the adolescents’ decision to drink alcohol (goldberg et al., 2002) while indian students in grades 5-12 smokers were three times more likely to drink alcohol (torabi et al., 1993). the early the age of using tobacco, drugs and alcohol drinking, the more problematic consumption of alcohol among madrid 15-24 years old young people (hernández lópez et al., 2009). contrarily, this study had been proven that the majority of university students did not miss the classes and involve in numerous risky practices (fights). one third of the participants felt guilty because of their drinking habit. the study found that mean age of alcohol drinking among university students was 16.4 years even though the legal age for consumption of alcohol in myanmar was 18 years. more than half of the students had an experience of drinking alcohol and nearly forty percent were low risk drinkers. easier accessibility to beer stations, bars and restaurants with peers and social events could lead to higher exposure to drinking practices through reasons among those university educated adolescents. on the other hand, this fact could be prevented as a law enforcement for the policy makers to raise taxes or action plan to tackle adolescent’s health program. as many of them reported that they favored beers (37.4%), wine (29%) and the last was rum (1.3%), it could be seen that the types of beverages among university students were not heavy drinkers. further, these drinkers were more likely to report an informative reason that they drank because of relaxation and peers’ effect. it could be prevented by providing the other recreations activities focus on physical activity like dancing clubs, yoga sections and fun fairs. 103 ghmj (global health management journal) 2019, vol. 3, no. 3 aung y et al. finally, living situation of students who did not live together with parents or guardians were more likely to drink alcohol. then, the relationship between alcohol drinking and smoking habit reflected the significant association. this finding highlighted the possible solution to consider within universal school-based alcohol prevention programs by raising awareness of the potential dangers of alcohol use and peers resistance skills related to health promotion intervention. although the results obtained with respect to personal variables, such as alcohol consumption practices and reasons of drinking coincide with the literature reviewed (abbey et al., 1993), their drinking risk level was rather regulated. beyond such observations of an individual nature, the results obtained show the importance of the participant’s environmental factor, especially the peer group. nevertheless, it was important to point out that the explanatory capacity of these findings remained without statistically significant. but the regression analysis results were possible to determine whether university students who drinking alcohol did so because their smoking habit and living situations with parents or, conversely, whether they did not live with parents and any guardians. the results presented here were based on cross-sectional data. a limitation is that all the variables had been self-reported, making it impossible to know with certainty to what extent university students might have underor overestimated their alcohol used disorders identification tests and risk levels of use. however, as various experts in the field of mental health, researchers with experiences of conducting alcohol studies and national drug abuse control program had investigated, self-report measures had proven to be reliable and even better than other methods when evaluating levels of alcohol (winters et al., 1990). the strengths of this study included the large sample size recruited from 6 universities in mandalay region. this work could be readily replicated in other universities across the country and used a standard, internationally recognized audit test for assessing risk level of drinking alcohol. however, self-reported measures were an important source of information, the extent to which these results may be generalized to students in other districts or other parts of myanmar remains unknown. replication of this study is also needed in others universities and it would be of great interest if future work could provide new variables to improve the prevention of health risk behaviors among university students’ alcohol prevention program. recommendations: findings from this study indicate a need for law governing the age at which adolescents start drinking alcohol and strictly prohibits the sale of alcohol directly or indirectly to those under the age of 18 years old. the health policy makers should be aware on implementation of effective alcohol control strategies by nudging the university students who under 18 years of age into raising awareness alcohol issues. the alcohol intervention program can be helpful in modifying behaviors change communication in health promotion of university students. 5. conclusion it provided evidence-based findings for knowing the alcohol consumption risk level among university students to prevent social deprivation and health risk behaviors. findings from this study indicate a need for law governing, strictly prohibits the sale of alcohol directly or indirectly to those under the age of eighteen years. the alcohol intervention program can be helpful in modifying behaviors change communication in health promotion of university students. acknowledgments the authors thanks to all responsible persons and students from study universities for collaborating and helping well to conduct this study. 104 aung y et al. ghmj (global health management journal) 2019, vol. 3, no. 3 funding funding for conduction this research was provided by the department of medical research, ministry of health and sports, myanmar. conflict of interest there is no conflict of interest. references abbey, a., smith, m. j., and scott, r. o. (1993). the relationship between reasons for drinking alcohol and alcohol consumption: an interactional approach. addictive behaviors, 18(6):659–670. babor, t. f., de la fuente, j. r., saunders, j., and grant, m. (2001). the alcohol use disorders identification test: guidelines for use in. davoren, m. p., shiely, f., byrne, m., and perry, i. j. (2015). hazardous alcohol consumption among university students in ireland: a cross-sectional study. bmj open, 5(1):e006045. giesbrecht, n., ialomiteanu, a., and anglin, l. (2004). drinking patterns and perspectives on alcohol policy: results from two ontario surveys. alcohol and alcoholism, 40(2):132–139. goldberg, j. h., halpern-felsher, b. l., and millstein, s. g. (2002). beyond invulnerability: the importance of benefits in adolescents’ decision to drink alcohol. health psychology, 21(5):477. heather, n., partington, s., partington, e., longstaff, f., allsop, s., jankowski, m., wareham, h., and st clair gibson, a. (2011). alcohol use disorders and hazardous drinking among undergraduates at english universities. alcohol and alcoholism, 46(3):270–277. hernández lópez, t., roldán fernández, j., jiménez frutos, a., mora rodríguez, c., sánchez-garnica, d., and pérez álvarez, m. (2009). the starting age of drugs consumption as an indicator for problematic consumption. psychosocial intervention, 18(3):199–212. macarthur, g. j., jacob, n., pound, p., hickman, m., and campbell, r. (2017). among friends: a qualitative exploration of the role of peers in young people’s alcohol use using bourdieu’s concepts of habitus, field and capital. sociology of health & illness, 39(1):30–46. oo, w. m., aung, m. s., soe, p. p., lwin, s. h., and win, m. o. (2015). alcohol consumption among adult males in urban area of thanlyin township, yangon region, myanmar. int j res med sci, 3:3192–6. page, r. m. and danielson, m. (2011). multi-country, cross-national comparison of youth tobacco use: findings from global school-based health surveys. addictive behaviors, 36(5):470–478. phyo, a. p. (2016). what, how and why they drink? : drinking of alcoholic beverages among youths in twantay township. powell, l. m., williams, j., and wechsler, h. (2004). study habits and the level of alcohol use among college students. education economics, 12(2):135–149. sakamoto, j. (2010). risk behaviours and associated factors among medical students and community youths in myanmar. nagoya j. med. sci, 72:71–81. supski, s., lindsay, j., and tanner, c. (2017). university students’ drinking as a social practice and the challenge for public health. critical public health, 27(2):228–237. thakker, k. d. (1998). an overview of health risks and benefits of alcohol consumption. alcoholism: clinical and experimental research, 22:285s–298s. torabi, m. r., bailey, w. j., and majd-jabbari, m. (1993). cigarette smoking as a predictor of alcohol and other drug use by children and adolescents: evidence of the “gateway drug effect”. journal of school health, 63(7):302–306. winters, k. c., stinchfield, r. d., henly, g. a., and schwartz, r. h. (1990). validity of adolescent self-report of alcohol and other drug involvement. international journal of the addictions, 25(sup11):1379–1395. world health organization (2004). global status report on alcohol 2004. https://apps.who.int/iris/ bitstream/handle/10665/42971/9241562722_(425kb).pdf. world health organization (2014). global status report on alcohol 2014. https://www.who.int/substance_ abuse/publications/alcohol_2014/en/. world health organization (2018). global status report on alcohol 2018. https://apps.who.int/iris/ bitstream/handle/10665/274603/9789241565639-eng.pdf. 105 https://apps.who.int/iris/bitstream/handle/10665/42971/9241562722_(425kb).pdf https://apps.who.int/iris/bitstream/handle/10665/42971/9241562722_(425kb).pdf https://www.who.int/substance_abuse/publications/alcohol_2014/en/ https://www.who.int/substance_abuse/publications/alcohol_2014/en/ https://apps.who.int/iris/bitstream/handle/10665/274603/9789241565639-eng.pdf https://apps.who.int/iris/bitstream/handle/10665/274603/9789241565639-eng.pdf ghmj (global health management journal) 2019, vol. 3, no. 3 aung y et al. cite this article as: aung y, ou ytn, wan nma, nyan bb, phyo ap, win ll. alcohol consumption and current situation of drinking risk level among university students in mandalay region. ghmj (global health management journal). 2019; 3(3):95-106. doi:10.35898/ghmj-33453 106 introduction method results background characteristics drinking risk level assessment using the alcohol use disorder identification test (audit) alcohol consumption situation and favorites types of beverages logistic regression analysis calculation of probability of drinking alcohol among university students when concentrate on gender, smoking and living situation discussion conclusion knowledge, attitudes, and hiv/aids risk behaviors of myanmar migrant workers in thailand ghmj (global health management journal) 2022, vol. 5, no. 2 indonesian scholars’ alliance open access photo essay politeknik kesehatan kemenkes palangka raya: health forum and international seminar the new normal: creating a pleasant virtual communication hand-washing promotion during covid-19 outbreak in riverbank of kahayan river, central kalimantan, indonesia missesa 1,* , trissa viranti 1 , shasa dini martha ewa kaswana 1 , carolin firsta athena 1 , hendrowanto nibel 2 1 department of nursing, poltekkes kemenkes palangka raya, indonesia 2 fakultas keguruan dan ilmu pendidikan, universitas palangka raya, indonesia *corresponding author’s e-mail: missesa@polkesraya.ac.id doi: 10.35898/ghmj-52944 selection and peer-review under responsibility of the scientific committee and the editorial board of the annual health forum and international seminar of the politeknik kesehatan kemenkes palangka raya © yayasan aliansi cendekiawan indonesia thailand (indonesian scholars’ alliance). this is an open-access following creative commons license deed attribution-noncommercial-sharealike 4.0 international (cc by-nc-sa 4.0) covid-19 is a new type of disease caused by infection with the virus severe acute respiratory syndrome coronavirus 2 (sarscov-2) virus (singhal, 2020). since the emergence of covid-19 in end of 2019 up to end of october 2020, the virus has infected 44,002,003 people and caused death to 1,167,988 people worldwide (who, 2020). according to child protection for population control and family planning (dp3, ap2kb) data, hundred and eleven (111) children were infected with covid-19 in 2020. in mid-2020, covid-19 cases in central kalimantan showed relatively high at 1,055 cases. in other words, approximately 10.5% of children suffered from covid -19. source: kasriadi dan hidayat, 2021 (https://www.antaranews.com) figure 1. children with covid 19 in central kalimantan, july 2021 3% 26% 71% < 1 years old 1 5 years old 6 15 years old mailto:missesa@polkesraya.ac.id https://doi.org/10.35898/ghmj-52944 missesa et. al. ghmj (global health management journal) 2022, vol. 5, no. 2 154 in 2021, covid-19 cases showed an increase in a number of cases in children compared to the previous year. in july 2021, a total of 3.241 cases were reported, including those aged 6-15 years old (2,302 cases), 1-5 years old (844 children), and < 1 year old (95 children) (figure 1). the increasing number calls all parties to protect, sustain, and accelerate progress in fighting childhood covid-19 by maintaining healthy standard behaviour. many institutions have been implementing health education on the positive healthy behaviour standard for covid-19 prevention, including regular hand washing, mask-wearing (figure 2), and social distancing. the purpose of this article is to give clear and actionable guidance for children living in river-basin residences. figure 2. masks to protect healthy children during the covid pandemic living in central kalimantan this photo essay records health promotion given during covid-19 outbreak in riverbank of kahayan river, central kalimantan, indonesia (figure 3). central kalimantan geographically has a number of rivers known as a watershed area (das). figure 4 shows the children use small boat made by wood to mobile or visit their friends to play. figure 3. view of the kahayan riverbank in central kalimantan figure 4. children playing together by the river in central kalimantan before pandemic 155 ghmj (global health management journal) 2022, vol. 5, no. 2 missesa et. al. before the covid-19 outbreak, using face mask in not compulsory and parents will just freely give permission to their children to play outside. it is shown that it is challenging to encourage children to protect themselves from the covid-19 infection in the area of das. moreover, the existence of this abundant water source is a potential natural asset for positive hygiene behaviour. thus, it is worth noting that hand washing with soap and water is recommended (przekwas and chen, 2020). research by widodo and alexandra (2018) reported that levels of knowledge about clean behaviour living habits in residents living in the riverbank of kahayan river were not optimal (56.8%) and behaviors of hand washing with soap were only 14%. the corona virus outbreaks impacted education across the word. our local government took action to prevent the spread of the virus by disclosing schools throughout all levels of education, including early childhood education (paud) level to higher education institutions. we have been learning about the covid-19. although basic information has been informed, parents are required to encourage their children, maintaining the healthy behaviour during the covid-19 pandemic. instead of continuously closing schools indefinitely for preventing the spreadable virus, teaching children good hand and respiratory hygiene practices for schools and outdoor activities are crucial. some educational health learning on these includes frequent hand washing, covering a cough or sneeze with a tissue or tugged elbow, followed by throwing the tissue into a closed waste bin, preventing their eyes, mouth, and noses from their dirty hands. moreover, it is also good to have a look at their mental health. some mental health which can be suffered by children during the pandemic involves sleeping disorders, bedwetting, pain in the stomach as well as stress. teaching them how to cope with stress can be encouraging. some efforts to address the spread of covid-19 and mental health problems during the pandemic should be made. those are as follows. firstly, regular surveillance of children’s health and asking them to stay at home in case of illness are encouraging. other efforts are teaching and demonstrating good hygiene practices for children (figure 5). as per government policy on covid-19 health protocol, hand washing with soap is recommended. the handwashing action can be conducted in schools figure 6. doing a focus group discussion activity is also helpful for children to understand better about covid-19 pandemic. furthermore, it can explore their feelings during the pandemic. hence, children feel secure when they face issues on covid-19. since the covid-19 virus is able to survive on various types of objects in a few hours, some even up to several days, it is suggestive to ask children to avoid touching their face, eyes, mouth, and nose. likewise, consideration for other people around children should be taught to children. therefore, asking them to cover their mouths with their elbows or a tissue once coughing and sneezing is a key message for parents and caregivers. figure 5. teaching children to wash their hands figure 6. children make a habit of washing hands in school activities missesa et. al. ghmj (global health management journal) 2022, vol. 5, no. 2 156 proper hand washing activities need to be taught as early as aged 2-10 years (who, 2020). at this age, children like to discover new things. hand washing was also suggested by anhusadar and islamiyah. (2020) that it is important to implement clean and healthy behavior for early childhood in the midst of the covid-19 pandemic. healthy living behavior in children must be taught from an early age stage because ofthe rapid development of the brain in early childhood. at early age, the memory capacity of the brain reaches its maximum level. therefore, it is useful to develop healthy behaviors at the early age that children will have a healthy lifestyle in adulthood. source : https://promkes.kemkes.go.id/ figure 7. educational poster on how to wash hands school environments are effective in disseminating health promotion strategies. a program which engages children in schools to support healthy lifestyles provides a medium for creating creative environments through posters. posters offer a great impact visually on audiences and give messages a lot of exposure, allowing posters to reach a number of different types of people. in the following are steps on how to wash hands. how to wash your hands in 20 seconds are (figure 7) 1) wet hands thoroughly with running water 2) rub soap into palms, backs of hands and between fingers. 3) clean under the nails 4) rinse hands with running water 5) dry your hands with a towel / tissue or dry with air / air dry 157 ghmj (global health management journal) 2022, vol. 5, no. 2 missesa et. al. posters delivered messages in the form of the comic along with words and pictures will have powerful message to tell stories which might be preferable to children. comics can convey key persuasive messages of covid-19 attractively to children to influence their behaviors. covid-19 campaign through poster is also known as an effort to prevent disease transmission which can be conducted to change children’s habits. hands are agents which carry germs and cause pathogens to move from one person to another, either by indirect or direct contact. campaigns on covid-19 to children can be conveyed through visual and auditory information. audiovisual campaigns encourage children to keep healthy lifestyles. research conducted by listiadestiet al. (2020) reported the effectiveness of audio-visual media as health promotion which significantly helped children's understanding on hand washing with soap. figure 8 shows our effort to support healthy lifestyles by storytelling which engages children with covid-19 information. it incorporates narrative texts and stories with a fun way which, attracts children's interest. it does not seem to be patronizing and can develop children's imagination in which storytelling contains a story of experiences and an incident or invention which actually happened in the real world. perdani's research results (2018) show an effective campaign, promoting the handwashing program to children. a cultural approach can also be an alternative for health campaigns. figure 9 shows how we use one of traditional musical instruments of central kalimantan, called japen, and the lute is used as an instrument for making audio-visuals. this instrument is made from a sack. it includes education and has a key message of moral wisdom with the social value of the dayak people in borneo. figure 8. educational activities by telling stories figure 9. children are taught to use a typical central kalimantan musical instrument "kecapi" maintaining children's health during the covid 19 pandemic with creative educational campaigns, using various modes such as posters, multimedia, and storytelling is beneficial for positive health behaviours. responsibility and health disciplines which are developed from an early age in the new normal era will enable them to build intrinsic motivation for stopping the spread of covid-19. .consent the informants (identifiable) photographed have given their consent for their pictures to be used in the publication of this photo essay. conflict of interests: none acknowledgments: the authors wish to thank politeknik kesehatan kemenkes palangka raya, central kalimantan. missesa et. al. ghmj (global health management journal) 2022, vol. 5, no. 2 158 references anhusadar, l. o. islamiyah.(2021). jurnal obsesi: jurnal pendidikan anak usia dini penerapan perilaku hidup bersih dan sehat anak usia dini di tengah pandemi covid, 19, 463-475. doi: 10.31004/obsesi.v5i1.555. kaltengpos (2020) memilukan ! tercatat, 111 anak di kalteng terpapar covid-19. available at: https://kaltengpos.co/berita/-50022-memilukan_!_tercatat,_111_anak_di_kalteng_terpapar_covid-19_.html (accessed: 30 october 2020). kasriadi dan hidayat, m.a. 2021. kasus covid 19 pada anak-anak di kalteng cukup tinggi https://www.antaranews.com/berita/2269882/kasus-covid-19-pada-anak-anak-di-kalteng-cukup-tinggi. (accessed: 30 october 2021). przekwas, a. & chen, z. 2020. washing hands and the face may reduce covid-19 infection. med hypotheses, 144, 110261. perdani, a. p. n. (2018) ‘pengaruh storytelling terhadap perilaku cuci tangan menggunakan sabun dengan benar pada anak di tk al-qodiri jember’, jurnal mid-z (midwivery zigot) jurnal ilmiah kebidanan, 1(1), pp. 13–18. available at: http://ejurnal.uij.ac.id/index.php/jm/article/view/322 (accessed: 30 october 2020). singhal, t. (2020). a review of coronavirus disease-2019 (covid-19). the indian journal of pediatrics, 87(4), 281-286. https://doi.org/10.1007/s12098-020-03263-6. listiadesti, a. u., noer, s. m., & maifita, y. (2020). efektivitas media vidio terhadap perilaku cuci tangan pakai sabun pada anak sekolah: a literature review. menara medika, 3(1). https://doi.org/10.31869/mm.v3i1.2198 widodo, t., alexandra., f.d. 2018. hubungan tingkat pengetahuan phbs tatanan rt dengan phbs warga di bantaran sungai kahayan palangka raya tahun 2016. jurnal pengelolaan lingkungan berkelanjutan. http://www.bkpsl.org/ojswp/index.php/jplb. cite this article as: missesa, viranti t, kaswana sdme, athena cf, nibel h. hand-washing promotion during covid-19 outbreak in riverbank of kahayan river, central kalimantan, indonesia. ghmj (global health management journal). 2022; 5(2):153-158. doi:10.35898/ghmj-52944 https://doi.org/10.31869/mm.v3i1.2198 https://doi.org/10.35898/ghmj-52944 cite this article as suryadinata hu. the benefits of automated dispensing machine for hospital pharmacy in indonesia: situation, implementation, and feasibility. 2017; 1(1): 15-22. global health management journal www.publications.inschool.id published by review the benefits of automated dispensing machine for hospital pharmacy in indonesia: situation, implementation, and feasibility haryman utama suryadinata faculty of public health, universitas indonesia, indonesia *corresponding author. email: harymanutamasuryadinata@gmail.com article info abstract article history: submitted 17 april 2017 accepted 17 june 2017 background: pharmacy as the main core of hospital is responsible for the quality and safety of medicines. yet the numbers of medication errors are still high. automated dispensing machine (adm) is one of the solutions to reduce the dispensing errors in pharmacy. many countries had studied and proved that the use of adm gives more benefit than liability. however, adm is considered as something new, a “nice to have” product. aims: this study will explain the benefits of adm especially in indonesian hospital pharmacy. methods: systemic review with prisma method uses 5 databases as scopus, springerlink, google scholar, science direct and proquest, with keywords automated dispensing machine, automated dispensing device, automated dispensing system, automated drug dispensing system, or robotic dispensing system. the inclusion criteria are all the studies that showed any impact in minimum of one aspect of adm in hospital. results: there are 13 studies that explained adm benefits such as increase staff satisfaction for the nurse and pharmacist, reduce dispensing errors about 35% or up to reducing all dispensing errors, time saving until 50% in peak hours and cost analysis and effectiveness. the cost analysis such as inventory stock reduction, increases the cost saving. conclusion: in indonesia, it needs many considerations to implement adm but it had already installed in 1 indonesia hospital. this hospital had proved that adm can reduce dispensing errors and can solve some pharmacy problem such as the human resources problems and the long waiting time. with the proven benefits of adm, it is justified for indonesian hospital to implement adm and information system in their pharmacy. the effectiveness will perceive the pharmacy and positively affect to all related departments in hospital. keywords: automated dispensing machine automated dispensing system automated dispensing device robotic dispensing system automated drug dispensing system this article is an extension of a selected paper “the benefits of automated dispensing machine as solutions for hospital pharmacy in indonesia: a systematic review” published in proceedings of the international conference on applied science and health (no. 1, february 2017). © 2017 publications of yayasan aliansi cendekiawan indonesia thailand this is an open access following creative commons license deed – attribution-noncommercial-sharealike 4.0 international (cc by-nc-sa 4.0) introduction pharmacy is a hospital's main core which products are widely used, such as medicines, medical devices, films and reagents. thus pharmacy becomes the revenue center in hospital [1]. in indonesia, most of hospitals pharmacies in indonesia are still using man-power to do their daily http://publications.inschool.id/ mailto:harymanutamasuryadinata@gmail.com http://publications.inschool.id/index.php/icash/article/view/27 http://publications.inschool.id/index.php/icash/article/view/27 http://publications.inschool.id/index.php/icash/issue/view/1 http://inschool.id/ http://creativecommons.org/licenses/by-nc-sa/4.0/ global health management journal, 2017, vol. 1, no. 1 16 activities. according to indonesia ministry of health regulation (undang-undang no. 35 year 2014), the pharmacy is responsible for the quality and safety of all medicines in hospital, this includes inventory planning, purchasing, receiving, distributing and evaluating the drug usage by the patient. in the ideal workflow, the pharmacy must get a prescription from the doctor, then continues to verification process, dispensing to hand over or administering the drug and educate the patient also evaluates the drug usage. this processes are not easy to do and error-prone, especially when using only man power; the risk of errors might harm the patient and it some cases it leads to death [2]. presently, pharmacy dispenses many drugs to the patients, meaning that dispensing is one of the main and most complex processes. dispensing includes picking and labelling the drugs. when it is manually done, dispensing error can happen any time, without anyone noticing until the patient is experiencing the harmful effect [2, 3]. there were 134,431 dispensing errors cases annually in england and wales [3]. another study showed there were 24% dispensing errors in community pharmacy and 12.5% in hospital outpatient pharmacy [2]. according to anacleto, perini, rosa, & césar, 2007 the dispensing errors are responsible for 11% from 50% of medication errors. the most common dispensing errors are wrong drug, wrong dose, wrong label, and wrong quantity [3]. hospitals are now focusing to improve patient safety and dispensing errors is one of the main concerns. there are some technologies to reduce the dispensing errors such as software, barcoding, automated dispensing machine (adm). adm is one of the ultimate solutions for pharmacy to help dispensing automatically and it will become the long-term care solution. adm uses barcode to identify the drugs, hence, it greatly reduces dispensing errors [5]. adm use barcode as the drugs identification and must integrated with hospital software. adm is relatively new in indonesia, even though some hospitals have already used it. many studies said that adm could give positive impacts to the pharmacy even just make the pharmacy focus on caring the patient. but there was study told that adm can reduce medication errors especially for dispensing errors, reduce the number of staff and make the services faster than before [6]. most of countries have been used and proved that adm was their main solutions to give more benefits for their pharmacy. so this study will explain and give some images of the benefits of adm especially for indonesia hospital pharmacy. methods there are many types of adm such as the box dispensing machine, cabinet dispensing machine, and unit dose dispensing machine. each machine has its own function for example cabinet system that can be used in emergency, or intensive care unit. the types of machine will be chosen, depends on where the place is pharmacy want to increase the quality services (see figure 1 to understand the pharmacy flow). this systematic review (sr) will not analyse the difference of the machines otherwise discuss the hall effect of the machine in all departments with some types of machines. searching this sr used prisma to make readers more understand with the simplest methods of adm. the figure 1. indonesia pharmacy workflow 17 global health management journal, 2017, vol. 1, no. 1 sources of the journals are searched via online from scopus, springerlink, sciencedirect, google scholar and proquest. the keywords are automated dispensing machine (adm), automated dispensing device, automated dispensing system, automated drug dispensing system (adds), or robotic dispensing system. others keywords used to find the local journal and used the synonym to get more variation of the journals. the limitation for this study is free journals that published from 2010 now. as the result, all journals that fulfilled the criteria are used even only the abstract is available. this study used 2 level filters are the title and abstract. inclusion and exclusion criteria the eligible journals parameter is all the studies that showed any impact of adm in hospital minimum one aspect such as the financial aspects, workflow efficiency, investment, services speed, etc. all the journals without any impact of the adm in the hospital explained had excluded. as the final, this study reviewed 13 journals (see figure 2). figure 2. prisma methods of the study global health management journal, 2017, vol. 1, no. 1 18 results there are 13 reviewed articles. there are 5 from 13 (2 abstract only) explained adm for outpatient pharmacy and 8 (2 abstract only) of 13 explained about adds (automated drug dispensing system) for intensive care, emergency or wards. most of those studies, 11 of 13, used observational study such as longitudinal (2 studies), case control (1 study), cross sectional (3 studies), 2 analysis study such as financial perspective. one from 13 used semi experimental study and another 1 study is a systematic review. they compared between before and after implementation of adm for many perspective in big hospitals (4 studies at more than 1000 beds hospitals, 4 studies at teaching hospital). adds is types of adm which mostly use for automated dispensing in ward. it doesn't matter about the name even adds and adm used only to represent the inpatient and outpatient department. the result is adm will give the efficient effect such as the cost saving, reducing error, reduced time services and smooth workflow for inpatient (including intensive and emergency unit) and outpatient department. another positive impact is especially for the nurse satisfaction and reduced total inventory control cost. one of study showed adm didn't give any impacts to increase the time for the service because their internal regulation put limited access for only some staff and another staff must wait those staff to use adm. on the other side, 1 studies also showed that adm need skilled staff to operate and the pharmacy have to choose kinds of medicines that adm can dispensed (see appendix). therefore, to maximize adm hospitals need to integrate with hospital information system and manage all the process including how to make the accurate filling and preparation process and also training the staff about the machine and how to through access to the machine. staff satisfaction from 2 journals which used adds as their solutions, all the nurses had satisfied and want to use adds as their dispensing system in wards. totally 91% nurses were very satisfied with adds. one journal gives the result that adm in outpatient, the average of the pharmacist satisfaction is 8.63± 0,744 and for the nurse satisfaction is 7.78 ± 0.667. according to gonzalez et al., 2016, his study divided 3 kinds of satisfaction based on the process and the results of adm (see table 1). the greatest result was in patient safety factor from pharmacy (9.75 ± 0.463), it means the pharmacy was satisfied with the adm because adm increase the safety [7]. table 1. the result of satisfaction types for the nurse and pharmacist [7] satisfaction pharmacist nurse patient safety 9.75 ± 0.463 8.00 ± 0.7077 ease of use 9.13 ± 0.641 8.2 ± 0.667 dispensing speed 7.75 ±0.886 6.33 ± 0.50 inventory control and integration > 8.5 7.75 ± 0.707 average 8.63 ± 0.744 7.78 ± 0.667 most of nurses and pharmacists actually aware, that they need adm as their solutions in their job. with the good operational and ease to use, adm can increase the patient safety, increase the inventory control quality and it had been approve by most nurses and pharmacists. reducing incidents or errors adm can increase patient safety by reducing dispensing errors and medication errors as final impact. five studies showed adds can reducing the errors, the administration errors by 57% and reduce dispensing errors by 6% [8–12]. for adm, there are 3 studies that showed adm has the effect to reduce errors. even 1 journal only showed the staff satisfaction about the patient safety, but it means the staff approved the adm reduced the errors and it made them satisfy [7, 13, 14]. sujatno 2016 showed that in his hospital, adm could reduce dispensing errors more than 35% (50.33 ± 34.77 to 15.67 ± 6.282). but beard & smith, 2013 and ong et al., 2014 had showed that adm can make all the dispensing process without any mistakes. time-saving as the result from the staff satisfaction parameter, they agree that adm and adds help them to serve faster. adds can reduce the time in emergency case, peak hour and for preparation process. adds also can increase the service-speed and can spare more work-time about 2 hours a day [9, 16, 17]. but roman et al., 2016 has another opinion, in 19 global health management journal, 2017, vol. 1, no. 1 emergency case adm could service faster than the normal situation. beard & smith, 2013 mention that adm can reduce 50% of the time with almost zero errors. as the saving-time effect from adm, the pharmacist and the nurse have more time to spend it with patients. cost analysis and effectiveness there are 6 studies about the effectiveness of adm or adds which showed as saving the total number of staff, space and total number of stock. adm compared by manual process, adm can save up to us$ 1,894,429 (for 10 years) if reach 75% dispensed volumes from adm[18].the more medicines dispense from the adm, the more effective the pharmacy will be[14]. beard & smith, 2013 explained that adm can reduced 4 staff, reduced the inventory stock about £250,000, increase the saving cost £500,000. adds can save approximately us$ 148,229 for 5 years [19]. another study showed also the costeffectiveness about us$ 80,000 annually. mostly in us, the adds are rented for the hospitals, with the rent cost about us$27,000 annually [9].however one study showed that adds can give the impact for the patient cost. the patient cost reduced 20.3% and can increase number of drugs for stocked about 11.4% with the less needed [16]. discussion situation in indonesia in indonesia, there is only one hospital already reported use adm, outpatient pharmacy of bethesda hospital yogyakarta [13]. the adm need to integrated with the hospital software system to maximize its potential as what beard & smith, 2013 results. the integration between adm and hospital information system (his) can make the zero result of errors. there are some challenges for indonesia to implement adm: the low cost of labor with the big population and the low economic rate. all the adm are made from foreign country such as italy, germany, japan, etc. so the prices usually expensive. nowadays, it is very difficult to get the well-trained staff even easier to recruit any new staff. as long as pharmacy still using human power, the errors incidents will be higher than use technology [14]. so the human resource problem for hospitals is still high and adm can solve the problem with its benefits. adm can reduce the total staff needed in pharmacy, increase the inventory control, reduce the errors, increase the time service and increase the staff satisfaction. all the benefits can calculate as the money or cost savings or cost-effectiveness. with those benefits, indonesian hospitals must considere to implement adm as their solutions in their pharmacy departments. claire chapuis et al., 2015 said that it is very profitable and improve efficiency with the adm. the only one barrier is the resistance of staff to changing. adm implementation in indonesia bethesda hospital has implemented adm in outpatient department since 2014. bethesda faced three main problems, the human resource problem, medication errors and very long waiting time before implemented adm. they had tried many ways to solve the errors problem such as human training, organizing the stocks, using information system and barcode system, but in reality, it just reduced some errors while dispensing errors were still high and the staff workload still very high. after adm installed, the staff were very satisfy and the dispensing errors incidents had reduced drastically. bethesda hospital used 20% and 80% role, to make the priority system for adm stocked medicines. most of indonesia medicines are finished as strips (aluminum foil) or blisters and packaged into 1 box with lot of number (e.g. 10 strips in 1 box), so bethesda hospital need to repackaged and put into the box and they called smart pack. those smart pack containing certain number of medicine. it will be possible if there will be 3 smart packs with the same medicine but different number. they also promoted adm to the physicians as the prescriber. they put any options of the medicines with different number that stocked in adm in electronic prescribing, so the physicians can choose the kinds and number of medicines to prescribed, which will be dispense with adm. as the result they got the dispensing errors reduction about 35%. with the combination between adm and electronic prescribing, they got 69.78% reduction of global health management journal, 2017, vol. 1, no. 1 20 dispensing errors, but the reduction not as much as the beard & smith, 2013; ong et al., 2014 studies. it because they still printed the label outside the machine. according to bethesda hospital experience, the biggest issue for hospital pharmacy is the variation of total medicines requested from the physician. sometimes, the patient also does not want to take hall the total number of medicines in prescription, they would like to buy half from the total amount of medicines. from that reason, the pharmacist should make priority, which medicines will be save inside adm. they can do a research to find the 3 top of total number from each medicines that the physicians often prescribed as the priority to keep inside the machine. the more medicines are going out from the adm, the less error will be happen. another problem pharmacy faced is about the software system and barcode system. some hospitals just have simple software just for logistic system, but adm need more complete software such as electronic prescribing and barcode system for each medicines. as the leaders who would like to implement adm, software and barcode is the first preparation of hospital must have. the leader also must to create the working climate into the technology based to all staffs because some staff could resists for the new technology and do not want to exit from their comfort zone. type of data for feasibility study the implementation of adm need more management consideration as the financial prospective become the main part to take any decision. the benefits of using adm should be calculated as the money, but it is not easy to convert all aspects as money value for example the staff satisfaction and the workflow efficient. first of all the hospitals should think about the standardization of the pharmacy procedure, to keeps the process and the result in good quality and safety as the requirement of accreditation. adm will record all the dispensing process by computerize and it will make stream-lining the processes. this benefit is the sample of the intangible aspect. another example is the nurse and pharmacist satisfaction when using adm. according to the result, the average for both satisfaction is more than eight, it means they are happy when implementing adm in their department. it should give any positive impact to their work when they are happy. the workload might be reducing and could give impact to their job quality for example incident errors less happen or the service time is faster for their job. second, adm could reduce the dispensing errors incidents. it should become the first priority as adm implementation consideration. reducing errors will saving-cost to the hospitals. hospitals will spend much money to prevent the errors or to solve the impact of errors. the amount of money that they spend for errors can be used for the fs calculation. third, the improvement of service time. adm could saving the time about 2 hours even in inpatient or in peak hour time of outpatient department. the time saving can be converted to the cost-saving and can be used for fs calculation. the converted time-saving become cost-saving can use the human power or staff cost/hour. the last one is the effectiveness of adm. from the human resource aspect, adm can reduced 4 people according to beard & smith, 2013. the reduction can be calculated as the cost-saving by using the total cost/month. for the stock efficiency, the average of cost-saving from adm is about us$ 189,442/year (1 usd = 13,200 idr, 2,500,634,400,idr), or from another study said adm increase the saving cost about £500,000(1 gbp = 16,800 idr, 8,400,000,000,idr). adm can give any extra saving money if using adm in inpatient department, from the result adm can save us$ 29,645/year or idr.391,314,000,per year (1usd = 13,200 idr). tsao et al., 2014 also said its profitable when rent adm while using manual (us$ 80,000 saving vs us$ 27,000 cost). if the hospitals use adm for inpatient, they can save about idr.699,600,000 annually. now, all the benefits can be calculated and accumulated and must be comparing with the adm selling price or another additional activity when adm had been implemented. adm implementation is also very depending on the leader strategic plan. if the leader didn't put technology as the strategic way to make any improvement for his hospital, it's very difficult to push that hospital to 21 global health management journal, 2017, vol. 1, no. 1 install the adm otherwise the fs calculation is ready for them, it might be change his mind. limitation and strength it is very good news for bethesda hospital that had started to used adm in indonesia even just in outpatient pharmacy. indonesia need another adm for the inpatient pharmacy (adds) to become the sample and as the evidence that adds improve the pharmacy process. it's not just for the pharmacy, but for all staff. it can help the nurse workload and their service care to patient. with the adds the nurse can safely administrate the medicine and as the result, the total incidents of medication error will reduce. adm as the solution is very depends on the leadership, management skill and all the departments support. adm need some consideration from the leader to make it as the priority for the pharmacy. they need to calculate some analysis to make the real feasibility study (fs) of the adm investment. in this study, the benefits had written so it can help the leader for their fs. in fact, there will be more benefits of adm rather than the listed in this study, such as the saving space or the opportunities of revenue rising. with the adm benefit, increase the speed of pharmacy services and reduce the waiting time, can make the patients who do not like to wait, to buy the medicines in hospital. this study requires more the data such as dispensing errors calculation as the money saving, another improvement in cost calculation. to maximize the function of adm, it needs trained staff, good managerial concept to review periodically the consumption of medicines inside adm. conclusion some studies showed adm could reduce medication errors, increase the staff satisfaction, increase the saving cost and reduce the inventory stock, saving time and make some efficiency such as the reduce the total number of staff and patient cost. with the benefits of adm, it's very feasible for indonesian hospital to implement adm and information system in their pharmacy. the effectiveness not just for the pharmacy, but it would positively change for all related departments in hospital. conflict of interests none declared. references 1. suciati s, adisasmito wbb. jurnal manajemen pelayanan kesehatan. j manaj pelayanan kesehat. 