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. 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. 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 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 themsm (menwho have sexwithmen) 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 newaids cases caused bymsm 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 canprovide the greatest protection againsthiv&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 sexwithmen is amajor risk for lgv infection (lymphogranuloma venereum), of which 89% of peoplewith lgv arehivpositive [8]. the use of condoms can preventhiv 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 theworld 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 sexwith aman 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 researchwas conducted by analysing interviewdata 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 andmarital 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, andmultivariate 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 respondentswere aged 15-45 yearswith 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 knowledgewere asmuch 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 condomuse 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 liawinahyu et. al. [14]whomentioned that the access tohiv&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 condomuse 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 thosewith 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. unitednations program onhiv /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 terhadaphiv 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 whohave sex withmen 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 microsoft word 3. accepted original, siska evi martina, 9-12.docx cite this article as martina se, bratajaya cna, ernawati. dengue hemorrhagic fever: knowledge, attitude, and practice in palmeriam, jakarta, indonesia. global health management journal. 2018; 2(1): 9-12. global health management journal www.publications.inschool.id published by original research article issn 2580-9296 (online) dengue hemorrhagic fever: knowledge, attitude, and practice in palmeriam, jakarta, indonesia siska evi martina *, cicilia nony ayu bratajaya, ernawati sint carolus school of health sciences, indonesia. *corresponding author. email: evi_sastro@yahoo.com article info abstract article history: received 11 december 2017 reviewed 05 january 2018 received in revised form 14 february 2018 accepted 28 february 2018 background: dengue hemorrhagic fever (dhf) is the most rapidly spreading mosquito-borne viral disease in the world. it is an emerging disease, episodic and occurring annually. aims: this study was to examine the knowledge, attitude, and practice of community in palmeriam, jakarta regarding dengue hemorrhagic fever. methods: a community-based cross-sectional study was designed in this study between june to july 2016. purposive sampling was done to collect data from 148 respondents. results: this study found that average age was 47 years old, 75% were women, and 46.6% finished secondary high school. in another hand, 23.6% respondents had good knowledge, and 49.3% had a neutral attitude for preventing dengue hemorrhagic fever. the study found that 68.2% respondents had a mid-level of practice prevention dengue hemorrhagic fever and it can be improved. this study indicated that the community was quite familiar with dengue hemorrhagic fever, but there was confusion about water storage and environment effect. conclusion: health promotion program and community participation should improve dengue awareness. continuous campaign for enhancing the knowledge and attitude would result in better practice for dhf prevention. keywords: knowledge attitude practice dengue hemorrhagic fever © 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 dengue hemorrhagic fever (dhf) is recognized as emerging infectious diseases. dengue is a viral infection carried by the typical household mosquito (aedes aegypti) and becomes a health problem in tropical countries. in the world, there were about 50 million people infected dhf with 2.5% death reported annually [1]. world health organization (who) has declared that dhf to be endemic in south east asia [1]. tropical areas such as indonesia provide a climate that is conducive to the breeding of dengue-transmitting mosquitoes. since the first case of dhf was reported in 1968 to 2009, who declares indonesia as a country with the highest dhf cases in south east asia [1]. the geographical distribution of dhf has included urban and rural areas, making indonesia as the most rapidly expanding dengue viral disease [2]. jakarta is the capital city of indonesia with the highest incidence rate of dhf [3]. public health office of jakarta reported the incidence rates of dhf were 12,254 cases with 7 mortality in 2012 [3]. the highest incidence was found in palmeriam with 3,801 cases and 134 per 100,000 population, with a 0.08 mortality rate per 100,000 population. then palmeriam is one of the districts in east jakarta with doubling increased incidence rates from 2010 to 2014 [3]. the data showed that palmeriam is one of global health management journal, 2018, vol. 2, no. 1 10 the endemic areas that need attention for dhf prevention. the government of jakarta concerns for decreasing dhf cases by some programs such as chemical insecticidal control. however, the who and centers for disease control and prevention recommend limited reliance on insecticidal control and emphasis on community educational programs that emphasize communities responsibility in reducing vector breeding sites [4,5]. this recommendation is supported by prior research which found that community education was more effective in lowering dengue vector breeding sites than chemicals alone [6]. therefore, the communities should know prevention program of dhf. then, the effective prevention transmission of the dhf requires support, cooperation and participation by the community. the concept of knowledge, attitude, and practice, or is known as kap is a useful conceptual framework for assessing the level of awareness and prevention practices on dengue hemorrhagic fever (dhf) problems in the endemic community [7]. therefore, kap concept was applied to guide this study. the idea explained how knowledge, attitude, and practice deliver benefits to improve participation of communities for doing dhf prevention. this kap study was designed to identify human behavior related to what people know (knowledge), what people feel (attitude), and what people do (practice). therefore, it is essential to know the level of knowledge, attitude, and practice (kap) of the community concerning the dhf. there is limited kap study on dengue in communities in the urban area. it is important to conduct a kap study concerning dengue in urban communities because almost a quarter of dengue cases occur in the urban setting. therefore, through this study, we will define the level of knowledge, attitude, and practice concerning dhf among communities living at palmeriam district in jakarta, one of endemic areas in indonesia. the results will identify the real community situation of dhf prevention and the success of government program. methods the cross-sectional study was conducted between june to july 2016 in district 01 palmeriam, jakarta, indonesia. there were one hundred forty-eight (148) participants where the sample size was determined using slovin’s formula. the purposive sampling was employed within inclusion criteria including; aged 18 to 55 years old, living in district 01 palmeriam, jakarta, able to read, write, and communicate in indonesian, and willing to participate in this study. questionnaires employed in this study were composed of demographic information questionnaire and dhf knowledge, attitude, and practice (kap) questionnaire. the dhf kap was adapted from previous study [8]. the dhf kap questionnaire consisted of 39 items dividing into 3 variables; 1) an interval scale of knowledge (14 items), 2) a likert attitude scale (12 items), and 3) an interval scale to measure practice of prevention dhf (13 items). the internal consistency obtained cronbach’s alpha was knowledge = .79, attitude= .79, and practice of prevention dhf= .80. the study was approved by the head of research center in sint carolus school of health sciences and data was collected after obtaining permission and written consent from the head of public health care and head of the district. the researchers also provided participants information sheets. the participants signed an informed consent before getting questionnaires. participants took approximately 30 to 45 minutes to complete all questions. results all of the participants (148 participants) completed the questionnaire. table 1 describes the sociodemographics of the participants. the majority age of participants was ranged 21 to 44 years old (43.9%) where 75% participants were women, and 46.2% participants had a middle level of education and only 16.2% participants had a high level of education. table 1. distributions and frequencies of sociodemographic of the participants among (n=148) characteristics n % age adolescents (13-20 years) adult (21-44 years) pra-elderly (45-59 years) elderly (≥ 60 years) 4 65 50 29 2.7 43.9 33.8 19.6 gender women men 111 37 75 25 education level elementary school secondary high school university 55 69 24 37.2 46.6 16.2 11 global health management journal, 2018, vol. 2, no. 1 the knowledge in this study divided to 3 levels; low level, moderate level, and high level. as shown in table 2, we noted that most participants had moderate level of knowledge about dhf (45.9%) followed by low level (30.4), where only 23.6% participants had a high level of knowledge. even though the majority of participants had a neutral attitude of prevention dhf (49.3%), the study found that 40.6% participants had a negative attitude of prevention dhf. this study also identifies practice of prevention dhf among participants. only 16.9% participants had a high level of practice of prevention dhf, the most participants (68.1%) had a moderate level of practice of prevention dhf. this finding means that participants did not practice the prevention dhf regularly. table 2. distributions and frequencies of knowledge, attitude, and practice of prevention dengue hemorrhagic fever (n= 148) variables n % knowledge low (0-8 scores) moderate (9-11 scores) high (12-14 scores) 45 68 35 30.4 45.9 23.6 attitude negative (12-40 scores) neutral (41-46 scores) positive (47-60 scores) 60 73 15 40.6 49.3 10.1 practice prevention low (0-4 scores) moderate (5-6 scores) high (7-8 scores) 22 101 25 14.9 68.1 16.9 discussion in this study, only 45.9% of the participants had a moderate level of knowledge about dhf, and 30.4% of the participants had a low level. this refers the participants’ knowledge needs improvements. this finding supported by the previous study that mentioned the majority of participants had heard of dhf, however, the level of knowledge was low. the knowledge will be affected by the attitude and practice regarding dhf. a study in nepal found that the enhancing knowledge is the critical campaign to prevent dhf in the community [9,10]. previous studies show that the level of knowledge was different in some areas. the knowledge should concern the breeding mosquitoes of dhf [11, 12], causes of bite aedes aegypti [11,12,13,14], prevention program [15], signs and symptoms of dhf [12,16], dhf related to seasonal [12], and dhf management [9]. regarding attitude towards dhf control, 40.6% participants in this study was classified as having a negative attitude. this shows that the majority of people had a less perceived risk of dhf and supports toward dhf control. however, this result might also be partially influenced by characteristic individuals who did not perceive the benefit of dhf prevention. this finding similar to previous studies in laos and philippines [17,18]. this is the area needs attention for the modification of health promotion related dhf prevention. the finding reported the majority of participants (68.1%) had a moderate level of practice on prevention dhf. the good practice level will achieve a good knowledge level. the results corresponded with study in central nepal where people with low knowledge of dhf had less potential breeding sites in and around their houses than people with a good knowledge [19]. one of the reasons for middle practice levels attained in this study may be that many questions on practice level were related to daily practices for the control of other common mosquitoborne diseases in this area. in another hand, the previous study reported the most people who had a good attitude towards dhf prevention by monitoring mosquito larvae found half of the people said the obstacle was no time to monitor mosquito larvae [12]. therefore, there is an urgent needed for awareness program to raise the knowledge of people of this area regarding dhf. conclusion the success of the preventive practices of the dhf was strongly influenced by the knowledge and attitudes towards the prevention of dhf. knowledge about the causes of disease, signs and symptoms of dhf, breeding, and the prevention dhf needs to be improved in order for dhf prevention. government should support the communities to improve the knowledge, attitude and practice prevention dhf. acknowledgment the authors are grateful for all participants. we also appreciate sint carolus school of health sciences, indonesia for supporting this study. conflict of interests we certify that there is no actual or potential conflict of interest in relation to this article. global health management journal, 2018, vol. 2, no. 1 12 references 1. world health organization. comprehensive guidelines for prevention and control of dengue and dengue haemorrhagic fever. revised and expanded edition. india: searo technical publication series. 