2006;9(4):177–84. 2. beso a, franklin bd, barber n. the frequency and potential causes of dispensing errors in a hospital pharmacy. pharm world sci. 2005;27(3):182–90. 3. james kl, barlow d, mcartney r, hiom s, roberts d, whittlesea c. incidence, type and causes of dispensing errors: a review of the literature. int j pharm pract. 2009;17(1):9–30. 4. anacleto ta, perini e, rosa mb, césar cc. drug-dispensing errors in the hospital pharmacy. clinics (sao paulo). 2007;62(3):243–50. 5. duane c, montgomery, larry, spernow, t j. chudy group, llc; patient issued for methods for item management. journanl eng. 2016; 6. fitzpatrick r, cooke p, southall c, kauldhar k, waters 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machines in the emergency department. australas emerg nurs j [internet]. 2016;19(2):112–7. available from: http://dx.doi.org/10.1016/j.aenj.2016.01.004 18. noparatayaporn p, sakulbumrungsil r, thaweethamcharoen t, sangseenil w. comparison of unit cost of pharmacy service using automatic and manual dispensing system. 2016;40:168–71. 19. chapuis c, bedouch p, detavernier m, durand m, francony g, lavagne p, et al. automated drug dispensing systems in the intensive care unit: a financial analysis. crit care [internet]. 2015;19(1):318. available from: http://ccforum.com/content/19/1/318 cite this article as permadani ad, mardiyono, santjaka a. the combination of alkaline water provision and asthma-induced gymnastics towards peak expiratory flow rate of asthma patients at surakarta lung clinic, indonesia. global health management journal. 2019; 3(1):8-13. global health management journal www.publications.inschool.id published by original research article issn 2580-9296 (online) the combination of alkaline water provision and asthma-induced gymnastics towards peak expiratory flow rate of asthma patients at surakarta lung clinic, indonesia agista delima permadani 1,*, mardiyono 2, aris santjaka 2 1 postgraduate applied science program in nursing, poltekkes kemenkes semarang, semarang, indonesia. 2 poltekkes kemenkes semarang, semarang, indonesia. *corresponding author. email: agista.delima@yahoo.com article info abstract article history: received 25 august 2018 reviewed 06 september 2018 received in revised form 23 february 2019 accepted 26 february 2019 background: asthma is an abnormality in the form of chronic airway inflammation which can be reduced by providing asthma-induced gymnastics and healthy lifestyle such as consuming alkaline water. aims: the objective of this study is to examine a combination of alkaline water provision and asthma-induced gymnastics towards peak expiratory flow rate of asthma patients at surakarta lung clinic, indonesia methods: this research was a quasi-experimental pre-test-post-test design with control group. the number of respondents in this study was 30 respondents, divided equally into intervention group and control group. the control group was given asthma-induced gymnastics twice a week for 14 days with duration of 60 minutes, while the intervention group was provided with a combination of alkaline water ph9+ for 14 days as much as 1,200 ml/day and asthma-induced gymnastics 4 times a week for 14 days with a duration of 60 minutes. results: there was a significant difference in the value of peak expiratory flow for 14 days in the intervention group and the control group (p < 0.001). there was an improvement in the average of peak expiratory flow rate values for each measurement in both groups, however, this study orchestrates that the intervention group has a higher improvement than the control group. the combination of alkaline water and asthmainduced gymnastics effectively and significantly improves the peak expiratory flow rate values at the day 8 (p = 0.039) and the day 14 (p = 0.012). conclusion: the combination of alkaline water and asthma-induced gymnastics can be applied in nursing care management in patients with intermittent and persistent asthma. keywords: alkaline water asthma-induced exercise peak expiratory flow rate asthma © 2019 publications of yayasan aliansi cendekiawan indonesia thailand this is an open-access following creative commons license deed – attribution-noncommercial-sharealike 4.0 international (cc by-nc-sa 4.0) introduction asthma is a disorder in the form of chronic inflammation of the airways that causes bronchial hyperactivity to various stimuli [1]. asthma has affected more than 5% of the world’s population, with a tendency to increase. the increased prevalence is allegedly due to undiagnosed asthma, poor air quality, and changes in people’s lifestyle [2]. world health organization (who) in collaboration with global asthma network (gan) predicts that the number of asthma patients in the world reaches 334 million people. it continues to increase to 400 million people in 2025 with 250 thousand deaths due to asthma among adults and children [3]. while asthma prevalence in indonesia shows a tendency to decrease from 4.5 percent in 2013 to 2.4 in 2018 [4, 5], in central java province, 113.028 asthma cases were reported (in 2015 only), with the surakarta as the highest rank with a total of 10.393 cases [6]. the indicator of asthma can be seen from the score of pulmonary function that has decreased or the results of the clinical picture of the peak expiratory flow rate value http://publications.inschool.id/index.php/ghmj/index http://publications.inschool.id/ http://inschool.id/ http://publications.inschool.id/index.php/ghmj/index mailto:agista.delima@yahoo.com http://inschool.id/ http://creativecommons.org/licenses/by-nc-sa/4.0/ 9 global health management journal, 2019, vol. 3, no. 1 permadani et al. global health management journal. 2019; 3(1):8-13 of less than 60%. patients with pulmonary function disorders, the ventilation capacity to maintain blood gas at normal levels is not working properly. as a consequence, an increase in pco2 causes a decrease in blood ph, and lead to an acidic state [7] which will negatively affect cells and molecules in the organs and overall human body. asthma management includes controllers, reliever, physical activity, and compliance. efforts to improve the health status of asthma patients are not optimal currently, hence, it is needed the development of asthma management in the form of combination intervention such as providing alkaline water and exercise. the alkaline improves the cells’ hydration through the diffusion of damaged cell membrane due to the extreme acidic state. the provision of alkaline water also increase the blood ph to become more alkaline so that hemoglobin will bind to a higher amount of oxygen and increase the bronchial muscle contractility in asthma patients. the adequate hydration will help in cell recovery and advanced restoration of bronchus to prevent irreversible remodeling[8]. alkaline water also serves as anti-allergen mechanism through the modulation of immune cells th2 which play an important role in asthma [9]. the provision of alkaline water will suppress the histamine production which will reduce the hyperactivity of bronchus and mucus secretion in asthma patient[10, 11]. the airways will be free from obstruction and smooth muscle spasm which improve the expiration air and increase the peak expiratory flow rate value [12]. there is a bulk of evidences that risk factors of asthma is not only limited to the dysfunction of bronchus but also due to lifestyle changes. poor diet and lack of physical activity has been shown to decrease the immune system and increase the likelihood to suffer from asthma. the overwhelming majority of studies demonstrated the capacity for asthmatic subjects to exercise safely and significantly improve their cardiovascular fitness and quality of life [13, 14] as exercise training is the key component to pulmonary rehabilitation. asthma-induced exercise such as walking, swimming, cycling, running, rowing, calisthenics, and gymnastics have been shown as good evidences in improved fitness of patients with asthma [13, 15]. the combine effect of alkaline water and asthma-induced gymnastics can strengthen the respiratory muscles and enhance the body’s immunological processes by suppressing the allergic process that triggers an inflammatory process in the airways. the objective of this study is to identify the effect of combination therapy by giving alkaline water and asthma-induced gymnastics towards the peak expiratory flow rate value status (ape) on asthma patients at council of public lung health of surakarta. methods this research was a quasi-experimental research using a pre-test and post-test design with control group. this research used non-probability with purposive sampling. matching was performed to omit patients with similar degree of asthma (whether it is intermittent and persistent), sex and the possible risk factors. each intervention group and control group was divided equally from each degree of asthma. the inclusion criteria in this research were patients who were willing to become respondents by signing an informed consent by their own or family patients, patients with asthma at intermittent and persistent classification, adult (> 18 years), who were not in a severe condition. the procedures and tools in this present study have approved by health research ethics commission of politeknik kesehatan kemenkes semarang (no.030/kepk/poltekkes-smg/ec/2018) on 20 february 2018 intermittent asthma is classified when asthma symptoms occur two days or less per week, does not interfere with normal activities, when not having an asthma attack, lung function tests are normal and vary little from morning to afternoon, and nighttime symptoms occur two days or less per month. mild persistent asthma is defined when the occurrence of symptoms is more than two days per week but not every day, but asthma attacks interfere with normal daily activities and nighttime symptoms occur three to four times a month. lung function tests are normal when not having an attack and may vary a small amount from morning to afternoon. moderate persistent asthma suffered from a daily occurrence of symptoms and a short-acting inhaler is used every day. symptoms interfere with daily activities, and nighttime symptoms occur more than one time a week, but do not happen every day and lung function tests are abnormal and vary more than 30 percent from morning to afternoon. severe persistent asthma is defined when symptoms occur throughout each day and severely limit daily physical activities. nighttime symptoms occur often, sometimes every night and lung function tests are abnormal and may vary greatly from morning to afternoon. thirty respondents were divided equally into intervention and control group. intervention group were treated by giving alkaline water ph 9+ 1200 ml/day for 14 days and asthma-induced gymnastics 4 times a week for 14 days, with 60 minutes gymnastic duration on the 1st, 3rd, 5th, 7th, 8th, 10th, 12th, and 14th day. while the control group were only treated by giving asthma-induced gymnastics on the 1st, 5th, 8th, and 14th day. the peak expiratory is an important indicator since it serves as the sensitive tools to assess asthma severity, diurnal variation, and response to treatment. monitoring peak expiratory is important to objectively measured and observe the prognosis of asthma global health management journal, 2019, vol. 3, no. 1 10 permadani et al. global health management journal. 2019; 3(1):8-13 including the probability of relapse. using an observational sheet, the researcher measured the peak expiratory flow rate (expressed in l/mins) by using a peak flow meter with the following steps, washing hands before the action, explaining to the asthma patients how to examine, put a mouthpiece to the end of the peak flow meter, making sure the marker is in position 0, asking the patient to breathe normally three times, asking the patient to stand or sit with his/her back straight and holds the peak flow meter in a horizontal position without touching or disturbing the marker movement. the patients breathe as broad as possible, then the mouthpiece was inserted into the mouth with the lips closed tightly around the mouthpiece, and exhale as quickly and forcefully as possible. when exhaling, the marker moves and shows the number on the scale, return the marker to position 0, repeat steps 5-8 three times, and note the highest value. compare the highest value of the patient with the predictive value, clean the mouthpiece by using an alcohol swab, note the ape results on the patient questionnaire sheet, then recap the observation sheet. then, it is evaluated from the results of pre-test and posttest, there was a deterioration or improvement with a value of 15% after getting the therapy or the intervention, washing hands after the treatment. a 1,200 ml alkaline water was provided for patients twice a day (each 600ml), in the morning and evening during the period of the study (14 days). however, patients are recommend to continue consuming alkaline water afterward. asthma-induced gymnastic was administered as scheduled appointment in the lung clinic four times in a week for 14 days. subjects of intervention (30 persons) joined the asthma gymnastic club membered of 70 asthma patients. the normality test of the data was using the shapiro-wilk tests and z-score. then, the homogeneity test was performed by using the one way anova test. the general linear model statistical test was used to determine the difference in peak expiratory flow rate values at each measurement time. table 1. results analysis of general linear model repeated measure anova test (tests of within-subjects effects) (n=30) group source (greenhouse-geisser) sum of squares df mean square f p value intervention time 382,280.00 2.40 159,306.049 125.100 .000 error (time) 42,781.11 33.59 1273.429 control time 150,751.33 2.08 72,477.917 45.107 .000 error (time) 467,88.67 29.12 1,606.783 231 234 312 321 339.67 352 365.67 374.33 381.33 232.67 234.33 304 323.33 339 0 100 200 300 400 500 1 2 3 4 5 6 7 8 9 p e a k e x p ir a to ry f lo w r a te (l /m in u te s) series1 series2 figure 1. patients’ peak expiration flow rate (l/min) at control and intervention group over the observation days from day 1 to day 14 11 global health management journal, 2019, vol. 3, no. 1 permadani et al. global health management journal. 2019; 3(1):8-13 results a combination of alkaline water and asthma-induced gymnastics effectively improve patients’ peak expiratory flow rate while the normal peak expiratory rate of male should be at least 504 l/mins, the average peak expiratory of asthma patients in the intervention group was recorded only at 403 l/mins, and those who were in the control group was recorder lower at 347 l/mins. unlike their male counterpart whom their respiratory performance below the normal level, 53% of women in the intervention group showed a better lung capacity with an average peak expiratory level at 370 l/mins, above the normal level 351 l/mins. the present study indicates that the intervention of combination of alkaline water and asthma-induced gymnastics is effective in improving the peak expiratory flow rate of patients in the intervention group by 65%, and 45% for patients in the control group. more patients in the intervention group showed a higher level of peak expiratory flow rate compared to their counterpart in the control group (see figure 1). more respondents of the intervention groups are able to achieve scores of normal values of peak expiratory flow rate whereas in the control group only a small proportion reaches normal values. how effective the proposed combination to improve the outcomes of respiratory performances? repeated anova test with greenhouse-geisser correction at table 1, showed that there was a significant difference in the peak expiration flow rate between intervention (p value = 0.000) and control group (p value = 0.000) which means, providing alkaline water and gymnastic will significantly improve the outcomes of respiratory performances. table 2 shows the differences in the peak expiratory flow rate before and after treatment at each measurement. the intervention combination of alkaline water and asthma-induced gymnastics has a significant effect in improving peak expiratory flow rate in the day 1 (post 1) with day 3 (post 2), day 3 (post 2) with day 5 (post 3), day 5 (post 3) with day 7 (post 4) , day 7 (post 4) with day 8 (post 5), day 8 (post 5) with day 10 (post 6), day 8 (post 6) with day 12 (post 7). however, there is no difference in the peak expiratory flow rate day 12 (post 7) with day 14 (post 8). in the control group, statistical analysis showed a significant difference in pre-treatment in day 14 (post 8), day 1 (post 1), and day 5 (post 2). the results acknowledge that the effectiveness of alkaline water and asthma-induced gymnastics can be obviously observed on the day 8 and 14 with values, respectively at p value = 0.039 and p value = 0.012, as shown in table 3. table 2. analysis of differences in peak expiration flow rate value before and after treatment in intervention groups and control groups (pairwise comparisons) group (i) day (j) day p value intervention pre ape ape day 14 (post 8) 0.000 pre ape ape day 1 (post 1) 1.000 ape day 1 (post 1) ape day 3 (post 2) 0.000 ape day 3 (post 2) ape day 5 (post 3) 0.031 ape day 5 (post 3) ape day 7 (post 4) 0.015 ape day 7 (post 4) ape day 8 (post 5) 0.016 ape day 8 (post 5) ape day 10 (post 6) 0.042 ape day 10 (post 6) ape day 12 (post 7) 0.000 ape day 12 (post 7) ape day 14 (post 8) 1.000 control pre ape ape day 14 (post 4) 0.000 pre ape ape day 1 (post 1) 1.000 ape day 1 (post 1) ape day 5 (post 2) 0.000 ape day 5 (post 2) ape day 8 (post 3) 0.274 ape day 8 (post 3) ape day 14 (post 4) 1.000 discussion the findings showed that there was an improvement in the average value of peak expiratory flow rate in day1 or post 1 and continued to increase until day 14 or post 8 both in the intervention and control group. however, patients in the intervention group showed a higher peak expiratory flow rate value than their counterparts in the control group. the results indicates that providing alkaline water and asthma-induced gymnastic may improve respiratory muscles of the asthma patients and also improve the cell hydration through the diffusion and osmotic processes of cell membranes that are damaged because the body is too acidic due to asthma. adequate hydration of smaller alkaline water cluster molecules will help the cell healing process and therefore, the body will obtain an additional o2 from the absorption through the digestive system, although it is not as much as the breathing process [11]. global health management journal, 2019, vol. 3, no. 1 12 permadani et al. global health management journal. 2019; 3(1):8-13 table 3. analysis of the effectiveness of alkaline water and asthma-induced gymnastics on the peak expiratory flow rate (post hoc analysis) observations peak expiratory flow rate p value mean sd difference (ik 95%) pre intervention 231.00 18.244 -1.667 (-15.804-12.471) 0.811 control 232.67 19.536 day 1 intervention 234.00 17.647 -.333 (-14.436-13.769) 0.962 control 234.33 19.988 day 5 intervention 321.00 39.152 16.667 (-15.335-48.668) 0.295 control 304.33 46.131 day 8 intervention 352.00 30.343 28.667 (1.523-55.810) 0.039 control 323.33 41.390 day 14 intervention 381.33 35.379 42.333 (10.012-74.655) 0.012 control 339.00 49.828 alkaline water that has gone through the process of electrolysis of water and has a high content of hydrogen molecules can easily diffuse into cells and body tissues and it is distributed through blood flow in the body [16, 8]. specifically, hydrogen molecules have antiinflammatory and anti-oxidant properties that can be beneficial for allergy patients [16]. according to research by kullman et al., it is shown that there is an effect of drinking water on the ph variability of the expired / exhaled breath condensate (ebc). ebc ph is believed to describe the condition of the liquid layer on the surface of the respiratory tract. it is suspected that water consumption can dilute the liquid layer and change the ph value of the respiratory tract. ebc contributes to the stability of blood and urine parameters which are also affected by the co2 content in it [17]. indirectly, it can explain the mechanism of the relationship between alkaline water consumption by drinking which can affect the condition of acid-base balance in the respiratory tract, especially in people with asthma in this study the multivariate analysis in this study uses repeated measure anova showed that there is a significant difference in overall peak expiratory flow rate value after the provision of alkaline water and asthma gymnastic therapy on day 1 to day 14. pairwise comparisons test shows differences in peak expiratory flow rate values for each measurement improves faster in the intervention group than in the control group because the movement from gymnastics will train the flexibility of chest muscles resulting in an improvement in vital lung capacity. asthma gymnastics also will cause the release of epinephrine and norepinephrine which will lead to dilatation of the airways [18]. respiratory capacity is doubled during maximum exercise compared when it is resting [19]. hence, the exercise will have an impact on improving the peak expiratory flow rate value. alkaline water affects the inhibition process of histamine production as the most cytokine in the airways of asthmatics. cells that hydrate due to the acidic environment will produce more histamine to compensate for continued water loss. this histamine will affect the hyperreactivity of bronchial smooth muscle. the alkaline administration of histamine is then expected to reduce bronchial muscle hyperactivity and mucin secretion in the pathophysiology of asthma attacks [20]. thus, this combination therapy has an effect on improving pulmonary function, especially peak expiratory flow rate value. general linear model and post hoc analysis shows that the combination of alkaline water and asthma-induced gymnastics is sufficient to improve peak expiratory flow rate value starting at day 8 with p=0.039 and in day 14. thus, by consuming alkaline water 1200 ml/day with ph 9+ for 8 days and asthma gymnastic therapy 4 times a week, it begins to show effective results in improving peak expiratory flow rate value. the therapeutic reaction process on day 8 is the culmination of success because the combination of therapies experienced a process of removing toxins in the body. exercise by training the respiratory muscles such as regular asthma-induced gymnastics will improve the work of the heart, consequently, the circulation of blood to the entire body is smoother, especially to the muscles of the 13 global health management journal, 2019, vol. 3, no. 1 permadani et al. global health management journal. 2019; 3(1):8-13 body including respiratory muscles [15]. smooth blood flow will bring more nutrients and oxygen to the respiratory muscles adequate nutrition includes calcium and potassium substances. the increase in calcium ions in the cytosol is due to the increasing release of ions from the sarcoplasmic reticulum [19]. thus, in this study, the group who are given combination alkaline water and asthma-induced gymnastics had a better peak expiratory flow rate value than the control group who are only given asthma-induced gymnastics therapy. the limitation of the study was due to the absence of blood gas analysis as an indicator in monitoring the function of oxygenation ventilation or pulmonary function values whose relations with alkaline water therapy. conclusion the study indicates that the provision of asthma-induced gymnastic was effective in improving the peak expiratory flow rate value by 45% (at control group) whereas the effectiveness increased to 65% when the patients were provided with a combination of alkaline water and asthma-induced gymnastic (at intervention group). although the peak expiratory flow rate value in asthma patients was improved at the both groups, however, the patients in the intervention showed a higher average value of the peak expiratory flow rate than the control group. the combination of alkaline water and asthma-induced gymnastics was effective in improving peak expiratory flow rate starting at day 8 and day 14. conflict of interests no conflict of interests declared in this study. references 1. bruner s. buku ajar keperawatan medikal bedah: penerbit buku kedokteran; ; 2013. 2. world health organization, public health agency of canada. preventing chronic diseases: a vital investment: world health organization; 2005. 3. global asthma network. the global asthma report 2014. 2014. 4. indonesia kkr. riset kesehatan dasar 2013. jakarta: badan penelitian dan pengembangan kesehatan ri. 2013. 5. indonesia kkr. laporan nasional riset kesehatan dasar 2018. jakarta: depkes ri. 2018. 6. tengah dkpj. profil kesehatan provinsi jawa tengah tahun 2012. semarang: dinkesjateng. 2014. 7. cotes je, chinn dj, miller mr. lung function: physiology, measurement and application in medicine: john wiley & sons; 2009. 8. shirahata s, hamasaki t, teruya k. advanced research on the health benefit of reduced water. trends in food science & technology. 2012;23(2):124-31. 9. wahyuningtiyas y, arkhaesi n, hardaningsih g. pengaruh pemberian air alkali terionisasi terhadap kualitas hidup anak asma: diponegoro university; 2016. 10. heil dp. acid-base balance and hydration status following consumption of mineral-based alkaline bottled water. journal of the international society of sports nutrition. 2010;7(1):29. 11. henry m, chambron j. physico-chemical, biological and therapeutic characteristics of electrolyzed reduced alkaline water (eraw). water. 2013;5(4):2094-115. 12. azzahra n, arkhaesi n, anam ms. pengaruh pemberian air alkali terhadap nilai peak expiratory flow rate anak asma. jurnal kedokteran diponegoro. 2016;5(4):1339-53. 13. lucas sr, platts-mills ta. physical activity and exercise in asthma: relevance to etiology and treatment. journal of allergy and clinical immunology. 2005;115(5):928-34. 14. randolph c. exercise-induced asthma: update on pathophysiology, clinical diagnosis, and treatment. current problems in pediatrics. 1997;27(2):49-77. 15. sahat cs, irawaty d, hastono sp. peningkatan kekuatan otot pernapasan dan fungsi paru melalui senam asma pada pasien asma. jurnal keperawatan indonesia. 2011;14(2):101-6. 16. gaisberger m, šanović r, dobias h, kolarž p, moder a, thalhamer j, et al. effects of ionized waterfall aerosol on pediatric allergic asthma. journal of asthma. 2012;49(8):830-8. 17. kullmann t, barta i, antus b, horváth i. drinking influences exhaled breath condensate acidity. lung. 2008;186(4):263-8. 18. rn. h, editor pengaruh latihan renang dan senam asma terhadap forced expiratory volume seminar nasional kesehatan jurusan kesehatan masyarakat 2012; purwokerto: universitas jendral sudirman. 19. guyton ac, hall je. human physiology and mechanisms of disease. 1992. 20. itoh t, fujita y, ito m, masuda a, ohno k, ichihara m, et al. molecular hydrogen suppresses fcεri-mediated signal transduction and prevents degranulation of mast cells. biochemical and biophysical research communications. 2009;389(4):651-6. knowledge, attitudes, and hiv/aids risk behaviors of myanmar migrant workers in thailand ghmj (global health management journal) 2022, vol. 5, no. 2 indonesian scholars’ alliance open access photo essay politeknik kesehatan kemenkes palangka raya: health forum and international seminar the new normal: creating a pleasant virtual communication health service communication in monitoring toddler growth and development in the new normal at posyandu hidup baru desa kaong, kecamatan upau, south kalimantan, indonesia yena wineini migang 1 *, evan kristianus migang 2 1 department of midwifery, poltekkes kemenkes palangka raya, indonesia 2 bkkbn south kalimantan *corresponding author’s e-mail: yenawineini.migang@yahoo.co.id doi: 10.35898/ghmj-52943 selection and peer-review under responsibility of the scientific committee and the editorial board of the annual health forum and international seminar of the politeknik kesehatan kemenkes palangka raya © yayasan aliansi cendekiawan indonesia thailand (indonesian scholars’ alliance). this is an open-access following creative commons license deed attribution-noncommercial-sharealike 4.0 international (cc by-nc-sa 4.0) during the covid-19 pandemic, there were many health protocols that had to be implemented, including the mandatory to use masks and maintain physical distance (kemenkes, 2020). there were even some areas that had to be locked down, so that it was difficult for people to meet each other, and communication was hampered (wijayanti, 2018). the growth and development of toddler need to be highlighted for health programs, because indonesia wants to prepare a demographic bonus with a high quality generation (mardiani, ita., purnomo, 2018). monitoring the growth and development of toddler during the pandemic continues, through the integrated service post (pos pelayanan terpadu/posyandu) activities (grantham-mcgregor et al., 2014); (jensen et al., 2015). at the toddler posyandu or posyandu balita, the health workers and mothers and toddlers are possible to meet, and they may communicate together to monitor toddlers growth and development (waqidil & adini, 2016); (grantham-mcgregor et al., 2014). figure 1. disciplinary posyandu officers apply health protocols in the new normal period so that they can communicate with each other for growth and development monitoring services without risking toddlers mailto:yenawineini.migang@yahoo.co.id https://doi.org/10.35898/ghmj-52943 migang & migang ghmj (global health management journal) 2022, vol. 5, no. 2 150 a basic health research in 2018 shows the prevalence of stunting in indonesia was considerably high (30.8%). whilst at central kalimantan, the percentage of stunting aged 0-59 months as much as 2016 (34.1%), but increased in 2017 (39.0%) (tim nasional percepatan penanggulangan kemiskinan, 2017); (kementerian kesehatan republik indonesia, 2018). malnutrition at an early age increases infant and child mortality, the cognitive abilities of sufferers are also reduced (hanum & khosman, 2012), resulting in longterm economic losses for indonesia, especially when indonesia faces a demographic bonus which is a strategic issue related to population control and strengthening governance. population management (aryastami & tarigan, 2017); (torlesse et al., 2016). figure 2. to improve the nutritional status of children under five, the posyandu is provided with additional food. during the covid 19 pandemic, food was packaged in closed packages so as not to be contaminated with the corona virus. figure 3. measuring a child under two years old, lying down, and needing help to calm a child crying out of fear. measuring height as an initial screening effort for early treatment of stunting in children under five. this activity cannot be done virtually, because not all mothers of toddlers have height measuring devices. 151 ghmj (global health management journal) 2022, vol. 5, no. 2 migang & migang figure 4. immunization must be given directly by health workers. this activity cannot be done virtually and must be communicated directly with the mother of the toddler figure 5. health workers document the results of measurements of weight and height of toddler part of monitoring the growth of toddler. this photo essay records our health service communication in monitoring toddler growth and development in the new normal at posyandu hidup baru desa kaong, kecamatan upau, south kalimantan, indonesia. the activities include counseling, height and weight checking for toddles, and immunization (migang et al., 2020). the visits cannot be done virtually, since we must directly provide examination of nutritional status, immunization, counseling and others monitoring to the mothers and toddlers following the standard protocols, (kemenkes, 2011); (aryastami & tarigan, 2017), and not all mothers of toddlers have the measuring devices. since the checking and monitoring have been done during the covid 19 pandemic, posyandu must apply health protocols when communicating and providing health service to the mothers and toddlers. thus, all participants presented at the posyandu will not get infected with covid 19, and the toddler growth and development can be monitored regularly. figure 7. the maternal and child health book contains records on the health of mothers (pregnant, childbirth and childbirth) and children (newborns to children aged 6 years) as well as various information on how to maintain and care for maternal and child health, also contains records of growth and development of children under five. figure 6. meeting in person is a need in communication between health workers and mothers of toddlers, so that health messages are conveyed, by living a new normal lifestyle. the mothers of the toddlers held the mother and child health books and took them to the posyandu. because for the sake of taking a short photo together, so the physical distancing is less 2 meters. migang & migang ghmj (global health management journal) 2022, vol. 5, no. 2 152 consent: the children and adults (identifiable) photographed have given their consent for their pictures to be used in the dissemination and publication of this research. conflict of interests: none acknowledgments: the authors would like to thank poltekkes kemenkes palangka raya for their facilitation in publishing this work as photo essays. the authors would also deliver a high appreciation to mr. beny julianto for providing the photos; and for the cadres, health workers and mothers of toddlers for their collaboration in the visit. references aryastami, n. k., & tarigan, i. (2017). kajian kebijakan dan penanggulangan masalah gizi stunting di indonesia. buletin penelitian kesehatan, 45(4), 233–240. https://doi.org/http://dx.doi.org/10.22435/bpk.v45i4.7465.233-240 bkkbn, bps, & kemenkes ri. (2018). survei demografi kesehatan indonesia. usaid, 1–606. grantham-mcgregor, s. m., fernald, l. c. h., kagawa, r. m. c., & walker, s. (2014). effects of integrated child development and nutrition interventions on child development and nutritional status. annals of the new york academy of sciences, 1308(1), 11–32. https://doi.org/10.1111/nyas.12284 hanum, n. l., & khosman, a. (2012). pola asuh makan, perkembangan bahasa, dan kognitif anak balita stunted dan normal di kelurahan sumur batu, bantar gebang bekasi. gizi dan pangan, 7(2), 81–88. jensen, s. k. g., bouhouch, r. r., walson, j. l., daelmans, b., bahl, r., darmstadt, g. l., & dua, t. (2015). enhancing the child survival agenda to promote, protect, and support early child development. seminars in perinatology, 39(5), 373–386. https://doi.org/10.1053/j.semperi.2015.06.002 kemenkes. (2011). pedoman umum pengelolaan posyandu. kemenkes. (2020). pedoman kesiapan menghadapi covid-19. pedoman kesiapan menghadapi covid-19, 0–115. kementerian kesehatan repubelik indonesia. (2018). data dan informasi profil kesehatan indonesia 2018. mardiani, ita., purnomo, h. n. (2018). permasalahan kependudukan dan bonus demografi. in kementerian pendidikan dan kebudayaan kementerian riset, teknologi dan pendidikan tinggi: vol. modul 23. migang, y. w., rarome, m. j., heriteluna, m., & dawam, m. (2020). intervention of specific nutrition and sensitive nutrition with nutritional status of under two-year infants in family planning village as efforts to face the demographic bonus. jurnal kesehatan masyarakat, 16(1), 101–110. https://doi.org/10.15294/kemas.v16i1.23172 tim nasional percepatan penanggulangan kemiskinan. (2017). 100 kabupaten/kota prioritas untuk intervensi anak kerdil ( (vol. 1). www.tnp2k.go.id torlesse, h., cronin, a. a., sebayang, s. k., & nandy, r. (2016). determinants of stunting in indonesian children : evidence from a cross-sectional survey indicate a prominent role for the water , sanitation and hygiene sector in stunting reduction. bmc public health, 1–11. https://doi.org/10.1186/s12889-016-3339-8 waqidil, h., & adini, c. (2016). hubungan antara tingkat pendidikan ibu dengan perkembangan balita usia 3-5 tahun. asuhan kesehatan, 7(2), 27–31. wijayanti, u. t. (2018). kendala-kendala bkb (bina keluarga balita) holistik integratif di provinsi sulawesi utara. jurnal komunikasi, 10(1), 65. https://doi.org/10.24912/jk.v10i1.205 cite this article as: migang yw, migang ek. health service communication in monitoring toddler growth and development in the new normal at posyandu hidup baru desa kaong, kecamatan upau, south kalimantan, indonesia. ghmj (global health management journal). 