2011. 2. johansson ma, dominici f, glass ge. local and global effect of climate on dengue transmission in puerto rico. plos neglected tropical diseases, 2009; 3(2), p. 382. 3. departemen kesehatan. profil kesehatan dki jakarta. 2012. avilable from: www.depkes.go.id/resources/download/profil/prof il_kes_provinsi_2012/11%20profil_kes.prov. dkijakarta_2012.pdf 4. cdc cfdcap. dengue fever. colorado: cdc; 2005. available from: http://www.cdc.gov/ncidod/dvbid/dengue/dengueqa.htm. 5. who geneva. dengue hemorrhagic fever: diagnosis, treatment, prevention and control. geneva: world health organization; 1997. 6. espinoza-gómez f, hernández-suárez c, collcárdenas r. educational campaign versus malathion spraying for the control of aedes aegypti in colima, mexico. journal of epidemiology and community health. 2002; 56(2):148–52. 7. malhotra v, kaur p. the community knowledge, attitude and practice regarding dengue fever in field practice area of urban training health center of patiala. int j res dev health. 2014; 2(1): 19-26. 8. ahmed n. knowledge, attitude, and practice of dengue fever prevention among the people in male, maldives. master thesis, chulalongkorn university, thailand. 2007. 9. castro m, sanchez l, perez d, sebrango c, shkedy z, van der stuyft p. the relationship between economic status, knowledge on dengue, risk perceptions and practices. plos one, 2013; 8(12): e81875. 10. dhimal m, aryal kk, lamichane m, gautam i, singh sp, bhousol cl. knowledge, attitude, and practice regarding dengue fever among the healthy population of highland and lowland community in central nepal. plos one, 2014; 9(7): e102028. 11. koeraadt jmc, tueten w, sithiprasasna r, kijchalao u, jones wj, scott wt. dengue knowledge and practice and their impact on aedes aegypti populations in kampheng phet, thailand. j trop med. 2006;74 (4), 692-700. 12. nerlander l., chau tn, nguyen t. study on knowledge, attitudes, and practices of community members in tien giang and ho chi minch city with regards to dengue fever and climate change. international federation of red cross and red crescent societies. 2011. 13. malhotra v, kaur p. the community knowledge, attitude and practice regarding dengue fever in field practice area of urban training health center of patiala. int j res dev health.2014; 2(1): 19-26. 14. gunasekara tdcp, velathanthiri vgns, weeraskara mm, fernando ssn, peelewattage m, & fernando s. knowledge, attitudes and practices regarding dengue fever in sub-urban community in sri lanka. galle medical journal. 2012;17(1), 10-15. 15. itrat a, khan a, javaid s, kamal m, khan h, javed, s, et al. knowledge, awareness and practices regarding dengue fever among the adult population of dengue hit cosmopolitan. plos one.2008;3(7). 16. shuaib f, todd d, campebell-stennett d, ehiri j, jolly ep. knowledge, attitudes and practices regarding dengue infection in westmoreland, jamaica. west indian med. 2010; 59(2),139-146. 17. mayxay m, cui w, thammavong s, khensakhou k, vongxay v, inthasoum l, at al. dengue in peri-urban pak-ngum district, vientiane capital of laos: a community survey on knowledge, attitudes and practices. bmc public health. 2013;13:434. 18. yboa bc, labrage lj. dengue knowledge and preventive practices among rural residents in samar on provinces, philipines. am j public health res. 2013;1:47-52. 19. dhimal m, aryal kk, dhimal ml, gautam i, singh sp, et al. knowledge, attitude and practice regarding dengue fever among the healthy population of highland and lowland communities in central nepal. plos one.2014; 9(7). 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 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.   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). 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. references 1. rocha de souza mc, marques ct, guerra dore cm, ferreira da silva fr, oliveira rocha ha, leite el. antioxidant activities of sulfated polysaccharides from brown and red seaweeds. j appl phycol. 2007;19(2):153-60. 2. van de velde f, de ruiter ga. carrageenan. biopolymers online. 2005. 3. campo vl, kawano df, da silva db, carvalho i. carrageenans: biological properties, chemical modifications and structural analysis–a review. carbohydrate polymers. 2009;77(2):167-80. 4. necas j, bartosikova l. carrageenan: a review. veterinarni medicina. 2013;58(6). 5. tobacman jk. review of harmful gastrointestinal effects of carrageenan in animal experiments. environmental health perspectives. 2001;109(10):983. 6. pangestuti r, kim sk. biological activities of carrageenan. adv food nutr res. 2014;72:113-24. 7. li l, ni r, shao y, mao s. carrageenan and its applications in drug delivery. carbohydrate polymers. 2014;103:1-11. 8. diogo jv, novo sg, gonzalez mj, ciancia m, bratanich ac. antiviral activity of lambdacarrageenan prepared from red seaweed (gigartina skottsbergii) against bohv-1 and suhv-1. res vet sci. 2015;98:142-4. 9. kalitnik a, barabanova ab, nagorskaya v, reunov a, glazunov v, solov’eva t, et al. low molecular weight derivatives of different carrageenan types and their antiviral activity. journal of applied phycology. 2013;25(1):65-72. 10. buck cb, thompson cd, roberts jn, müller m, lowy dr, schiller jt. carrageenan is a potent inhibitor of papillomavirus infection. plos pathogens. 2006;2(7):e69. 11. rodriguez a, kleinbeck k, mizenina o, kizima l, levendosky k, jean-pierre n, et al. in vitro and in vivo evaluation of two carrageenan-based formulations to prevent hpv acquisition. antiviral res. 2014;108:88-93. 12. de sf-tischer pc, talarico lb, noseda md, guimarães smpb, damonte eb, duarte mer. chemical structure and antiviral activity of carrageenans from meristiella gelidium against herpes simplex and dengue virus. carbohydrate polymers. 2006;63(4):459-65. 13. girond s, crance j, van cuyck-gandre h, renaudet j, deloince r. antiviral activity of carrageenan on hepatitis a virus replication in cell culture. research in virology. 1991;142(4):261-70. 14. roberts jn, buck cb, thompson cd, kines r, bernardo m, choyke pl, et al. genital transmission of hpv in a mouse model is potentiated by nonoxynol-9 and inhibited by carrageenan. nat med. 2007;13(7):857-61. 15. wang w, zhang p, yu g-l, li c-x, hao c, qi x, et al. preparation and anti-influenza a virus activity of κ-carrageenan oligosaccharide and its sulphated derivatives. food chemistry. 2012;133(3):880-8. 16. gonzalez m, alarcon b, carrasco l. polysaccharides as antiviral agents: antiviral activity of carrageenan. antimicrobial agents and chemotherapy. 1987;31(9):1388-93. 17. eccles r, meier c, jawad m, weinmüllner r, grassauer a, prieschl-grassauer e. efficacy and safety of an antiviral iota-carrageenan nasal spray: a randomized, double-blind, placebo-controlled exploratory study in volunteers with early symptoms of the common cold. respiratory research. 2010;11(1):108. 18. koenighofer m, lion t, bodenteich a, prieschlgrassauer e, grassauer a, unger h, et al. carrageenan nasal spray in virus confirmed common cold: individual patient data analysis of two global health management journal, 2018, vol. 2, no. 2 36 randomized controlled trials. multidisciplinary respiratory medicine. 2014;9(1):57. 19. carlucci m, scolaro l, damonte e. inhibitory action of natural carrageenans on herpes simplex virus infection of mouse astrocytes. chemotherapy. 1999;45(6):429-36. 20. reunov a, nagorskaya v, lapshina l, yermak i, barabanova a. effect of κ/β-carrageenan from red alga tichocarpus crinitus (tichocarpaceae) on infection of detached tobacco leaves with tobacco mosaic virus/effekt von κ/β-karragheen aus der rotalge tichocarpus crinitus (tichocarpaceae) auf die infektion abgeschnittener tabakblätter mit tabakmosaikvirus. zeitschrift für pflanzenkrankheiten und pflanzenschutz/journal of plant diseases and protection. 2004:165-72. 21. nagorskaya v, reunov a, lapshina l, yermak i, barabanova a. influence of κ/β-carrageenan from red alga tichocarpus crinitus on development of local infection induced by tobacco mosaic virus in xanthinc tobacco leaves. biology bulletin. 2008;35(3):3104. 22. nagorskaya v, reunov a, lapshina l, ermak i, barabanova a. inhibitory effect of κ/β-carrageenan from red alga tichocarpus crinitus on the development of a potato virus x infection in leaves of datura stramonium l. biology bulletin. 2010;37(6):653-8. 23. carlucci mj, pujol ca, ciancia m, noseda md, matulewicz mc, damonte eb, et al. antiherpetic and anticoagulant properties of carrageenans from the red seaweed gigartina skottsbergii and their cyclized derivatives: correlation between structure and biological activity. international journal of biological macromolecules. 1997;20(2):97-105. 24. silva f, dore c, marques c, nascimento m, benevides n, rocha h, et al. anticoagulant activity, paw edema and pleurisy induced carrageenan: action of major types of commercial carrageenans. carbohydrate polymers. 2010;79(1):26-33. 25. yermak im, barabanova ao, aminin dl, davydova vn, sokolova ev, solov’eva tf, et al. effects of structural peculiarities of carrageenans on their immunomodulatory and anticoagulant activities. carbohydrate polymers. 2012;87(1):713-20. 26. liang w, mao x, peng x, tang s. effects of sulfate group in red seaweed polysaccharides on anticoagulant activity and cytotoxicity. carbohydr polym. 2014;101:776-85. 27. de araujo ca, noseda md, cipriani tr, goncalves ag, duarte me, ducatti dr. selective sulfation of carrageenans and the influence of sulfate regiochemistry on anticoagulant properties. carbohydr polym. 2013;91(2):483-91. 28. matsumoto k, obara s, kuroda y, kizu j. antiinflammatory effects of linezolid on carrageenaninduced paw edema in rats. j infect chemother. 2015;21(12):889-91. 29. yao za, xu l, wu hg. immunomodulatory function of kappa-carrageenan oligosaccharides acting on lps-activated microglial cells. neurochem res. 2014;39(2):333-43. 30. yuan h, song j, li x, li n, dai j. immunomodulation and antitumor activity of kappacarrageenan oligosaccharides. cancer lett. 2006;243(2):228-34. 31. prasedya es, miyake m, kobayashi d, hazama a. carrageenan delays cell cycle progression in human cancer cells in vitro demonstrated by fucci imaging. bmc complement altern med. 2016;16:270. 32. zhou g, sheng w, yao w, wang c. effect of low molecular lambda-carrageenan from chondrus ocellatus on antitumor h-22 activity of 5-fu. pharmacol res. 2006;53(2):129-34. 33. yuan h, song j, li x, li n, liu s. enhanced immunostimulatory and antitumor activity of different derivatives of κ-carrageenan oligosaccharides from kappaphycus striatum. journal of applied phycology. 2011;23(1):59-65. 34. zhou g, sun y, xin h, zhang y, li z, xu z. in vivo antitumor and immunomodulation activities of different molecular weight 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. 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. hypercholesterolemia and microvascular dysfunction: interventional strategies. journal of inflammation. 2010;7(1):54. 5. kaplan nm, victor rg. kaplan's clinical hypertension: wollters kluwer health/lippincott williams & wilkins; 2010. 455 p. 6. direktorat bina farmasi komunitas dan klinik. pharmaceutical care untuk penyakit hipertensi (pharmaceutical care for hypertension). jakarta: direktorat bina farmasi komunitas dan klinik ditjen bina kefarmasian dan alat kesehatan; 2006. 7. kumala m. peran diet dalam pencegahan dan terapi hipertensi (diet for prevention and hypertension theraphy. damianus journal of medicine. 2014;13(1):50–61. 8. fitriana r, lipocto ni, triana v. faktor risiko kejadian hipertensi pada remaja di wilayah kerja puskesmas rawat inap sidomulyo, kota baru (hypertension incidence in teenager at the inpatient unit care of sidumolyo's health center, pekanbaru city). jurnal kesehatan masyarakat. 2012;7(1). 9. arsana pm, rosandi r, manaf a, budhiarta a, hikmat permana, sucipta kw, et al. panduan pengelolaan dislipidemia di indonesia 2015: pb.perkeni; 2015. 10. henley e, chang l, hollander s, illinois r. treatment of hyperlipidemia. the journal of family practice. 2002;51:4. 11. varras j. managing hyperlipidemia: an evidence-based approach. journal of managed care medicine. 2010;11:2. 12. verma n. introduction to hyperlipidemia and its treatment: a review. int j curr pharm res. 2016;9(1): 614. 13. asdaq sm, inamdar mn. potential of garlic and its active constituent, s-allyl cysteine, as antihypertensive and cardioprotective in presence of captopril. elsevier. 2010;17:1016–26. 14. rahajeng e, tuminah s. prevalensi hipertensi dan determinannya di indonesia. kedokteran indonesia. 2009;50(12). 15. fauziah na, praselia o. correlation of age and parity with hypertension incidence among pregnant women. proceedings of the international conference on applied science and health. 2017(2):264-8. 16. wratsangka r. pemberian terapi sulih hormon sebagai upaya meningkatkan kesehatan wanita menopause (the provision of hormon theraphy to increase the health of menopause woman). j kedokter trisakti. 2011;18(3):155-62. 17. korneliani k, meida d. obesitas dan stress dengan kejadian hipertensi (obesity and stress with the hypertension incidence). jurnal kesehatan masyarakat. 2012;2:117-21. 19 global health management journal, 2019, vol. 3, no. 1 hadi et al. global health management journal. 2019; 3(1):14-19 18. rosenthal t, alter a. occupational stress and hypertension. journal of the american society of hypertension. 2012;6(1):2-22. 19. trevor a, katzung bg, masters s. katzung & trevor's pharmacology examination and board review: eighth edition: mcgraw hill professional, 2008; 2008. 20. reinhart km, talati r, white cm, coleman ci. the impact of garlic on lipid parameters. nutrition research. 2009;22:39-48. 21. yeh y-y, liu l. cholesterol-lowering effect of garlic extracts and organosulfur compounds: human and animal studies. american society for 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. 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 ak e xp ir at o ry f lo w r at e (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. 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. 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 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 p. evaluation of an automated dispensing system in a hospital pharmacy dispensary. pharm j. 2005;274(7354):763–5. 7. gonzalez r, alonso h, manzorro g, vilaplana e, larisgoiria a, herrero r, et al. staff satisfaction after the implementation of a robotic dispensing system in an outpatient pharmacy. eur j hosp pharm. 2016;23. 8. balar dj. medbox, inc.; medbox provides automated drug dispensing system to reduce medication errors in an intensive care setting. medical patent business week. 2012;1090. 9. tsao nw, lo c, babich m, shah k, bansback nj. decentralized automated dispensing devices: systematic review of clinical and economic impacts in hospitals. can j hosp pharm [internet]. 2014;67(2):138–48. available from: http://www.ncbi.nlm.nih.gov/pubmed/24799724 %5cnhttp://www.pubmedcentral.nih.gov/article render.fcgi?artid=pmc4006759 10. chapuis c, roustit m, bal g, schwebel c, pansu p, david-tchouda s, et al. automated drug dispensing system reduces medication errors in an intensive care setting. crit care med [internet]. 2010;38(12):2275–81. available global health management journal, 2017, vol. 1, no. 1 22 from: http://www.ncbi.nlm.nih.gov/pubmed/20838333 11. zaidan m, rustom f, kassem n, al yafei s, peters l, ibrahim mim. nurses’ perceptions of and satisfaction with the use of automated dispensing cabinets at the heart and cancer centers in qatar: a cross-sectional study. bmc nurs [internet]. 2016;15(1):4. available from: http://www.biomedcentral.com/14726955/15/4%5cnhttp://www.pubmedcentral.nih. gov/articlerender.fcgi?artid=4712505&tool=pm centrez&rendertype=abstract 12. risør bw, lisby m, sørensen j. an automated medication system reduces errors in the medication administration process: results from a danish hospital study. eur j hosp pharm [internet]. 2015;(june 2013):ejhpharm-2015000749. available from: http://ejhp.bmj.com/lookup/doi/10.1136/ejhphar m-2015-000749 13. sujatno p, pinzon rt, meliala a. evaluasi dampak penerapan automated dispensing machine terhadap dispensing error di farmasi rawat jalan instalasi farmasi rumah sakit bethesda yogyakarta. 2016;13(1):7–14. 14. ong ysp, chen ll, wong ja, gunawan y, goh wj, tan mc, et al. evaluating the impact of drug dispensing systems on the safety and efficacy in a singapore outpatient pharmacy. value heal [internet]. 2014;17(7):a791–2. available from: http://www.sciencedirect.com/science/article/pii /s1098301514023705 15. beard rj, smith p. integrated electronic prescribing and robotic dispensing: a case study. springerplus [internet]. 2013;2(2009):295. available from: http://www.pubmedcentral.nih.gov/articlerender .fcgi?artid=3724990&tool=pmcentrez&renderty pe=abstract 16. serrano s, pin c, copa c, rodriguez p. introduction of an automated drug dispensing system in an intensive care unit. eur j hosp pharm [internet]. 2012;19(2). available from: http://dx.doi.org/10.1016/j.taap.2012.11.001 17. roman c, poole s, walker c, smit dv, dooley mj. a “time and motion” evaluation of automated dispensing 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 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. 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 dmpatients 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 dmmanagement, namely engaging in low-carb dmdiet, 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. themost 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 includingmetabolic, 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 commonmethods 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 alsomore 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%, swabbingwas performed zigzag until covered all ulcer areas. cotton swabswere 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 groupwere 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 *pn % 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 groupwhose 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) *pmean±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 awhich 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 tometabolic 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 tomacrophage 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 cleansedwith 0.9%nacl solution had a longer healing duration compared to ozonewatertreated 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 therewas no difference in themean of the number of bacterial colonies between thewounds 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. 2004;351(1):48-55. 2. maiorana a, o’driscoll g, goodman c, taylor r, green d. combined aerobic and resistance exercise improves glycemic control and fitness in type 2 diabetes. diabetes research and clinical practice. 2002;56(2):115-23. 3. kujath p, michelsen a. wounds-from physiology to wound dressing. deutsches ärzteblatt international. 2008;105(13):239-48. 4. aulia nf. pola kuman aerob dan sensitifitas pada gangren diabetik (patern and sentivity of aerobic bacteria in diabetic gangrene). medan: universitas sumatera utara; 2008. 5. rohman a, sugeng r, man yc. characterizaton of red fruit (pandanus conoideus lam) oil. international food research journal. 2012;19(2): 563-7. 6. sarungallo zl, hariyadi p, andarwulan n, purnomo eh, wada m. analysis of α-cryptoxanthin, βcryptoxanthin, α-carotene, and β-carotene of pandanus conoideus oil by high-performance liquid chromatography (hplc). procedia food science. 2015;3:231-43. 7. little rc. some physical properties of soap/solvent systems and their relation to the solubility parameter of the solvent. journal of colloid and interface science. 1966;21(3):266-72. 8. bhat r, prajna p, menezez vp, shetty p. antimicrobial activities of soap and detergents. adv biores. 2011;2(2):52-62. 9. gardner se, frantz ra. wound bioburden and infection-related complications in diabetic foot ulcers. biological research for nursing. 2008;10(1):44-53. 10. noor s, zubair m, ahmad j. diabetic foot ulcer a review on pathophysiology, classification and microbial etiology. diabetes & metabolic syndrome: clinical research & reviews. 2015;9(3):192-9. 11. indrawati i, editor sensitivity of pathogenic bacteria to buah merah (pandanus conoideus lam.). aip conference proceedings; 2016: aip publishing. 12. timsina b, shukla m, nadumane vk. a review of few essential oils and their anticancer property. international journal of shoulder surgery. 2012;6(2). 13. rohman a, riyanto s, yuniarti n, saputra w, utami r, mulatsih w. antioxidant activity, total 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: dewihk,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 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 betweenmaternal 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. (2016). the timing of antenatal care initiation and the content of care in sindh, pakistan. bmc pregnancy and childbirth, 16(1):190. agustina, r. (2015). hubungan karakteristik ibu hamil dengan kunjungan anc k4 di bpm sri nirmala palembang tahun 2014. jurnal harapan bangsa, 2(2):177–181. cholifah, c. and putri, n. a. (2016). faktor-faktor yang berpengaruh terhadap pencapaian k4 di desa sumberejo wonoayu sidoarjo. jurnal kebidanan midwiferia, 1(2):111–123. dinkes kota yogyakarta (2016). profil kesehatan tahun 2016 kota yogyakarta (data tahun 2015). https:// docplayer.info/87951958-profil-kesehatan-tahun-2016-kota-yogyakarta.html. direktorat kesehatan keluarga (2018). lakip direktorat kesehatan keluarga ta 2017. http://kesga.kemkes. go.id/images/pedoman/lakip%20kesga%202017%20final.pdf. heredia-pi, i., servan-mori, e., darney, b. g., reyes-morales, h., and lozano, r. (2016). measuring the adequacy of antenatal health care: a national cross-sectional study in mexico. bulletin of the world health organization, 94(6):452. hidayat, a. a. (2014). metode penelitian kebidanan dan teknik analisis data: contoh aplikasi studi kasus. salemba medika, jakarta. hidayatun mukaromah, s. (2014). analisis faktor ibu hamil terhadap kunjungan antenatal care di puskesmas siwalankerto kecamatan wonocolo kota surabaya. jurnal promkes, 2(39-48). 34 https://docplayer.info/87951958-profil-kesehatan-tahun-2016-kota-yogyakarta.html https://docplayer.info/87951958-profil-kesehatan-tahun-2016-kota-yogyakarta.html http://kesga.kemkes.go.id/images/pedoman/ lakip%20kesga%202017%20final.pdf http://kesga.kemkes.go.id/images/pedoman/ lakip%20kesga%202017%20final.pdf yulyani l and daryan ms ghmj (global health management journal) 2020, vol. 4, no. 1 hoelman, m. b., parhusip, b. t. p., eko, s., bahagijo, s., and santono, h. (2015). panduan sdgs untuk pemerintah daerah (kota dan kabupaten) dan pemangku kepentingan daerah. infid, jakarta. kemenkes ri (2008). standar pelayanan minimal bidang kesehatan di kabupaten/kota. http://www.pdpersi. co.id/peraturan/permenkes/pmk7412008.pdf. kemenkes ri (2010). pedoman pemantauan wilayah setempat kesehatan ibu dan anak (pws-kia). http://www. akbidmuhammadiyahmadiun.ac.id/backsite/file_download/pedoman-pws-kia.pdf. kemenkes ri (2015a). profil kesehatan indonesia. https://www.depkes.go.id/resources/download/ pusdatin/profil-kesehatan-indonesia/profil-kesehatan-indonesia-2014.pdf. kemenkes ri (2015b). rencana strategis kementerian kesehatan tahun 2015-2019. lumempouw, g. a., pelealu, f., and maramis, f. (2015). hubungan antara pengetahuan, status pendidikan, dan status pekerjaan ibu dengan kunjungan antenatal care di puskesmas teling atas kecamatan wanea kota manado. manuaba, i. b. g. (2010). ilmu kebidanan, penyakit kandungan dan keluarga berencana, volume 15. egc, jakarta. marullyta, a. and pudjirahardjo, w. (2013). keputusan pembelian k4 oleh ibu hamil di wilayah kerja puskesmas tembok dukuh. jurnal administrasi kesehatan indonesia, 1(2):108–119. nimi, t., fraga, s., costa, d., campos, p., and barros, h. (2016). prenatal care and pregnancy outcomes: a cross-sectional study in luanda, angola. international journal of gynecology & obstetrics, 135:s72–s78. notoatmodjo, s. (2010). ilmu prilaku kesehatan. rineka cipta, jakarta. onasoga, o. a., afolayan, j. a., and oladimeij, b. d. (2012). factor’s influencing utilization of antenatal care services among pregnant women in ife central lga, osun state nigeria. advances in applied science research, 3(3):1309–1315. padila (2014). buku ajar keperawatan maternitas. nuha medika, yogyakarta. pell, c., meñaca, a., were, f., afrah, n. a., chatio, s., manda-taylor, l., hamel, m. j., hodgson, a., tagbor, h., kalilani, l., et al. (2013). factors affecting antenatal care attendance: results from qualitative studies in ghana, kenya and malawi. plos one, 8(1):e53747. pongsibidang, g. s. and abdulah, z. (2013). faktor yang berhubungan dengan keteraturan kunjungan antenatal di wilayah kerja puskesmas kapala pitu kabupaten toraja utara. jurnal fakultas kesehatan masyarakat universitas hasanuddin makassar. priani, i. f. (2012). faktor faktor yang mempengaruhi keteraturan ibu hamil melakukan antenatal care di puskesmas cimanggis kota depok. universitas indonesia. putri, s. d. k., christiani, n., and nirmasari, c. (2015). hubungan usia ibu hamil dengan kepatuhan anc di puskesmas suruh kabupaten semarang. jurnal keperawatan maternitas, 3(1):33–41. saifuddin, a. b. (2010). buku panduan praktis pelayanan kesehatan maternal dan neonata. sari, g. n. s. n., fitriana, s., and anggraini, d. h. (2015). faktor pendidikan, pengetahuan, paritas, dukungan keluarga dan penghasilan keluarga yang berhubungan dengan pemanfaatan pelayanan antenatal. jurnal ilmu dan teknologi kesehatan, 2(2):77–82. sari, l. w. f. and indriani, i. (2014). identifikasi kelengkapan kunjungan antenatal care (anc) pada ibu hamil trimester iii dan faktor-faktor yang mempengaruhinya di puskesmas mergangsan yogyakarta. phd thesis, stikes’aisyiyah yogyakarta. sarminah (2012). faktor-faktor yang berhubungan dengan kunjungan antenatal care di provinsi papua tahun 2010 (analisis data sekunder riskesdas 2010). http://lontar.ui.ac.id/file?file=digital/20296280s-sarminah.pdf. simkhada, b., teijlingen, e. r. v., porter, m., and simkhada, p. (2008). factors affecting the utilization of antenatal care in developing countries: systematic review of the literature. journal of advanced nursing, 61(3):244–260. sriwahyu, a. (2013). faktor yang berhubungan dengan pemanfaatan antenatal care (anc) di wilayah kerja puskesmas kecamatan lawe sumur kabupaten aceh tenggara tahun 2013. who (2015). who | trends in