2022; 5(2):149-152. doi:10.35898/ghmj-52943 https://doi.org/10.35898/ghmj-52943 knowledge, attitudes, and hiv/aids risk behaviors of myanmar migrant workers in thailand ghmj (global health management journal) 2023, vol. 6, no. 1 indonesian scholars’ alliance open access editorial what to include in a review, commentary, editorial, and special edition of global health management journal andrew john macnab 1 department of pediatrics, university of british columbia, canada. 2 the stellenbosch institute for advanced study (stias), wallenberg research center at stellenbosch university south africa. 3 editor in chief, global health management journal, yayasan aliansi cendekiawan indonesia thailand, indonesian scholars' alliance (inschool) *corresponding author’s email: ajmacnab@gmail.com; andrew.macnab@ubc.ca doi: 10.35898/ghmj-61955 abstract there are several different types of article that authors can submit for publication in a journal. the article types are intended to allow for original research, commentaries, and reviews that are relevant to the stated focus and scope of the journal to be presented to the readers in an interesting and informative manner. some journals have a special interest in less common forms of communication, and so will accept submissions to other categories, such as interesting images, videos, case reports, or descriptions of teaching methods or learning points. authors should read the instructions and their editorial policies for authors section on each journal’s website to identify the types of article the editorial team will consider, and then prepare their submission to comply with the description given for each type of article and specific instructions on how each should be formatted. this editorial describes three categories of article and their guidelines to be included in the global health management journal: editorial, commentary and review. to provide more exposure of papers and works presented at international forums, seminars, and conferences, the journal creates specific guidelines to publish the selected papers from the meetings in global health management journals as a special edition. keywords: editorial policies, author guidelines, author instructions, global health management journal © yayasan aliansi cendekiawan indonesia thailand (indonesian scholars’ alliance). this is an open-access following creative commons license deed attribution-noncommercial-sharealike 4.0 international (cc by-nc-sa 4.0) 1. introduction previous articles have outlined how to prepare your research for publication (macnab, 2022), and how to report your work in the form of a photo-essay (macnab et al., 2018). this editorial describes two other forms of submission that authors should consider. both are now welcomed by the editorial team of ghmj (global health management journal), so the requirements and format for each article type are also summarized. in addition, how the journal’s editorials are prepared is explained. the focus of ghmj is public health, with the journal’s scope including but not limited to maternal and child health, nursing, midwifery, sexual and reproductive health, nutrition, environmental health, occupational health and safety, health promotion, and health economics in south east asia and other mailto:ajmacnab@gmail.com mailto:andrew.macnab@ubc.ca https://doi.org/10.35898/ghmj-61955 https://publications.inschool.id/index.php/ghmj/index 45 ghmj (global health management journal) 2023, vol. 6, no. 1 macnab, a.j. regions. applied science in health is a priority area; especially the fields of health information and technology, innovation in health, and development of devices, medicines, vaccines, procedures and systems able to solve health-related problems and improve quality of life. the journal’s website (https://publications.inschool.id/index.php/ghmj/authorguideline) includes instructions for authors; these describe the following forms of submission:  research article,  systematic and literature review,  best practice,  photo essays,  perspectives. 2. reviews for ghmj, the purpose of a review is to provide an expert and informed summary of an issue of major importance to the field of global health. in addition to systematic and literature reviews, this type of article can also be used to provide a topical overview of a matter of current interest for our journal’s readership; also to share ‘historic’, ‘cutting edge’ or ‘state of the art’ information as an ‘expert opinion’ relevant to improving health globally, guiding or implementing public health policy, promoting or disseminating research, and advancing health education. all reviews must present a balanced and definitive summation supported by high calibre references, as the fundamental reason for writing a review is to create a readable synthesis of the best resources available on an important question or current area of research (gülpınar & güçlü, 2013). authors need prior approval from the editorial board for submissions in this category or an invitation by the board to contribute a review (or expert opinion) on a specific topic area. reviews submitted are first assessed to ensure they are relevant to the focus and scope of the journal; only those that meet this criterion are sent for peer review. acceptance is not automatic; all submissions, whether invited or on approved topics, must conform to the publication standards of the journal. the format requires a 250-300 word unstructured abstract that summarizes the purpose and main findings of the review. reviews may be up to 4500 words in length but shorter, concise submissions are encouraged as they are more accessible to our readers. the style of writing should be clear, succinct and meaningful. no more than 50 references should be cited; these references should be chosen based on their importance, and the credibility of both their source and content. inclusion of authoritative websites that readers can refer to for additional information is encouraged. the addition of up to 5 tables or diagrams that clarify content for the reader can be helpful. systematic reviews are considered to be original research and so should be submitted as regular articles and not as a review. such reviews require a paragraph that clearly states the search strategy used to identify the information and opinions presented; this should include the search terms chosen and selection criteria employed to include or exclude studies. 3. commentaries commentaries can either be written in response to an article published in the journal or to highlight a topical or important issue relevant to global health and the education, research or practice of our readers. commentaries are usually commissioned by the editorial team, but individual authors may also contribute submissions to this section. such authors should have in-depth knowledge of the subject and provide a new or novel view on a current problem, fundamental issue or controversial topic (berterö, 2016). the format may include a short abstract (150 words); commentaries should be no longer than 750 words, have 10 or fewer references and may have one table or figure. commentaries will be reviewed initially by the editorial team and can also be sent for independent peer review. https://publications.inschool.id/index.php/ghmj/authorguideline macnab, a.j. ghmj (global health management journal) 2023, vol. 6, no. 1 46 4. editorials editorials are the voice of the global health management journal, and for this reason are written by the editor in chief, members of the journal’s editorial team or other individuals who are invited to contribute an editorial on a specific topic. review is by the editorial board. the most effective editorials are concise insightful and thought-provoking. 5. special editions to provide more exposure for papers and work presented at international forums, seminars, and conferences, the journal creates individual guidelines to enable selected papers from these meetings to be published in the global health management journal as a special edition. the journal will carefully check each organizer to avoid predatory conferences before initiating the memorandum of understanding (mou) for the cooperation. later, the conference committees can publish their efforts, presented work, and documentation as a conference summary. we have documented where young trainees in the health care professions have come together to share their work and interests and hear from experienced faculty on topics of interest and policies of importance at two conferences just before and after the pandemic hit the world (widyastari, et. al., 2019; yeyentimalla, sera, & sinaga, 2022). the conference committees are required to read the guidelines for conference organizer before requesting this form of collaboration. conflict of interest there is no conflict of interest. nothing to disclosure. references berterö, c. (2016). guidelines for writing a commentary. int j qual stud health well-being, 11(1), 31390. https://doi.org/10.3402/qhw.v11.31390 fontanarosa, p. b. (2014). editorial matters: guidelines for writing effective editorials. jama, 311(21), 21792180. https://doi.org/10.1001/jama.2014.6535 gülpınar, ö., & güçlü, a. g. (2013). how to write a review article? turk j urol, 39(suppl 1), 44. macnab, a.j., mukisa, r., & stothers, l. (2018) the use of photo-essay to report advances in applied health. ghmj (global health management journal), 2(2):44-47. https://doi.org/10.35898/ghmj-22199 macnab, a.j. editorial. how and why to publish your scientific research. ghmj (global health management journal), 5(2): 88-91 (2022) https://doi.org/10.35898/ghmj-52930 widyastari, d.a., sinaga, d. m., wibowo, c.p., rahman, p. a., noor, h. m., sondang, d., fatmarizka, t., diary, d. g., putra, i. g. n. e., maretalinia, viniriani, m. a., destiwi, m., shidiq, g. a., pratiwi, i. a., kusuma, m. d. s., dharmapatni, n. w. k., pratama, m. n. a., norsaputra, a., pancanugraha, a., kurniawan, f. h., putra, w. m., fattah, r. a., moehas, p. k., samosir, r. a., hananto, a. a. f., agastya, i. g. n., susilo, t. e., vejvisithsakul, p. p., nauphar, d., sari, a. i. p., & macnab, a. j. (2019). the international conferences on applied science and health (icash): efforts and commitments in translating research results into policy and practices, for a better society. ghmj (global health management journal), 3(3), 79–83. https://doi.org/10.35898/ghmj-33580 yeyentimalla, y., sera, a. c. ., & sinaga, d. m. (2022). the first international seminar poltekkes kemenkes palangka raya: a journey full of meaning. ghmj (global health management journal), 5(2), 165–170. https://doi.org/10.35898/ghmj-52945 cite this article as: macnab, a. j. (2023). what to include in a review, commentary, editorial, and special edition of global health management journal. ghmj (global health management journal), 6(1), 44–46. https://doi.org/10.35898/ghmj-61955 https://publications.inschool.id/index.php/ghmj/article/view/580 https://publications.inschool.id/index.php/ghmj/article/view/945 https://publications.inschool.id/index.php/ghmj/conference-organizer https://doi.org/10.3402/qhw.v11.31390 https://doi.org/10.1001/jama.2014.6535 https://doi.org/10.35898/ghmj-22199 https://doi.org/10.35898/ghmj-52930 https://doi.org/10.35898/ghmj-33580 https://doi.org/10.35898/ghmj-52945 https://doi.org/10.35898/ghmj-61955 microsoft word 5-2. accepted review, pujiyono, 37-43.docx cite this article as pujiyono, budiyanti rt. selective abortion after preimplantation sex selection: an ethical and legal issue in indonesia. global health management journal. 2018; 2(2): 3743. global health management journal www.publications.inschool.id published by review issn 2580-9296 (online) selective abortion after preimplantation sex selection: an ethical and legal issue in indonesia pujiyono 1, rani tiyas budiyanti 2 1 faculty of law, universitas sebelas maret, indonesia 2 health policy and administration, faculty of public health, diponegoro university, indonesia. *corresponding author. email: ranitiyasbudiyanti@gmail.com article info abstract article history: received 28 march 2018 reviewed 29 april 2018 received in revised form 24 may 2018 accepted 27 june 2018 background: the emerging of sex selection technology in indonesia is sperm sorting, meanwhile sex selection with preimplantation genetic diagnosis (pgd) methods is not widely used. the use of sperm sorting has bigger chance to fail than pgd, thus potentially cause ethical and legal problems that is selective abortion during pregnancy. the potency for selective abortion is enlarged by indonesian law that permitting sex selection without distinction of medical and non-medical reasons. there is no special policy to regulate the selective abortion because of sex selection failure. aims: this study aims to find out the legal concept of selective abortion after preimplantation sex selection that appropriate to be applied in indonesia. methods: this research is normative research that use analytics method with legal approach and conceptual approach. the research material consists of primary legal material (legislation about sex selection and abortion in indonesia), secondary legal materials (legal journals, law books, and legal proceedings), and also non-legal materials (journals, books, and health proceedings about sex selection and abortion). results: in indonesia meanwhile in general, abortion is permitted for pregnancy with medical indication and rape victim. through a statue approach in indonesia, selective abortion after preimplantation sex selection can be implemented for strong medical reasons. while the failure for non-medical reasons can’t be aborted. this regulation contrary with ethics, morals and religion. selective abortion should not be done because of preimplantation sex selection failure either medical or non-medical reasons. conclusion: selective abortion after preimplantation sex selection both medical and non medical reason contrary with moral, ethical, and religion. indonesia needs to regulate further policy about selective abortion if there is a failure of preimplantation sex selection. keywords: selective abortion sex selection sperm sorting preimplantation genetic diagnosis (pgd) © 2018 publications of yayasan aliansi cendekiawan indonesia thailand this is an open-access following creative commons license deed – attribution-noncommercial-sharealike 4.0 international (cc by-nc-sa 4.0) introduction sex selection has occurred since some decades that constituted by medical and non-medical reasons which referred to parental preference towards particular gender on children [1]. they have been done several efforts to get future children like what they desire, for example calculating the fertile period, determining diet/ food intake, timing and positioning during coitus and also using chemical substance [2]. at the old times, children’s gender is known after the labor. it often brings disappointment for parents who global health management journal, 2018, vol. 2, no. 2 38 expected different gender of their newborn. at that times, male gender is preferred than female because they could be the family’s economic backbone, religious leader and so on which increase the parental preference towards male gender. these become one of the murder’s reasons for newborn with female gender [3]. as the time goes by, there are technologies such as usg, amniosynthesis, chorionic villus sampling (cvs), and maternal blood test that make parents possible to know their baby’s gender at the first and second trimester [4]. this technology is originally used to determine fetus’s condition during pregnancy, but now it is becoming an entrance for selective abortion, one of the reason is because gender or known as sex-selective abortion. this situation also developes in china and india which have higher preference towards male gender [5]. inequality of ratio male compare to female (sex birth ratio) and gender discrimination are starting to happen. using usg technology, impairment or physically abnormality in fetus can be detected during pregnancy. it becomes a new problem, if a fetus is known to have an impairment during pregnancy, should he/ she be aborted or retained. reproductive technology is growing rapidly marked by emerging of assisted reproductive technology (art) that may help infertile couples who tries to get a child. it also becomes one of the way to get child the desired sex before embryo’s implantation. there are two methods in sex selection i.e. sperm sorting and pre implantation genetic diagnosis (pgd) [6]. sperm sorting is a method that achieves by separation of x and y chromosomes in the sperm then reunite with x chromosome from ovum. if the desire sex is female then it will be used x chromosome in the sperm, whereas if the desire sex is male, it will be used y chromosome in the sperm. the successfulness from that method is approximately 50-85% for female and 50%-65% for male [7]. pgd is another sex selection method which achieve after the conception. by this method, parents could know their embryo’s gender then select which one they desire before implant into the uterus. the successfulness of this method is beyond perfect [8]. it is because only embryo with desired gender that will be implanted. nevertheless, implementation of sex selection using art has potency that contrary with ethical, legal, and religion. experts agreed the sex selection using art only acceptable for medical reasons and not for non-medical reasons. they argued that sex selection for non-medical reasons is considered to create gender discrimination, selective abortion, baby designer and eugenics [9]. human fertilization and embryology authority (hfea) at united kingdom said that sex selection using art must be done only for severe disease reasons that associated with sex as duschene musculer dystrophy, unsevere disease such as color blindness is not recommended for sex selection [10]. sex selection using art also develops in indonesia both medical and non-medical reasons. another reason that develop is parental preference to have a child with particular gender that different with the last one (family balancing). they suggested that an ideal family is the one which have children both male and female. in several regions, there are some ethnics/ local indigeous that prefer to particular gender. for example, batak people in north sumatra prefer male gender [11]. in that society, the position of male is considered higher than female (patrilineal system). conversely, for minangkabau people in padang, west sumatera, prefer female gender than male due to descendant of the family is determined by female or matrilineal system [12]. gender preference in some regions and ethnic could affect the sex birth ratio (sbr) balancing. although, there are no reports of significant effect from sbr increasing in indonesia [13]. recent sex selection method using art that develop in indonesia is sperm sorting method, whereas pgd not commonly used because of human resource and technology limitation. indonesia has legalized sex selection both medical and medical reasons, but this regulation permitted for second child and so on. this policy is regulated by government regulation no.61 article 44, 2014 on reproductive health [14]. failure in using sperm sorting as a sex selective method was large enough, it can caused selective abortion in pregnancy if the gender of children not in line with parents expectation. the problem is when sex selection failure due to medical and non-medical reasons. sex selection due to medical reasons such as duchene muscular dystrophy disease that fails can cause ethical, moral, and religion problems. can the fetus be aborted if it has different gender than parent’s expectation? indonesia has regulations about abortion but has no specific regulation about selective abortion after sex selection failure. 39 global health management journal, 2018, vol. 2, no. 2 methods this research is normative research that use analytics method with legal approach and conceptual approach. the research material consisted of primary legal material (legislation about sex selection and abortion in indonesia), secondary legal materials (legal journals, law books, and legal proceedings), and also non-legal materials (journals, books, and health proceedings about sex selection and abortion). regulation of abortion and selective abortion in indonesia since 2001, people’s consultative assembly of the republic of indonesia (mpr-ri) had issued a decree of people’s consultative assembly of the republic of indonesia (mpr-ri) no. vi/mpr/2001 on the ethics of nation life. the inception of this decree was influenced by the weak understanding of the ethics in having a nation, a state, and religion. the reasons were the emergence of some anxiety of the nation unity and the existing setback of the implementation of nation life ethics. it could be seen from some prolonged social conflicts, the lack of manners and nobility in social interaction, the weakening of honesty and trusted attitude in nation life, the abandonment of rule of law and regulation, which were caused by some factors either from inside or outside the country. liberalism values had entered and become a freedom campaign which was increasingly massive, including in the application of the allowed abortion for sex selection reason. this decree had given a base for the inception of the next generation that was government regulation no. 61 article 44, year 2014 on reproductive health. in chapter iv of government regulation no. 61 year 2014, it is regulated the medical emergency indicators and rape as an exception for the disallowance of abortion. abortion is only allowed with some strict requirements, which are only two conditions: first, a pregnancy as the result of act of rape, when the gestational age is 40 days or less, and second, because of medical emergency indication. the examples of medical emergency indicators are the pregnancy can threaten the mother’s life and/ or threaten the infants’ health because of genetic disorder which can make the infant difficult to live outside the womb. however, for the last condition there are still some different opinions. abortion procedure was done after the approval from minimal 2 specialist and another expert like forensic expert, religion expert, and psychologist. besides that, a counseling and informed consent were done by the patient before and after abortion. indonesia has no specific regulation for selective abortion due to sex selection failure. meanwhile, according to the statue approach of abortion’s regulation in indonesia, selective abortion after preimplantation sex selection can be done only for sex selection by medical reason. selective abortion after preimplantation sex selection with non-medical reason should be prohibited. in practice, there is a controversy with the regulation including the ethical, moral, and religion perspectives. moral perspective of selective abortion indonesia is one of eastern countries which always uphold morality values based on religious dogma and local wisdom which exist and develop in society. the meeting of religion and local wisdom will present a value which is embraced as a state fundamental norm that is pancasila, five principles, a different value with most western countries, liberalism. liberal approaches to the abortion practice for sex selection tends not to mind it. it precisely contradicts to pancasila. there are many positive values insides pancasila, which are unraveled in its moral principles, including on divinity, humanity, unity, democracy, and social justice. these existing values are the indonesian’s views of life which has become the reflection of indonesian’s personality. (1) divinity it contains the meaning religions that become the references in social, nation and state life. indonesia admits 6 (six) religions which are embraced by its population, including islam, protestantism, catholicism, hinduism, buddhism, and confucianism. these six religions admit that an infant is going to born and life is a god’s will, human being does not have any rights to end the infant’s life, moreover abortion for sex selection failure. (2) humanity the values of humanity values contained in pancasila teach indonesian nation to live humanist. at the one end of parents’ rights, there is infant’s right exist which also should be respected, even it is a natural rights, the rights to live. therefore abortion for sex selection reason is not justified. there are agreements that abortion due to failure of sex selection will lead to human engineering. global health management journal, 2018, vol. 2, no. 2 40 (3) unity unity values give us a guideline in life to continuously unite, gives priority to unity and harmony for all indonesia people who have different religion, ethnic, language, and culture. nation is a communion of common living among the elements which construct the nation, in the form of ethnics, races, groups, classes, or religious groups. these differences should not to be sharpened which are able to create some conflict and hostility, but should be directed on a mutualism synthesis, that is a unity in common life in order to realize the common goals. the implementation of unity value is imbued by the divinity and humanity principles. it contains a value that indonesian nationalism is a religious nationalism that is a nationalism which has the moral of believe in the one and only god, a humanist nationalism that upholds human dignity and prestige as god’s creatures. subjectively, at the context of abortion for sex selection reason, there are some different perspectives that should be placed in a religious and humanist frame. thus, there are not any justifications for the abortion for sex selection reason can be accepted. (4) deliberation (democracy) principles abortion is an action which socially cannot be accepted in indonesia. the democracy principles have some teachings for the good of all indonesia people. deliberation also means democracy, where the result of democracy can be determined by the owned regulation. until now, there are no regulations which allow the abortion for sex selection reason. (5) social justice principles the explanation for this principle in rejecting abortion is similar to the explanation which is explained at the beginning. at the context of pancasila, the social values are imbued by divinity, humanity, unity, and deliberation (democracy). ethical aspect of selective abortion ethics is always related to some values which have source in mind that functions in encouraging and directing human’s attitude and behavior. value as a system is a form of culture. social norms are common habits which become a criterion of behavior in such society group and such borderline. norms will develop along with its society’s social agreements. ethics is generally understood as the discipline which can act as the performance index or reference for our control system. ethics is a kind of discipline which discusses on either morality or human as long as related to morality. ethics is a discipline that explores moral behavior [15]. ethics gives a standard that regulates human’s association in his social group. it is embodied in the form of behavioral values which are systematically made base on the existing moral principles; and when they are needed, they will be able to be functioned as a tool to control all kinds of action that are logically-common sense considered deviate. thus, ethics is a reflection or self-social control. each discipline has its own ethics, including biomedical. it has its own ethical value which belongs to professional ethics. the dilemma in medical field, could be solved by bioethics review or biomedical ethics. in the beginning, bioethics is introduced by van renssaealer potter, a biology expert in cancer and a professor in wisconsin university. in his research, potter said that bioethics is a new major of knowledge which compares biological science with human value system from ethics. as a final destination from this new major, he saw “not only to enrich individual lives but to prolong the survival of human species in an acceptable form of society” [16]. as in another branch of applied ethics, in biomedical ethics, it is also using some different methods and approaches. however, tom beauchamp and james childress introduced a method in their book, with tittle principle of biomedical ethics (1979). that method consist of four basic principles i.e. beneficence, autonomy, nonmaleficence, and justice [17]. (1) beneficence selective abortion because of a sex selection failure not a good thing, even it aims to prevent a newborn lived with x-linked disease. several experts said that thing not so different with a eugenic process which not permitted a fetus with genetics impairment to live. even more, if the sex selection aimed just because a non-medical reason based on parental desired. intervention of the embryo and life based on parental desired only, contradict with beneficence principal. selective abortion because of medical sex selection failure also made a devaluation on disability patient. fetus with genetics disease will regarded as a physically imperfect human. although, the fetus probably has a good mental, spiritual and intelligence in their development. in this context of benefit, sex selection has more mudharat (inappropriateness) than giving some benefits. therefore it tends to contradict with the bioethical principles. 41 global health management journal, 2018, vol. 2, no. 2 opening access for selective abortion should become an attention in art process. parents who did sex selection at their child should agree with all agreement in informed consent. before and after sex selection procedure counseling should be done, thus the parents can accept whatever the result. no demand or reintervention to the embryo which already implanted to the uterus. development study must be addressed wisely for humanity of human in contrast with embryo’s devaluation and human especially because of genetic and physic. in hipocrates oath which becoming the basic oath told that a doctor should appreciate life since conception [18]. (2) autonomy autonomy is patient rights to decide their destiny or medical decision. in basic principal of bioethics, autonomy has the highest power compare with another principal. this principal underlies several people to agree and fight for the selective abortion because of sex selection failure. those parents who agree said that sex selection is a right as same as their right to reproduce and have a descent, postpone to have a child, decide and determine the number of children that they desired. they also said that desire to get child’s gender is one of the autonomous rights of parents to be cherished and respected. desire for particular gender caused by social, economic, the tendency towards a particular gender reasons are some reasonable and humane things. however, the effort to get that thing is limited through the origin ways such as timing the coitus, food diet and using chemical substance. intervention to the embryo candidate followed by selective abortion is contradicted with moral. if it is left behind, it will be a eugenics process and baby designer, where children will only be parental production commodity and preferences. in contrast, we must pay attention to children and their human rights. it is better, if the parent’s freedom and autonomy right are not use to rob the children’s rights and freedom. there is a genre which is used as an approach to analysis the morality issues. hedonism is an ethical theory which emphasizes that according to his nature, human being tends to seek for some pleasures and tries to avoid some displeasure. hedonism even encloses the pleasures into morality. consequently, hedonism will contain a kind of egoism because it only accentuates his own interest. autonomy contexts should not be given to adults only, but also to infants in the womb who have had a life and had the rights to live. abortion precisely is seizing the infants’ autonomy rights to live. thus, at this context, abortion because of sex selection reason cannot be bioethically accepted. (3) non maleficence in the world of medicine, there is a latin slogan that closed with this principal “primum non nocere” the first thing is do not harm [16]. the medicine procedure that aims to provide benefits and minimalize the patient’s risks. this also applied for selective abortion caused by sex selection failure. preventing a fetus to have an x-linked disease does not mean restricting their right to born. if medical sex selection was failed, we should expand the medical technologies to help that child to improve his/ her quality, life expectancy and productivity. several experts are asking, if the technology always develops to get a perfect child, why it does not develop to accomplish and facilitate a less perfect child? principally, sex selection is merely an elementary activity to make a preference, not a required thing. abortion should not be something which is done because of sex selection reason. because abortion which is done for sex selection reason truly ignores the risk effect reduction on the infant. removing a life infant is a dangerous action. thus, bio-ethically, abortion because of sex selection reason is completely not allowed because it is non-maleficence. this precisely contradicts to the bio-ethics. (4) justice sex selection because of non-medical reasons such as desired towards a particular gender (gender discrimination) breaks the equity or justice principal. there are many cases of gender discrimination that tend to accentuate and feature the male, thus the female becomes an inferior like what has been happened in india and china. parents should not distinguish and make a different perspective with their male or female children. even though in family balancing case, where parents desire to have different child’s gender with their recent child’s gender, but in principle, having children with the same gender either male or female is not an abnormal situation which needs to intervene. like genetically disease, it is a natural selection process. religion aspect of selective abortion indonesian moslem scholars council had issued a special fatwa (instruction) on abortion in 2005. this fatwa which followed up the government regulation global health management journal, 2018, vol. 2, no. 2 42 no. 61 year 2014 regulated on the medical emergency indicators and rape as an exception for the disallowance of abortion. the fatwa committee of indonesian moslem scholars council decided that principally abortion is prohibited, especially on the pregnancy as the result of fornication. abortion can be permitted because the presence of good things which are emergency or intent in nature. the intended emergency condition is pregnant woman who suffers severe physical illness, such as advanced cancer, tbc with caverna, and other severe physical diseases that should be determined by the doctors. abortion is also permitted if the pregnancy can threaten the mother’s life. in an intent consideration, abortion is permitted in such conditions. first, the infant which is conceived has been detected for having genetic disorder, which is difficult to be healed when it is born later. second, a pregnancy as a result of rape which is determined by an authorized team, including the victim, doctor team, and ulema. the requirements for abortion because of rape is that the age of the infant is not more than 40 days. the fatwa of law in indonesia is different with the fatwa committee of kingdom of saudi arabia. although there are some indications of infant abnormalities and disability detected which feared after the birth, the fatwa committee of saudi arabia still refuses abortion. the committee has an opinion that this medical information is still predictive in nature. to prevent negative access like eugenics and baby designer, indonesia’s government should make a more clearly further regulation and detailed about selective abortion that only done if there is a preimplantation sex selection failure. in establishment the regulation, it needs discussion and cooperation from several elements, like a doctor, law experts, religion experts, forensic experts and psychologist who will make a regulation that walk through the ethics, norm and religion in indonesia. actually sex selection technology with pgd method, should start to develop in indonesia, because it has minimal failure number. this will reduce the repeating intervention in human and preventing the selective abortion risk during pregnancy even though implementation fee is more expensive than compared with sperm sorting. legal concept of selective abortion in indonesia indonesia legalized sex selection using assisted reproductive technology both medical and nonmedical reasons [14]. this regulation is contrary with ethics, morals, and religion primarily for sex selection with non-medical reasons. it is also increases one of negative effects of sex selection failure i.e. selective abortion. there is a case that related with sex selection failure in indonesia. this case happened in surabaya in january, 2017. the patient expected to get son child, but the reality the child was girl. moreover, the child suffers from gastrointestinal disorder, thus patient accused the doctor. although selective abortion did not happen in this case, but there was a potency to the abortion. according to statue approach of abortion in indonesia, sex selection with medical reasons can be done in indonesia and sex selection with non-medical reasons should be prohibited. the approval of abortion due to sex selection failure is contradictory with ethics, moral, and religion in indonesia. selective abortion due to sex selection failure should be prohibited both medical and non-medical reason. this is because repeat intervention to embryo and fetus can lead human engineering. sex selection failure by medical reasons can cause genetic defects. however, assessing the degree of disability is important. fetus with genetic defect or disability should receive the attention and facilities from government, thus can increase the productivity and survival of people with the disabilities rather than to reducing the disability people through selective abortion. conclusion indonesia has no specific regulation about selective abortion after sex selection failure, both medical and non-medical reasons. according to statue approach, selective abortion after sex selection failure due to medical reasons can be done, but indonesia doesn’t legalize selective abortion after sex selection failure due to the non-medical reasons. this regulation is contrary with moral, ethics, and religion in indonesia. selective abortion after sex selection failure both medical and non-medical reason should be prohibited because it can lead to human engineering. therefore, if necessary, indonesia may need to regulate the selective abortion policy further to synchronize the sex selection practice and ethics and norm in indonesia. 43 global health management journal, 2018, vol. 2, no. 2 conflict of interests none declared. references 1. mitra aparna. son preference in india : implications for gender development. journal of economic issue. 2014.48(4); 1021-1037. 2. barthakur, ik & shroof, g. natural selection of gender of the 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prohibition of euthanasia and medical oaths of hippocratic stemma. acta bioethica. 2017. 