maternal mortality: 1990 to 2015. https://www.who.int/reproductivehealth/ publications/monitoring/maternal-mortality-2015/en/. wijaya, a. (2013). fenomena tingginya angka kematian ibu (aki atau mmr) berdasarkan sdki 2012. https://www.infodokterku.com/index.php/en/98-daftar-isi-content/data/datakesehatan/219-angka-kematian-ibu-tahun-2012. wulandari, e. c. and ariesta, r. (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 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 considered a vulnerable popula on for hiv infec on. the current informa on on hiv/aids andmigrant workers 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: a cross-sec onal study was conducted in myanmar male migrant workers aged 18-60 years collected from february tomay 2018. a total of 400 migrant workers who live in patumthani provinces were selected by a 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/aids disease and preven on (61.25%). risk behaviors 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. having sexwith temporary partnerwithout condomuse that 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. using condomwith non-partner can reducehiv / aids risk 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 knowledge of samples from overall 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. having mul ple partners increase risk 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 the blood or secre ons of hiv/aids paent 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. have to use condomwith temporary partner 154 (38.5) 101 (25.3) 70 (17.5) 46 (11.5) 29 (7.2) 11.have to use condomwith sexworker 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. (2003). hiv/aids knowledge, attitudes, and practices among burmese migrant factory workers in tak province, thailand. aids care, 15(1):63–70, doi: 10.1080/0954012021000039761. sena, a. c., hammer, j. p., wilson, k., zeveloff, a., and gamble, j. (2010). feasibility and acceptability of doorto-door rapid hiv testing among latino immigrants and their hiv risk factors in north carolina. aids patient care and stds, 24(3):165–173, doi: 10.1089/apc.2009.0135. thepthien, b., srivanichakorn, s., and chucharoen, p. (2015). the behavioral surveillance survey of 9 target groups in bangkok. unaids (2018a). thailand: hiv and aids estimates. https://www.unaids.org/en/regionscountries/ countries/thailand. (accessed on 1 april 2019). unaids (2018b). unaids report on the global summary of the aids epidemic 2018. https://www.unaids.org/ sites/default/files/media_asset/unaids-data-2018_en.pdf. (accessed on 1 april 2019). unaids (2019). the gap report: migrants. https://www.unaids.org/sites/default/files/media_asset/ 04_migrants.pdf. (accessed on 1 april 2019). weine, s., bahromov, m., and mirzoev, a. (2008). unprotected tajik male migrant workers in moscow at risk for hiv/aids. journal of immigrant and minority health, 10(5):461–468, doi: 10.1007/s10903-007-9103-5. weine, s. m. and kashuba, a. b. (2012). labor migration and hiv risk: a systematic review of the literature. aids and behavior, 16(6):1605–1621, doi: 10.1007/s10461-012-0183-4. zafar, m., nisar, n., kadir, m., fatmi, z., ahmed, z., and shafique, k. (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. 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. references 1. rocha de souza mc, marques ct, guerra dore cm, ferreira da silva fr, oliveira rocha ha, leite el. antioxidant activities of sulfated polysaccharides from brown and red seaweeds. j appl phycol. 2007;19(2):153-60. 2. van de velde f, de ruiter ga. carrageenan. biopolymers online. 2005. 3. campo vl, kawano df, da silva db, carvalho i. carrageenans: biological properties, chemical modifications and structural analysis–a review. carbohydrate polymers. 2009;77(2):167-80. 4. necas j, bartosikova l. carrageenan: a review. veterinarni medicina. 2013;58(6). 5. tobacman jk. review of harmful gastrointestinal effects of carrageenan in animal experiments. environmental health perspectives. 2001;109(10):983. 6. pangestuti r, kim sk. biological activities of carrageenan. adv food nutr res. 2014;72:113-24. 7. li l, ni r, shao y, mao s. carrageenan and its applications in drug delivery. carbohydrate polymers. 2014;103:1-11. 8. diogo jv, novo sg, gonzalez mj, ciancia m, bratanich ac. antiviral activity of lambdacarrageenan prepared from red seaweed (gigartina skottsbergii) against bohv-1 and suhv-1. res vet sci. 2015;98:142-4. 9. kalitnik a, barabanova ab, nagorskaya v, reunov a, glazunov v, solov’eva t, et al. low molecular weight derivatives of different carrageenan types and their antiviral activity. journal of applied phycology. 2013;25(1):65-72. 10. buck cb, thompson cd, roberts jn, müller m, lowy dr, schiller jt. carrageenan is a potent inhibitor of papillomavirus infection. plos pathogens. 2006;2(7):e69. 11. rodriguez a, kleinbeck k, mizenina o, kizima l, levendosky k, jean-pierre n, et al. in vitro and in vivo evaluation of two carrageenan-based formulations to prevent hpv acquisition. antiviral res. 2014;108:88-93. 12. de sf-tischer pc, talarico lb, noseda md, guimarães smpb, damonte eb, duarte mer. chemical structure and antiviral activity of carrageenans from meristiella gelidium against herpes simplex and dengue virus. carbohydrate polymers. 2006;63(4):459-65. 13. girond s, crance j, van cuyck-gandre h, renaudet j, deloince r. antiviral activity of carrageenan on hepatitis a virus replication in cell culture. research in virology. 1991;142(4):261-70. 14. roberts jn, buck cb, thompson cd, kines r, bernardo m, choyke pl, et al. genital transmission of hpv in a mouse model is potentiated by nonoxynol-9 and inhibited by carrageenan. nat med. 2007;13(7):857-61. 15. wang w, zhang p, yu g-l, li c-x, hao c, qi x, et al. preparation and anti-influenza a virus activity of κ-carrageenan oligosaccharide and its sulphated derivatives. food chemistry. 2012;133(3):880-8. 16. gonzalez m, alarcon b, carrasco l. polysaccharides as antiviral agents: antiviral activity of carrageenan. antimicrobial agents and chemotherapy. 1987;31(9):1388-93. 17. eccles r, meier c, jawad m, weinmüllner r, grassauer a, prieschl-grassauer e. efficacy and safety of an antiviral iota-carrageenan nasal spray: a randomized, double-blind, placebo-controlled exploratory study in volunteers with early symptoms of the common cold. respiratory research. 2010;11(1):108. 18. koenighofer m, lion t, bodenteich a, prieschlgrassauer e, grassauer a, unger h, et al. carrageenan nasal spray in virus confirmed common cold: individual patient data analysis of two global health management journal, 2018, vol. 2, no. 2 36 randomized controlled trials. multidisciplinary respiratory medicine. 2014;9(1):57. 19. carlucci m, scolaro l, damonte e. inhibitory action of natural carrageenans on herpes simplex virus infection of mouse astrocytes. chemotherapy. 1999;45(6):429-36. 20. reunov a, nagorskaya v, lapshina l, yermak i, barabanova a. effect of κ/β-carrageenan from red alga tichocarpus crinitus (tichocarpaceae) on infection of detached tobacco leaves with tobacco mosaic virus/effekt von κ/β-karragheen aus der rotalge tichocarpus crinitus (tichocarpaceae) auf die infektion abgeschnittener tabakblätter mit tabakmosaikvirus. zeitschrift für pflanzenkrankheiten und pflanzenschutz/journal of plant diseases and protection. 2004:165-72. 21. nagorskaya v, reunov a, lapshina l, yermak i, barabanova a. influence of κ/β-carrageenan from red alga tichocarpus crinitus on development of local infection induced by tobacco mosaic virus in xanthinc tobacco leaves. biology bulletin. 2008;35(3):3104. 22. nagorskaya v, reunov a, lapshina l, ermak i, barabanova a. inhibitory effect of κ/β-carrageenan from red alga tichocarpus crinitus on the development of a potato virus x infection in leaves of datura stramonium l. biology bulletin. 2010;37(6):653-8. 23. carlucci mj, pujol ca, ciancia m, noseda md, matulewicz mc, damonte eb, et al. antiherpetic and anticoagulant properties of carrageenans from the red seaweed gigartina skottsbergii and their cyclized derivatives: correlation between structure and biological activity. international journal of biological macromolecules. 1997;20(2):97-105. 24. silva f, dore c, marques c, nascimento m, benevides n, rocha h, et al. anticoagulant activity, paw edema and pleurisy induced carrageenan: action of major types of commercial carrageenans. carbohydrate polymers. 2010;79(1):26-33. 25. yermak im, barabanova ao, aminin dl, davydova vn, sokolova ev, solov’eva tf, et al. effects of structural peculiarities of carrageenans on their immunomodulatory and anticoagulant activities. carbohydrate polymers. 2012;87(1):713-20. 26. liang w, mao x, peng x, tang s. effects of sulfate group in red seaweed polysaccharides on anticoagulant activity and cytotoxicity. carbohydr polym. 2014;101:776-85. 27. de araujo ca, noseda md, cipriani tr, goncalves ag, duarte me, ducatti dr. selective sulfation of carrageenans and the influence of sulfate regiochemistry on anticoagulant properties. carbohydr polym. 2013;91(2):483-91. 28. matsumoto k, obara s, kuroda y, kizu j. antiinflammatory effects of linezolid on carrageenaninduced paw edema in rats. j infect chemother. 2015;21(12):889-91. 29. yao za, xu l, wu hg. immunomodulatory function of kappa-carrageenan oligosaccharides acting on lps-activated microglial cells. neurochem res. 2014;39(2):333-43. 30. yuan h, song j, li x, li n, dai j. immunomodulation and antitumor activity of kappacarrageenan oligosaccharides. cancer lett. 2006;243(2):228-34. 31. prasedya es, miyake m, kobayashi d, hazama a. carrageenan delays cell cycle progression in human cancer cells in vitro demonstrated by fucci imaging. bmc complement altern med. 2016;16:270. 32. zhou g, sheng w, yao w, wang c. effect of low molecular lambda-carrageenan from chondrus ocellatus on antitumor h-22 activity of 5-fu. pharmacol res. 2006;53(2):129-34. 33. yuan h, song j, li x, li n, liu s. enhanced immunostimulatory and antitumor activity of different derivatives of κ-carrageenan oligosaccharides from kappaphycus striatum. journal of applied phycology. 2011;23(1):59-65. 34. zhou g, sun y, xin h, zhang y, li z, xu z. in vivo antitumor and immunomodulation activities of different molecular weight 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. cite this article as 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. global health management journal www.publications.inschool.id published by photo essay the un sustainable development goals; using world health organization’s ‘health promoting schools’ to create change andrew john macnab 1,2, 3,*, ronald mukisa 1,3,4 1 stellenbosch institute of advanced study (stias), wallenberg research centre at stellenbosch university, stellenbosch 7600, south africa. 2 department of pediatrics, university of british columbia 3 rose charities, canada 4 health and development agency (heada) uganda *corresponding author. email: ajmacnab@gmail.com accepted 23 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) the global epidemiological relevance of the united nations sustainable development goals (sdgs) is implicit from the range of targets they address. the 17 sdgs have the overarching aim of addressing poverty worldwide [1]. figure. 1. the undp poster illustrating the 17 sustainable development goals (sdgs) as sdgs 1-6 directly address factors that contribute to health, disease and well-being in children (poverty, malnutrition, health, education, empowering women and girls and water), an innovative approach is to use the world health organization’s (who) health promoting school (hps) model to create change [2-4]. figure 2. child malnutrition and disease are addressed specifically in sdgs 1 and 4 school-based health promotion employs multidisciplinary strategies to engage a school community. who’s ultimate objective is to generate life-long awareness that choice and behavior offer a way to positively influence the social determinants of health [1,2,5]. hps programs have been used successfully to address many specific locally-identified diseases, living circumstances and lifestyles that negatively impact health, e.g. diarrhea, dental caries, diet, hygiene, 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 24 malaria, mental health, sexual health, and worms [4,6-12]. figure 3. a who health promoting school classroom: the visual aids around the walls speak to health knowledge, factors that are protective and healthy behaviors the fundamental hps approach is suited to the sdgs as two synergistic educational principles drive change; the acquisition of knowledge via creative additions to the curriculum and learning health-promoting behaviors through conduct of school-based healthy practice exercises. figure 4. visual aid production by pupils and the use of age-appropriate ‘voice’ and ‘messaging’ underscore hps learning principles figure 5. healthy practices are learned through sessions that teach and reinforce health-related skills (e.g. tooth brushing, hand washing, mosquito control, and food cultivation, preparation and safe storage) hps programs, particularly in low and middle income countries, often include planting a school garden. it has been documented that school gardening contributes to improved nutrition and academic achievement, promotes healthier eating, enhances environmental awareness and fosters skill development in multiple fields [13]. these skills which range from how to grow food, through team building to commercial expertise from produce marketing are all relevant to sdgs 1-6, and are accrued comparably worldwide [14]. figure 6. school gardens generate awareness of cultivation techniques, food security and sustainable agriculture and acquisition of life skills, in addition to growing produce 25 global health management journal, 2017, vol. 1, no. 1 figure 7. lunch programs that use school garden produce to supplement the nutrition of pupils who come to school hungry improve health and educational attainment figure 8. sweet potatoes grow as an underground tuber on the plant ipomoea batatas. when a garden’s produce is also used to feed children who come to school hungry improved educational achievement results, presumably reflecting reversal of the effects of malnutrition on the cognitive behavior of these children and their ability to learn [15,16]. hence, while local factors will drive the choice of crops schools grow, the nutritional benefit of the produce chosen is relevant. in our hps programs in africa we plant maize with iron-rich beans grown under the canopy; together these provide a good yield with a nutritious combination of complex carbohydrates, protein, and micronutrients. recently we have successfully introduced a new orange fleshed sweet potato varietal (ofsp) which is particularly rich in bioavailable nutrients including vitamins a, b5, b6 and c [17]. figure 9. orange fleshed varietals offer important nutritional benefits in low and middle income countries, and contain high levels of beta-carotene ofsp cultivation should be promoted as vitamin a deficiency (vad) is prevalent in >50% of countries worldwide, with > 250,000 preschool children and many pregnant and lactating mothers affected [18]. vad weakens immunity, stunts growth, increases child and maternal mortality and is the commonest preventable cause of blindness worldwide [19]; eating ofsp reduces rates of blindness [20]. figure 10. eating fruit and vegetables has known beneficial effects for health; increased awareness, production and consumption are fundamental aims of the sdgs. when parents understand that micronutrients in fruit and vegetables improve child health and learning, and especially that they can prevent delayed reading, they are motivated to engage in helping to plant and maintain school gardens [15,21]. parents and children then benefit by acquiring knowledge and skills side by side, and robust improvements in nutrition, food security and sustainable agriculture are achievable [22,23] global health management journal, 2017, vol. 1, no. 1 26 figure 11. vitamin a deficiency is the principal preventable cause of blindness. orange sweet potato consumption preserves vision and is a nutritional adjunct that aids learning the sdgs are a challenge, but importantly, who now endorses school programs as a way to address the social determinants of health worldwide [24, 25]. schools are recognized to provide the most effective and efficient way to reach a large segment of the population, and globally more than 1 billion children have the potential to benefit from change created through sdg-focused initiatives based on the who hps model. figure 12. education in safe and supportive schools is a powerful determinant of health (5). children engaged in effective who health promoting school initiatives will acquire knowledge and behaviours that directly address the un sustainable development goals. acknowledgement: this work was made possible by invitations to the authors to collaborate at stellenbosch institute for advanced study (stias). stias supports the undp sustainable development goals. the collaboration of the children, parents and teachers in who health promoting school projects supported by rose charities canada (hillman medical education fund) is central to their success. 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 references 1. www.un.org/sustainabledevelopment/sustainabledevelopment-goals (accessed september 10 2016) 2. world health organization (2013). what is a health promoting school? http://who.int/school_youth_health/gshi/hps/en/in dex.html. (accessed september 10 2016) 3. west p, sweeting p, leyland a. school effects on pupil’s health behaviours: evidence in support of health promoting school. research papers in education. 2004; 19(30): 261-292. 4. tang k, nutbeam d, aldinger c, st leger l, bundy d, hoffmann m et al. schools for health, education and development: a call for action. health promotion international. 2008; 24(1):6877. 5. viner rm, ozer em, denny s, marmot m, resnick m, fatsui a et al. adolescence and the social determinants of health. the lancet. 2012; 379(9826):1641-52. 6. kwan syl, petersen pe, pine cm, orutta a. health-promoting schools: an opportunity for oral health promotion. bulletin world health organization 2005; 83(10):1590/s004296862005000900013 7. migele j, ombeki s, ayalo m, biggerstaff m. diarrhea prevention in kenyan school through the use of simple safe water and hygiene intervention. american journal of hygiene and tropical medicine. 2007; 76: 351-353. 8. macnab aj. mukisa r, mutabazi s, steed r. malaria in uganda: school-based rapid diagnostic testing and treatment. int j epidemiology 2016; doi: 10.1093/ije/dyw262 9. mukisa r, macnab aj, mutabazi s, steed r. teachers as agents of change: school-based diagnosis of malaria positively impacts child morbidity. proceedings of the international http://www.un.org/sustainabledevelopment/sustainable-development-goals http://www.un.org/sustainabledevelopment/sustainable-development-goals http://who.int/school_youth_health/gshi/hps/en/index.html http://who.int/school_youth_health/gshi/hps/en/index.html 27 global health management journal, 2017, vol. 1, no. 1 conference on applied science and health. 2017; 93-102. http://publications.inschool.id/index.php/icash 10. kirby d, obasi a, laris b. the effectiveness of sex education and hiv education interventions in schools in developing countries. who technical report series. 2006: 938:103-150. 11. paul-ebhohimhen va, poobalan a, van teijlingen er. a systematic review of school-based sexual health interventions to prevent sti/hiv in subsaharan africa. bmc public health 2008; 8(4) doi:10.1186/1471-2458-8-4 12. miguel e, kremer m. worms: identifying impacts on education and health in the presence of treatment externalities. econometrica. 2004; 72(1): 159-217. 13. royal horticultural society. food growing in schools taskforce report. 2012 pp. 1-66. http://www.gardenorganic.org.uk 14. armstrong d. a survey of community gardens in upstate new york: implications for health promotion and community development. health and place. 2000; 6:319-327. 15. macnab aj, kasangaki a. ‘many voices, one song’: a model for an oral health programme as a first step in establishing a health promoting school. health promotion international. 2012; 27(1): 6373, doi: 10.1093/heapro/dar039 16. bundy da, shaeffer s, jukes m, beegle k, gillespie a, drake l et al. school-based health and nutrition programs. in: jamison dt, breman jg, measham ar. editors. disease control priorities in developing countries. the world bank, washington, dc, 2nd edition. 2006; pp 10911108. 17. hotz c, loechl c, de brauw a, eozenou p, gilligan d, moursi m et al. a large-scale intervention to introduce orange sweet potato in rural mozambique increases vitamin a intakes among children and women. british journal of nutrition. 2012; 108(01): 163-76. 18. who. global prevalence of vitamin a deficiency in populations at risk 1995-2005. who global database on vitamin a deficiency. geneva: world health organization. 2009 19. who vitamin a deficiency | micronutrient deficiencies http://www.who.int/nutrition/topics/vad/en/ (accessed march 20 2017) 20. low jw, arimond m, osman n, cunguara b, zano f, tschirley d. a food-based approach introducing orange-fleshed sweet potatoes increased vitamin a intake and serum retinol concentrations in young children in rural mozambique. the journal of nutrition. 2007; 137(5): 1320-7. 21. knai c, pomerleau j, lock k, mckee m. getting children to eat more fruit and vegetables: a systematic review. preventive medicine, 2006; 42(2): 85-95. 22. pérez-rodrigo c, aranceta j. school-based nutrition education: lessons learned and new perspectives. public health nutrition. 2001; 4(1a): 131-9. 23. macnab aj, gagnon f, stewart, d. health promoting schools: consensus, challenges and potential. health education. 2014; 114(3):170185. 24. commission on social determinants of health. closing the gap in a generation: health equity through action on the social determinants of health: final report of the commission on social determinants of health. world health organization, geneva. 2008. 25. marmot m, friel s, bell r, houweling ta, taylor s, and commission on social determinants of health. closing the gap in a generation: health equity through action on the social determinants of health. the lancet. 2008; 372(9650): 1661-1669. http://publications.inschool.id/index.php/icash http://www.gardenorganic.org.uk/ http://www.who.int/nutrition/topics/vad/en/ 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.   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. the international conferences on applied science and health (icash): efforts and commitments in translating research results into policy and practices, for a better society indonesian scholars’ alliance ghmj (global health management journal) 2019, vol. 3, no. 3 open access photo essay the 4th interna onal conference on applied science and health (icash 2019), 23-24 july 2019, faculty of graduate studies, mahidol university, thailand the international conferences on applied science and health (icash): efforts and commitments in translating research results into policy and practices, for a better society dyah anantalia widyastari1,2, doni marisi sinaga1,2, canggih puspo wibowo1,2, pamuko aditya rahman1,2, hafizh muhammad noor1, dimas sondang irawan1, tiara fatmarizka1, dwina gustia diary1, i gusti ngurah edi putra1, maretalinia1, marina ayu viniriani1, monita destiwi1, galih albarra shidiq1, ivana aprilia pratiwi1, made dian shanti kusuma1, ni wayan kesari dharmapatni1, mahendrawan nugraha aji pratama1, ary norsaputra1, andi pancanugraha1, febrian hendra kurniawan1, wahyu manggala putra1, rifqi abdul fattah1, puput kusumawardani moehas1, ricky alexander samosir1, andang adi fitria hananto1, i gusti ngurah agastya1, taufik eko susilo1, pichpisith pierre vejvisithsakul1, donny nauphar1, ariestya indah permata sari1, andrew john macnab3,4 1commi ee of interna onal conference on applied science and health (icash) 2yayasan aliansi cendekiawan indonesia thailand (indonesian scholars’ alliance) 3faculty of medicine, university of bri sh columbia, canada 4editor-in-chief, global health management journal (ghmj) *corresponding author’s email: info@inschool.id doi: 10.35898/ghmj-33451 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) yayasan aliansi cendekiawan indonesia thailand, or internationally known as indonesian scholars’ alliance (inschool), has organized the international conferences on applied science and health (icash) at mahidol university, bangkok since 2017, and the fourth event in this series has just been completed. the conferences are hosted and co-hosted by several academic institutions in indonesia and thailand. icash offers important opportunities for young trainees in the health care professions to come together to share their work and interests and hear from experienced faculty on topics of interest and policies of importance. this photo essay captures the moments during the 4th international conference on applied science and health (icash 2019), held at faculty of graduate studies, mahidol university, thailand, on 23-24 july 2019. the two-day event involves 6 universities from indonesia. four of these universities have signed a memorandum of understanding letter (mou) with inschool to support icash. these are: universitas swadaya gunung jati, poltekkes kemenkes semarang, poltekkes kemenkes yogyakarta, and poltekkes palangka raya. for your information, ”poltekkes kemenkes” means ”health polytechnic under ministry of health of indonesia”. and the other two university partners: poltekkes kemenkes sorong and poltekkes kemenkes ternate have signed a letter of intent with a commitment  to participate next year at icash5 as co-hosts. icash is organized by a team of volunteers who advertise the event, solicit abstracts, provide 79 mailto:info@inschool.id https://dx.doi.org/10.35898/ghmj-33451 ghmj (global health management journal) 2019, vol. 3, no. 3 widyastari da et al. (a) (b) figure 1. (a) par cipants receive a warmwelcome at icash conferences; (b) registra on at the faculty of graduate studies at mahidol university, bangkok. (a) (b) figure 2. (a) the conference chair welcomes the co-hosts, university representa ves and par cipants; (b) the delega on from universitas indonesia to icash 4. peer review of submissions and produce the event program of keynote speeches, and oral and poster presentations by participants. addressing issues in the philosophy of ”science for the mankind”, icash 2019 raises the efforts of the scholars in translating research results into policy and practices, for a better society. scientific sessions are divided into 6 main groups: (1) health service and management from the perspectives of the providers and users; (2) health education and promotion; (3) nutrition and health behavioral intervention; (4) health education, service and management; (5) maternal and