23 (1): 171-178. ghmj (global health management journal) 2023, vol. 6, no. 1 indonesian scholars’ alliance open access research article emotional intelligence and transformational leadership: the two factors affecting the nurses’ performance at a general hospital in bolaang mongondow monompia, kotamobagu, indonesia juritno harmi gaib*, fery mendrofa, rita dewi department of nursing, universitas karya husada, semarang, indonesia *corresponding author’s e-mail: harmi.gaib@gmail.com doi: 10.35898/ghmj-61929 abstract background: emotional intelligence and transformational leadership are two important factors for nurses to be able to motivate themselves and build intra relationships in hospitals, and may affect to the nurses’ performance. aims: the purpose of the study was to determine how emotional intelligence and leadership affecting the nurses’ performance at the general hospital of the evangelical masehi church, bolaang mongondow monompia, kotamobagu, indonesia methods: this original research employed an analytic observational with a quantitative approach and a cross sectional study design. a set of questionnaires was distributed to the participated nurses to define the respondents’ characteristics, emotional intelligence (10 questions), leadership transformation (12 questions), and the nurses’ performances (8 questions). a total of 48 nurses were selected in august 2022 using a total sampling technique, and their answers were included to the further statistical analysis using pss software version 15. results: not different with other hospitals, at the regional general hospital of kotamobagu the majority of nurses was female, and relatively has worked for more than 5 years. it has been noted that the nurses were measured with sufficient emotional intelligence (43.8%), transformational leadership (54.1%), and performances (58.3%). however, the number of nurses having poor emotional intelligence and performance were relatively high, respectively at 12.4% and 14.6%. it is indicated that the nurses performance were significantly resulted by the two factors: emotional intelligence (p-value: 0.025) and transformational leadership (p-value: 0.005). conclusion: this study concludes that the emotional intelligence and transformational leadership are moderating variables to strengthen the nurses’ performance. this study noted that the higher number of nurses highly perform if having good emotional intelligence and good transformational leadership. therefore, it is recommended to pay attention to the two strong indicators from this study if a hospital manager plans to improve the nurses’ performance. keywords: emotional intelligence, transformational leadership, nurse performance. received: 19 november 2022; revised: 5 december 2022; accepted: 31 january 2023 doi: 10.35898/ghmj-xxxx © yayasan aliansi cendekiawan indonesia thailand (indonesian scholars’ alliance). this is an open-access following creative commons license deed attribution-noncommercial-sharealike 4.0 international (cc by-nc-sa 4.0) mailto:harmi.gaib@gmail.com https://doi.org/10.35898/ghmj-61929 https://dx.doi.org/10.35898/ghmj-xxxx 37 ghmj (global health management journal) 2023, vol. 6, no. 1 gaib, mendrofa, & dewi 1. introduction nurses learn to manage their feelings through emotional intelligence so that they can express them appropriately and effectively (mccloughen & foster, 2018). nurses in their daily work almost always involve feelings and emotions, so nurses are required to have high emotional intelligence (soto-rubio et al., 2020). hospital nurses in particular need high emotional intelligence because they are the representative the organization to interact with many people both inside and outside the organization (geun & park, 2019). nurses who have empathy will be able to understand the needs of the person or family they are caring for and can provide constructive solutions (ross et al., 2015). transformational leadership is a type of leadership that motivates their followers in the direction of established goals by clarifying roles and task guidelines (sadeghi & pihie, 2012). transformational leaders pay attention to the concerns and developmental needs of individual followers; they change followers' awareness of problems by helping them view problems in new ways (begum et al., 2022). performance is a real behavior that is produced by everyone as work performance produced by employees in accordance with their role in an organization (widarko & anwarodin, 2022). performance is an accumulation of the quantity, quality and time used in carrying out tasks (romero & barbera, 2011). a successful leader is not one who seeks power for himself, but distributes power to many people to achieve common goals (joullié et al., 2021). through clarity of authority, responsibility, and balanced with discipline in dealing with problems with employees effectively and efficiently (tampi et al., 2022). this is also balanced by positive interactions, namely the main skills in managing human resources (thorn & jensen, 2022). leaders must also be sensitive in interacting, both to verbal language, tone of voice, as well as nonverbal or body language (king et al., 2021). the existence of a transformational leader is expected to inspire their followers to go beyond selfinterest and who is able to have a deep and extraordinary influence on his followers (wang et al., 2021). a leader who has a transformational leadership style will be an inspirational figure for his subordinates (bosak et al., 2021). the ability of the leader as a role model for his subordinates includes in acting, acting, and carrying out work responsibilities (simorangkir et al., 2021). proposed four dimensions in a person's level of transformational leadership are namely idealized influence, inspirational motivation, intellectual stimulation, and individual consideration (tsang et al., 2022). based on data obtained from the monompia hospital gmibm kotamobagu in april 2022, it can be seen that the composition of its employees is as follows: ns 110 nurses, d4 20 people, d3 dental nurses 2 and d3 nurses 86 people. problems obtained from interviews with several hospital service users include lack of friendliness, lack of nurse control over patients, confusion of information about politeness and complaints from the community as users of hospital services, becoming a must for the management to continue to improve performance. the results of a preliminary study in april 2022 found that there were still ± 30 employees who worked as nurses who had not been able to manage their emotions well such as being less friendly in providing services to patients, less caring and rarely conveying the information needed. therefore, this study aims to determine the effect of emotional intelligence and transformational leadership on the performance of nurses at monompia hospital, kotamobagu. 2. methods this original research employed an analytic observational with a quantitative approach and a cross sectional study design. this study was aimed to determine the effect of emotional intelligence and leadership on the performance of nurses at the general hospital gereja masehi injili bolaang mongondow monompia kotamobagu, indonesia. of 56 nurses selected in august 2022 using a total sampling technique based on the data from the human resources division, data from 48 nurses were included to the further statistical analysis. nurses who did not attend at the time of survey were excluded. a set of questionnaires was distributed to the participated nurses to define the respondents’ characteristics, emotional intelligence (10 questions), leadership transformation (12 questions), and the gaib, mendrofa, & dewi ghmj (global health management journal) 2023, vol. 6, no. 1 38 nurses’ performances (8 questions). it is important to measure the nurses’ emotional intelligence since it covers the nurses’ ability to recognize their own feelings and the feelings of others, and how the nurses able to motivate themselves and to manage emotions through the instruments. leadership transformation questionnaire covers a measure of leadership in the form of motivating in carrying out its role as a nurse. meanwhile, by measuring nurse performance, the authors are able to identify the number of nurses who can provide good service and are able to carry out tasks independently in a timely manner. to measure the variables of emotional intelligence (x1), transformational leadership (x2), nurse performance (y), a set of questionnaire was employed with a measuring instrument likret scale with alternative answers arranged based on five categories, namely: strongly agree (ss), agree (s), disagree (ks), disagree (ts), and strongly disagree (sts). in the favorable statement, strongly disagree (sts) has a weighted value of 1, disagree (ts) has a weighted value of 2, doubtful (rg) has a weighted value of 3, agree (s) has a weighted value of 4 and strongly agree (ss) has a weighted value of 5. in the unfavorable statement, the answer strongly disagree (sts) has a weighted value of 5, disagree (ts) has a weighted value of 4, doubtful (rg) has a weighted value of 3, agree (s) has a weight value of 2, and strongly agree (ss) has a weight value of 1. the questionnaire in this study has been tested for validity and reliability. in the performance of nurses in hospitals, the r-table value was 0.432 and all questions were declared valid. so, the researchers did not re-validity test because it was standard and valid. on the performance of nurses in hospitals, the cronbach alpha value was 0.982, which means high validity or high reliability, so this research is considered reliable and feasible to continue in research. the results of this study were analyzed using univariate and bivariate methods using pss software version 15. this study is ethically approved by the universitas karya husada semarang with number 56/baak/s2kep/sa/vii/2022. data collection has been approved by department of health, regional general hospital of kotamobagu with number 445/1351/rsud-kk/s.ket/vii/2022. 3. results respondent characteristics from table 1, it is shown that the majority of nurses participated in this study were female (90.4%), aged 25-35 years old (70.8%), graduated from vocational school (90.4%), and relatively senior with length of work more than 5 years (64.6%). of 48 nurses, the results noted that only 5 male nurses (10.4%) participated in this study. not only that, it is known that only 10.4% nurses continued their study to bachelor or profession. table 1. distribution of respondent in this study variables (n = 48) frequency percent age (years old) <25 3 5.3 26-35 34 70.8 36-45 9 18.8 >45 2 4.2 sex male 5 10.4 female 43 89.6 level of education diploma 43 89.6 bachelor/profession 5 10.4 length of working <3 years 5 10.4 3-5 years 12 25 >5 years 31 64.6 39 ghmj (global health management journal) 2023, vol. 6, no. 1 gaib, mendrofa, & dewi parameter distribution univariate analysis on the three distributed questionnaires shows that among the 48 nurses working at the general hospital gereja masehi injili bolaang mongondow monompia kotamobagu, indonesia, it has been noted that the majority have sufficient emotional intelligence (43.8%), transformational leadership (54.1%), and performances (58.3%). even though, there were 2 of 48 nurses measured with poor transformational leadership, from the results we noted that the number of nurses having poor emotional intelligence and performance were relatively high, respectively at 12.4% and 14.6%. table 2. distribution all of variables in this study variables frequency percent emotional intelligence poor 6 12.4 enough 21 43.8 good 21 43.8 transformational leadership poor 2 4.2 enough 20 41.7 good 26 54.1 nurse performance poor 7 14.6 enough 13 27.1 good 18 58.3 bivariate analysis: factors affecting the nurses performance by a bivariate analysis, we noted how emotional intelligence and transformational leadership style separately affecting the nurses performance at the selected hospital. from table 3, it is noted the type of emotional intelligence and transformational leadership among the nurses with different performance. the data shows the higher number of nurses highly perform if having good emotional intelligence and good transformational leadership. it is indicated that the nurses performance were significantly resulted by the two factors: emotional intelligence (p-value: 0.025) and transformational leadership (p-value: 0.005). we can see from the table 3, of 21 nurses identified with good emotional intelligence, there were 17 nurses (81%) with sufficient performances. in line with that, of 26 nurses measured with good transformational leadership, there were 21 nurses (81%) with good performance. it is suggested that the emotional intelligence and transformational leadership are important variables to strengthen the nurse performance. table 3. analysis bivariate variable nurse performance p-value poor enough good f % f % f % emotional intelligence poor 2 33.3 1 16.7 3 50.0 0.025 enough 3 14.3 10 47.6 8 38.1 good 2 9.5 2 9.5 17 81.0 transformational leadership poor 1 50 0 0 1 50 0.005 enough 4 57.1 10 50 6 30 good 2 7.7 3 11.5 21 80 gaib, mendrofa, & dewi ghmj (global health management journal) 2023, vol. 6, no. 1 40 4. discussion based on result of this study shows that the frequency distribution of emotional intelligence is mostly adequate and good (43.8%) and enough (43.8). in line with previous research which found that emotional intelligence is high (good) as much as 90.6% (misto et al., 2022). another research said that emotional intelligence has a positive impact on the performance of a nurse (oktafiani, 2019). the better the emotional intelligence, the higher the performance will be resulted by the nurse (mcqueen, 2004). emotional intelligence is an emotional ability that includes the ability to control oneself, have endurance when facing a problem, be able to control impulses, motivate oneself, be able to regulate moods, be able to empathize and build relationships with others. emotional intelligence can put a person's emotions in the right portion, sort out satisfaction and regulate moods (tj et al., n.d.). mood coordination is at the core of good social relationships (tan et al., 2022). if someone is good at adjusting to the moods of other individuals or can empathize, that person will have a good emotional level and will more easily adjust to social interactions and the environment (rangki, 2019). emotional intelligence is strongly influenced by the environment, is not permanent, can change at any time (sun et al., 2021). for this reason, the role of the environment, especially parents in childhood, greatly influences the formation of emotional intelligence (li et al., 2015). the frequency distribution of transformational leadership is mostly good as much as 54.2%. a transformational leader is a leader who is able to inspire his followers to go beyond individual interests and is capable of having a profound and extraordinary influence on his followers. transformational leadership can provide motivation and inspiration to every employee (rahim et al., 2020). transformational leadership seeks to develop the role of employees in a direction that is better and more profitable for employees and can benefit the organization as a whole in terms of increasing organizational productivity. transformational leadership is a leader who is able to grow in each of his follower’s trust, admiration, loyalty, respect for the leader and motivates to do more than expected (ribeiro et al., 2018). the leader transforms and motivates followers by making them more aware of the importance of the results of a job, encouraging them to place more importance on the organization or team than self-interest, and activating their needs at a higher level (hassan et al., 2013). transformational leaders have certain behavioral components, including integrity and fairness, setting clear goals, having high expectations, providing support and recognition, arousing followers' emotions, and getting people to see things beyond their own self-interest to achieve the impossible (sadeghi & pihie, 2012). the distribution of nurse performance is mostly good as much as 58.3%. nurse performance is a real behavior that is produced by everyone as work performance produced by employees according to their role in an organization. performance is the quantity, quality and time used in carrying out tasks (alghamdi, 2016; mccloughen & foster, 2018). quantity is a result that can be calculated the extent to which a person can successfully achieve the goals that have been set. a person's performance is related to one's maturity, maturity, and ability at work (mcqueen, 2004). mental maturity and faster rational thinking of nursing, are proves to show the nurses are able to make decisions, wiser, able to control emotions, obey rules and norms and commitment to work (yosiana et al., 2020). the results of statistical tests using the chi square test of the relationship of emotional intelligence to the performance of nurses at monompia hospital kotamobagu obtained p-value: 0.025 (p <0.05). this proves that there is a relationship between emotional intelligence and the performance of nurses. this research is in line with previous research showing that emotional intelligence has a positive and significant effect on employee performance (amelia & hersona, 2022). supported other study with the results of multiple linear regression analysis explains that the variables of self-awareness, self-regulation, motivation, empathy, and social skills have a positive influence on employee performance (behbahani, 2011; kaur & jiwan, 2014). the results of statistical tests using the chi square test of the relationship of transformational leadership to the performance of nurses obtained p-value: 0.005 (p <0.05). this proves that there is a 41 ghmj (global health management journal) 2023, vol. 6, no. 1 gaib, mendrofa, & dewi relationship of transformational leadership to the performance. the transformational leadership has a positive and significant effect on nurse performance (amelia & hersona, 2022). in line with the other research that the results showed that the transformational leadership style had a positive and significant effect on performance (murtiningsih, 2017). the transformational leadership supported by emotional intelligence can also improve nurse performance more optimally (kaslow et al., 2012; mcqueen, 2004). the patient safety climate in hospitals is also built through transformational leadership that prioritizes patient safety to reduce unexpected events through supervision (l. c. hughes et al., 2009; p. hughes & ferrett, 2011). an expert in emotional intelligence defines emotional intelligence as the ability to recognize one's own feelings and the feelings of others, the ability to motivate oneself and the ability to manage emotions well in oneself and in relationships with others (morrison, 2007). the skills in emotional intelligence are divided into personal skills and social skills (goleman, 2018). nurses need to recognize the influence of the client's internal and external environment on the client's health and disease conditions. concepts are relevant to the internal environment including mental and spiritual well-being, and sociocultural beliefs for an individual. while the external environment includes variables of epidemiology, comfort, privacy, safety, cleanliness and an aesthetic environment. because the client may experience changes from both the internal and external environment, the nurse must assess and facilitate the client's ability to adapt to physical, mental, and emotional changes (kaslow et al., 2012). 5. conclusion this study found that the nurses working at the general hospital gereja masehi injili bolaang mongondow monompia kotamobagu, indonesia, were measured with sufficient emotional intelligence (43.8%), transformational leadership (54.1%), and performances (58.3%). however, the number of nurses having poor emotional intelligence and performance were relatively high, respectively at 12.4% and 14.6%. this study noted that the higher number of nurses highly perform if having good emotional intelligence and good transformational leadership. it is indicated that the nurses performance were significantly resulted by the two factors: emotional intelligence (p-value: 0.025) and transformational leadership (p-value: 0.005). therefore, it is recommended to pay attention to the two strong indicators from this study if a hospital manager plans to improve the nurses performance. conflict of interest there is no conflict of interest. nothing to disclosure. references alghamdi, m. g. 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(2023). emotional intelligence and transformational leadership: the two factors affecting the nurses’ performance at a general hospital in bolaang mongondow monompia, kotamobagu, indonesia. ghmj (global health management journal), 6(1), 36–43. https://doi.org/10.35898/ghmj-61929 https://doi.org/10.3390/ijerph17217998 https://doi.org/10.1111/jocn.15548 https://doi.org/10.1186/s12877-021-02632-w https://doi.org/10.18261/nsf.12.2.3 https://doi.org/10.2224/sbp.11041 https://doi.org/10.2224/sbp.9712 https://doi.org/10.52970/grhrm.v2i2.207 https://doi.org/10.31328/jsed.v3i1.1326 https://doi.org/10.35898/ghmj-61929 microsoft word accepted-antarini-4-9.docx cite this article as antarini, masfiah s, fitriani a, junaidi l. unmet need to space and limit childbirth among reproductive age women in pangkalpinang city, bangka belitung province, indonesia. global health management journal. 2017; 1(1): 4-9. global health management journal www.publications.inschool.id published by original research article unmet need to space and limit childbirth among reproductive age women in pangkalpinang city, bangka belitung province, indonesia antarini 1,*, siti masfiah 2, ayu fitriani 3, lili junaidi 4 1 poltekkes kemenkes pangkalpinang, health polytechnic of pangkalpinang, indonesia. 2 universitas jenderal soedirman, purwokerto, indonesia. 3 universitas respati yogyakarta, indonesia. 4 kantor kesehatan pelabuhan semarang, port health office of semarang, indonesia *corresponding author. email: antarini22@gmail.com article info abstract article history: submitted 3 may 2017 accepted 17 june 2017 background: population growth has become one of priority problems should be solved in almost all of developing countries, including indonesia. backward, indonesia had successful family planning history. however, it shows decline figures nowadays. while, unmet need of family planning in several regions found increased. in 2007, unmet need was 8.6 %, inclined to 11.4% in 2015, which is consisted of 4.5% for spacing children and 8.6% for limiting children. social demography, economic, access to health services, family support and perception revealed have the contribution to unmet need. aims: this study aimed to identify unmet need family planning due to birth spacing and limiting situation among reproductive age women in pangkal pinang city, bangka belitung province. methods: this study was a cross-sectional descriptive design. the population was women of childbearing age who experienced unmet need of family planning in pangkal pinang, 2016. ninety-eight women were taken by proportional random sampling to participate in this study. results: research showed that the most of the unmet need for family planning were among 25-29 years old women. about two third (66.3%) of unmet need women occurred due to the willingness to space the childbirth and 33.7% willing to limit the childbirth. birth spacing tended to be favored by young mothers, early marriage (1-5 years old), had low parity and had low education attainment. whilst, limiting childbirth tended to be preferred by women with lenght marriage experience (>15 years old), had high parity, older mothers, and middle education level (senior high school) attainment. conclusion: both of spacing and limiting have no difference according to the economic situation, all of them mostly were the household wife from low-income family. husband support to do not use contraception were found in both birth spacing and birth limiting. the study suggest to provincial health office and national family planning coordination board that family planning program should not just involve the wife, but husband as well due to their high influence in family planning decision. keywords: unmet need family planning birth spacing and limiting this article is an extension of a selected paper “unmet need for family planning program: a situational analysis of birth spacing and limiting among reproductive age women in pangkalpinang city, bangka belitung province, indonesia” published in proceedings of the international conference on applied science and health (no. 1, february 2017). © 2017 publications of yayasan aliansi cendekiawan indonesia thailand this is an open access following creative commons license deed – attribution-noncommercial-sharealike 4.0 international (cc by-nc-sa 4.0) 5 global health management journal, 2017, vol. 1, no. 1 introduction world population data sheet 2013, reported indonesia as the fifth populated nation in the world, consist of 249 million people and the largest among asean countries. total fertility rate (tfr) showed above average line of asean countries (2.4). based on statistic indonesia 2014, among the number of population in indonesia (252.164,8 thousand people), about 51% are female. with the rate of growth of 1.4% per year (2010-2014), it is predicted will reach 337 million people in 2015 [1]. population growth in indonesia started to raise again since 2000, while it had declined in several previous decades before. backward, start in 1969, indonesia have been implementing family planning program to reduce the population growth. it recorded as one of the successful history worldwide on population program. family planning program can push down the number of people. however, it changes, now it becomes one of the biggest challenge in indonesia [1]. rapid population growth effects many sectors of development in indonesia. ministry of health and national family planning coordination board (bkkbn) tried hard to evaluate and examine family planning related problems [2]. family planning program is an effort to limited the number of children spouse should have and how to make space for delivery. it includes contraception methods and family planning strategy. the basic principle of contraception method is to prevent fertilization, how to make sperm can not reach the egg, or how to make fertilized egg can not develop further in the uterus [3]. succesful history of family planning program in indonesia was influenced by many factors included family planning related knowledge, perception, adherence to used contraception method, religion support, cultures support, family support and sexual activity [4]. government has been doing massive socialization related to family planning program, however recently there is still a huge number of unmet need. unmet need is the condition when specific people, including childbearing age spouses, need the contraception but did not use the contraception. based on demographic and health survey (dhs), the group of people included in this category is all fertile women who were married or living together, which included sexual partners active, who do not want more children or wanting to delay the next child in at least two years but did not use any of the types of contraceptives. the number of unmet need in indonesia reached 11.4% which is consisted of 4.5% for spacing children and 6.9% limiting children. this number increased compared to previous number 8.7% in 2007. contraception used prevalence increased from 50% to 62% in 1991 to 2012, however, in last decade it just increased 1%. the percentage of married women who need family planning services in indonesia is currently around 73%, however, it just about 85% of them has been fulfilled. the reason for the high unmet need mostly related to the socio-demographic and economic factor, access to the services, quality of supply and service planning, lack of information, conflicts in the family and society, lack of information, low support from husband, families and communities, also perception of the risk of pregnancy [5]. unmet need number varies between provinces, in 2007 the lowest unmet need was 3.2% in bangka belitung and the highest 22.4% in maluku. in 2012 indonesia demographic and health survey lowest position was central kalimantan 7.6% and the highest was papua 23.8% [5]. on the contrary, bangka belitung became one of high unmet need province in 2015. the number of spouses in childbearing age was 251,304 people. of those, 205,072 people were acceptors active, and 28,093 people (11.1%) did not participate in family planning due to the willingness to delay having children and willingness to stop having children [6]. unmet need for family planning in bangka belitung spread in six districts, particularly in the urban area. one of the high numbers is pangkal pinang district. this study aimed to explore unmet need family planning due to birth spacing and limiting situation among reproductive age women in pangkal pinang city, bangka belitung province. global health management journal, 2017, vol. 1, no. 1 6 table 1. distribution of respondent based on characteristics of respondents toward unmet need in the pangkalpinang city 2016 characteristics n percentage age group (year) 15-49 20-24 0 9 0 9.2 25-29 33 33.7 30-34 17 17.3 35-39 18 18.4 40-44 10 10.2 45-49 11 11.2 total 98 100 length of married 1-5 years 30 30.6 6-10 years 27 27.6 11-15 years 15 15.3 >15 years 26 26.5 total 98 100 education no education 1 1 unpassed primary school 6 6.1 primary school 19 19.4 junior high school 14 14.3 unpassed senior high school 3 3.1 senior high school 50 51 bachelor 5 5.1 total 98 100 job civil servant 3 3.1 private employee 5 5.1 labor 1 1 trader 24 24.5 housewife 64 65.3 others 1 1 total 98 100 income (idr) <1 million 17 17.3 1-2 million 54 55.1 2-4 million 24 24.5 >4 million 3 3.1 total 98 100 parity 0 10 10.2 1-2 66 67.3 3-4 20 20.4 >4 2 2 total 98 100 methods this type of research was a cross-sectional descriptive design. a sample of 98 respondents used the criteria that reproductive age women between 15-49 years, women who need to space their birth (birth spacing) and unwanted children anymore (birth limiting). this study was to identify unmet need family planning due to birth spacing and limiting situation. data were analyzed using descriptive statistics were used to report the results in the form of frequency distribution and percentage (%) of each item. the ethical clearance for the study was approved by the health polytechnic of semarang, ministry of health, republic of indonesia. result characteristics of respondents from table 1, it can be noted that the highest percentage of unmet need women in pangkal pinang is on range of age 25-29 years (33.7%). the lenght of married is not much varied, respondents with lenght married 5 to 10 years have a high percentage of unmet need (30.6%). last education of respondents with unmet need was senior high school (51%), their work as housewife (65.3%) and income permonth around 1 to 2 million (55.1%). most of the women with unmet need have marital status is married (98%) with parity 1 to 2 childs (67.3%). the highest percentage is women who unmet need in this study were at the age range 25-29 years (33.7%). unmet need in this age range is targeted delay the child pregnancy. the length of marriage is not varied in this study, respondents with a long marriage between 5 to 10 years old have a high percentage of unmet need (30.6% and 27.6%). education attainment of respondents mostly are high school (51%), they are the housewife (65.3%) with the range of income were between 1 to 2 million rupiahs (55.1%). almost all of the respondents are married (98%) and the rest of them have been divorced. the number of living children they have is about 1 to 2 children (67.3%). 7 global health management journal, 2017, vol. 1, no. 1 table 2. unmet need for family planning to space and limit the childbirth across different socio-demographic situation characteristic unmet need for famili planning total spacing limiting n % n % n % age (year) adolescent (15-24) 8 88.9 1 11.1 9 100 adult (25-49) 57 64 32 36 89 100 education under senior high school 28 65.1 15 34.9 43 100 senior high school/upper 37 67.3 18 32.7 55 100 job work 19 55.9 15 44.1 34 100 no work 46 71.9 18 28.1 64 100 length of married 1-5 years 27 90 3 10 30 100 6-10 years 20 74.1 7 25.9 27 100 11-15 years 11 73.7 4 26.3 15 100 >15 years 7 26.9 19 73.1 26 100 parity 1-2 59 77.6 17 22.4 76 100 >2 6 27.3 16 72.7 22 100 income (idr) <1 million 12 70.6 5 29.4 17 100 1 -2 juta 38 70.4 16 29.6 54 100 >2 juta 15 55.6 12 44.4 27 100 husband’s role yes 64 66.7 32 33.3 96 100 no 1 50 1 50 2 100 husband’s attitude agree 59 67 29 33 88 100 disagree 6 60 4 40 10 100 discussion about contraceptive yes 59 69.4 26 30.6 85 100 no 6 46.2 7 53.8 13 100 discussion in indonesia the number of unmet need reached 11% of women in reproductive age, of that 4 % were due to spacing, and 7% for limiting childbirth. this figure increased compared to the previous survey resulted from 8.6 percent of women in reproductive age [5]. in fact, the prevalence of contraceptive use increased from 50% in 1991 to 62% in 2012, but within the last 10 years of modern contraceptive use increased by only 1% only. the percentage of married women who need family planning services in indonesia is currently around 73% of which 85% of them have been fulfilled. if all requirements of planning services are met then contraceptive prevalence can be improved from 62% to 73%. from the report idhs 2012, this data has not changed. as many as 88% of married women have the unmet need for family planning services are almost the same as a state in 2007 (87%), meaning that the percentage of new acceptors has not risen significantly 1% only [5]. national family planning coordination board tries to reduce this number of unmet need, because it revealed as one of leading causes of maternal mortality (75%). this phenomenon occurred globally as well. indonesia's maternal mortality is estimated to increase to 359 / 100,000 live births and if unmet need is not immediately addressed, then this figure will be higher. women of reproductive age who do not use birth control have high risk to get pregnant and has a great opportunity to experience complications during pregnancy, childbirth and postpartum. this can be caused abortion due to unwanted pregnancy, pregnant spacing, and gave birth too frequent, complications during pregnancy, childbirth and postpartum. global health management journal, 2017, vol. 1, no. 1 8 the results shows a decreasing pattern of the need for birth spacing after reaching the age of 30 years, and for the purpose of limiting childbirth reach the peaked at age 35-44. this is in accordance with the framework analysis of the relationship of age with unmet need for family planning that status of unmet will be high in younger women and tend to decrease as the age getting older, it looks like inverted u-shaped [7]. situational analysis of unmet need to space childbirth in pangkal pinang this study found that about two third (66.3%) of unmet need women in pangkal pinang occurred due to willingness to space the childbirth. birth spacing tended to be favored by young mothers. a previous study found that younger women were more likely to desire to add children [8]. they still tend to have a willingness to have children, however they want to space the birth. the study conducted in kenya established that older women tend to have unmet need for child spacing whereas a woman with a bigger family size would necessarily seek for family planning to limit child bearing and that there is no favorable association between unmet need for family planning and level of education [9]. as age increases, a woman especially from rural area’s propensity of having unmet need for family planning to space child bearing decreases. this trend is so consistent that younger women are bound to experience higher risk of unmet need for contraception to space births. as wangila points out, as women grow older by age, they tend to achieve their desired family sizes [10]. moreover, older women tend to have a reduced coital frequency, and therefore may not need contraception to space their births [11]. unmet need for space childbirth in women in pangkal pinang revealed mostly from early marriage (1-5 years old) women, had low parity and had low education attainment. it is similar to other research, ojaka found that total unmet need is higher among women with a larger number of living children and among those who have primary level of education. woman’s level of education can predict her level of unmet need for contraception to space [12]. this is because of the lower the level of education, the greater the chances that such a woman would have unmet need for spacing. benard reports that women with primary education are most likely to have unmet need for spacing [13]. however, the level of unmet need reduces with a rising in educational level, such that individuals with post-secondary education are least likely to experience unmet need to space childbirths. it is arguable that education imparts knowledge on the importance of using contraception to space childbirths. moreover, education presents a woman with the opportunity to interact with other women from diverse cultural and geographical bounds, from which they are able to acquire new information and skills including use of family planning to space births. situational analysis of unmet need to limit childbirth in pangkal pinang this study reported that unmet need to limit childbirth tended to be preferred by women with length of marriage experience (>15 years old), had high parity, older mothers, and middle education level (senior high school) attainment. this research also found both of spacing and limiting have no difference according to the economic situation, all of them mostly were the household wife from the low-income family. husband support to do not use contraception were found in both birth spacing and birth limiting. ojakaa reports that working women are more likely to report method-related reasons for not using family planning methods and are less likely to report opposition to family planning than women who do not work. it is clear that women who are currently employed are less likely to experience unmet need to space compared to women who are not employed [12]. casterline et al. argue that women who are employed have the capacity to make the decision and to purchase contraceptives to space their births [14]. moreover, it is arguable that currently employed women would need adequate time to concentrate more on their employmentrelated activities than family matters, as such would opt to space their births [15]. coupled with the difficulty a woman faces in acquiring maternity leave, many women would not want to frequently seek for maternity leaves from their employers, thus would want to have wider spaces between their births. 9 global health management journal, 2017, vol. 1, no. 1 conclusion the percentage of married women ages 15-49 who unmet need is higher in women aged 25-29 years, who have children 1-2, has been married five (5) years or more, secondary education (high school), income of 1-2 million , does not play a role in household decision-making. most women of childbearing age who never discussed the unmet needs of family planning with their husbands (86.7%) and the attitude of their husbands agree to family planning (89.8%). both of spacing and limiting have no difference according to the economic situation, all of them mostly were the household wife from low-income family. husband support to do not use contraception were found in both birth spacing and birth limiting. the study suggest to provincial health office and national family planning coordination board that family planning program should not just involve the wife, but husband as well due to their high influence in family planning decision. conflict of interests none declared. references 1. statistics indonesia, 2014. statistical yearbook of indonesia, jakarta: bps 2. irianto, k., 2014. pelayanan keluarga berencana, bandung: alfabeta. 3. walyani, e., 2015. kesehatan reproduksi dan keluarga berencana, yogyakarta: pustaka baru press. 4. sulistyawati, a., 2012. pelayanan keluarga berencana, jakarta: salemba medika. 5. bkkbn, 2012. survei demografi dan kesehatan indonesia. survei demografi dan kesehatan indonesia. 6. bkkbn, 2015. laporan tahunan kb provinsi kepulauan bangka belitung, pangkalpinang. 7. katulistiwa, r., baroya, n. & wati, d.m., 2014. determinan unmet need kb pada wanita menikah di kecamatan klabang kabupaten bondowoso (determinants for family planning among married women at klabang sub district in bondowoso)., 2(2). 8. withers, m., kano, m. and pinatih, g.n. 2010. “desire for more children, contraceptive use and unmet need for family planning in a remote area of bali, indonesia.” journal of biosocial science, 42: 549-562. 9. ukaranja, s.m. 1997. unmet need for contraception and their demographic significance in kenya. unpublished m.a. thesis, psri: university of nairobi. 10. wangila, s.w. 2001. factors underlying unmet need for contraception in kenya. unpublished m.a.thesis, psri: university of nairobi. 11. robey, b., ross, j. and bushan, i. 1996. “meeting unmet need: new strategies.” population reports, 43:1-35. 12. ojakaa, d. 2008. “trends and determinants of unmet need for family planning in kenya.” dhs working papers no. 56. calverton, md: macro international, inc. 13. benard nyauchi and gilbert omedi. determinants of unmet need for family planning among women in rural kenya. african population studies. vol 28 no 2 supplement july 2014. 14. casterline, j.b., perez, a.e. and anne, b.e. 1997. “factors underlying unmet need for family planning in the philippines.” studies in family planning, 28(3):173-191. 15. becker, g.s. 1991. a treatise on the family. cambridge, mass.: harvard university press. microsoft word 3. accepted original, sarah jane racal, 63-69.docx cite this article as molina s, racal sj. stress, coping, and mental health status among nursing students at a private university in nakhon pathom, thailand. global health management journal. 2018; 2(3): 63-9. global health management journal www.publications.inschool.id published by original research article issn 2580-9296 (online) stress, coping, and mental health status among nursing students at a private university in nakhon pathom, thailand stephanie molina, sarah jane racal * faculty of nursing, christian university of thailand, nakhonpathom, thailand. *corresponding author. email: racalsarahjane@gmail.com article info abstract article history: received 08 august 2018 reviewed 10 september 2018 received in revised form 17 october 2018 accepted 21 october 2018 background: stress, especially among young people, leads to life-threatening mental conditions such as depression and suicide. nursing students, in particular, are exposed to different kinds of stress such as pressures from both academic and clinical exposures coupled with expectations to succeed. these stressors influence individual coping styles which may eventually affect students’ mental, physical, and over-all wellbeing leading to the decline in their learning and academic performance. aims: this descriptive-correlational study was aimed at exploring the relationships among stress, coping, and mental health status among nursing students at a private university in nakhon pathom, thailand. methods: using a systematic random sampling, a descriptive cross-sectional study was done among one hundred and fifty 3rd and 4th year nursing students under the international nursing program. the perceived stress scale, brief cope, and the general health questionnaire were used to assess the level of stress, the coping strategies used, and the mental health status of the respondents. descriptive statistics, t-test, and pearson’s correlation were used to answer the research questions. results: it revealed that the nursing students had moderate level of perceived stress, used acceptance as the most common form of coping, and substance use and denial as the least used. furthermore, the respondents had mild level of mental health related-illness. significant gender differences were found in the perceived level of stress, and use of coping strategies. while mental health status significantly differed according to year level and interest in nursing. significant mild to moderate relationships were found among perceived stress level, coping strategies, mental health status, and selected socio-demographic variables. conclusion: the findings of the study provide additional useful information on the relationships of stress, coping, and health outcomes. results can also be useful in creating a stress management program for nursing students such as awareness on individual stress response and reinforcing the use of healthy coping strategies. keywords: stress coping mental health nursing students thailand © 2018 publications of yayasan aliansi cendekiawan indonesia thailand this is an open-access following creative commons license deed – attribution-noncommercial-sharealike 4.0 international (cc by-nc-sa 4.0) introduction stress and health-related response is a growing concern. the world health organization has recognized the influence of stress on several mental health problems such as depression and suicide, particularly among the youth [1]. although everyone experiences stress in various degrees and intensity, health professionals such as nurses carry extra global health management journal, 2018, vol. 2, no. 3 64 coping strategies perceived stress level mental health status socio-demographic variables: gender year level interest in learning further about nursing responsibility as they take care of other people while having to deal with their own personal challenges. it is important to address this concern while they are still in school under the supervision of their instructors as they face pressures from academic and clinical responsibilities stress among the nursing students is recognized as one of the most significant issues in contemporary education [2]. aside from belonging to a vulnerable age group, nursing students are frequently exposed to several stressors which may have direct or indirect influence in their learning and academic performance. they do not only face high levels of stress related to academic assignments but also from clinical skills training. in effect, these stress influence students’ over-all wellbeing particularly their mental health [3]. to deal with the challenges and stress, students employ certain coping mechanisms some of which could be healthy and some not. in thailand, nursing students under the international program face additional challenges particularly from living away from their families, and from learning nursing using a second language (english). major adjustments are expected since nursing concepts learned in this program do not only focus on their own country’s healthcare practices but also include culture, procedures and ways of thinking rooted mostly from other global regions. on top of the physical short and long-term outcomes from stress, students may feel anxious, confused, lonely, and mentally overwhelmed—all unseen and intangible but may have serious impacts on their overall health and wellbeing. the concept of stress, coping, and health outcome has been a point of interest for decades, such as the transactional model of stress and coping by lazarus and folkman [4]. it is in fact, part and parcel of every educational curriculum among health professional. the challenge, however, is to integrate these concepts in research and practice to have a deeper understanding of the stress, coping, and related health outcomes among student health professionals such as nurses. in line with the world health organization’s call to recognize the importance of mental health and build resilience among the young people, the aim of this study was to determine the levels of stress, the coping strategies used, and the mental health status of students; and to explore the correlation of these factors among 3rd and 4th year nursing students. knowledge on these would serve as an important information in identifying, planning, and creating effective intervention programs to reduce or prevent stress and among student nurses which in turn would facilitate their performance and learning both in academic and clinical area. figure 1. conceptual framework in this study methods research design this study used the descriptive – correlational research design. according to leedy and ormrod [5], a descriptive-correlational design is one which surfaces a prevailing situation and at the same time shows the relationship between and among several variables. this is appropriate in examining the existence of relationship between independent variables without the need for manipulation and outcomes [6]. the study was sought to determine the mental health status of nursing students in a private university at nakhon pathom province and at the same time correlate it with their perceived stress level and coping strategies. thus, the researcher believed that the descriptive correlational design is appropriate to use. respondents of the study to identify the sample size in this study, the yamane's formula was used resulting to a sample size of 150. from an official list of students enrolled in academic year 2017, systematic sampling method was used to randomly select the respondents from the 3rd year and 4th year bachelor of nursing science (international program) students. the data was collected in november 2017. they were informed of the objective of the study and anonymity of the students was observed. questionnaires were filled out completely by all respondents. 65 global health management journal, 2018, vol. 2, no. 3 research instruments the research instrument that was used to gather data in this study were modified standardized questionnaire. these were the socio-demographic information, perceived stress level scale (pss), brief cope questionnaire, and general health questionnaire (ghq-12). socio-demographic information: general information included were age, gender, year level, monthly allowance, and interest in nursing. perceived stress level scale (pss): to examine nursing students’ stress levels, the perceived stress level scale developed by cohen in 1988 was used [7]. this consists of 14 positive and negative statements referring to the experiences of the respondents within the last month and rated on a five point scale with scores ranging from 0 (never) to 4 (very often). pss score was obtained by reversing responses to the seven positivity worded items (4, 5, 6, 7, 10, and 13) and summing across all scale items. higher scores mean higher perceived stress level. the authors of this questionnaire have done extensive validity checks and reported reliability for subscales ranging from 0.50 to 0.72 [8]. in this study, the reliability coefficient of the instrument is 0.86 (cronbach’s alpha). brief cope: this scale is a shortened item version of the cope inventory that was developed for the assessment of a broad range of coping responses that was developed by carver in 1997 [9]. this scale is composed of 14 subscales with two items in each, for a total of 28 items, that are rated using a four-point scale, ranging from “i usually don’t do this at all” (score 0) to “i usually do this a lot” (score 4). items assess both functional and dysfunctional coping responses that include planning, acceptance, using instrumental support, self-distraction, denial, venting, substance use, active coping, humor, positive reframing, religion, using emotional support, behavioral disengagement, and self-blame. internal reliabilities range from cronbach’s alpha 0.57 to 0.90. general health questionnaire (ghq 12-item version): to measure the current mental health status of nursing students, the general health questionnaire (ghq) developed by goldberg (1978) was used [10]. a scoring of 0 (never), 1, 2, and 3 (always) was used corresponding to the four response options per item, of which the participants select one. the response options refer to degrees of change in normal day to day functioning and emotional states. the total score of 3 or higher indicates “caseness” or risk of developing a transitory stress-related illness. the reliability of the ghq questionnaire was assessed by cronbach’s alpha coefficient is equal or greater than 0.70 was considered satisfactory. the internal validity of this version have been demonstrated to be adequate or good in numerous studies [9]. ethical considerations approval was obtained from the ethical review board of the private educational institution prior to data collection. the consent form which included details on voluntary participation, freedom to withdraw, and confidentiality was given to the respondents. data analysis the data was analyzed using the spss (statistical package for the social science) version 16.0. descriptive statistics used the frequency, percentage, and mean. independent samples t-test was used to test differences between two means. pearson’s correlation coefficient and point-biserial was used to test the relationships among stress factors, perceived stress level, coping strategies, and mental health status. a pvalue of equal to or less than 0.5 was considered significant. results demographic information and characteristics of participants in this section, descriptive statistics regarding frequencies and percentage were used to describe gender, age, year level, monthly allowance, and interest in nursing. the total participants of this study were 150 nursing students, majority of which were female (80%) coming from 3rd year (66.7%) and 4th year (33.3%), with age ranging mostly from 21-22 (98.7%). most of the participants receive a monthly allowance of 6,000-9,000 baht (68.7%). more than half of the participants were less interested in nursing (52.7%). a detailed presentation on the perceived stress scale is shown in table 1. results showed that item 7 (able to control irritation in life) has the highest mean score (m = 2.66, sd = .64), followed by item 8 (felt on top of things) with mean and standard deviation of m = 2.63, sd = .63. items 6 (could not cope with all the things hard to do) and 9 (angered because of things that were outside of control) were the lowest scores at m= 2.02, sd = .69 and m= 2.17, sd = .63, respectively. overall, the students have a moderate level of stress (m=2.36, sd= .63). global health management journal, 2018, vol. 2, no. 3 66 table 1. distribution of students by perceived stress scale statements mean sd verbal interpretation 1. been upset of events that happened unexpectedly 2.47 .56 moderate 2. felt of unable to control important things in life 2.35 .63 moderate 3. felt nervous or stressed 2.29 .58 low 4. felt confident to handle personal problems 2.40 .60 moderate 5. felt things were going according to own way 2.41 .62 moderate 6. felt unable to cope with things that should be done 2.02 .69 low 7. been able to control irritation in life 2.66 .64 moderate 8. felt on top of things 2.63 .63 moderate 9. been angered of things that were happening outside of control 2.17 .63 low 10.felt difficulties were piling up so high that they could not be solved 2.23 .70 low over-all mean 2.36 .63 moderate table 2: distribution of students by brief cope questionnaire coping strategies mean sd 1. self-distraction 2. active coping 3. denial 4. substance use 5. use of emotional support 6. use of instrumental support 7. behavioral disengagement 8. venting 9. positive reframing 10. planning 11. humor 12. acceptance 13. religion 14. self-blame over-all mean 4.87 5.28 3.81 3.85 5.44 5.60 4.57 4.77 5.44 5.49 4.82 5.61 4.48 4.24 4.88 .75 1.07 1.08 1.01 1.20 1.17 .97 .84 1.20 1.16 .80 1.27 .82 1.06 1.03 table 3: distribution of students by general health questionnaire for mental health status assessment questions mean sd verbal interpretation 1. feeling that you had not made good use of time 2. feeling that you were not decisive 3. feeling that you had suffered from pressure 4. feeling that you could not overcome your own difficulties 5. feeling unhappy or distressed 6. able to lead a happy life 7. able to face your own difficulties 8. sleepless because of worrying something 9. having lost self-confidence 10. able to concentrate on doing anything 11. feeling that you were a useful person 12. feeling happy in general 2.24 2.23 2.08 2.03 2.24 2.75 2.30 2.29 2.55 2.38 1.81 1.59 .65 .54 .59 .56 .65 .82 .64 .56 .65 .71 .77 .69 mild mild mild mild mild moderate mild mild mild mild mild mild over-all mean 2.21 .65 mild 67 global health management journal, 2018, vol. 2, no. 3 table 2 exhibits details on the brief cope questionnaire. results showed subscale 12 (acceptance) has the highest mean score (m = 5.61, sd = 1.27), followed by subscale 6 (use of instrumental support) with mean and standard deviation of m = 5.60, sd = 1.17. subscales 4 (substance use) and 3 (denial) were the lowest scores at m = 3.85, sd = 1.01 and m = 3.81, sd = 1.08, respectively. table 3 presents details on the mental health assessment. results showed that item 6 (able to lead a happy life) has the highest mean score (m = 2.75, sd = .82), followed by item 9 (having lost self-confidence) and item 10 (able to concentrate on doing anything) with mean and standard deviation of m = 2.55, sd = .65 and m = 2.38, sd = .71, respectively. items 11 (feeling of being a useful person) and 12 (feeling happy in general) were the lowest scores at m = 1.81, sd = .77 and m = 1.59, sd = .69, respectively. overall, the students showed a mild to moderate mental health status (m= 2.21, sd=.65). table 4: significant findings on stress level and coping strategies using t-test (df=148) characteristics stress level coping strategies mental health m sd t m sd t m sd t gender male female year level third year fourth year interested in nursing yes no 17.00 1.41 -7.36* 66.25 2.62 -.83* 29.50 1.91 2.97 23.84 1.94 68.37 5.08 26.43 2.03 24.15 1.52 3.48 70.46 3.92 9.192 26.33 1.67 -1.36* 22.68 2.78 64.04 4.23 26.90 .38 23.57 1.80 .44 68.16 4.90 .34 26.63 2.03 -.63* 23.73 2.46 68.45 5.17 26.41 2.14 * p <0.05 table 5: correlation among the study variables variables agender ayear level ainterest in nursing perceived stress level coping strategies mental health status a gender 1 -.234** -.175* .518** .068 -.237** a year level -.234** 1 .123 -.326** -.603** .129 a interest in nursing -.175** .123 1 -.037 -.029 .052 perceived stress level .518** -.326** -.037 1 .237** -.094 coping strategies .068 -.603** -.029 .237** 1 .036 mental health status -.237** .129 .052 -.094 .036 1 *p < 0.05, **p < 0.01, a point-biserial. table 4 shows the significant difference in the stress level, coping strategies, and mental health status when grouped according to selected socio-demographic variables. results were statistically significant according to year level t (148) = -1.36, p < .05 between the third year (x̅= 26.33, sd =1.67) and fourth year nursing students (x̅= 26.90, sd =.38) and between those male (x̅= 17.00, sd =1.41) and female (x̅= 23.84, sd =1.94) nursing students t (148 ) = -7.36, p < .05, and between those interested (x̅=26.63, sd =.633) and not interested (x̅= 26.41, sd =2.14) in nursing. the stress level and use of coping strategies significantly differed between male and female nursing students t (148) = -7.36 and -.83, p <.05, respectively. the mental health status also significantly differed between the third year and fourth year nursing students t (148) = -1.36, p <.05, and those who are interested and not interested in nursing t (148) = -.63, p <.05. the third year nursing students (x̅= 70.46, sd =3.92) have higher mean frequency in the use of coping strategies compared to the fourth year students (x̅= 64.04, sd = 4.23). table 5 orchestrates the significant relationship among perceived stress level, coping strategies, and mental health status, results revealed significant positive relationships between gender and perceived stress level (r = .518, p = .01), and between perceived stress level and coping strategies (r = .237, p = .01). while significant negative relationships were found between year level and perceived stress level (r = .326), between coping strategies and perceived stress level (r = .237, p = .01), between year level and coping global health management journal, 2018, vol. 2, no. 3 68 strategies (r = -.603, p = .01), and between gender and mental health status (r = -.237, p = .01). discussion guided by the transactional model of stress and coping [4], this study assessed the correlation of perceived stress level, coping strategies, and mental health status among nursing students who enrolled at a private university at nakhon pathom province. descriptive analyses showed that the respondents as a whole has a moderate level of stress, most of the students used acceptance and instrumental support as their coping strategies, and the students had a relatively healthy mental health status. the results showed a mild to moderate verbal interpretation of stress level and a dominantly mild presence of stressrelated mental problems. this finding is similar with the results obtained by previous authors of studies conducted in other asian countries [3, 12, 13, 14, 15]. from the selected socio-demographic variables (gender, year level, and interest in nursing), it is important to note that mean differences in stress level and the use of coping strategies were found when grouped according to gender. females, reported higher stress levels and more frequent use of coping strategies than males. the higher stress level among females may be due to greater responsibilities and expectations given to female students simultaneously coming from their homes/families and from the academic environment. consequently, the use of coping strategies in response to stress was more frequent among females. the use of coping among females may be related to their early recognition and acceptance of the need to address the link between stress and over-all wellbeing. the results also revealed that third year students had higher level of stress compared to the fourth year nursing students. this could be due to a fact that, as they got to a higher level, they were able to adapt and adjust to the academic and clinical requirements of the program [3]. moreover, the higher the level of the students, the more they gained confidence and acquired expertise in nursing skills which might have helped them in effectively dealing with different stressors. the findings showed that the mental health status among nursing students was considered as good amidst the presence of moderate stress level. this result is similar with a study among chinese and spanish nursing students [14, 16]. this could be a good indication that nursing students are able to cope better with various stressors that they faced in their theoretical and clinical exposures. these results present opportunities for educators and learning institutions to integrate stress management in the teaching and learning activities and promote healthy coping strategies in and outside the campus. finally, consistent with the transactional model of stress and coping by lazarus and folkman [4], this study reflected that amidst stressful situations, a good health outcome can be achieved when adaptive coping strategies are being used. although, no causal relationship is shown, this descriptive-correlational design provided baseline information on the stress, coping, and health response of nursing students. results particularly highlighted the major role of coping in buffering the unwanted effects of stress on one’s well-being. conclusion findings from this study showed that 3rd year and 4th year nursing students from the international program of a private university in thailand were exposed to different stressors during their education and training. results showed that, as a whole, they were at the moderate stress level affecting their overall health status especially their emotional health. this provides helpful and useful information for educators and administrators in identifying students’ needs, facilitating their learning and planning effective interventions and strategies to reduce or prevent stress in nursing education and training as well as promote helpful and positive strategies to cope with stress. it is recommended that further study be conducted among all levels of nursing education, both thai and international program. comparative studies among nursing school offering international programs is also recommended. a qualitative study to explore the indepth stress experiences of students could add to the richness of these data. it is further recommended to investigate the influence of socio-demographic factors on stress, coping, and health outcomes. other concepts of the transactional model of stress and coping, not included in the present research, can also be integrated in future studies. conflict of interests authors declared no conflict of interest of the presented content. 69 global health management journal, 2018, vol. 2, no. 3 references 1. world health organization (who). world mental health day 2018: young people and mental health in a chaning world.[online], available from http://www.who.int/mental_health/world-mentalhealth-day/2018/en/ 2. kalaivani, s & rajkumar, k. stress among the nursing students. international journal of advances in nursing management 2017; 5(3): 270-272. 3. labrague l. stress, stressors, and stress responses of student nurses in a government nursing school. health science journal 2013; 7(4) 4. lazarus, r. and folkman, s.. stress, appraisal, and coping. new york: springer; 1984. 5. leedy, p., and ormord, j.. practical research: planning and design, 7th ed. upper saddle river, nj and thousand oaks, ca.: merrill prentice hall and sage publications; 2001. 6. graziano, a. & raulin, m.. research methods: a process of inquiry, 6th ed. : pearson allyn and bacon; 2007. 7. cohen s., kamarck t., and mermelstein, r.. a global measure of perceived stress. journal of health and social behavior 1983; vol 24. 8. carver, c.s.. you want to measure coping but your protocol's too long: consider the brief cope. international journal of behavioral medicine,1997; vol 4. 9. mccubbin hi, thompson ai, mccubbin ma. family measures: stress, coping, and resiliency inventories for research and practice. honolulu hi: kamehameha schools; 2001. 10. goldberg, d.p.. manual of the general health questionnaire.windsor: nfer-nelson; 1978. 11. goldberg, d. & williams, p.. a user's guide to the general health questionnaire. windsor: nfernelson; 1988. 12. racal, s., & acedera-cordova, l.. the relationship between stress, coping, and physio-psycho-social responses to stress of bns students at a private unviersity in thailand. international journal of nursing and health science 2016; 1(2). 13. sharma n., & kaur, a.. factors associated with stress among nursing students. nursing and midwifery research journal 2011; 7(1). 14. chan, k., so, k., & fong, y.. hongkong baccalaureate nursing students' stress and their coping strategies in clinical practice. journal of professional nursing 2009; 25(5). 15. prasad, c.., suresh, a., thomas, d., prittyy, m., beebi, s., & multazim, v.. the level of stress and coping mechanism adopted by year 1 b.sc. nursing students. archives of medicince and health science 2013; 1(1). 16. jimenez, c., navia-osorio, p., & diaz, c.. stress and health in novice and experienced nursing students. journal in advanced nursing 2010; 66(2). cite this article as macnab aj. promoting global health innovation: on the need for global health care solutions in the spirit of the international conference on applied science and health (icash). global health management journal. 2017; 1(1): 1-3. global health management journal www.publications.inschool.id published by editorial promoting global health innovation: on the need for global health care solutions in the spirit of the international conference on applied science and health (icash) andrew j macnab editor in chief, global health management journal *corresponding author. email: ajmacnab@gmail.com accepted 26 may 2017 © 2017 publications of yayasan aliansi cendekiawan indonesia thailand this is an open access following creative commons license deed – attribution-noncommercial-sharealike 4.0 international (cc by-nc-sa 4.0) health and well-being are the fundamental right of every human. while governments of every nation are responsible for the policies and infrastructure that enable people to access health care services, it is now recognized that the innovation necessary to improve health and well-being is something to be conscientiously fostered and directed towards the achievement of particular objectives, [1] and that there is a growing need for bold ideas able to save and improve lives that integrate innovation in science, technology, education and social change. where do such ideas come from and who has the responsibility to generate them? at a global level, agencies such as the united nations (un) and world health organization (who) formulate global polices; the un sustainable goals (sdgs) announced in the document “transforming our world: the 2030 agenda for sustainable development” is an example of a clear call to action. the sdgs, which supersede the millennium development goals, incorporate 17 overarching global goals and 169 targets and set a comprehensive agenda, principally to address directly or indirectly needed improvements in human growth, survival and thriving. [2,3] there is also accumulating evidence from worldwide academic research of the growing need for new ideas, novel programs and more effective interventions. for example, studies on the developmental origins of health and disease (dohad) now convincingly show how early life exposures related to conception, pregnancy, infancy and childhood can have a significant impact on health and disease risk in later life; examples include trends in obesity, type 2 diabetes, heart disease, some cancers and mental illness. [4,5] this new knowledge requires a paradigm shift in how we work to address non-communicable chronic diseases. at a national level there is a need for political vision, commitment and leadership at the highest level. it is important for experts, practitioners, professionals and academics at universities to provide government and policy makers with clear priorities. for example, millions of deaths would be averted and the economic cost of healthcare reduced if the focus on prevention was greater. [6] it is often economic incentives that prove to be the strongest argument for change. however, in this context there is now robust evidence that investing in health is beneficial to socio-economic development, [2] and that in turn socio-economic development results in better health and human capital. at all levels, the generation and testing of novel ideas by young investigators is an important http://publications.inschool.id/ mailto:ajmacnab@gmail.com http://inschool.id/ http://creativecommons.org/licenses/by-nc-sa/4.0/ global health management journal, 2017, vol. 1, no. 1 2 mechanism for driving scientific and social innovation. especially where these ideas are bold and involve new approaches or forms of cooperation that can contribute to sustainable health improvements for society. the sharing of such ideas and exchange of knowledge and experience by young investigators was the aim of the first international conference on applied science and health (icash) held in bangkok in february 2017. icash was a joint initiative designed by the institute of population and social research at mahidol university, thailand, the doctoral program in public health science at diponegoro university, indonesia, and universitas ‘aisyiyah yogyakarta, indonesia. icash brought together experts, practitioners, professionals and students from applied science and health related fields, and what they shared is available in the published conference proceedings registered at national library of indonesia and available at <http://publications.inschool.id/index.php/icash/in dex> the global health and development journal was established by the founders of icash to be a platform for presenting the outcome of projects intended to define where scientific, educational, technological and social innovation can be applied to improve health. this first edition highlights five of the presentations made at icash 2017. antarini et al identify unmet need family planning due to birth spacing and limiting situation among reproductive age women in indonesia. birth spacing tended to be favored by young mothers, early marriage, had low parity and low education attainment, whilst limiting childbirth tended to be preferred by older mothers with longer marriage experience, high parity, and secondary education attainment. suryadinata conducted a systematic review to evaluate the benefits of automated dispensing machine (adm) use as a potential solution for hospital pharmacy dispensing errors in indonesia. the 13 studies reviewed describe benefits that included significant reduction in dispensing errors, and also additional benefits of time saving in peak hours and cost savings; all relevant to consideration of installation of adm in indonesia. diartama et al describe the design of a radiology viewing box using a potentiometer system intended to improve radiograph viewing. the mean viewing box illumination achieved reached 220 lux and enabled optimal radiograph viewing by the radiologists and radiographers evaluating it. in addition, there is a photo essay on how the world health organization ‘health promoting school’ (hps) model can be used to address the challenges involved in seeking to achieve the un sustainable development goals (sdgs). health promotion uses a range of complimentary approaches to provide individuals and communities with the knowledge and skills that will enable them to improve their own health and wellbeing. encouraging children to adopt healthy lifestyle habits is a central objective, and health promotion at a community level, particularly through use of the who ‘hps’ model health promoting schools, is a strategy many of us can consider as a means of effectively generating new health knowledge and promoting healthy behaviors. health promotion and health care initiatives delivered through schools are well within the capacity of low and middle income countries, as they require a change in mindset and refinement of educational objectives rather than provision of major new resources, engagement of nongovernmental resources or obtaining international funding. there is consensus on the validity of the hps model [7] and a growing literature on the evidence of efficacy and cost savings related to school-based health initiatives. the global health and development journal also has another potential role of importance. currently, there is a gap between our level of knowledge of effective treatments and the healthcare interventions and services being received by people of all ages in many countries. while much is known from research about interventions that are effective, all too often this knowledge does not get translated into policies and practices that improve health outcomes for our children, families and adults in ways that they need and deserve. [8] a process of inquiry is required in parallel with conventional research to improve our understanding of how to implement interventions effectively and enhance service delivery processes at local, state, and national levels. to gain this understanding, evidence-based data of “what works and why” are http://publications.inschool.id/index.php/icash/index http://publications.inschool.id/index.php/icash/index 3 global health management journal, 2017, vol. 1, no. 1 needed. this means that we must develop locally relevant and applicable ways to evaluate how we introduce, deliver and sustain the innovative programs we develop, and have an avenue to report them. the journal will be valuable in this regard, as it will provide a forum for young investigators to describe bold scientific ideas and social innovations able to save and improve lives alongside reports of new forms of cooperation and effective health services delivery. this combination of innovations that integrate science and technology with education and social change together will meet the recognized need for greater understanding of “what works and why” and in turn contribute to more sustainable health improvements for society as a whole. references 1. brook d, macmaster c, singer pa. innovation for development. 2013. https://idl-bncidrc.dspacedirect.org/handle/10625/51577 (accessed may 22, 2017). 2. united nations. transforming our world: the 2020 agenda for sustainable development. united nations, new york; 2015. https://sustainabledevelopment.un.org/content/do cuments/212520302 agenda for sustainable development web.pdf (accessed may 11 2017). 3. sachs jd. from millennium development goals to sustainable development goals. the lancet. 2012; 379, 9832: 2206-11. 4. gluckman pd, hanson ma. the developmental origins of health and disease: an overview. in developmental origins of health and disease (eds. gluckman p, hanson m), 2006; pp. 1-5. cambridge university press, cambridge. 5. international society for developmental origins of health and disease. the cape town manifesto – november 2015. international society for developmental origins of health and disease, cape town; 2015. https://dohadsoc.org/wpcontent/uploads/2015/11/ dohad-society-manifesto-nov-17-2015.pdf (accessed may 15 2017). 6. bloom de, cafiero et, jané-llopis e, abrahamsgessel s, bloom lr, fathima s et al. the global economic burden of non-communicable diseases. geneva: world economic forum. 2011 7. macnab aj. the stellenbosch consensus statement on health promoting schools. global health promotion. 2013; 20(1):78-81. 8. morel cm, acharya t, broun d, dangi a, elias c, ganguly nk, et al. health innovation networks to help developing countries address neglected diseases. science. 2005; 309(5733):401-4. the period of perineal wound healing in postpartum mothers between the decoction water treatments of bihanong leaves with red betel leaves indonesian scholars’ alliance ghmj (global health management journal) 2019, vol. 3, no. 3 open access original research the 4th interna onal conference on applied science and health (icash 2019), 23-24 july 2019, faculty of graduate studies, mahidol university, thailand the period of perineal wound healing in postpartum mothers between the decoction water treatments of bihanong leaves with red betel leaves nahdiyah karimah* , nur khafidhoh, triana sri hardjanti, riska ismawati hakim postgraduate applied science program in midwifery, poltekkes kemenkes semarang, indonesia *corresponding author’s email: nahdiyahkarimah@gmail.com abstract background: the global prevalence of the second degree of the perineal wound of postpartum mothers is 73.4%. pharmacological treatments have a cytotoxic effect. other treatments is non-pharmacological treatments are such as using decoc on waters of binahong leaves and red betel leaves. both have compounds that accelerate epithelializa on of wounds. this study aims to analyze the differences of the perineal wound recovery period of postpartum mothers between the decoc on water treatments of binahong leaves compared to red betel leaves. methods: this study is a quasi-experiment post-test only without control group design. there are 32 respondents mee ng the inclusion criteria who are taken by accidental sampling. the sample is divided equally into two groups, namely binahong group and the red betel group. binahong or red betel leaf decoc on waters are used for genital washing a er urina ng at the last rinse at 7 am and 3 pm on 1-3 postpartum days. perineal wound recovery is assessed by using the reeda score from the second postpartum day un l the wound fully recovered. sta s c analysis with chi-square, me series analysis, mann whitney and kruskal wallis test. results: the average of perineal wound recovery period of binahong group is 6 days, while the red betel group is 4.69 days. there are significant differences of perineal wound recovery period between the binahong group and the red betel group with a p-value of 0.0001 < α (0.05). respondents’ characteris cs are age, bmi, frequency of changing pads, and educa onal background between binahong and red betel groups have no significant differences. conclusion: red betel leaf decoc on water is recommended for postpartum mothers suffering perineal wounds. further research is needed with a larger number of respondents and true experiments are needed to analyze the effect of red betel leaves on perineal pain, platelets, and leukocyte level. keywords: binahong leaves, red betel leaves, perineal wound’s treatment received: 25 april 2019 reviewed: 28 may 2019 revised: 20 june 2019 accepted: 5 july 2019 doi: 10.35898/ghmj-33454 selec on and peer-review under responsibility of the scien fic commi ee and the editorial board of the 4th internaonal conference on applied science and health (icash 2019) © yayasan aliansi cendekiawan indonesia thailand (indonesian scholars’ alliance). this is an open-access following crea ve commons license deed a ribu on-noncommercial-sharealike 4.0 interna onal (cc by-nc-sa 4.0) 1. introduc on puerperium is period needed for anatomy and physiology to return into normal condition before pregnancy, started after birth of placenta until 6 weeks after the labor (o’reilly et al., 2012). there are various problems during puerperium, one of them is the perineal wound. perineal wound may occur spontaneously or intentionally through episiotomy (lindsay et al., 2018). there are four degrees of perineal wounds. the first degree includes vaginal mucosa, posterior fourchette and perineal skin. 107 mailto:nahdiyahkarimah@gmail.com https://dx.doi.org/10.35898/ghmj-33454 ghmj (global health management journal) 2019, vol. 3, no. 3 karimah n et al. the second degree involves perineal muscle. the third degree involves external anal sphincter muscle. the fourth degree involves anterior rectal wall (lindsay et al., 2018). about 80% of primiparous women in the world have perineal wounds (who, 2015). considering from the degree of perineal wound, the most prevalence is second degree (73.4%), then first degree (17.7%), third degree (8.4%) and fourth degree (0.5%) (smith et al., 2013). factors associated to perineal wound recovery are internal and external factors. internal factors are age, body mass index (bmi), hemoglobin, and disease. meanwhile, external factors are abstaining from certain food, educational background, early mobilization, frequency of changing pads, and treatment. treatment is dominant factor associated to perineal wound recovery (rohmin et al., 2017; said et al., 2016; gunanti, 2010; greenhalgh, 2003; hartiningtiyaswati, 2010; sari, 2019). perineal wound that are not treated properly may lead to complications such as persistent pain, severe wound damage, dyspareunia, urinary retention, fecal incontinence, infection and disrupt the bond between mother and baby during the postpartum period (lindsay et al., 2018). thus, treatment for perineal wound is important to prevent morbidity in postpartum mothers. pharmacological treatment is such as by using povidone iodine. povidone iodine inhibits tissue granulation, damages endothelial cells, leukocytes, fibroblasts, keratinocytes, deactivates phagocytes, and separated wound edge. therefore, wound recovery is delayed (koca kutlu et al., 2013). meanwhile, non-pharmacological treatments are such as by using binahong and red betel leaf decoction waters. binahong leaf contains antimicrobial substances namely alkaloids (marwoko, 2013). binahong leaf also contain ascorbic acid to form collagen (ariani et al., 2014). the collagen formation is stage of proliferation and maturation of wound recovery (suriadi, 2004). polyphenols, flavonoids, and saponins in binahong leaf can accelerate epithelialization of wounds. the first degree of perineal wound in postpartum mothers treated by using binahong leaf extract is recovered for 6 days (aditia et al., 2017). red betel leaf contains alkaloids, carvacrol, eugenol, and essential oils functioning as antimicrobials and antibiotics. red betel leaf has double antiseptic power than green betel leaf. red betel leaf also contains polyphenols, saponins, flavonoids, and tannin which accelerate epithelialization of wounds (suhermanto et al., 2013; fithriyah et al., 2016). average of perineal wound recovery for 5 days by using red betel leaf decoction water (r, 2017). previous research about binahong or red betel leaf decoction waters did not assess the process of perineal wounds recovery day by day until fully recovered. daily assessment is important to compare redness, edema, ecchymosis, discharge, and approximation of perineal wound. there is no previous research comparing binahong and red betel leaf decoction waters to find out effectiveness of perineal wounds recovery treatment. the number of postpartum mothers suffering second degree of perineal wound at gubug i community health center in 2017 was 136 of 226 spontaneous labor. meanwhile, gubug ii community health center was 161 of 269 spontaneous labor. postpartum mothers in gubug i and ii community health center experienced perineal wound recovery for 7 days (80%) and 10 days (15%). about 5% experiencing perineal wound infection. this problem insists midwives to be aware of proper perineal wound treatment. this study aims to analyze the differences of perineal wound recovery period of postpartum mothers treated by using binahong compared to red betel leaf decoction waters. 