child health; and (6) applied science in health. at these sessions presentations are made by participants based on abstract submissions reviewed by the icash scientific committee. each session is chaired by an experienced investigator who leads discussion on each participants’ presentation to provide learning points to aid future research, or expand the description of the method, data presented and conclusions formed to make it suitable for publication. all submitted papers presented at oral session have been published online on proceedings of the international conference on applied science and health (issn 25794434). participants may also submit their work for presentation in poster format. the poster sessions generate valuable discussion between participants and presenters. the closing ceremonies offer the opportunity for cultural exchange with participants and the organizers contributing music and dance. at this time awards are given for many categories to encourage and recognize excellence. these include best oral presentation and best poster in each health discipline 80 https://publications.inschool.id/index.php/icash https://publications.inschool.id/index.php/icash widyastari da et al. ghmj (global health management journal) 2019, vol. 3, no. 3 (a) (b) figure 3. (a) keynote speakers introduce par cipants to a number of topics on the icash conference theme; (b) ques ons from par cipants are welcome as part of the learning opportuni es offered at icash. (a) (b) figure 4. (a) the par cipants scien fic sessions a ract enthusias c audiences; (b) presenters in the health promo on scien fic session receive their cer ficates. category, and a range of special awards including promotion of icash topics using social media, and best researcher and best young scientist awards. at each conference a group photo is taken for of the participants and the conference faculty. conference proceedings published on line include details of the work of all participants who present in the scientific and poster sessions. participants sharing outstanding science at icash are encouraged to submit manuscripts for review by the editorial board of the global health management journal (ghmj). ghmj is another inschool project and this on-line journal is indexed by several reputable organizations including directory of open access journal, google scholar, oclc worldcat, and crossref. after receiving 207 outstanding submissions for this year international conference on applied science and health, the conference editorial board has selected 8 best papers from the conference to be published as 2019’s special edition of global health management journal (ghmj). all icash conferences celebrate the culture and traditions of indonesia and thailand, and aim to identify health priorities relevant to both countries, and explore related science and creative solutions. first and foremost, the icash model is intended to attract young people entering the health sciences and related fields, and give them new insights, knowledge and enthusiasm to pursue their chosen path of applying science to health. information about past and future icash conferences can be found on line. 81 https://publications.inschool.id/index.php/icash https://publications.inschool.id/index.php/icash https://publications.inschool.id/index.php/ghmj https://publications.inschool.id/index.php/ghmj http://icash.inschool.id/ http://icash.inschool.id/ ghmj (global health management journal) 2019, vol. 3, no. 3 widyastari da et al. figure 5. the poster session a racts par cipants to discuss the research and findings of the presenters (a) (b) figure 6. (a) at the closing ceremony par cipants share their culture and tradi ons; (b) the closing ceremony is also the me for the presenta on of awards, including a young scien st award at icash 4. cite this article as: widyastari da, sinaga dm, wibowo cp, rahman pa, noor hm, irawan ds, fatmarizka t, diary dg, putra igne, maretalinia, viniriani ma, destiwi m, shidiq ga, pratiwi ia, kusuma mds, dharmapatni nwk, pratama mna, norsaputra a, pancanugraha a, kurniawan fh, putra wm, fattah ra, moehas pk, samosir ra, hananto aaf, agastya ign, susilo te, vejvisithsakul pp, nauphar d, sari aip, macnab aj. 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). 2019; 3(3):79-83. doi:10.35898/ghmj-33451 82 widyastari da et al. ghmj (global health management journal) 2019, vol. 3, no. 3 figure 7. all par cipants and faculty are invited for the icash conference group photo (a) (b) figure 8. (a) the culture tradi ons and health priori es of indonesia and thailand are central to icash conferences; (b) icash par cipants leave with new knowledge, new friends and souvenirs. 83   cite this article as  sawasdee k, choksawad p, pimcharoen s, prapainop k. development of size‐tunable  polymeric nanoparticles for drug delivery applications. global health management  journal. 2017; 1(2): 31‐6.    global health management journal  www.publications.inschool.id  published by  original research article issn 2580-9296 (online) development of size-tunable polymeric nanoparticles for drug delivery applications komkrich sawasdee 1, ployphailin choksawad 1, sopida pimcharoen 2, kanlaya prapainop1,* 1 department of biochemistry, faculty of science, mahidol university, bangkok, thailand. 2 samsenwittayalai school, rama vi road, bangkok, thailand. *corresponding author. email: kanlaya.pra@mahidol.edu article info abstract article history: submitted 16 october 2017 accepted 27 october 2017 background: poly lactide-co-glycolide (plga) nanoparticles (nps) have been widely used in drug delivery applications because of their excellent properties such as biocompatibility, and biodegradability along with the ability to deliver hydrophobic drugs, increase drug bioavailability and improve drug absorption to targeted cells in both oral and parenteral administrations. the plga nps can be synthesized using an emulsion solvent evaporation method. each parameter during synthesis plays a role in the formation of nanoparticles and can affect np size; important factors for successful development of a drug delivery system. aims: the aim of this study was to prepare different sizes of plga nps by investigation of four factors (molecular weight, mw) of plga, emulsifier concentrations, organic solvent type and power of ultrasonication) involved in plga nanoparticle synthesis. methods: plga nanoparticles were prepared by an emulsion solvent evaporation method. size and size distribution were analyzed by dynamic light scattering and polydispersity index (pdi). results: the effect of four parameters: plga mw, emulsifier concentrations, solvent types, and amplitude of ultrasonication on plga nps preparation were evaluated. changing one parameter results in different sizes of plga nps that varied from 150300 nm. pdi which is an indicator for determination of size distribution of nps, varied with an overall value <0.2. conclusion: mw of plga polymer, emulsifier concentration, type of organic solvent and power of ultrasonication affect the size and size distribution of plga nps. keywords: drug delivery polymeric nanoparticles tunable size of nanoparticles © 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 cancer is a worldwide health problem with millions of people suffering from this disease in both economically developed countries and developing countries [1]. the current strategies for treatment of cancer include surgery, radiation, immunotherapy or chemotherapy. the chemotherapeutic drug is administered intravenously can spread to accumulate in offtargeted tissues or organs leading to undesirable side effects. to solve these problems, anti-cancer drug loaded nanoparticles have gained extensive attention to use as an effective drug delivery system to specific target sites [1, 2]. polymeric nps have unique properties including stability, biocompatibility and ease of surface chemistry modification [3, 4]. therefore these nanoparticles have been used in drug delivery global health management journal, 2017, vol. 1, no. 2  32      systems to protect drugs from bioand chemical degradation which also help to increase drug stability. in addition, the nanoparticle surface can be further modified for specific targeting purposes. for example, nps are conjugated with specific antibodies against cancer cells and used to deliver anti-cancer drugs for therapeutic purpose [5]. poly lactide-co-glycolide (plga) is one of the polymers that can form nanoparticles [6]. this linear copolymer can be hydrolyzed into the two non-toxic monomers: lactic acid and glycolic acid [7], therefore, plga has been approved for use in biomedical applications such as drug delivery by the united states food and drug administration (fda) and european medicine agency (ema) [8, 9]. in order to develop a successful drug carrier system, the size of nps is a key factor especially in cancer therapy [1, 2]. several reports show that size and size distribution of nps play important role in term of in vivo biodistribution, biological fate and toxicity [10]. smaller particles have relatively higher uptake efficiency to the targeted cells compared to larger particles but have smaller inner space for drug entrapment [11]. in addition, the drugs in the small nps are at or near the particle surface, leading to faster drug release compared to large particle size [12]. this faster release rate in smaller nanoparticles was also observed in a bovine serum albumin protein release model [13]. therefore, the small nps would be suitable for drug delivery that requires fast release rate whereas the large particles would be appropriate for drug that requires slow release rate. due to the importance of drug carrier size, the development of synthesis methods for preparation of different np sizes is important to provide the most optimal size and property to each specific drug delivery requirement [14]. this study focuses on development of tunable size of plga nps. four different parameters that might affect particle sizes (molecular weight of plga polymer, emulsifier concentrations, type of organic solvent and power of ultrasonication) are investigated. the overall scheme of plga nps synthesis is shown in figure 1. figure 1. schematic representation of general procedure of preparation of plga nanoparticle by emulsion solvent evaporation method. 33                                 global health management journal, 2017, vol. 1, no. 2        methods materials plga nps were prepared by a modification of emulsion solvent evaporation method as previously described [15,16]. four parameters were investigated: (i) size of plga polymer (60,000 g/mol and 80,000 g/mol), (ii) concentration of pva that acts as emulsifier (1-10 % (w/v)), (iii) type of organic solvent (etoac and dcm) and (iv) power of ultrasonication (10%, 35% and 38% amplitude). preparation of plga nps plga nps were prepared by a modification of emulsion solvent evaporation method as previously described [15, 16]. four parameters were investigated: (i) size of plga polymer (60,000 g/mol and 80,000 g/mol), (ii) concentration of pva that acts as emulsifier (1-10 % (w/v)), (iii) type of organic solvent (etoac and dcm) and (iv) power of ultrasonication (10%, 35% and 38% amplitude). preparation of plga nps using different molecular weight of plga a total of 50 mg of two different mw of plga polymer (60,000 and 80,000 g/mol) was dissolved in 0.5 ml etoac. the plga solution was added dropwise to 2 ml of pva dissolved in water under vortex. afterwards, the emulsion solution was treated with 3 cycles of 30 seconds pulse (38% amplitude). at the end of the cycles, the solution was quickly added into 25 ml of 0.3 % pva under stirring for 4 hours to evaporate the organic solvent. the plga nanoparticles were collected by centrifugation at 15,000 rpm for 15 minutes. after that, plga nanoparticles were washed for three times with deionized water and followed by lyophilization. preparation of plga nps using different emulsifier concentrations to study the effect of emulsifier concentrations, 50 mg plga polymer (60,000 g/mol) was dissolved in 0.5 ml etoac. the plga solution was added dropwise to 2 ml of different pva concentrations dissolved in water (1%, 5% and 10% (w/v)) under vortex. the mixture was emulsified, collected and stored using the same procedure as described above. preparation of plga nps using different organic solvent types to study the effect of organic solvent type, 50 mg plga polymer (60,000 g/mol) was dissolved in 0.5 ml of different organic solvents (etoac or dcm). the plga solution was added dropwise to 2 ml of 5% (w/v) pva dissolved in water under vortex. the mixture was emulsified, collected and stored using the same procedure as described above. preparation of plga nps using different power of ultrasonication to study the last parameter: the power of ultrasonication, 50 mg plga polymer (60,000 g/mol) was dissolved in 0.5 ml etoac. the plga solution was added dropwise to 2 ml of 5% (w/v) pva dissolved in water under vortex. the mixed solution was subsequently emulsified by sonication with 3 cycles of 30-second pulses (10%, 35% and 38% amplitude). the mixture was collected and stored using the same procedure as described above. characterization of particle size and pdi value nps were dispersed in milli q water at concentration of 0.1 mg/ml before characterization. the size and pdi value of the particles were analyzed using nanosizer 90 zs (malvern instrument ltd., malvern, uk) at 25c. all