2. method this quasi experiment research uses two post test groups without control group design. there are 32 respondents as sample selected by using accidental sampling. they are divided equally into binahong and red betel groups. respondents in the working area of gubug i community health center are grouped in binahong group and respondents in the working area of gubug ii community health center are grouped in red betel group. selection of samples is based on inclusion and exclusion criteria. the inclusion criteria of this study are postpartum mothers suffering second degree perineal wounds due to spontaneous tearing or episiotomy, mobilizing based stages, taking oral medication (amoxicillin 125 mg 3 times a day, methylergometrine 0.125 mg twice a day, paracetamol 500 mg 3 108 karimah n et al. ghmj (global health management journal) 2019, vol. 3, no. 3 times a day, vitamin a 200000 iu every 24 hours for 2 days and samcobion once a day) as program of gubug i and ii community health center for postpartum mothers. meanwhile, the exclusion criteria are postpartum mothers who are not willing to be respondents, suffering diseases such as diabetes mellitus, malignant disease and tuberculosis, smoker, abstaining from certain food, suffering from anemia (hb <11 g/dl), and having bmi <18.4 kg/m2. the procedures of making decoction water of binahong leaves are 50 grams of fresh binahong leaves put into 800 ml of boiling water. it is boiled for 15 minutes on medium heat by using clay pan to prevent damaging the content of binahong leaf substances and closed during the manufacturing process. the decoction water is let to cool, then it is filtered and only the water is left (wijayanti and rahayu, 2017). meanwhile, the procedures of making decoction water of red betel leaves was 25 grams of fresh red betel leaves put into 100 ml of boiling water on clay pan and closed until it is cool. then it is filtered and only the water is left (r, 2017). binahong or red betel leaf decoction waters are used for genital washing after urinating at last rinse at 7am and 3pm on 1-3 postpartum days. it was observed every morning to assess perineal wound recovery from the second postpartum day until fully recovered by using reeda score. reeda score is an assessment tool of perineal wound recovery that was primarily developed by davidson. reeda score includes redness, edema, ecchymosis, discharge, and aproximation with the highest score of each aspect is 3 and the lowest score is 0. a higher score indicates a greater level of tissue trauma and perineal wounds recovered when reeda score is 0 (davidson, 1974). this research receives ethical approval by the health research ethics commission (kepk) of poltekkes kemenkes semarang number 036/kepk/poltekkes-smg/ec/2018. primary data collection has gained respondents’ approval through informed consent. anonymity and confidentiality are guaranteed in this study and respondents have the right to stop participate in the research process. using chi square, time series analysis, mann whitney and kruskal wallis test. table 1. reeda score (hill, 1990) points redness oedema ecchymosis discharge approxima on 0 none none none none none 1 within 0.25 cm of the incision bilaterally perineral, < 1 cm from incision within 0.25 cm bilaterally or 0.5 cm unilaterally serum skin separa on 3 mm or less 2 within 0.5 cm of the incision bilaterally perineal and or between 1-2 cm from the incision between 0.25-1 cm bilaterally or between 0.5-2 cm unilaterally serosanguinous skin and subcuntaneous fat separa on 3 beyond 0.5 cm of the incision bilaterally perineal and or vulvar > 2 cm from incision > 1 cm bilaterally or > 2 cm unilaterally bloody, purulent skin, subcuntaneous fat and fascial layer separa on 3. results 3.1 respondents’ characteris cs respondents’ characteristics in this study are based on age, body mass index (bmi), frequency of changing pads, and educational background. table 2 shows that most of respondents are on reproductive ages (93.8%), have normal bmi (81.25%), change of pads frequency more than 3 times a day 109 ghmj (global health management journal) 2019, vol. 3, no. 3 karimah n et al. (59.4%), and have basic education level (59.4%). respondents in binahong and red betel groups have no significant differences with p value > α (0.05). table 2. respondents’ characteris cs no respondents’ characteris cs binahong group (n=16) red betel group (n=16) total (n=32) p value f % f % f % 1 age 1 < 20 years old 1 6.2 1 6.2 2 6.2 20-35 years old 15 93.8 15 93.8 30 93.8 2 bmi 0.654 normal (18.5 24.9 kg/m2) 12 75 14 87.5 26 81.25 fat (≥ 25 kg/m2) 4 25 2 12.5 6 18.75 3 frequency of changing pads 1 ≤ 3 mes a day 6 37.5 7 43.8 13 40.6 > 3 mes a day 10 62.5 9 56.2 19 59.4 4 educa onal background 0.473 basic (elementary and junior high school) 11 68.8 8 50 19 59.4 secondary (senior high school) 5 31.2 8 50 3 40.6 3.2 the average of reeda score assessment of perineal wound recovery by using reeda score. a higher score indicates a greater level of tissue trauma. the average of reeda score between binahong and red betel groups was assessed from the second postpartum day until fully recovered. figure 1. analysis of the average of reeda score by using me series analysis figure 1 shows that average reeda score on 2-7 postpartum days of binahong and red betel groups decreased every day. the red betel group has an average reeda score on 2-7 postpartum days lower than the binahong group. therefore, the perineal wound recovery period of red betel 110 karimah n et al. ghmj (global health management journal) 2019, vol. 3, no. 3 group is better than in binahong group. on day 6, perineal wound of red betel group is fully recovered. meanwhile, on day 7, perineal wound of binahong group is fully recovered. 3.3 perineal wound recovery period perineal wounds recovered when reeda score is 0. perineal wound recovery period between binahong and red betel groups was assessed in this study. table 3. perineal wound recovery period dependent variable binahong group (n=16) red betel group (n=16) mean ± sd min-max mean ± sd min-max perineal wound recovery period 6 ± 0.73 5-7 4.69 ± 0.79 4-6 table 3 shows that perineal wound recovery averagely 6 days in binahong group. the fastest recovery period is 5 days and the longest one is 7 days. meanwhile, perineal wound recovery averagely 4.69 days in red betel group. the fastest recovery period is 4 days and the longest one is 6 days. 3.4 normality test of dependent variables normality test is related to statistic analysis. normality test of this study is on dependent variables (reeda score and perineal wound recovery period of binahong and red betel groups). table 4. normality test of dependent variables no dependent variables p value binahong group red betel group 1 reeda 2 0.008 0.278 2 reeda 3 0.02 0.290 3 reeda 4 0.007 0.002 4 reeda 5 1 0.0001 5 reeda 6 0.0001 0.0001 6 perineal wound recovery period 0.005 0.001 based on table 4, reeda score in binahong and red betel groups have not normal distribution with p value < α (0.05). thus, bivariate is done by using kruskal wallis test. perineal wound recovery period in binahong and red betel groups is not normal distribution with p value < α (0.05). thus, bivariate is done by using mann whitney test. 3.5 differences of reeda score between binahong and red betel groups table 5. differences of reeda score between binahong and red betel groups no dependent variables binahong group (n=16) red betel group (n=16) p value mean ± sd mean ± sd 1 reeda 2 7.06±1.12 5.69±1.54 0.012 2 reeda 3 5.56±1.15 3.56±1.55 0.001 3 reeda 4 3.44±1.26 1.19±1.45 0.0001 111 ghmj (global health management journal) 2019, vol. 3, no. 3 karimah n et al. 4 reeda 5 1.56±1.20 0.31±0.70 0.002 5 reeda 6 0.44±0.81 0.00±0.00 0.036 6 reeda 7 0.00±0.00 0.00±0.00 1 table 5 shows that there is significant differences of reeda score between binahong and red betel groups starting on the second postpartum day with p value < α (0.05). 3.6 differences of perineal wound recovery period between binahong and red betel groups table 6. differences of perineal wound recovery period between binahong and red betel groups dependent variable group p value perineal wound recovery period binahong group red betel group 0.0001 based on table 6, there is significant differences of the perineal wound recovery period between the binahong and red betel groups with p value 0.0001 < α (0.05). 4. discussion the majority of respondents are on reproductive ages. postpartum mothers in reproductive ages have 6 times better perineal wounds recovery because speed of cellular recovery is normal (rohmin et al., 2017). the respondents mostly have normal nutritional status based on bmi. postpartum mothers who have good nutritional status have better perineal wound recovery because nutrients are needed for recovery process (said et al., 2016). most of respondents have change of pads frequency more than 3 times a day as a safe cleanliness of the genital area to prevent infections inhibiting perineal wound recovery (sari, 2019). respondents’ characteristics are age, bmi, frequency of changing pads, and educational background between binahong and red betel groups have no significant differences. thus, respondents’ characteristics do not affect perineal wound recovery in both groups. internal and external factors associated to perineal wound recovery are bmi, hemoglobin, disease, abstaining from certain food, and mobilizing based stages (rohmin et al., 2017; said et al., 2016; gunanti, 2010; greenhalgh, 2003; hartiningtiyaswati, 2010). all of these factors have been controlled in this study with inclusion and exclusion criteria. thus, internal and external factors do not affect perineal wound recovery in binahong and red betel groups. this study reveals that there is significant differences in the recovery period between binahong and red betel groups. in red betel group, the average day of perineal wound recovery is 4.69 days. this is faster than binahong group which requires 6 days. thus, decoction water treatment of red betel leaves is effective for recover perineal wounds among postpartum mothers. binahong and red betel groups receives the same oral medication (amoxicillin 125 mg 3 times a day, methylergometrine 0.125 mg twice a day, paracetamol 500 mg 3 times a day, vitamin a 200000 iu every 24 hours for 2 days and samcobion once a day) as program of gubug i and ii community health center for postpartum mothers. thus, oral medication do not affect perineal wound recovery in both groups and the perineal wound is recovered by the binahong or red betel leaf decoction waters. amoxicillin is an antibiotic to prevent infection. based on fouelifack et al. (2017), the perineal wound of postpartum mothers treated by using povidone iodine compared to combination of amoxicillin 1000 mg and clavulanic acid 125 mg twice a day, could recover perineal wound on day 9 of both groups. thus, amoxicillin does not affect the process of perineal wound recovery. methylergometrin is an ergot alkaloid used to prevent postpartum haemorrhage by stimulating uterine contractions (borgelt et al., 2010). paracetamol was able to reduce 62% perineal wound pain 112 karimah n et al. ghmj (global health management journal) 2019, vol. 3, no. 3 (akil et al., 2014). vitamin a 200000 iu eases postpartum mothers recovery better (who, 2003). samcobion is an iron tablet to prevent anemia. based on the research of dewi et al. (2016), iron consumption of postpartum mothers did not affect the second degree perineal wound recovery. this study indicate that perineal wound treated using binahong leaf decoction water, wound recovery averagely 6 days and longest recovery is 7 days. it is different from wijayanti and rahayu (2017). their study shows postpartum mothers who used binahong leaf decoction water for perineal wound, recovery averagely 7 days and longest recovery is more than 7 days. it is different because the respondents in wijayanti and rahayu (2017) were postpartum mothers suffering 1-3 degree perineal wounds. meanwhile, the respondents of this study are postpartum mothers suffering second degree perineal wound. third degree of perineal wound have deeper and wider wounds than first and second degree of perineal wound. thus, third degree of perineal wound experience prolonged proliferation and the edges of the wound will fuse longer. therefore, the recovery period is longer than first and second degree of perineal wound (suriadi, 2004). binahong leaf decoction water in wijayanti and rahayu (2017) was initially given on the third postpartum day. about 9.1% of respondents experienced perineal wound recovered longer than 7 day. meanwhile, decoction water of binahong leaves in this study is initially given on the first postpartum day and perineal wound is recovered no later than 7 days. thus, decoction water treatments of binahong leaves given on the first postpartum day quickly recovers perineal wound than given on the third postpartum day. in terms of maintenance of red betel leaf decoction water, the results of this study are in accordance with research of r (2017). the average perineal wound recovery for 5 days by using decoction water of red betel leaves and perineal wound healed proves to be fastest within 4 days. the wound recovery process started from coagulation, inflammatory, proliferation, and maturation. in the coagulation phase, released thrombocyte occurrence causes vasoconstriction and coagulation to prevent wider bleeding. then, the inflammatory phase triggers an inflammatory reaction to fight infection. when there is no infection, the granulation process and epithelialization occur in the proliferation stage. then during phase of maturation, collagen fibers are bound together and fused to recover the tissue (middleton, 2011). the reeda score of the binahong and red betel groups show significant differences starting on the second day of postpartum. the daily average reeda score in the red betel group is lower than the binahong group. it means that daily perineal wound recovery of red betel group is better than the binahong group. thus, decoction water of red betel leves is effective for perineal wound recovery of postpartum mothers. the effectiveness of red betel leaf decoction water in perineal wound recovery is caused by some specific compounds of red betel leaves rather than binahong leaves. some of these compounds are red betel leaves contain alkaloid 543.75 mg/g, polyphenols 210.11 mg/g, and flavonoids 6.09 mg/g (suhermanto et al., 2013; fithriyah et al., 2016; r, 2017; wijayanti and rahayu, 2017; davidson, 1974; hill, 1990; fouelifack et al., 2017; borgelt et al., 2010; akil et al., 2014; who, 2003; dewi et al., 2016; middleton, 2011; kusumowati et al., 2012). whereas binahong leaves only contain alkaloids 0.86 mg/g, polyphenols 70,25 mg/g, and flavonoids 0.11 mg/g (marwoko, 2013; sulistyaningsih et al., 2015; selawa et al., 2013). alkaloid is antibacterial by interfering constituent components of bacterial cell peptidoglycan (juliantina et al., 2008). polyphenols are antioxidants that are 100 times more effective than vitamin c and 25 times more effective than vitamin e (sulistyaningsih et al., 2015). flavonoids have antibiotic ability to disrupt microorganism functions, causing death of microorganisms (suhermanto et al., 2013). all of them abilities prevent infection. thus, they accelerate the ending stage of the inflammatory phase during the recovery and rapid proliferation phase (selawa et al., 2013). inflammation is an inflammatory process characterized by several symptoms such as redness (rubor) and swelling (tumor). assessment by using reeda score shows the wound recovery uses terms redness (rubor) and edema (swelling) (davidson, 1974). this is the reason why red betel group has better average score of redness and edema than the binahong group. 113 ghmj (global health management journal) 2019, vol. 3, no. 3 karimah n et al. flavonoids may also accelerate period of epithelialization of wounds in the proliferation phase. polyphenols and saponins are able to stimulate collagen formation in the proliferation phase (suriadi, 2004). the content of flavonoids and polyphenols in red betel leaves is more than the content in binahong leaves. this is why the red betel group has better average score of ecchymosis and approximation than binahong group. some of the compounds are contained in red betel leaf but not in binahong leaves are tannin 3.97 mg/g as antibacterial and new tissue regeneration, carvacrol as antibiotic, and eugenol 2.2 mg/g as antiseptic, antimicrobial, and analgesic which stimulating formation of new epithelial cells, and supporting process of re-epithelialization (nisa et al., 2014). meanwhile, some compounds contained in binahong leaves but are not found in red betel leaves are protein and ascorbic acid. protein function in fostering tissue formation and accelerating epithelialization period of wounds. ascorbic acid plays a role in the formation of collagen, so that collagen fibers formed will be more robust (mercandetti and cohen, 2012). 5. conclusion this study suggests that decoction water treatment of red betel leaves is effective for perineal wound recovery of postpartum mothers. then, red betel leaf decoction water is recommended as an alternative treatment for postpartum mothers suffering perineal wounds. however, further research with a larger number of respondents and true experimental research design is needed to analyze effect of red betel leaves on perineal pain, platelets level, and leukocyte level. acknowledgments the authors would like to thanks all staff of gubug i and iii community health center and all staff of poltekkes kemenkes semarang. conflict of interest there is no conflict of interest. references aditia, d. s., hidayat, s. t., khafidhoh, n., suhartono, s., and suwondo, a. 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(2015). analisis kadar fenol total dan uji aktivitas antioksidan ekstrak daun binahong (anredera cordifolia (tenore) steenis) (analysis total phenolic content and antioxidant activity of binahong leaves extract (anredera cordifolia (tenore) steenis)). universitas gadjah mada, yogyakarta. suriadi (2004). perawatan luka (wound care). sagung seto, jakarta. who (2003). pregnancy, childbirth, postpartum, and newborn care: a guide for essential practice. world health organization. who (2015). nurses and midwives: a vital resource for health. european compendium of good practices in nursing and midwifery towards health 2020 goals. http://www.euro.who.int/__data/assets/pdf_ file/0004/287356/nurses-midwives-vital-resource-health-compendium.pdf. wijayanti, k. and rahayu, h. (2017). effectiveness of binahong decoction water (anredera cordifolia (ten) steenis) for perineal wound healing at home delivery aesya grabag magelang. international journal of research in medical sciences, 5(5):1970–1975. cite this article as: karimah n, khafidhoh n, hardjanti ts, hakim ri. the period of perineal wound healing in postpartum mothers between the decoction water treatments of bihanong leaves with red betel leaves. ghmj (global health management journal). 2019; 3(3):107-116. doi:10.35898/ghmj-33454 116 http://www.euro.who.int/__data/assets/pdf_file/0004/287356/nurses-midwives-vital-resource-health-compendium.pdf http://www.euro.who.int/__data/assets/pdf_file/0004/287356/nurses-midwives-vital-resource-health-compendium.pdf introduction method results respondents' characteristics the average of reeda score perineal wound recovery period normality test of dependent variables differences of reeda score between binahong and red betel groups differences of perineal wound recovery period between binahong and red betel groups discussion conclusion indonesian scholars’ alliance ghmj (global health management journal) 2019, vol. 3, no. 2 open access original research hevny kartika dewi1*, mardiyono2, diyah fatmasari2, sudirman2, and djenta saha2 effect of red fruit oil soap (pandanus conoideus lam) as wound cleansing on wound healing and the number of bacterial colonies among grade ii diabetic ulcer patients at griya qound care clinic kudus, indonesia 1postgraduate applied science program in nursing, poltekkes kemenkes semarang, semarang, indonesia. 2poltekkes kemenkes semarang, semarang, indonesia. *corresponding author’s email: hevnykd@gmail.com abstract background: diabetic ulcer is an open wound on the skin layer to the dermis due to hyperglycemia and neuropathy. this condition often causes infection and becomes an inhibitor in the wound healing process. red fruit oil soap can be used as an alternative cleansing to reduce the number of bacterial colonies and accelerate the wound healing process. this present study aimed to observe the effect of red fruit oil soap in the cleansing process to reduce the number of bacterial colonies and the wound healing process in grade ii diabetic ulcer patients methods: this is a quasi-experimental study with the pre-test post-test non-equivalent control group design. wound cleansing in the intervention group used 0.9% nacl solution and red fruit oil soap with a ph of 5.74, while the wound cleansing in the control group used 0.9% nacl solution. bacterial colonies were assessed and the type of bacteria was observed by the swab method. the wound healing was assessed with bates-jensen wound assessment tool (bwat) instrument for 14 days with observations every 3 days. analysis test used mann whitney and repeated measure anova. results: there was no difference in the mean of the number of bacterial colonies between the wounds that were cleansed with 0.9% nacl solution and red fruit oil soap and the wounds which were cleansed by using 0.9% nacl solution (p> 0.05). the mean of the number of colonies in the intervention group until the 14th day reduced by 3.14x106 and in the control group was reduced h 1.40x106. there was a significant decrease in the wound healing scores in each group, in each assessment for 14 days. conclusion: this study found that the wound cleansing using red fruit oil soap and 0.9% nacl solution could reduce the number of bacterial colonies on the wound surface and accelerate the wound healing process among patients with grade ii diabetic ulcer. keywords: red fruit oil soap, wound cleansing, wound healing, diabetic ulcer received: 25 august 2018; reviewed: 4 september 2018; revised: 24 june 2019; accepted: 28 june 2019 c©yayasan aliansi cendekiawan indonesia thailand (indonesian scholars’ alliance). this is an open-access following creative commons license deed attribution-noncommercial-sharealike 4.0 international (cc by-nc-sa 4.0) 1. introduction diabetes mellitus (dm) is a chronic metabolic disease characterized by hyperglycaemia due to a decrease in the level of the insulin hormone. indonesia is the 7th largest with the number of dm patients in the world where an estimated of 21.3 million adults suffered from dm in 2013. the increasing incidence of dm usually will be followed by the increased incidence of diabetic ulcers. it is estimated, 15% -25% of people with diabetes will experience diabetic ulcers during their lives and the condition of the ulcer will be worse if the ulcer is infected [1]. there are five basic principles in dm management, namely engaging in low-carb dm diet, routine physical activity (exercise), taking oral hyperglycaemia drug (ohd) or insulin, routine health check and blood glucose level monitoring to healthcare services, and stress management [2]. the proper management of dm is necessary in order to prevent complications such as macroangiopathy and microangiopathy. the most frequent complication is the occurrence of pathological changes in the lower limbs called diabetic ulcers which are often not felt and can develop into infections caused by aerobic 55 dewi hk et al. ghmj (global health management journal) 2019, vol. 3, no. 2 or anaerobic bacteria. diabetic ulcers is one of the most severe and disabling complications of dm because the tissue damages that occurs in diabetic foot ulcers is caused by neurological (neuropathy) and vascular disorders on the legs. dm patients who are accompanied by diabetic ulcer complications not only require medical management but also a holistic management including metabolic, vascular, infection, ulcer, pressure/ mechanical, and institutional control. ulcer control as the most critical intervention in ulcer treatment is a wound treatment by removing infected tissue and necrosis regularly. the wound treatment itself comprised of three stages namely cleansing, debridement, and dressing [3]. cleansing is the initial stage in wound care which plays a vital role in maintaining the cleanliness of germs in the wound area, removing debris, exudate, dead tissue from the wound surface, minimizing bacterial colonization and facilitating wound healing. showering technique is the most common methods in cleansing, which normally use 0.9% nacl. unfortunately, 0.9% nacl does not have specific anti-bacterial power and thus, makes it less appropriate to be applied in people with infected diabetic foot ulcer such as diabetic ulcer, especially in grade ii dm [4]. red fruit contains beta crypto samine, phenolic compounds, triterpenoids (essential oils), steroids, phenylpropanoid glycosides, coumarin, chlorogenic acid, caffeic acid, squalene, phytosterol, and stigmasterol which functioned as anti-bacterial and anti-inflammatory which will damage the bacterial membrane and kill the bacteria [5, 6]. the active ingredient of the red fruit can be used as a cleansing solution for dm ulcers because it aims to reduce the number of bacterial colonies and accelerate the process of wound healing to optimize this function. soap is a salt compound of high fatty acids, such as sodium stearate, c17h35coona+. cleansing action of soap is produced by emulsifying forces and the ability to reduce surface tension from the water. this concept can be understood by remembering the two properties of soap anions [7]. antiseptic soap is soap with the addition of chemical compounds used to kill or inhibit the growth of microorganisms in living tissue such as the surface of the skin and mucous membranes. ordinary soap requires rubbing to mechanically remove microorganisms, while antiseptic soap (antimicrobial) can remove and also more effective to kill or inhibit the growth of most microorganisms (broad range) than detergent or plain soap [8]. considering the potential of red fruit as the wound cleaning and wound healing materials, it is interesting to develop a study with the presence of new creativity and innovation related to red fruit oil soap to reduce the number of bacterial colonies, as a wound cleansing in the process of ulcer healing among the grade ii diabetic ulcer patients at griya wound care clinic kudus. the present study would be the first soap made from red fruit oil which is used as a cleansing before performing wound care by using modern topical dressing. 2. method this study used the quasi-experimental method with the pre-test post-test non-equivalent control group design. this type of study design was used to analyse red fruit oil soap as a wound cleansing agent for wound healing and decrease the number of bacterial colonies in grade ii diabetic ulcer patients. the study samples were all dm patients with a complication of grade ii diabetic ulcer with a wound size of at least 4 cm2 and were treated during march-april 2018 at griya wound care clinic kudus, indonesia. there were 27 respondents involved in the study, of whom, 15 respondents were assigned as the intervention group and 12 respondents as the control group. the intervention group was administered at wound surface with red fruit oil soap and 0.9% nacl solution as cleansing treatment whereas the control group received ulcer cleansing treatment using 0.9% nacl solution only. the red fruit oil soap was prepared by the researchers with the guidance of a herb specialist. the soap was made from red fruit oil with 250gr of 0.9% nacl powder and 750gr of texapone dissolved in distilled water. viscosity, ph, foam power, and irritation test were performed in a university’s laboratory while the soap’s power in inhabiting and killing bacteria was performed in the central java laboratory. data collection was carried out by pre-test and post-test using bwat (bates-jensen wound assessment tool) instrument and tissue culture was collected to observe the number of bacterial colonies. the bacterial pus colony culture was collected using the swabbing technique using 56 ghmj (global health management journal) 2019, vol. 3, no. 2 dewi hk et al. sterile cotton swabs with dry evaporation above 100oc for 30 minutes. the ulcer was moistened with nacl 0.9%, swabbing was performed zigzag until covered all ulcer areas. cotton swabs were immediately put into sterile bottles that contained 3 cc of 0.9% nacl solution in closed test tubes to prevent it from drying out, and on the outer tube was labeled with patient identity. the thee were immediately sent to the laboratory using the cool box for the examination process. repeated cleansing and ulcer treatments were conducted every 3 days while colonies observation and ulcer healing were assessed using bwat tools for five times (day 1, 3,7,10 and 14) in a duration of 14 days of observation. higher score of bwat indicating a poor ulcer healing process (wound degeneration) while the lower score indicating wound regeneration. considering that blood glucose affects the wound healing process, measurements of this confounding variable was also performed following the treatment. examination of the number of bacterial colonies was conducted by pus culture with swabbing technique to observe the number of bacterial colonies while the ulcer healing process observation was conducted before and after the wound cleansing intervention. examination of study samples to determine the number of bacterial colonies was carried out at the central java laboratory, indonesia. analysis of the results of the wound healing process was performed using repeated general linear model and pos hoc tests, whereas the number of bacterial colonies was assessed by friedman and post hoc and man whitney. this study has received an ethical clearance from the education institution of semarang health polytechnic, indonesia. 3. results 3.1 demographic characteristics the characteristics of the respondents between intervention and control group in this study was relatively homogeneous (see table 1). most of respondents in both groups were older person aged 55-64 years old with the mean age of 55. the proportion of male-female was different, where the males dominate control group, however, the females dominate intervention group. the vast majority of respondents both in the control and intervention groups did not have regular exercise (93% in the intervention and 100% in the control group) and engaged in regular smoking (66% in the intervention and 51.9% in the control group). for co-morbidities, the majority of respondents had non-dm comorbidities, such as renal failure, visual impairment, hypertension, and peptic ulcer. 3.2 blood glucose the blood glucose of dm patients with a complication of grade ii diabetic ulcer in the intervention and control group were mostly above the normal level (>200 mg/dl). although the homogeneity test results on the five blood glucose measurements also showed that there was no difference of the data variants between the control group and the intervention group, however, table 2 showed that the blood glucose levels of respondents in the control group were generally lower than their counterparts in the intervention group. in both intervention and control group, there is a tendency of decreasing blood glucose level where the blood glucose levels in the latest day of observation were at the lowest compared to the initial period. 3.3 bacterial colonies the number of bacterial colonies of patients of the control group in the initial period (day 1) was lower compared to their counterparts in the intervention group (see table 3). the number of bacterial colonies in the control group and the intervention group for 14 days of study with 5 times assessment showed a gradual decrease in the number of bacterial colonies but still in a state of infection (>105). however, table 3 also showed that the number of bacterial colonies in the intervention group significantly increased in the last day of observation. independent t-test mann-whitney (see table 4) showed that that there was no difference in bacterial colonies on the ulcer surface between groups at each assessment. however clinically, the number 57 dewi hk et al. ghmj (global health management journal) 2019, vol. 3, no. 2 table 1. frequency distribution of respondents’ characteristics based on demographic characteristics in the control group and intervention group characteristic control group (n=12) intervention group (n=15) total *p n % n % n % age 0.724* 45-54 5 41.7 7 46.7 12 44.4 55-64 6 50.0 7 46.7 13 46.1 64-75 1 8.3 1 6.7 2 7.4 gender 0.495* male 8 66.7 6 40.0 14 51.9 female 4 33.3 9 60.0 13 48.1 regular exercise 1.000* yes 0 0 1 6.7 1 3.7 no 12 100 14 93.3 26 96.3 co-morbidities 0.948* without co-morbidities (dm) 4 33.3 4 26.7 8 29.6 renal failure 1 6.7 1 3.7 glaucoma 2 16.7 1 6.7 3 11.1 hypertension 2 16.7 4 26.7 6 22.2 cataract 4 33.3 4 26.7 8 29.9 peptic ulcer 1 6.7 1 3.7 antibiotic 0.59* ciprofloxacin 500 mg 8 66.7 8 53.3 16 59.2 metronidazole 500 mg 4 33.3 7 46.7 11 40.8 *homogenity test: leven’s test of colonies in both the control group and the intervention group experienced a decrease in each assessment with the final number of below 107. 3.4 ulcer healing figure 1 showed a description of tthe ulcer healing process both in the control group and the intervention group withshowed an ulcer improvement (wound degeneration). it can be seen from, the decrease of ulcer score in each because the ulcer score always decreased in each assessment, but unfortunatelyit had not reached the remodeling stage. repeated measure post hoc bonferroni analysis showed a p-value of <0.05 in each day of measurement, indicating a difference in wound healing scores between the control and the intervention group. bwat observation scores illustrated the wound healing process for grade ii diabetic ulcer patients who received red fruit oil soap and the group treated by using 0.9% nacl solution (intervention group) progressed better (wound regeneration) compared to patients in the control group whose wound only cleansed using 0.9% nacl solution (see table 5). 4. discussion a diabetic ulcer is one of the chronic ulcers and is known as difficult to heal. since the improvement of the healing process is slower and longer, the evaluation of ulcer improvement can be done every 3 days along with ulcer treatment. in this study, evaluation or assessment of ulcer healing status was conducted 5 times in 14 days, i.e. every intervention with cleansing and ulcer treatment as well as assessments before (pre) and after (post) intervention. the first pre and post-tests were conducted on 58 ghmj (global health management journal) 2019, vol. 3, no. 2 dewi hk et al. table 2. frequency distribution of blood glucose in the control group and intervention group blood glucose control group (n=12) intervention group (n=15) *p mean±sd min-max mean±sd min-max day 1 270.50±43.617 189-345 337.07±89.515 95-445 0.097 day 3 243.25±45.383 165-303 305.20±96.295 90-492 0.090 day 7 211.25±39.651 147-275 279.40±78.656 84-380 0.115 day 10 187.33±37.655 133-253 247.47±71.109 121-412 0.112 day 14 156.58±38.030 101-201 210.40±70.440 103-380 0.139 *homogenity test: levene test table 3. number of bacterial colonies before and after wound cleansing in the control and intervention group day of assessment control group (n=12) intervention group (n=15) mean mean pre post pre post day 1 3.61x107 3.18x107 8.21x106 7.08x106 day 3 2.56x107 2.48x107 1.18x107 5.74x106 day 7 3.03x107 2.47x107 6.69x106 4.11x106 day 10 2.72x107 2.45x107 6.33x106 2.13x106 day 14 2.77x107 2.63x107 4.03x106 9.24x105 day 1, second pre and post-tests were conducted on day 3, third pre and the post-tests were conducted on day 7, fourth pre and post-tests were conducted on day 10, fifth pre and post-tests were conducted on day 14. 4.1 bacterial colonies in addition to evaluating the ulcer healing process using the bates-jensen wound assessment tool (bwat), the authors also evaluated the number of bacterial colonies on the ulcer surface. gram positive and negative bacteria were found at the pus samples in dm ulcer patients examined for bacterial colonies. gram-positive bacteria include staphylococcus epidermis, while negative gram bacteria include enterobacter aerogenes, proteus mirabilis, and klebsiella spp [9]. infection with respect to superficial ulcers is most often caused by aerobic gram-positive bacteria while aerobic and anaerobe gram bacteria are rare to find in deep ulcers which are usually considered due to mixed infections. anaerobic bacterial infections are generally associated with tissue necrosis and osteomyelitis [10]. the study found that the number of bacteria on the ulcer surface decreased, and it was applied both in the control group and the intervention group. there was no significant difference in the mean number of bacteria before and after treatment in each assessment between the groups. the final assessment results of bacterial colonies still showed the number of above 105, indicating the wound was still in the inflammatory phase. however, it can be seen from the mean value and the difference in the assessment results of bacterial colonies carried out 5 times during 14 days showed a decrease. in the intervention group where the ulcer was cleansed using 0.9% nacl solution and red fruit soap showed a higher decrease than the ulcer that was cleansed only by using 0.9% nacl solution. one of the substances contained in red fruit is essential oils that have antibacterial properties [11]. essential oils in red fruit oil are in the form of triterpenoid compounds which carbon frame is derived from six isoprene units and biosynthetically derived from acyclic c-30 hydrocarbons, namely squalene. triterpenoid compounds consist of four groups, namely steroids, saponins, and triterpenes. steroids are triterpenoid compounds that act as an anti-inflammatory [5]. squalene is a high-saturated aliphatic hydrocarbon that includes triterpenes. this compound has the potential to enter the body through the skin by rubbing it on the surface of the skin, and this compound can be absorbed within 0.5 seconds, spread over 1 mm and in less than 1 minute to reach the blood vessels, so this compound is very good for skin health [12]. besides, red fruit also contains phenylpropanoid glycosides which work by damaging the bacterial membrane that can kill the bacteria [13]. 59 dewi hk et al. ghmj (global health management journal) 2019, vol. 3, no. 2 table 4. differences in the number of bacterial colonies on the ulcer surface in control group and intervention group the difference in the number of bacterial colonies group mean difference *p day 1 intervention 1.13x106 0.283 control 4.30x106 day 3 intervention 6.05x106 0.608 control 7.98x105 day 7 intervention 2.58x106 0.558 control 5.59x106 day 10 intervention 4.20x106 0.272 control 2.65x106 day 14 intervention 3.10x106 0.283 control 1.40x106 *independent test: man-whitney figure 1. description of ulcer healing before and after wound cleansing there was no difference in the number of bacterial colonies and it was likely due to age, systemic disease, immune disorders, and consumption of immunosuppressant. in this study, the mean of age was 55-year-old which showed that the respondents were in the elderly adult phase with deteriorated body function, coupled with the dm disease so that the un-optimal immune function resulted in increased bacterial growth. 