measurements were carried out as the average of value with triplicate measurements and at least 10 runs within each analysis. the results were reported as a mean of three independent readings  standard deviation. results plga np size and size distribution from different mw of plga in this experiment, the particles prepared by 60,000 and 80,000 g/mol plga have a size about 179 and 261 nm respectively (figure 2). both nps prepared by the two mw showed pdi values less global health management journal, 2017, vol. 1, no. 2  34      than 0.2 which indicated that the nps were monodispersed. figure 2. characterization of plga nps prepared using different molecular weight of plga. the 5% pva, etoac was applied to the reaction and 38% power of sonication was used. size (black bars, left yaxis) and pdi (white bars, right y-axis) values are presented. plga np size and size distribution from different emulsifier concentrations and organic solvent types the sizes of plga nanoparticles decreased when the pva concentration was increased (figure 3). using etoac as solvent (figure 3a), at 1% (w/v) pva, the particle size was about 259 nm. when the pva concentration was increased to 5% and 10% (w/v), the particle sizes were 179 and 176 nm, respectively. it was found that at 5% and 10% (w/v) pva the particle sizes were not significantly different. the pdi value that indicates nanoparticle size distribution showed the value less than 0.2 which suggested that plga nanoparticles prepared by these pva concentrations were monodispersed. similar results were also obtained from nps preparation using dcm as a solvent (figure 3b). nps size and pdi values prepared in etoac were smaller (170-220 nm) (figure 3a) than the particles that prepared in dcm (300-500 nm) (figure 3b). figure 3. characterization of plga nps prepared using different pva concentrations and different solvents. a) nps prepared using etoac, b) nps prepared using dcm. the 60,000 g/mol plga, and solvent were applied to the reaction and 38% power of sonication was used. size (black bar, left y-axis) and pdi (white bars, right y-axis) values are presented. plga np size and size distribution from different power of ultrasonication nps prepared by 38% sonication were of smaller size (179 nm) than particles prepared by 10% (246 nm). this result indicated that higher power of sonication induced the production of smaller size of nps. the pdi values from both conditions were less than 0.2 that represented monodispersity of nps (figure 4). 35                                 global health management journal, 2017, vol. 1, no. 2        figure 4. characterization of plga nps prepared by using different ultrasonication power. the 5% pva, 60,000 g/mol plga and etoac were applied to the reaction. size (black bars, left y-axis) and pdi (white bars, right y-axis) values are presented. plga np size after long storage in aqueous solution to use nps as a drug delivery system the stability of drug carrier is important. figure 5 illustrates examples of nps size after long storage in aqueous solution up to 7 months. the nps size remains similar to short storage time and no sign of aggregation was observed. this result suggested that the obtained plga nps are stable up to 7 months and has high potential for development as a drug carrier system. figure 5. characterization of plga nps prepared by using different pva concentrations and after long term storage. nps prepared using 60,000 g/mol plga, and etoac were applied to the reaction and 35% power of sonication was used. size after one week (black bars) and size after 7 months (white bars) are presented. discussion plga np size is easily tunable by simple changes in the synthesis parameters. with high mw of plga a larger particle size is produced because the long chain of polymer can induce larger oil droplets [17]. data show that pva can be used to stabilize emulsion and lead to formation of small and monodispersed particles [18, 19]. therefore, when increasing the concentration of pva the size of particles tend to decrease. in addition, organic solvent can affect the particles size of plga nps. the nps prepared by dcm were bigger than particles prepared by etoac. these results could be due to different properties of the solvent. dcm is a non-miscible solvent in water, unlike etoac. therefore, dcm has a higher surface tension in oil droplets from the emulsion step, resulting in larger nanoparticles [20]. apart from mw, emulsifier concentrations and organic solvent type, power of sonication can affect particle size. the power of sonication applied to the emulsion step can disrupt the surface tension of the larger oil drops to create a smaller oil drop which leads to formation of smaller particles as previously observed [21]. conclusion different sizes of plga nps were successfully prepared by changing each of four synthesis parameters. the factors that contribute to the achievement of desirable size are plga mw, pva concentrations, organic solvent type, and sonication power. the nps obtained are stable in aqueous solution, and therefore are suitable for further development as a drug carrier system for cancer treatment. acknowledgements this project was supported by mahidol university and faculty of science, mahidol university, development and promotion of science and technology talents project. this project was partially supported by cif grant, faculty of science, mahidol university. ks was supported by research assistantships, faculty of graduate studies, mahidol university. pc was supported by science achievement scholarship of thailand. sp was supported by development and promotion of science and technology talents project. global health management journal, 2017, vol. 1, no. 2  36      conflict of interests the authors have no conflict of interests. references 1. tabatabaei mirakabad fsn-k, kazem; akbarzadeh, abolfazl; yamchi, mohammad rahmati; milani, mortaza; zarghami, nosratollah; zeighamian, vahideh; rahimzadeh, amirbahman; alimohammadi, somayeh; hanifehpour, younes; joo, sang woo. plga-based nanoparticles as cancer drug delivery systems. asian pacific journal of cancer prevention. 2014;15(2):517-35. 2. dinarvand r, sepehri n, manoochehri s, rouhani h, atyabi f. polylactide-co-glycolide nanoparticles for controlled delivery of anticancer agents. international journal of nanomedicine. 2011;6:877-95. 3. marguet m, bonduelle c, lecommandoux s. multicompartmentalized polymeric systems: towards biomimetic cellular structure and function. chemical society reviews. 2013;42(2):512-29. 4. kumari a, yadav sk, yadav sc. biodegradable polymeric nanoparticles based drug delivery systems. colloids and surfaces b: biointerfaces. 2010;75(1):1-18. 5. kocbek p, obermajer n, cegnar m, kos j, kristl j. targeting cancer cells using plga nanoparticles surface modified with monoclonal antibody. journal of controlled release. 2007;120(1):18-26. 6. yin win k, feng s-s. effects of particle size and surface coating on cellular uptake of polymeric nanoparticles for oral delivery of anticancer drugs. biomaterials. 2005;26(15):2713-22. 7. zhou s, deng x, li x, jia w, liu l. synthesis and characterization of biodegradable low molecular weight aliphatic polyesters and their use in proteindelivery systems. journal of applied polymer science. 2004;91(3):1848-56. 8. danhier f, ansorena e, silva jm, coco r, le breton a, préat v. plga-based nanoparticles: an overview of biomedical applications. journal of controlled release. 2012;161(2):505-22. 9. lü j-m, wang x, marin-muller c, wang h, lin ph, yao q, et al. current advances in research and clinical applications of plga-based nanotechnology. expert review of molecular diagnostics. 2009;9(4):325-41. 10. alexis f, pridgen e, molnar lk, farokhzad oc. factors affecting the clearance and biodistribution of polymeric nanoparticles. molecular pharmaceutics. 2008;5(4):505-15. 11. singh r, lillard jw. nanoparticle-based targeted drug delivery. experimental and molecular pathology. 2009;86(3):215-23. 12. redhead hm, davis ss, illum l. drug delivery in poly(lactide-co-glycolide) nanoparticles surface modified with poloxamer 407 and poloxamine 908: in vitro characterisation and in vivo evaluation. journal of controlled release. 2001;70(3):353-63. 13. panyam j, dali mm, sahoo sk, ma w, chakravarthi ss, amidon gl, et al. polymer degradation and in vitro release of a model protein from poly(d,l-lactideco-glycolide) nanoand microparticles. journal of controlled release. 2003;92(1):173-87. 14. choi hs, liu w, misra p, tanaka e, zimmer jp, ipe bi, et al. renal clearance of nanoparticles. nature biotechnology. 2007;25(10):1165-70. 15. montalvo-ortiz bl, sosa b, griebenow k. improved enzyme activity and stability in polymer microspheres by encapsulation of protein nanospheres. aaps pharmscitech. 2012;13(2):632-6. 16. morales-cruz m, flores-fernández gm, moralescruz m, orellano ea, rodriguez-martinez ja, ruiz m, et al. two-step nanoprecipitation for the production of protein-loaded plga nanospheres. results in pharma sciences. 2012;2:79-85. 17. mittal g, sahana dk, bhardwaj v, ravi kumar mnv. estradiol loaded plga nanoparticles for oral administration: effect of polymer molecular weight and copolymer composition on release behavior in vitro and in vivo. journal of controlled release. 2007;119(1):77-85. 18. dutschk v, chen j, petzold g, vogel r, clausse d, ravera f, et al. the role of emulsifier in stabilization of emulsions containing colloidal alumina particles. colloids and surfaces a: physicochemical and engineering aspects. 2012;413(supplement c):23947. 19. sahoo sk, panyam j, prabha s, labhasetwar v. residual polyvinyl alcohol associated with poly (d,llactide-co-glycolide) nanoparticles affects their physical properties and cellular uptake. journal of controlled release. 2002;82(1):105-14. 20. mccall rl, sirianni rw. plga nanoparticles formed by singleor double-emulsion with vitamin e-tpgs. journal of visualized experiments : jove. 2013(82):51015. 21. bilati u, allémann e, doelker e. sonication parameters for the preparation of biodegradable nanocapsulesof controlled size by the double emulsion method. pharmaceutical development and technology. 2003;8(1):1-9. cite this article as 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. global health management journal www.publications.inschool.id published by photo essay the un sustainable development goals; using world health organization’s ‘health promoting schools’ to create change andrew john macnab 1,2, 3,*, ronald mukisa 1,3,4 1 stellenbosch institute of advanced study (stias), wallenberg research centre at stellenbosch university, stellenbosch 7600, south africa. 2 department of pediatrics, university of british columbia 3 rose charities, canada 4 health and development agency (heada) uganda *corresponding author. email: ajmacnab@gmail.com accepted 23 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) the global epidemiological relevance of the united nations sustainable development goals (sdgs) is implicit from the range of targets they address. the 17 sdgs have the overarching aim of addressing poverty worldwide [1]. figure. 1. the undp poster illustrating the 17 sustainable development goals (sdgs) as sdgs 1-6 directly address factors that contribute to health, disease and well-being in children (poverty, malnutrition, health, education, empowering women and girls and water), an innovative approach is to use the world health organization’s (who) health promoting school (hps) model to create change [2-4]. figure 2. child malnutrition and disease are addressed specifically in sdgs 1 and 4 school-based health promotion employs multidisciplinary strategies to engage a school community. who’s ultimate objective is to generate life-long awareness that choice and behavior offer a way to positively influence the social determinants of health [1,2,5]. hps programs have been used successfully to address many specific locally-identified diseases, living circumstances and lifestyles that negatively impact health, e.g. diarrhea, dental caries, diet, hygiene, 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 24 malaria, mental health, sexual health, and worms [4,6-12]. figure 3. a who health promoting school classroom: the visual aids around the walls speak to health knowledge, factors that are protective and healthy behaviors the fundamental hps approach is suited to the sdgs as two synergistic educational principles drive change; the acquisition of knowledge via creative additions to the curriculum and learning health-promoting behaviors through conduct of school-based healthy practice exercises. figure 4. visual aid production by pupils and the use of age-appropriate ‘voice’ and ‘messaging’ underscore hps learning principles figure 5. healthy practices are learned through sessions that teach and reinforce health-related skills (e.g. tooth brushing, hand washing, mosquito control, and food cultivation, preparation and safe storage) hps programs, particularly in low and middle income countries, often include planting a school garden. it has been documented that school gardening contributes to improved nutrition and academic achievement, promotes healthier eating, enhances environmental awareness and fosters skill development in multiple fields [13]. these skills which range from how to grow food, through team building to commercial expertise from produce marketing are all relevant to sdgs 1-6, and are accrued comparably worldwide [14]. figure 6. school