4.2 healing process of diabetic ulcers statistical test result using repeated measure general linear model (glm) anova showed that there was a significant difference in bwat scores between the control group and the intervention group which illustrated the healing process of a diabetic ulcer on each assessment (p <0.05). in both groups, ulcer healing scores decreased during the 14 days of the study, but the ulcer had not reached the maturation stage. the group that was cleansed using red fruit oil soap showed a decrease in the number of bacterial colonies more than the group cleansed only with 0.9% nacl solution. in addition to the antibacterial property possessed by red fruit oil soap, red fruit also contains vitamins c, e (tocopherol) and a which have a role in collagen synthesis, fibroblast proliferation, and angiogenesis so as to accelerate the process of ulcer healing [14, 13]. vitamin e also plays a role in the healing process of the ulcer by protecting the cell membrane from damage caused by oxidant substances. red fruit also contains minerals such as zinc (zn) and iron (fe) which play a role in ulcer healing. zn plays a role by increasing collagen and protein synthesis, and increasing tissue growth. whereas iron plays a role in providing oxygen for tissue that has injury or ulcer, and also plays a role in collagen synthesis and strengthens new tissue that is formed after the ulcer healing. in this study modern dressing was used based on the wound bed and the state of the patient’s 60 ghmj (global health management journal) 2019, vol. 3, no. 2 dewi hk et al. table 5. differences in bwat scores between the control group and intervention group bwat score variable group mean±sd *p day 1 control 48.92±2.275 0.001 intervention 34.20±4.902 day 3 control 47.33±2.348 0.001 intervention 33.40±4.672 day 7 control 40.67±3.339 0.001 intervention 27.73±4.183 day 10 control 35.83±2.823 0.001 intervention 22.80±2.597 day 14 control 31.92±2.712 0.001 intervention 19.13±2.748 ulcer. the type of modern dressing used was hydrogel in the form of metcovazin and dermozone salt which usually used for wound care management in indonesia [15]. metcovazin salt is a salt with the active ingredient of iodine-cadexomer which has antibacterial property, besides it has a function to support autolysis debridement, maintain a moist atmosphere, and stimulate the growth of granulation tissue. meanwhile demozone salt is a salt with an active ingredient and dalethyne compound derived from ozone-treated olive oil which is able to kill mrsa bacteria and help bactericidal processes and has anti-inflammatory property. from the score of the ulcer assessment at baseline (the first time the respondents arrived), all respondents were in the phase of degenerative ulcer (the score was more than 13) where the ulcer was in the inflammatory phase. the duration of the ulcer healing process is related to the body’s ability to respond to infection by metabolizing to produce materials that fight the bacteria, especially white blood cells and nutrients for the continuation of ulcer healing. the state of blood glucose in the respondent also affected the body’s metabolism so that the components that should be produced by the body and transported through the blood vessels became disrupted due to metabolic disorders due to hyperglycemia [16]. according to a study the presence of necrotic tissue, devitalization tissue and high infection of the ulcer resulted in an excess increase in metabolism which caused tissue hypoxia [17]. the occurrence of tissue hypoxia results in the damaged extracellular matrix and fibroblast formation for ulcer healing will be disrupted which causes the longer duration of the ulcer healing. the longer duration of ulcer healing is due to macrophage cells identify hypoxic cells as cells that no longer function for phagocytosis. this causes the time for macrophages to do phagocytosis of bacteria or unhealthy tissue in the framework of autolytic debridement and for the subsequent process to increase in length, so that the fibroblasts cannot perform their functions maximally [17]. the choice of dressing is a technique in creating a moist ulcer environment. this is found in ulcer care management (time). the results of a systematic review conducted by dumville et al (2012) on modern dressing for diabetic ulcer healing, stated that the selection of bandages in accordance with evidence-based practice could accelerate ulcer healing [18]. the results of this study differed from julianto’s (2014) study, which found that the improvement of ulcers treated using nacl solution was 0.9% lower than those treated with hydrogel [19]. a study conducted by paradika (2016) also found that ulcers cleansed with 0.9% nacl solution had a longer healing duration compared to ozone watertreated ulcers [20]. changes in wound conditions that can be observed directly include the reduced amounts of exudate from many to a little, necrotic tissue with only a small amount of exudate, skin color around the wound is bright red and the growth of granulation tissue and epithelialization which show good progress. granulation tissue at the time of the pre-test was not visible or only <23%, with the pale red of 78, while the tissue growth in post-test iii was <75% with light and bright red. meanwhile the wound closure by epithelial tissue at pre-test was <25% and became 25-49% in post-test iii. acceleration of granulation tissue growth and epithelialization is determined with good wound control and also influenced by a high protein diet such as consuming more than 4 eggs per day and consuming snakehead fish rich in protein content. 61 dewi hk et al. ghmj (global health management journal) 2019, vol. 3, no. 2 the condition of the ulcer that was cleaned using 0.9% nacl solution and red fruit oil soap showed that the ulcer was in the granulation phase, with the clinical condition of 75% granulation tissue growth, the ulcer edge began to show contractions and clear border, no erythema, induration, and the skin color around the ulcer was normal with minimal exudate production and the ulcer surface was covered with necrotic tissue <25%. based on this description, ulcer treatment with cleansing using 0.9% nacl solution and red fruit oil soap by maintaining the moist condition of the ulcer with the right choice of dressing according to wound bed was very likely to be applied to accelerate the healing process of grade ii diabetic ulcer in the inflammatory phase even though the observation on day 14 showed that it had not reached the maturation phase. thus, the clinical application of ulcer treatment with cleansing using 0.9% nacl solution and red fruit oil soap should be conducted until the ulcer reached the maturation phase accompanied by the selection of the appropriate dressing. 5. conclusion although there was no difference in the mean of the number of bacterial colonies between the wounds that were cleansed with 0.9% nacl solution and red fruit oil soap, and the wounds which were only cleansed by using 0.9% nacl solution (p> 0.05), the study found the mean of the number of colonies in the intervention group until the 14th day reduced by 3.14x106 and in the control group was only reduced by 1.40x106. the results indicating that wound cleansing using red fruit oil soap and 0.9% nacl solution could reduce the number of bacterial colonies on the wound surface and accelerate the wound healing process among patients with grade ii diabetic ulcer. references 1. boulton aj, kirsner rs, vileikyte l. neuropathic diabetic foot ulcers. new england journal of medicine. 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phenolic, and total flavaonoid of extracts and fractions of red fruit (pandanus conoideus lam). international food research journal. 2010;17(1):97-106. 14. crowe t, brockbank c. nutrition therapy in the prevention and treatment of pressure ulcers. wound practice and research. 2009;17(2):90-9. 62 ghmj (global health management journal) 2019, vol. 3, no. 2 dewi hk et al. 15. gitarja ws, jamaluddin a, hasyim a, wibisono v, megawati n, fajar k. wound care management in indonesia: issues and challenges in diabetic foot ulceration. wounds asia. 2018;1(2):13-7. 16. velander p, theopold c, hirsch t, bleiziffer o, zuhaili b, fossum m, et al. impaired wound healing in an acute diabetic pig model and the effects of local hyperglycemia. wound repair and regeneration. 2008;16(2):288-93. 17. velnar t, bailey t, smrkolj v. the wound healing process: an overview of the cellular and molecular mechanisms. journal of international medical research. 2009;37(5):1528-42. 18. dumville jc, o’meara s, deshpande s, speak k. alginate dressings for healing diabetic foot ulcers (review). cochrane database of systematic reviews. 2012(2). 19. julianto e, sudiarto s. hidrogel ekstrak bonggol pisang, rumput laut dan daun sirih untuk luka bakar (hydrogel from the extract of banana hump, seaweed and betel leaf for burn wound). mahakam nursing journal (mnj). 2018;2(4):151-8. 20. pradika j, astuti y, sari nk. efektivitas cleansing luka menggunakan infussa daun jambu biji 20% dengan teknik showering tekanan 15 psi terhadap penyembuhan ulkus kaki penderita diabetik di klinik kitamura pontianak (the effectiveness of wound cleansing using guava-leaf infusion 20% with showering technique of 15 psi pressure towards healing of diabetic foot ulcer in kitamura pontianak clinic) [thesis]. yogyakarta: uny yogyakarta; 2016. cite this article as: dewi hk, mardiyono, fatmasari d, sudirman, and saha d. effect of red fruit oil soap (pandanus conoideus lam.) as wound cleansing on wound healing and the number of bacterial colonies among grade ii diabetic ulcer patients at griya qound care clinic kudus, indonesia. ghmj (global health management journal). 2019; 3(2):55-63 63 introduction method results demographic characteristics blood glucose bacterial colonies ulcer healing discussion bacterial colonies healing process of diabetic ulcers conclusion knowledge, attitudes, and hiv/aids risk behaviors of myanmar migrant workers in thailand ghmj (global health management journal) 2023, vol. 6, no. 1 indonesian scholars’ alliance open access research article the correlation between job satisfaction, compensation, and work environment on nurse's turnover intention in kotamobagu regional general hospital using structural equation modeling path analysis echa effendy siswanto amir*, eko winarto, rita dewi sunarno, shindi hapsari department of community health nursing, universitas karya husada, semarang, indonesia *corresponding author’s e-mail: echamasashi13@gmail.com doi: 10.35898/ghmj-61925 abstract background: turnover intention is the tendency of employees to leave the organization or resign voluntarily from their job. several factors that might influence turnover intention are included job satisfaction, work environment, and compensation. aims: this study aimed to determine the path analysis of the effect of job satisfaction, compensation, and work environment on the turnover intention of nurses at kotamobagu regional general hospitals. methods: a total of 34 nurses (total sampling method) contributed in this cross-sectional study. the model is presented with a single-directed arrow indicating cause and effect. the regression weights predicted by the model are compared with the correlation matrix from the observed data and then the goodness of fit is calculated. this study uses data analysis that is adapted to the research pattern and the variables studied. a causal model was employed, and to test the proposed hypothesis the sem analytical technique (structural equation modeling) was operated through the amos program. results: from the statistical analysis, the study shows a significant relationship between job satisfaction and turnover intention (p-value = 0.011), and between the compensation and the turnover intention (pvalue = 0.026). however, we found that there was no relationship between work environment and turnover intention among the nurses at kotamobagu regional general hospitals (p-value = 0.935). conclusion: this study concluded that there is a correlation between work satisfaction and compensation on turnover intention (direct factor), but there was no correlation between work environment on turnover intention (mediator). it is suggested a need to arrange regular evaluation in terms of job satisfaction and compensation to prevent turnover among the nurses. keywords: turnover intention, job satisfaction, compensation, work environment received: 03 october 2022 reviewed: 24 october 2022 revised: 10 december 2022 accepted: 31 january 2023 © yayasan aliansi cendekiawan indonesia thailand (indonesian scholars’ alliance). this is an open-access following creative commons license deed attribution-noncommercial-sharealike 4.0 international (cc by-nc-sa 4.0) 1. introduction hospital is a public health facility provided by the government or the private sector in charge of providing basic and referral health services. there are many challenges faced by human resources working in the hospital during these decades. the changes that are occurring in society today greatly affect the competition, both changes in demographics, socioeconomics, science and technology, market competition, and human resources (andini, 2015). hospital management can improve human resources in the health sector, including nurses. the quality of health services is a service that uses the resources available at the hospital according to the code of ethics that has been established efficiently and mailto:echamasashi13@gmail.com https://doi.org/10.35898/ghmj-61925 amir, et. al. ghmj (global health management journal) 2023, vol. 6, no. 1 2 effectively in an effort to fulfil health status so that patients feel safe and satisfied (herlambang, 2016). one issue in the human resources of the hospital is turnover. turnover is an event where employees move from one organization to another organization. turnover is often used by employees to find or seek better conditions, but this can cause harm to the organization they left behind. one of the causes of employee turnover is dissatisfaction during work, any dissatisfaction obtained at work will have a negative impact, one of which is turnover intention (prihanjana, 2013). the occurrence of turnover begins with the emergence of a desire to change jobs (turnover intention) by employees. turnover intention is the desire to change jobs or the desire to leave an organization because they do not feel comfortable and want to get a better job. this desire arises when employees are still working at the company and is influenced by many factors (prihanjana, 2013). the factors that affect the turnover are divided into two, including the characteristics of nurses (age, gender, background, work experience, motivation, self-perception) and internal hospital environmental factors (management, recruitment, selection, socialization, training, and education). additionally, there are other factors such as development, performance appraisal, reward system, promotion, transfer and termination of employment, organizational culture, and work comfort) (lusiati & supriyanto, 2010). in addition, there are several factors that influence the emergence of turnover intention, including individual characteristics, work environment, job satisfaction, and compensation (pranowo, 2016). nurses are the most employees among all health workers in hospitals and play an important role in the process of providing health services in hospitals because they are directly involved with patients for 24 hours (irawan & suroso, 2018). nurses are required to work quickly in their environment, always ready to provide nursing care to patients, convince family members, and are required to always follow the standard operational procedure (sop) that has been determined by the hospital. this condition might cause stress to nurses so many health care organizations have high nurse turnover rates (irawan & suroso, 2018). turnover is a normal phenomenon in hospital institutions if the prevalence is still up to standard. according to gillies standard turnover is 5-10% per year is considered an ideal condition. however, the facts show that turnover that occurs in hospital organizations tends to increase above the standard limit (mardiana et al., 2014). several studies have reported the incidence of turnover in health services. according to the 2014 american hearth care association "aha" survey, their turnover was recorded about 44.3%, while in canada the average turnover of nurses in hospitals reached 19.9% per year (hayes et al., 2012). indonesia is one of the countries that have problems of turnover. based on several studies in indonesia, it was recorded that the turnover rate of health services was 23% of the total employee turnover and 50% of them were nurses (elizabeth, 2012). based on the background and conditions in one of the regional general hospitals in kotamobagu city that has been described above, the researchers are interested in conducting research with the title path analysis of turnover intention of nurses at regional general hospitals based on job satisfaction, work environment, and compensation factors. researchers use path analysis because they want to see which variables have a direct and indirect influence on the independent variable on the dependent variable. 2. methods this cross-sectional study has been done in july 2022 in regional general hospitals in kotamobagu city. this study selected 34 nurses using total sampling based on the data from the human resources division. the inclusion criteria of the sample were those independent nurses. the exclusion criteria were the nurses who are civil servants, contracted by the local government, and contracted by the national government. the validity and reliability test has been done in datoe binangkang hospital in bolaang mongondow regency. the result from ten nurses found the tools of this study were valid and reliable. each question was found valid based on the counted that counted r is higher than r in the table. the questionnaire is also reliable because the scores were in the range of high and very high reliability. 3 ghmj (global health management journal) 2023, vol. 6, no. 1 amir, et. al. the data collection followed the ethical consideration using the questionnaire. the data has been cleaned before analyzing. the data was examined using univariate, bivariate, and multivariate analysis. univariate analysis is this analysis is used to see the description of the frequency distribution of each variable, both the dependent variable and the independent variables. this analysis was conducted on the dependent variables related to the characteristics of respondents such as age, gender, education, length of service, job satisfaction, work environment, compensation, and turnover intention using a questionnaire. path analysis is an extension of the regression model, which is used to test the correlation matrix on the causal model. the model is presented with a single-directed arrow indicating cause and effect. the regression weights predicted by the model are compared with the correlation matrix from the observed data and then the goodness of fit is calculated. furthermore, the best model is chosen by the researcher for theory development. this study uses data analysis that is adapted to the research pattern and the variables studied. the model used in this study is a causal model and to test the proposed hypothesis in this study, we employed a multivariate statistical technique sem (structural equation modeling) which is operated through the amos program. this study has been approved from the universitas karya husada semarang with number 56/baak/s2kep/sa/vii/2022. additionally, the data collection has been approved by department of health, specifically regional general hospital of kotamobagu with number 445/1351/rsudkk/s.ket/vii/2022. 3. results respondent characteristics univariate analysis in this study explains the frequency distribution of nurse characteristics, job satisfaction, work environment, compensation, and turnover intention of nurses at regional general hospitals. table 1 shows that the majority of nurses at the regional general hospital involved in the study are 25-35 years old, namely 26 respondents (76.5%), the sex of the majority are women with 22 respondents (64.7%), the educational characteristics of the majority have vocational (d3) nursing education level is as many as 25 respondents (73.5%), while the majority of working years are 1-3 years, namely as many as 14 respondents (41.2%). table 1. the general characteristics of the respondents variables (n = 34) n % age < 25 years 25 – 35 years >35 years 3 26 5 8.8 76.5 14.7 sex male female 12 22 35.3 64.7 level of education vocational bachelor or professional 25 9 73.5 26.5 length of work 1-3 years 4-6 years >6 years 14 10 10 41.2 29.4 29.4 parameter distribution table 2 shows that the description of the level of job satisfaction of nurses at regional hospitals in 2022 is mostly quite satisfied at 67.6%. the description of the work environment is quite satisfactory, which is 44.1%. the nurse's work compensation is quite satisfactory, which is 50.0%. turnover intention of nurses working in general hospitals in 2022 was mostly not intentional, which was 58.8%. amir, et. al. ghmj (global health management journal) 2023, vol. 6, no. 1 4 table 2. job satisfaction, work environment, work compensation, and turnover intention of nurses at regional general hospitals variables n % work satisfaction not satisfied quite satisfied satisfied 2 23 9 5.9 67.6 26.5 workplace environment less enough good 12 15 7 35.3 44.1 20.6 compensation less enough good 12 17 5 35.3 50.0 14.7 turnover intention no yes 20 14 58.8 41.2 total 34 100,0 multivariate analysis the multivariate analysis in this study is the path analysis of nurses' turnover intention at the regional general hospital based on job satisfaction, work environment, and compensation factors. test the effect using amos spss 26.0. x1 = work environment, as an exogenous (independent) variable; x2 = work compensation, as an exogenous (independent) variable; x3 = job satisfaction, as an endogenous (dependent) variable; y1 = turnover intention, as an endogenous (dependent) variable. e1, e2 = error, which means the error rate/error margin of the data on research variables that affect turnover intention. px1x2 = correlational relationship between exogenous variables (work compensation with turnover intention); py1x1 = path coefficient from work environment to turnover intention. py1x2 = path coefficient from job satisfaction to turnover intention; py2x1 = path coefficient from work environment to turnover intention; py1x2 = path coefficient from work compensation to turnover intention; py1y1 = path coefficient from satisfaction to l turnover intention. figure 1. path analysis of nurse turnover intention (t1-t7) in regional general hospitals based on job satisfaction (kk1-kk7), work environment (lk1-lk9), and compensation factors (k1-k9) using amos 2022 5 ghmj (global health management journal) 2023, vol. 6, no. 1 amir, et. al. sem is a multivariate statistical technique that combines factor analysis and regression analysis (correlation), which aims to examine the relationships between variables that exist in a model, both between indicators and their constructs, or relationships between constructs. sem is a statistical analysis technique used to build and test statistical models in the form of causal models. sem analysis combines regression, factor, and path analysis so as to simultaneously calculate the relationship that occurs between latent variables, measure the loading value of latent variable indicators, and calculate path models from these latent variables. basically, sem is a multivariate technique that will show how to represent a series or series of causal relationships in a path diagram. from the result, we figured that each variable will affect each other, but it can be seen what variables have a direct effect and the variable as a mediator in this study. the variables that have a direct effect are job satisfaction and work compensation, while the work environment is a mediator in this study. we have noted that job compensation provides the largest direct positive influence on the turnover intentions (15.4%), and work environment will slightly contribute to negative turnover intention (0.07). the above multivariate analysis sem also exhibits that work environment (7,177) and work compensation (19,717) are the indirect and moderating influencer on nurse’s turnover in the subjected hospital, following with job satisfaction (4,189). further analysis found that indirect influence relationship between job satisfactions with the work environment (0.200) and job compensation (0.252). however, it seems that compensation received by the nurses will significantly create positive work environment (0.028). relationship between job satisfaction, work environment, and compensation to turnover intention table 3 shows that the relationship between job satisfaction, work environment, and compensation on the turnover intention of nurses at the regional general hospital, namely the relationship between job satisfaction and turnover intention, obtained an estimate value (0.289) which means that the effect of job satisfaction on turnover intention is 0.289 times or 28.9. % and is positive, which means that the better the nurse's job satisfaction, the less turnover intention will be. se (0.137) which means the standard error or error rate is 0.137 or 13.7%, while p-value: 0.011 which means the value < (0.05) which means the hypothesis ha is accepted, namely there is a relationship between job satisfaction and turnover intention of nurses at home regional general hospital. table 3. relationship between job satisfaction, work environment, and compensation with turnover intention of nurses at regional general hospitals the results of the path analysis statistical test of the relationship between the work environment and turnover intention show that the estimate value is (-0.007), which means that the influence of the work environment on turnover intention is -0.007 times or 0.07% and is negative, which means that the work environment has a negative effect on turnover. the worse the work environment, the higher the turnover intention will occur in the hospital. while se (0.118) which means the standard error or error rate is 0.118 or 11.8%, while the p-value: 0.935 which means the value > (0.05) which means that the ho hypothesis is accepted, namely there is no relationship between the work environment and the nurse's turnover intention. at the regional general hospital. the results of the path analysis statistical test of the relationship between compensation and turnover intentions show that the estimate value is (0.154), which means that the effect of y<---x1,2,3 estimate s.e. pvalue r square turnover intention <--job satisfaction 0.289 0.137 0.011 0.171 turnover intention <---compensation 0.154 0.069 0.026 turnover intention <---environment of workplace -0.007 0.118 0.953 amir, et. al. ghmj (global health management journal) 2023, vol. 6, no. 1 6 compensation on turnover intention is 0.154 times or 15.4% and is positive, meaning that the better the nurse's work compensation, the lower the turnover intention. the se value (0.069) which means the standard error or error rate is 0.069 or 0.69%, while the p-value: 0.026 which means the value <α (0.05) which means that the ha hypothesis is accepted, namely there is a relationship between work compensation and the turnover intention of nurses in regional public hospital. analysis of direct contributing factors and mediator factors on turnover intention table 4 shows the analysis of factors that directly contribute to and mediate factors to turnover intention in the regional general hospital of kotamobagu city. table 4. direct and mediator factors to turnover intention in regional general hospital. variables direct effect p-value indirect effect turnover intention satisfaction environmental compensation 0.000* 0.007* 0.003* 0.018* 0.000* 4. discussion the relationship between job satisfaction and turnover intention the results showed that there was a relationship between job satisfaction and turnover intention of nurses at the regional general hospital of kotamobagu city. job satisfaction is an employee's attitude towards work related to work situations, cooperation between employees, rewards received at work, and matters relating to physical and psychological factors (sutrisno et al., 2010). several studies described job satisfaction as a positive or negative attitude that individuals have towards their work. in addition, it stated job satisfaction as an attitude that workers have about their work (yuniasanti & setyawan, 2016). job satisfaction is a very satisfying feeling that can support nurses to able to have a positive attitude towards a job. nurses who are satisfied with a job will feel happy and comfortable doing the duty. therefore, job satisfaction requires special attention from the hospital management because high job satisfaction can also contribute to a decrease in a nurse's desire to be able to leave to be able to find another job (mobley, 1986). the normal turnover intention rate is 5-10% per year. turnover intention is usually one of the last options for a nurse if a staff experiences a work situation that no longer matches compared to the expectation (gillies, 1996). the results of research conducted at brawijaya women and children hospital jakarta that nurses who are dissatisfied with a job and can have a higher desire to resign or change jobs are more than nurses who can report being satisfied with a job which can be concluded that the variable of satisfaction with a job can be significantly related to turnover intention (satar & amran, 2013) . research conducted at the anna medika hospital found the result that there is a relationship between nurse job satisfaction and nurses' turnover intention (wahyuni, 2021). this means that there is a relationship between job satisfaction and turnover intentions (mardiana et al., 2014). the researcher assumes that the higher the job satisfaction, the lower the nurse's turnover intention and vice versa if the high turnover intention, the lower the nurse's job satisfaction. in other words, job satisfaction variables can play a role in the emergence of turnover intention. relationship between work environment and turnover intention the results showed that there was no relationship between the work environment and the turnover intention of nurses at the regional general hospital of kotamobagu city. the work environment is including temperature, humidity, ventilation, lighting, noise, cleanliness of the workplace, and whether which might affect the process of working. the work environment can be interpreted as the entire tooling faced, the surrounding environment where a worker is, and his work methods, as the influence of his work both as individuals and groups (afandi, 2018). meanwhile, according to several studies, it 7 ghmj (global health management journal) 2023, vol. 6, no. 1 amir, et. al. is said that the work environment is the entire work facilities and infrastructure that exist around employees who are doing work that can affect the implementation of work (suwondo & sutanto, 2015). the results showed that the work environment had a negative and significant effect on turnover intention. this shows that if the work environment accepted by employees is lower, employee turnover intention will increase (putra & utama, 2017). the results of this study are inversely proportional to other studies which revealed the significant relationship between the work environment and the turnover intention of nurses at rsu x. denpasar (d. ariani et al., 2020)). the results of this study are also inversely proportional to research where the results show that there is a positive effect of variable x2 (work environment) on variable y, nurses' desire to stop working (turnover intention). this means that the work environment (x2) partially has a significant influence on the nurse's desire to stop working (turnover intention) (y) (saputra & djastuti, 2021). the results of the study in rsu x denpasar found a significant relationship between the work environment and the turnover intention of nurses (g. a. k. ariani, 2021). relationship between compensation and turnover intention the results showed that there was a relationship between workers compensation and turnover intention of nurses at the regional general hospital of kotamobagu city. compensation is everything that employees receive as remuneration for their work that is balanced with employee expectations to meet the need for satisfaction with achievements that have been achieved and are in line with the company's strategic business objectives (fikry, 2021) . compensation can be physical or non-physical and must be calculated and given to employees according to the sacrifices they have made to the organization/company where they work (ariandi, 2018). compensation programs based on fair and proper principles and external consistency are competitive, so employee stability is more guaranteed because the number of job transfers is relatively small (hasibuan & hasibuan, 2016). as also stated by researchers that if the level of compensation is not competitive, surely many good employees will leave. to prevent employee turnover, wages must be kept competitive with other companies (handoko, 2016). the compensation provided by the hospital to the nurse will determine the nurse's desire to change jobs. if nurses have used their knowledge, skills, energy, and part of their time to work in hospitals, the other hand nurses also expect to receive certain compensation and rewards. based on the results of the study, there was a relationship between compensation and the desire to change nurses' jobs (suyono et al., 2018) . the results of the analysis found that compensation has a negative and significant effect on turnover intention (ariyanti & suartina, 2021). the results of the study showed a relationship between compensation and the desire to change nurses' jobs at hospital type c in batam city (suyono et al., 2018). the researcher assumes that compensation is one of the factors in the occurrence of turnover intention. this shows that the greater the compensation received, the intention to leave work will decrease because employees feel valued with their needs that can be met, on the other hand, if the compensation received is low, the turnover intention will be higher. so compensation will be very useful if it is given with the sacrifices that nurses give to the organization. analysis of direct contributing factors and mediator factors the results showed that job satisfaction, work environment, and nurse compensation were in the medium category, and the turnover intention of nurses at the regional general hospital was in the high category. the first and second hypotheses of this study state that job satisfaction and compensation have a direct effect on nurses' turnover intention. the results of the hypothesis test prove that job satisfaction and compensation affect nurses' turnover intention significantly, so the first and second hypotheses in this study are accepted. the path coefficient is positive, but the results are reversed, indicating that job satisfaction and compensation have a negative effect on nurses' turnover intention, which means that the higher the job satisfaction and compensation, the lower the nurse's turnover intention, and vice versa. the theory put forward by several researchers asserts that job satisfaction is amir, et. al. ghmj (global health management journal) 2023, vol. 6, no. 1 8 related to a person's attitude or feelings about the job itself, salary, and promotion opportunities (purba et al., 2019). job satisfaction is an emotional state in which employees view work as pleasant or unpleasant, reflecting their feelings towards their work (handoko, 2016). there are 5 dimensions of job satisfaction, namely: (1) satisfaction with the work itself (work itself) (2) satisfaction with salary (pay) (3) satisfaction with supervision (4) satisfaction with co-workers (5) satisfaction with promotions (robbins, 2003). the theory put forward by the researcher says that compensation is all the rewards received by employees for their work in the organization. compensation can be physical or non-physical and must be calculated and given to employees according to the sacrifices they have made to the organization where they work (ariandi, 2018). compensation is one of the important functions in human resource management. cases that occur in an employment relationship contain compensation issues and various related types, such as benefits, compensation increases, compensation structures, and compensation scales (halimah et al., 2016). the result of this study showed that job satisfaction had a significant negative effect on turnover intention, similar with the other previous work (deswarta & mardiansah, 2021; pegia & nuvriasari, 2021; putri & irfani, 2020; ridwan & jahrizal, 2020; surbakti, 2018; zakaria & astuty, 2017). 5. conclusion more than half of the respondents in this study did not have turnover intention. according to the general characteristic of respondents, the majority aged 25 to 35 year, female, and graduated from vocational study, have working for 1 to 3 years. there is a correlation between work satisfaction and compensation on turnover intention (direct factor), but there was no correlation between work environment on turnover intention (mediator). the government and stakeholders may ensure the worth between compensation and the responsibility of the workers, especially nurses. the human resources department in the hospital could arrange regular revaluation in terms of job satisfaction and compensation to prevent turnover among the workers. the next study might add other variables to specifically examine the factors of turnover intention. conflict of interest there is no conflict of interest. nothing to disclosure. references afandi, p. 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(2017). pengaruh kompensasi terhadap turnover intention dengan job embeddedness sebagai variabel intervening (studi pada karyawan di pt. primissima). jurnal manajemen bisnis, 8(1), 82–97. cite this article as: amir, e. e. s., winarto, e., sunarno, r. d., & hapsari, s. (2023). the correlation between job satisfaction, compensation, and work environment on nurse's turnover intention in kotamobagu regional general hospital using structural equation modeling path analysis. ghmj (global health management journal), 6(1), 01-10. https://doi.org/10.35898/ghmj-61925 https://doi.org/10.9744/jmk.17.2.145-154 https://doi.org/10.24854/jps.v4i1.515 https://doi.org/10.35898/ghmj-61925 global health initiatives to reduce malaria morbidity in school-aged children indonesian scholars’ alliance ghmj (global health management journal) 2020, vol. 4, no. 1 open access review andrew j macnab global health initiatives to reduce malaria morbidity in school-aged children 1stellenbosch ins tute for advanced study (stias), wallenberg research centre at stellenbosch university, stellenbosch, south africa. 2the department of pediatrics, the university of bri sh columbia, vancouver, bc, canada. *corresponding author’s email: ajmacnab@gmail.com abstract background: to review global ini a ves to reduce the burden of disease from malaria on school-aged children. the focus is on approaches with poten al to reduce mortality and morbidity, improve the health and ability of children to a end school, avoid malaria impac ng their poten al academic achievement, and minimize the risk of shortand long-term cogni ve impairment. methods: literature searches using defined terms related to malaria and educa on, and a scoping review of the key literature selected, to provide a narra ve summary of the challenges and poten al solu ons iden fied. results: there is robust evidence that school-aged children are par cularly vulnerable to malaria, and need special measures to protect them; calls are widespread for be er diagnos c approaches and program innova on because of current levels of malaria-related morbidity and mortality. school-based programs that educate children broadly on causa on, preven on and care required can improve access to mely diagnosis and treatment; however, currently na onal malaria control interven ons do not specifically target school-age children. the literature describes interven on strategies that include seasonal chemoprophylaxis, intermi ent protec ve treatment and an malarial therapy linked to mass drug administra on for neglected tropical diseases. recently, a community par cipatory interven on model based on who-endorsed diagnos c and treatment principles has taught teachers to screen all children sick at school using rapid point-of-care diagnos c tes ng and treat promptly with artemesinin combina on therapy; morbidity and absenteeism are significantly reduced. there is no consensus on the op mal interven on strategy; approaches will need to vary, but evidence of ‘what works and why’ exists to guide construc ve implementa on measures in each endemic region. conclusion: malaria exemplifies how health inequity nega vely impacts a child’s health and ability to benefit from educa on, yet simple and effec ve school-based approaches exist that posi vely impact morbidity, provide access to who-endorsed diagnosis and treatment, are applicable worldwide and can increase the capacity of children to learn. keywords: absenteeism; artemesinin combina on therapy; cogni ve impairment; intermi ent protec ve treatment; rapid diagnos c tes ng; seasonal malaria chemoprophylaxis; teachers received: 14 may 2020 reviewed: 14 june 2020 revised: 28 june 2020 accepted: 28 june 2020 doi: 10.35898/ghmj-41495 © yayasan aliansi cendekiawan indonesia thailand (indonesian scholars’ alliance). this is an open-access following crea ve commons license deed a ribu on-noncommercial-sharealike 4.0 interna onal (cc by-nc-sa 4.0) 1. introduc on globally, malaria kills more than 1 million people a year, and perhaps closer to 3 million when the role of malaria in deaths related to other disease is included. much of the mortality in endemic areas is concentrated among children under the age of five years; the number between 5 and 14 years (schoolaged children) who die from malaria is not known, but in many lowand middle-income countries (lmics) worldwide malaria is reported to be the main reason a school-aged child will die; in parallel, an important measure of the morbidity malaria causes is the fact that infection is cited as the principal reason why a child will be absent from school. 5 mailto:ajmacnab@gmail.com https://dx.doi.org/10.35898/ghmj-41495 ghmj (global health management journal) 2020, vol. 4, no. 1 macnab aj teachers recognize the negative impact of malaria on pupil’s health and the adverse effects of infection on their capacity to learn. the duration of malaria-related absence, frequency of absence due to repeated infection, residual malaise from sub-optimal treatment and temporary or permanent neurological complications of falciparum malaria are all known to compromise a child’s potential to learn, yet school-age children have attracted relatively little attention as a group in need of special measures to protect them against malaria. there are now widespread calls for innovation and implementation of programs to address malaria mortality and morbidity in school-age children. 2. method searches were undertaken of the published literature on malaria in children using the following search terms, singly, or in combination: malaria, children, school, school children, school-based, teachers, teacher-based, rapid diagnostic testing (rdt), artemisinin combination therapy (act), chemoprevention, africa, sub-saharan africa. search results were supplemented by papers identified from the reference lists published in these papers and material familiar to the author. review was limited to the english language and focused predominantly on africa and research published in the last 20 years, except where prior work had historic relevance. 3. background ”school-age children have attracted relatively little attention as a group in need of special measures to protect them against malaria.” (nankabirwa et al., 2014a) new and better diagnostic approaches are required to address malaria in children because of the current levels of morbidity and mortality (bell et al., 2016). schools present an obvious and logical opportunity to improve the access of school children to timely diagnosis and treatment, (temperley et al., 2008; macnab et al., 2016), however, currently national malaria control interventions do not specifically target school-age children despite increasing evidence that this age group bears the highest burden of infection (cohee et al., 2018). awareness of the impact of malaria among school-age children has stimulated investigation into interventions that can be delivered through schools, but currently there remains no consensus as to the optimal intervention strategy (drake et al., 2011). despite being preventable, detectable and curable, malaria remains one of the main causes of mortality due to infectious disease (world health organization, 2015). in school-aged children the burden of disease and prevalence of infection varies widely depending on the level of transmission, setting and season, but, 7 out of 10 in côte d’ivoire were found to be infected with plasmodium falciparum in a national, cross-sectional study (houngbedji et al., 2015); 14–64% in uganda are parasitemic at any one time (nankabirwa et al., 2014a), and in mali, malaria accounts for 36% of medical consultations in school children during peak transmission season (barger et al., 2009). there is broad agreement that school-age children represent an underappreciated reservoir of malaria infection, have less exposure to antimalarial interventions, and malaria control and elimination strategies need to expand to include this age group (walldorf et al., 2015). delay in the treatment of fever is a potent obstacle to the goal of achieving a reduction in malaria mortality (white, 2005). failure to obtain who recommended diagnosis and therapy leads to poor disease management, which in turn contributes to a cycle of poverty in affected communities (amexo et al., 2004; sachs and malaney, 2002). lack of access to early and accurate diagnosis is common; studies indicate that in sub-saharan africa <50% of sick, febrile children receive artemisinin combination therapy (act) within 24 hours (macnab et al., 2016; simba et al., 2010; tipke et al., 2009) barriers to care include those of (mutabingwa, 2005; rutebemberwa et al., 2009): 6 macnab aj ghmj (global health management journal) 2020, vol. 4, no. 1 • access (distance to a clinic and a lack of parental awareness of need) • cost (of prescribed medication, time away from livelihood, and transport) • uncertain availability of diagnostics and therapy at government clinics • inadequate numbers of skilled staff • variations in the quality of health care services and prescribing habits • preference for traditional practices or use of unreliable treatment sources, and • school-age children being brought less often for treatment compared to younger children in 2014 a structured review summarized the negative impact of malaria on pupil’s health and the adverse effects of infection on their ability to learn (nankabirwa et al., 2014a); school teachers recognize these problems as they see first-hand the impact on school-age children’s performance. they know infection robs children of the ability to attend school, that sub-optimal treatment leaves residual malaise which negatively impacts the capacity to be fully present in class, and repeated infection can permanently compromise a child’s academic potential due to neurological complications (fernando et al., 2010; holding and snow, 2001; kihara et al., 2006; jukes et al., 2006). the review emphasizes that school children need special measures to protect them against malaria, with more program implementation and innovative measures both being important. ongoing research and evaluation are also called for to build the evidence base of ’what works and why,’ and where such interventions are most effective. a factor relevant to school-based health promotion in most lmics, is that teachers generally send home children found to be sick at school (macnab et al., 2014b). this devolves key care decisions to parents, which is problematic in malaria endemic areas, as many families lack the knowledge and/or resources necessary to provide what a child with probable malaria requires. this situation often contributes to morbidity, as in many cases appropriate diagnosis and treatment do not occur, or at best are delayed (rutebemberwa et al., 2009). the world health organization (who) advocates early, accurate diagnosis of malaria and prompt, effective and affordable treatment within 24 hours of the onset of illness (world health organization, 2015). validated measures to do this exist, but in most lmics the health resources necessary are limited, and are especially scarce in rural and low resource communities. the fact that malaria symptoms are not specific is an additional factor, as a reliable diagnosis cannot be made based on history and examination alone. even using a who-derived diagnostic algorithm designed for community health workers (world health organization, 1992), trained teachers in ghana lacked the ability to match all presumptive malaria to the case definition (afenyadu et al., 2005). this difficulty with diagnosing malaria on clinical grounds, also contributes to morbidity and mortality. hence, simple, accurate and inexpensive diagnostic tools wider availability of effective therapy and health education are needed to reduce the impact of malaria on children. malaria education and health promotion initiatives centered on schools are an example of the type of innovative intervention called for by the who commission on social determinants of health to promote health behaviors and empower young people to take control of their lives (who commission on social determinants of health and world health organization, 2008). such ‘task shifting’ to school-based programs can also increase provision of other essential health services (agyepong et al., 2017). robust, successful, valuable and cost-effective teacher-administered health programs in schools in lmics include provision of intermittent anti-malarial therapy in kenya (temperley et al., 2008; okello et al., 2012) prophylactic chloroquine in sri lanka (fernando et al., 2006), and nationwide anti-helminth treatment in uganda, and in ghana (brooker et al., 2008; opoku et al., 2016). cost-benefit analysis shows that health program delivery costs can be reduced by having teachers implement such programs (drake et al., 2011; laxminarayan et al., 2006). 7 ghmj (global health management journal) 2020, vol. 4, no. 1 macnab aj 4. burden of disease in school-age children while the overall incidence and number of deaths from malaria are decreasing worldwide the disease is still a major cause of mortality and morbidity among children (world health organization, 2015). mortality: fifty percent of deaths in school-aged children (defined as children aged between 5 and 14 years) are estimated to be due to malaria in africa (nankabirwa et al., 2014a). cerebral malaria, (defined as: severe p. falciparum malaria presenting with neurological symptoms, including coma (glasgow coma scale <11, or a blantyre coma scale <3), or with coma that lasts >30 minutes after a seizure), affects more than half a million children per year in africa, and kills between 10-40% of those infected (holding and snow, 2001). poor health, poverty, lack of knowledge at a community level and limited access to care are contributory factors that increase a child’s risk (houngbedji et al., 2015; mutabingwa, 2005). morbidity: studies in africa and thailand indicate that malaria causes 5-8% of all school absenteeism. reports from kenya indicate primary school students miss 11% of school days per year because of malaria, and secondary students can miss 4.3% of school days (leighton and foster, 1993). such data equate with malaria being the cause of approximately 50% of all preventable absenteeism (fernando et al., 2003b). hence, reducing morbidity offers real potential for school children to gain increased educational benefits just from improved attendance. however, the adverse effects on schooling clearly go far beyond compromised attendance. even an attack of uncomplicated malaria can cause significant short-term impairment of cognitive performance; the impairment a child experiences often persists for around two weeks; and, adverse effects appear to be cumulative with repeated attacks (kihara et al., 2006). in addition, where the principal infecting agent is p. falciparum, infection can be associated with permanent loss of cognitive and fine motor function from complications, especially where diagnosis is delayed and/or treatment is sub-optimal (boivin et al., 2007; fernando et al., 2010; birbeck et al., 2010; thuilliez et al., 2010). in the brazilian amazon (where infection is predominantly with p. vivax) multivariate analysis indicates that presenting with at least one episode of malaria independently predicts a poor performance at school (vitor-silva et al., 2009). in asian studies in low transmission areas, most indices of performance tested at school entry in a cross-sectional study were poorer as the number of malaria infections experienced by the child increased (fernando et al., 2003a); school performance of 6-14 year old children was related to the number of previous episodes of malaria; acute uncomplicated attacks caused short term learning difficulty for a week or more, and the effects were compounded by subsequent attacks. thus, the combined effects of absence, sub-optimal convalescent health and long-term neurological compromise can adversely affect performance in class and pass rates, lead to the need for a child to repeat grades, and even cause children to drop out of school altogether. the exact mechanisms causing long-term detriment to cognitive development and learning ability are debated. there is a clear relationship between infection intensity and the magnitude of the adverse cognitive effect (i.e. the higher the parasitemia, the higher the impact on cognitive score). thuilliez et al. (2010) provide an excellent schematic that illustrates the probable effects and pathways depending on falciparum and vivax malaria. those children who survive ’cerebral’ malaria frequently show clear evidence of neurological sequelae, including impaired ability to carry out executive functions (e.g. planning, initiating and executing executive tasks), and behavioral disorders that compromise their ability to engage fully in class. kenyan school children hospitalized for cerebral malaria were 4.5 times more likely to have mild-tosevere learning difficulties 3-4 years later, even though half of them had no neurological problems at the time of admission (holding and snow, 2001). the risk of impaired intellectual function is increased where seizures accompany clinical malaria. thus, prolonged, severe and repeated illness can reduce both the opportunity and the ability of a school-age child to learn. consequently, there is great potential worldwide for health and educational benefits to be accrued where a reduction in child morbidity due to malaria can be achieved. 8 macnab aj ghmj (global health management journal) 2020, vol. 4, no. 1 5. school-based interven on 5.1 health educa on who has always placed community participation at the centre of its ’health for all’ strategies (lasker and weiss, 2003). it is often teachers who identify health issues that warrant attention, and seek to initiate education or skills teaching in school to address them, and teachers have collaborated in programs addressing a range of health issues. this evidence of cooperation and long-term commitment by teachers is important in the necessary dialogue about whether teachers will be motivated enough to invest the time required to initiate and then sustain any school-based intervention. globally more than 1 billion children have the potential to benefit from school-based health delivery (world health organization, 2013b; macnab et al., 2014a). the who ’health promoting school’ (hps) model is an innovative approach to health promotion which employs multi-disciplinary strategies to engage a school community; children readily assimilate ’knowledge’ and ’skills;’ and who’s overarching objective is to generate life-long learning that positively influences the social determinants of health (viner et al., 2012; tang et al., 2009). who now endorses school programs as a way to address specific health challenges worldwide (airhihenbuwa et al., 2014). in my opinion, inclusion of education on malaria in all schools in endemic areas should be the norm. educational and protective strategies can be delivered in parallel and are potentially synergistic. schools can play a vital role in ensuring that pupils understand key facts about malaria, transmission, prevention, diagnosis and treatment. i agree with other authors that such knowledge must be regarded as essential, and that there are many simple, effective and inexpensive ways to give children this knowledge through additions to the curriculum. however, for these messages to have impact, the facts shared and how they are taught must have ’resonance’ and ’relevance’ for the learner if there is to be any chance that what is learned will lead to a change in behavior. the incentive to educate effectively is research showing that adolescents tend to retain knowledge that they perceive to be personally and socially relevant; that effective learning can translate into positive behaviors, and many of these persist into adult life (viner et al., 2012). motivated teachers seek out novel approaches to engage their pupils; for example, implementing a clean-up program around the school where pupils collect discarded plastic bottles, bags and bottle caps, provides evidence-based learning when pupils understand these items offer a breeding habitat for mosquito larvae, and a way to encourage effective prevention practices (de silva and marshall, 2012). worldwide it is still commonplace to find children lack even the most basic knowledge about malaria. in a recent survey in ugandan primary schools only 1 in 5 children knew what caused malaria or if it can be prevented, what signs and symptoms suggest infection, and what can be done to treat an infection (macnab et al., 2016). evidence that the broader community also lacks essential knowledge comes from data showing how small a proportion of sick, febrile children with presumptive malaria are taken for appropriate care. simba at al. identified that < half (44.8%) were taken to government facilities and only 37.6% had prompt access to act (tipke et al., 2009). my experience is similar; only 1 in 4 children (26%) sent home from schools with febrile illness compatible with malaria received management that met who criteria; the majority (42%) were only given an anti-pyretic, and care of the remainder included local herbal remedies (19%), being taken to church (8%), or visiting a traditional healer (6%). there is also growing evidence that where children are taught about health effectively, they can act as agents for change in both the school and their local community (simovska and carlsson, 2012); knowledge and skills learned from school-based health education that engages children ”ripple” out to involve siblings and parents (macnab, 2020). such willingness to share learned concepts and practices indicates acquisition of higher levels of health literacy (st leger, 2001). a ghanaian study evaluated the impact of malaria related participatory health education activities designed and led by teachers. comparing communities with and without the school-based intervention: knowledge on malaria causation was significantly more accurate among pupils in the participating schools and adults in 9 ghmj (global health management journal) 2020, vol. 4, no. 1 macnab aj their communities; the prevalence of parasitemia in pupils decreased from 31% to 10%, and the number of adults who had treated a bed net with insecticide in the past six months doubled (ayi et al., 2010). similar findings come from lao pdr, where school-based education improved knowledge, attitudes, and practices towards malaria control in the community (nonaka et al., 2008). in keeping with other authors, in my opinion the following are key components where interventions to reduce morbidly from malaria among school children are to be offered: 1. education: aim for all children to have ’health literacy’ about malaria. include key facts in the curriculum of all schools in endemic areas about the cause, prevention and clinical features of malaria, and how and why diagnosis and prompt treatment are necessary. 2. prevention: promote the use of insecticide treated nets, with the aim that all school-age children in malarial areas sleep under one. children should understand vector control and contribute to local measures to clean-up garbage providing habitat. 3. accurate diagnosis and prompt treatment: advocate for the use of who approved methods, for example rdt and act. facilitate effective intervention; in rural areas or where access to clinics and/or alternative points of care providing such services are limited ’task shifting’ is valid, by training teachers to provide rdt/adt as a school-based health service. 4. policy: establish local and national programs, inter-sectorial collaboration and leadership. these are needed to highlight current epidemiological findings and research data on malaria in schoolage children, and give communities specific recommendations and direction on how to address the problems faced. 5.2 prophylaxis: regular administra on of preven ve drugs chemoprophylaxis involves the administration of antimalarial drugs to those at risk of infection with the aim of maintaining protective levels within the blood stream (temperley et al., 2008). prophylaxis is generally not recommended for children in malaria endemic areas for multiple reasons; these include problems with adherence to prescribed regimens, compliance due to cost, and the significant risk of emergence, or increased risk of drug resistance. over time, side-effects also preclude the use of chemoprophylactic drugs in children, particularly chloroquine. 5.3 intermi ent protec ve treatment (ipt) ipt involves the periodic administration of a full therapeutic dose of an antimalarial drug or combination of drugs at predefined intervals to those at high risk of malaria, regardless of their infection status (white, 2005; greenwood, 2006). ipt is one of a number of possible malaria control strategies which could be delivered through schools; the study reported by fernando et al. (2006) in sri lanka is an example of a comprehensive school-based intervention. in a randomized double-blind placebo-controlled trial weekly chloroquine or placebo was given to school children (6-12 years) for 9 months. in addition to a reduction in the incidence of malaria in the treated group, this study also documented a significant difference in absenteeism between those receiving chloroquine versus placebo, and a marked improvement in school performance. for children, ipt is now considered a preferable alternative to chemoprophylaxis. trials have involved 2 main approaches: • seasonal malaria chemoprevention (smc), and • intermittent parasite clearance (ipc). smc is a control strategy recommended by who that targets children living in areas of seasonal malaria transmission. smc is recommended for children under five years of age in countries where >60% of the burden of malaria occurs in the months of the rainy season (which coincide with peak malaria transmission (?); an example is use of a single curative dose of sulfadoxine-pyrimethamine (sp) administered with a three-day course of amodiaquine (aq). a number of alternative approaches are reported (chandramohan et al., 2007; cairns et al., 2012; thera et al., 2018); evidence from several african countries has also shown that smc is highly effective, eradicating most severe malaria, 10 macnab aj ghmj (global health management journal) 2020, vol. 4, no. 1 and leading to strong reduction in p. falciparum prevalence, the incidence of clinical uncomplicated malaria, and malaria anemia. however, concerns with smc, include that it does not provide complete protection and is demanding to deliver for families and healthcare providers. trials data on ipt generally indicate ipt regimens provide significant benefit for school-age children, providing reduced rates of infection, improved health, a decrease in absence from school, enhanced academic achievement, and improved cognitive ability (dicko et al., 2008; clarke et al., 2008; nankabirwa et al., 2014b). the consensus is that ipt is a safe, simple strategy offering remarkable protection in schoolchildren in high-malarial-transmission settings, that also appears to have a substantial protective effect against all-cause mortality. clarke et al. (2017) concluded that effective malaria ipt interventions could be a valuable addition to school health programs. two systematic reviews and meta-analysis on efficacy and safety summarize the pros and cons of specific drug regimens (wilson et al., 2011; matangila et al., 2015). however, in cluster randomized trial, halliday et al. failed to show benefit from an intermittent screening and treatment program (ist) (halliday et al., 2014). in a review examining why, von seidlein (2014) emphasized the results cannot be attributed to methodological uncertainty as the trial was conducted in a large sample of schools, to the highest procedural standards, with excellent adherence and follow-up. instead, the author concluded that children found to be parasitemic most likely did benefit from early treatment; however, this was not an outcome the investigators measured. 5.4 mass drug administra on (mda) mda is a who endorsed strategy to control neglected tropical diseases (ntds). the ntds are a group of 13 major disabling conditions that are among the most common chronic infections in the world’s poorest people; 7 of these are now targeted using mda ascariasis, trichuriasis, hookworm infection, schistosomiasis, lymphatic filariasis, trachoma, and onchocerciasis (hotez et al., 2007). a key component of current ntd control policy is at least annual preventive chemotherapy distributed through school-based mda initiatives (world health organization, 2013a); hence, mda offers the opportunity to deliver school-based malaria strategies conjointly. a ghanaian intervention combining ipt of malaria with mda to control intestinal soil-transmitted helminths (sth) is a positive example; measures of anemia, sustained attention, and recall in the schoolchildren improved (opoku et al., 2016). the addition of antimalarials to routine annual mda programs has been shown in malawi to be well-tolerated, safe for teachers to administer, beneficial and well-received by parents (cohee et al., 2018). hence, this is an appealing model, and adding malaria treatment to already established platforms for ntd control may also increase the cost-effectiveness of both interventions, leading to increased sustainability. 5.5 rapid diagnos c tes ng (rdt) and artemesinin combina on therapy (act) rdt kits provide point-of care diagnosis from a drop of blood; the major advantage is that this makes immediate treatment feasible. rdts are especially useful where heath facilities are scarce and/or operate using staff with minimal skill levels. overall, research confirms that rdts represent a cheap diagnostic approach in school malariometric surveys, and can be used to reliably estimate infection in low and high prevalence categories (world health organization, 2015). the sensitivity and specificity of rdts are good enough for them to replace conventional testing for malaria, and are more cost effective than diagnostic microscopy (wongsrichanalai et al., 2007; world health organization and others, 2011; abba et al., 2011). however, in the context of employing school-based diagnosis, minimizing mistakes is crucial; it has been shown that job aids (step-by-step instructions) that supplement manufacturer’s instructions can improve performance (rennie et al., 2007). the positive impact of rdts on malaria management has been widely demonstrated, and effective roll-out and use is achievable on a national scale through well planned implementation (thiam et al., 2011). proof of the relevance for scale up of use by appropriately trained teachers in schools includes: 11 ghmj (global health management journal) 2020, vol. 4, no. 1 macnab aj 1) kits can be stocked and used correctly outside formal health facilities, (kyabayinze et al., 2010) and, 2) basic training programs enable teachers and other individuals without a formal health care background to use rdt reliably and effectively (counihan et al., 2012; witek-mcmanus et al., 2015). act is the first-line treatment for p. falciparum malaria recommended by who for use worldwide since 2001 in all countries with endemic disease (group et al., 2004; benjamin et al., 2012) benefits of genuine acts include high efficiency, fast action, few adverse effects, low cost and the potential to lower the rate at which resistance emerges and spreads. but care must be taken in lmics over the choice of the preparation used, as sub-standard and counterfeit products with little or no efficacy are unfortunately widespread which pose severe threats to human health. estimates in 2013 indicated that > 100,000 deaths in sub-saharan africa in children < 5 years of age were associated with poor quality antimalarials. in addition to risking patient health because of limited or absent efficacy, falsified medicines also contribute significantly to the risk of drug resistance developing; for example, the efficacy of act has declined on the thai–cambodian border, a site of emerging antimalarial-drug resistance historically (dondorp et al., 2009). since the efficacy of acts is high, more could be achieved through increased availability; the major challenge is finding effective ways to deliver these drugs to those who need them most (whitty et al., 2008). exploratory avenues trialed include: a community case management approach, where a variety of trained providers deliver act (akweongo et al., 2011), deployment through trained agents in drug stores, pharmacies and private medical clinics, and via teachers in school programs (mbonye et al., 2015; mphwatiwa et al., 2017). 6. developing a model for teacher-driven school-based care ”if teachers could be trained to promptly detect and adequately treat uncomplicated malaria and promptly refer severe forms of the disease, improved access to this critical service would be achieved. for example, school absenteeism and man�hours lost to the disease would be reduced, especially in these rural communities.” (afenyadu et al., 2005) these words, written in a 2005 review on how to improve access to early treatment, introduced the concept that teachers should be trained to intervene, and were followed by calls for innovative solutions to the health burden of malaria in school-children from who, (agyepong et al., 2017) and other experts. the authors also identified that decentralization to the district level, and collaboration between health and education sectors, were required in order to improve the health status of school children. in an early exploratory trial, 12 ghanaian schools trained teachers to diagnose and treat uncomplicated malaria using an adaptation of a who diagnostic algorithm and recognize and refer severe forms of the disease for appropriate treatment. the authors concluded that primary school teachers in rural communities are willing partners in bringing early case detection and adequate management closer to the people (afenyadu et al., 2005). findings were similar in a contemporaneous study in tanzania where the clinical diagnostic algorithm included measurement of body temperature, although training in diagnosis and treatment only involved head teachers and selected ’health’ teachers (magnussen et al., 2001). in malawi, teachers were taught to use pupil-treatment kits containing drugs dispensed according to national guidelines. the authors concluded school-based interventions could play a part in mitigating malaria based on comparison of overall and malaria-specific mortality rates (pasha et al., 2003). in a second malawian study significant reductions in general absenteeism and grade repetition by students were noted (simwaka et al., 2009). the first model for teacher-administered rdt/act was developed as a community outreach health education project by a local ngo after teachers had identified the unacceptable health bur12 macnab aj ghmj (global health management journal) 2020, vol. 4, no. 1 den malaria was creating among their pupils (macnab et al., 2016; macnab, 2020); the decision to introduce school-based rdt/act was made collaboratively during community-based dialogue. macnab reported evaluation of this 2-year trial. four rural schools in uganda were involved. all teachers were trained broadly on malaria causation, prevention and treatment; two volunteer teachers in each school were specifically trained to collect the required data, conduct rdt and administer act in children falling sick at school (macnab et al., 2016; macnab, 2020). the effect on absenteeism was evaluated as a surrogate for morbidity. a baseline ’pre-intervention’ year’s data were compared to a subsequent treatment year when all sick children had a teacher-administered rdt and prompt act if they tested positive. a single dose act preparation was used to ensure a full course of treatment was completed. pre-intervention 953/1764 pupils were sent home due to presumed infectious illness, parental management only approached who standards for malaria diagnosis and treatment in 1:4 children, and the mean duration of absence from school was 6.5 school days. during school-based teacher-administered rdt/act 1066/1774 pupils were identified as sick, 765/1066 were rdt positive and received act, and duration of absence fell to 0.6 school days. after being promptly treated many children felt well enough to ask to return to class within hours, and consequently had no days when they were absent from school. overall, absence from school was reduced by 60.8% by this intervention. if the same percentage of children sent home in the ’pre-intervention’ year had malaria as were diagnosed using rdts in the ’treatment’ year this would equate to 1358 cases in 1775 children over the 2 years a malaria incidence rate of 79% across the 4 schools. no children died from malaria during the intervention year. delivery was readily implemented subsequently mphwatiwa et al. (2017) reported on a similar approach in malawi. an impressive element was that this trial was established following intersectoral collaboration between the ministry of health and ministry of education science and technology. findings included: • positive outcomes: trained teachers were trusted providers of malaria testing and treatment; access to treatment by children increased; absenteeism decreased. • potential barriers: increased teacher workloads and need for supervision from health workers. • concerns: lack of incentives and concerns for sustainability of drug supply. both macnab and mphwatiwa concluded that training teachers to ”test and treat” was well received, supported national health and education policies and was seen to be a worthwhile intervention. importantly, sustainability is demonstrated by ongoing data from uganda; for 3 years post intervention the target schools have independently continued rdt/act and the significant reduction in malaria morbidity has been sustained, and there is also robust evidence of greater knowledge about many aspects of malaria among the school-children and in the broader community (macnab, 2020). 6.1 training a key question is can teachers be trained to provide appropriate diagnostic and treatment services for school children in the context of malaria? importantly, trials show that teachers can be trained to correctly perform safe blood collection, accurate interpretation of rdt, correct dispensing of act, and sustain this competency (witek-mcmanus et al., 2015; macnab et al., 2016). evaluative literature describes how to provide effective training and how to minimize common errors; comprehensive instructions on rdt/act are essential; periodic performance appraisals to monitor user rdt/act behavior should be basic component of implementation; common challenges described were how to dispose of medical waste and refer complicated patients to public facilities. 6.2 cost the cost and cost-benefit of rdt/act are relevant to their deployment. in 2008, studies comparing presumptive treatment and rdt use in rural health facilities in sub-saharan africa deemed the intervention cost-effective (shillcutt et al., 2008). in the same year, cost of teacher-delivered ipt in kenya was estimated to be us$ 1.88 per child treated per year. the largest components were drug 13 ghmj (global health management journal) 2020, vol. 4, no. 1 macnab aj and teacher training costs. cost benefit analysis equated each anemia case averted to us$ 29.84 and each p. falciparum parasitemia case averted to us$ 5.36 (temperley et al., 2008). in 2009 benefits far outweighed costs where teachers were trained to identify and treat children with malaria in malawi; cost benefit accrued from significant reductions in both general absenteeism and grade repetition by students (simwaka et al., 2009). in 2011 the estimated cost of school-based ist from kenya was us$ 6.61 per child screened. key components were: rdt kits 22%, salaries 36%, and 47% redeployment of resources including (health worker time and use of hospital vehicles), but costs would likely reduce by 40% with changes in delivery (alternative rdts and removal of supervised treatment) (drake et al., 2011). in the 2016 ugandan trials, cost for rdt kits and act were us$ 0.50 and us$ 2.20 respectively; for every 3 sick/febrile children tested 2 were rdt positive (macnab, 2013). cost savings were made subsequently when the single dose act formulation used to eliminate any partial treatment bias was replaced with a conventional 3-day 6 dose preparation costing us$ 1.0. training and supervision costs were not included as the program was delivered as part of aid provided by a medical charity. a key element of the affordability, cost-effectiveness and long-term sustainability of school-based treatment will be drug choice. drugs best suited to mass treatment programs should be inexpensive, easy to administer (preferably as a single dose), and well-tolerated with minimal side-effects; for ipt, a long half-life is also advantageous. a global act subsidy would significantly increase usage of acts and reduce retail price; in rural tanzania, a 90% subsidy increased the proportion of consumers purchasing acts from 1% to 44.2% one year later, and purchasing for children rose considerably (sabot et al., 2009). importantly, effective program rollout offers potential overall savings; in senegal a major reduction in anti-malarial drug consumption occurred after nation-wide introduction of rdt, and considerable cost-savings were achieved through centralized act procurement (thiam et al., 2011); half of global demand for antimalarials has been estimated to be due to overuse in patients without malaria (cohen et al., 2012). substantial long-term cost-benefit will also accrue from improving the health of schoolaged children in ways that aid cognitive development and promote educational achievement; future research is needed for this to be established. 7. future direc ons ”in africa, there is increasing evidence of the dramatic reductions in malaria mortality and morbidity in early childhood due to recent up-scaling of malaria control efforts.” (temperley et al., 2008) in this report of epidemiologic change, the authors provide evidence from many useful trials of ’what works and why’ that can be used to guide future directions. increased recognition of the consequences of malaria has prompted growing interest and calls for innovative concepts in its control in children who attend school (bundy et al., 2000; jukes et al., 2006). the detrimental effects on hemoglobin levels (koukounari et al., 2008), and then on learning and educational achievement (lalloo et al., 2006), led to models that provide school-children with access to accurate diagnosis and treatment in endemic areas, reduce morbidity, and increase the capacity of children to benefit from their education. the argument for universal, parasite-based diagnosis is clear. a broad selection of literature now describes the rationale, therapeutic options, design, delivery, training, effectiveness, cost, challenges and future research priorities for interventions applicable to school-based delivery. what school-based malaria testing and treatment is undertaken in future will depend on priorities set nationally, which in turn requires vision beyond the conventional political time frame, but it is now clear that big benefits are there to be achieved. while funding agencies tend to call for bold, novel and disruptive thinking, there are strong grounds to argue that substantive investment in proven schoolbased models is needed in parallel. the efforts of major agencies made rdt and act more affordable 14 macnab aj ghmj (global health management journal) 2020, vol. 4, no. 1 and hence more available; the benefits of now making teacher-driven diagnosis and treatment broadly available in endemic areas would be considerable. arguably there is still no consensus as to the optimal intervention approach, and more evidence on the costs and cost-effectiveness for school-based malaria control are still needed. but individual region-specific programs can be tailored from the evidence now available to provide viable interventions for at risk populations. many malaria-endemic countries are considering scaling up rdt use in a variety of locations; it is not overstated to say that when well used, rdts can transform fever management, reform understanding of malaria transmission, and have even made malaria elimination look achievable (thiam et al., 2011). there is need for intersectoral collaboration at a national level, and only when this is realized is it likely that the effective upscaling of rdt/act availability will be achieved (akweongo et al., 2011); legislative changes and investment in support programs and infrastructure will be required in parallel (visser et al., 2017). use of rdt/act in school-based programs warrants special consideration, because, in addition to being simple to implement and low cost, this model uses who-endorsed testing and treatment methods, has broad relevance and is applicable to low-resource settings worldwide where the schoolage population is at risk. innovative ways are called for to make who endorsed entities more available to those in need, globally schools offer more than 1 billion children the potential to benefit from schoolbased healthcare delivery, and teachers can be effective agents for change, through innovative schoolbased models that engage and train them to deliver health education and elements of care endorsed by who. such models already meet the who commission on social determinants of health call to adopt a ’community empowerment approach’, use ’non-traditional outlets’ and ’improved tools’ to address health challenges faced by young people, and seek longer and healthier lives for africans (?). future models that use novel ways to engage and train teachers to deliver health education and care, will also meet recommendations from the lancet commission on the future of health in sub-saharan africa to extend population access to services, by using ‘people-centered approaches’ and ‘innovative education and training of personnel that correspond to local needs.’ (agyepong et al., 2017) acknowledgments the stellenbosch institute for advanced study at the wallenberg research centre at stellenbosch university and the hillman medical education fund (hmef), canada made the research and literature searches included here possible; 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