gardens generate awareness of cultivation techniques, food security and sustainable agriculture and acquisition of life skills, in addition to growing produce 25 global health management journal, 2017, vol. 1, no. 1 figure 7. lunch programs that use school garden produce to supplement the nutrition of pupils who come to school hungry improve health and educational attainment figure 8. sweet potatoes grow as an underground tuber on the plant ipomoea batatas. when a garden’s produce is also used to feed children who come to school hungry improved educational achievement results, presumably reflecting reversal of the effects of malnutrition on the cognitive behavior of these children and their ability to learn [15,16]. hence, while local factors will drive the choice of crops schools grow, the nutritional benefit of the produce chosen is relevant. in our hps programs in africa we plant maize with iron-rich beans grown under the canopy; together these provide a good yield with a nutritious combination of complex carbohydrates, protein, and micronutrients. recently we have successfully introduced a new orange fleshed sweet potato varietal (ofsp) which is particularly rich in bioavailable nutrients including vitamins a, b5, b6 and c [17]. figure 9. orange fleshed varietals offer important nutritional benefits in low and middle income countries, and contain high levels of beta-carotene ofsp cultivation should be promoted as vitamin a deficiency (vad) is prevalent in >50% of countries worldwide, with > 250,000 preschool children and many pregnant and lactating mothers affected [18]. vad weakens immunity, stunts growth, increases child and maternal mortality and is the commonest preventable cause of blindness worldwide [19]; eating ofsp reduces rates of blindness [20]. figure 10. eating fruit and vegetables has known beneficial effects for health; increased awareness, production and consumption are fundamental aims of the sdgs. when parents understand that micronutrients in fruit and vegetables improve child health and learning, and especially that they can prevent delayed reading, they are motivated to engage in helping to plant and maintain school gardens [15,21]. parents and children then benefit by acquiring knowledge and skills side by side, and robust improvements in nutrition, food security and sustainable agriculture are achievable [22,23] global health management journal, 2017, vol. 1, no. 1 26 figure 11. vitamin a deficiency is the principal preventable cause of blindness. orange sweet potato consumption preserves vision and is a nutritional adjunct that aids learning the sdgs are a challenge, but importantly, who now endorses school programs as a way to address the social determinants of health worldwide [24, 25]. schools are recognized to provide the most effective and efficient way to reach a large segment of the population, and globally more than 1 billion children have the potential to benefit from change created through sdg-focused initiatives based on the who hps model. figure 12. education in safe and supportive schools is a powerful determinant of health (5). children engaged in effective who health promoting school initiatives will acquire knowledge and behaviours that directly address the un sustainable development goals. acknowledgement: this work was made possible by invitations to the authors to collaborate at stellenbosch institute for advanced study (stias). stias supports the undp sustainable development goals. the collaboration of the children, parents and teachers in who health promoting school projects supported by rose charities canada (hillman medical education fund) is central to their success. 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 references 1. www.un.org/sustainabledevelopment/sustainabledevelopment-goals (accessed september 10 2016) 2. world health organization (2013). what is a health promoting school? http://who.int/school_youth_health/gshi/hps/en/in dex.html. (accessed september 10 2016) 3. west p, sweeting p, leyland a. school effects on pupil’s health behaviours: evidence in support of health promoting school. research papers in education. 2004; 19(30): 261-292. 4. tang k, nutbeam d, aldinger c, st leger l, bundy d, hoffmann m et al. schools for health, education and development: a call for action. health promotion international. 2008; 24(1):6877. 5. viner rm, ozer em, denny s, marmot m, resnick m, fatsui a et al. adolescence and the social determinants of health. the lancet. 2012; 379(9826):1641-52. 6. kwan syl, petersen pe, pine cm, orutta a. health-promoting schools: an opportunity for oral health promotion. bulletin world health organization 2005; 83(10):1590/s004296862005000900013 7. migele j, ombeki s, ayalo m, biggerstaff m. diarrhea prevention in kenyan school through the use of simple safe water and hygiene intervention. american journal of hygiene and tropical medicine. 2007; 76: 351-353. 8. macnab aj. mukisa r, mutabazi s, steed r. malaria in uganda: school-based rapid diagnostic testing and treatment. int j epidemiology 2016; doi: 10.1093/ije/dyw262 9. mukisa r, macnab aj, mutabazi s, steed r. teachers as agents of change: school-based diagnosis of malaria positively impacts child morbidity. proceedings of the international http://www.un.org/sustainabledevelopment/sustainable-development-goals http://www.un.org/sustainabledevelopment/sustainable-development-goals http://who.int/school_youth_health/gshi/hps/en/index.html http://who.int/school_youth_health/gshi/hps/en/index.html 27 global health management journal, 2017, vol. 1, no. 1 conference on applied science and health. 2017; 93-102. http://publications.inschool.id/index.php/icash 10. kirby d, obasi a, laris b. the effectiveness of sex education and hiv education interventions in schools in developing countries. who technical report series. 2006: 938:103-150. 11. paul-ebhohimhen va, poobalan a, van teijlingen er. a systematic review of school-based sexual health interventions to prevent sti/hiv in subsaharan africa. bmc public health 2008; 8(4) doi:10.1186/1471-2458-8-4 12. miguel e, kremer m. worms: identifying impacts on education and health in the presence of treatment externalities. econometrica. 2004; 72(1): 159-217. 13. royal horticultural society. food growing in schools taskforce report. 2012 pp. 1-66. http://www.gardenorganic.org.uk 14. armstrong d. a survey of community gardens in upstate new york: implications for health promotion and community development. health and place. 2000; 6:319-327. 15. macnab aj, kasangaki a. ‘many voices, one song’: a model for an oral health programme as a first step in establishing a health promoting school. health promotion international. 2012; 27(1): 6373, doi: 10.1093/heapro/dar039 16. bundy da, shaeffer s, jukes m, beegle k, gillespie a, drake l et al. school-based health and nutrition programs. in: jamison dt, breman jg, measham ar. editors. disease control priorities in developing countries. the world bank, washington, dc, 2nd edition. 2006; pp 10911108. 17. hotz c, loechl c, de brauw a, eozenou p, gilligan d, moursi m et al. a large-scale intervention to introduce orange sweet potato in rural mozambique increases vitamin a intakes among children and women. british journal of nutrition. 2012; 108(01): 163-76. 18. who. global prevalence of vitamin a deficiency in populations at risk 1995-2005. who global database on vitamin a deficiency. geneva: world health organization. 2009 19. who vitamin a deficiency | micronutrient deficiencies http://www.who.int/nutrition/topics/vad/en/ (accessed march 20 2017) 20. low jw, arimond m, osman n, cunguara b, zano f, tschirley d. a food-based approach introducing orange-fleshed sweet potatoes increased vitamin a intake and serum retinol concentrations in young children in rural mozambique. the journal of nutrition. 2007; 137(5): 1320-7. 21. knai c, pomerleau j, lock k, mckee m. getting children to eat more fruit and vegetables: a systematic review. preventive medicine, 2006; 42(2): 85-95. 22. pérez-rodrigo c, aranceta j. school-based nutrition education: lessons learned and new perspectives. public health nutrition. 2001; 4(1a): 131-9. 23. macnab aj, gagnon f, stewart, d. health promoting schools: consensus, challenges and potential. health education. 2014; 114(3):170185. 24. commission on social determinants of health. closing the gap in a generation: health equity through action on the social determinants of health: final report of the commission on social determinants of health. world health organization, geneva. 2008. 25. marmot m, friel s, bell r, houweling ta, taylor s, and commission on social determinants of health. closing the gap in a generation: health equity through action on the social determinants of health. the lancet. 2008; 372(9650): 1661-1669. http://publications.inschool.id/index.php/icash http://www.gardenorganic.org.uk/ http://www.who.int/nutrition/topics/vad/en/ 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. 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 systemwith quality control and cost control framework [1]. implementation of health services that remain of good qualitywith 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). thismade 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 kemuliaanhospital in batamhave the potential to be one of the examples of general surgery patientswith guaranteedbpjs in health sector from inpatient claims data in the general surgery section in the period january todecember 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 treatmentmeasures, amounting to 12 people, including themain 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 2017was 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 andunits 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 manygeneral surgeons already knew that the cost ofacuteappendicitis services in patientswith 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, andmay 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. zibarechou in 1992 stated that a personwho aware of costswould 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 disposablematerials 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 managementmonitoring carried out on the service of acute appendicitis patients with bpjs in helath sector was by implementing a utilization review andmonitoring of hospital income disparity with income from ina-cbgs. utilization review as a control systemwas 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 themedical services was still lack of monitoring. the head of themedical services whichwas 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 fromeach component of the service cost ofacuteappendicitis is strengthened by incomplete txtdata. inputting the hospital billing grouping to the txtdata variable forbpjs 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 pkumuhammadiyah surakarta penerapan manajemen pasien saraf dalam rangka peningkatan mutu pelayanan di rumah sakit (analysis of application of patient management. analysis of pkumuhammadiyah surakarta application of management of nerve patients to improve service quality in hospitals). surakarta: muhammadiyah university of surakarta; 2013. 3. ministry of health of the republic of indonesia. peraturan menteri kesehatan republik indonesia nomor 27 tahun 2014 tentang petunjuk teknis sistem indonesian case base groups (ina-cbgs) (regulation of the minister of health of the republic of indonesia number 27 of 2014 concerning technical guidelines for the indonesian case base groups (ina-cbgs) system). jakarta: ministry of health. 2014. 4. suhartoyo. klaim rumah sakit kepada bpjs kesehatan berkaitan dengan rawat inap dengan sistem inaâăş cbgs (claims of the hospital to bpjs health insurance relating to hospitalization with the ina-cbgs system). adminitrative law & governance journal. 2018;1(1). 5. hanna p., subanegara, modul cost containment (pengendalian biaya di rumah sakit) (modul of cost containment (cost control at the hospital)). (online). 2010, https://www.slideshare.net/aak6666/modulcost-containtment, accessed on may 24, 2018 6. allan g.m., joel l., natasha w. physician awareness of drug cost: a systematic review. plos medicine. 2007;4(9). 7. paruntu, s. analisis cost awareness dan cost monitoring untuk efisiensi biaya pelayanan di sub departemen radiologi rumkital dr. mintohardjo (studi kasus : pelayanan thoraks ap/pa foto) (analysis cost awareness andmonitoring cost for service cost efficiency in the radiology sub department of dr. mintohardjo (case study: thorax service ap / pa photo)). jakarta: university of indonesia; 2012. 8. rechou, z. cost awareness among staff level hospital nurse. proquest dissertations and theses. 1992 9. cheah, j. development and implementation of a clinical pathway program in an acute care general hospital in singapore. international journal for quality in healthcare. 2000;12(5):403-12. 10. spath, p.l. clinical path: tools for outcomes management. chicago: american hospital publishing. inc; 1994. 11. allen, n. j., john p. meyer. the measurement and antecedents of affective, continuance, and normative commitment to the organization. journal of occupational psychology. 1990: 1-18. 12. aden, c. m. mutu pelayanan kesehatan (quality of health service). (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 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.   cite this article as  sawasdee k, choksawad p, pimcharoen s, prapainop k. development of size‐tunable  polymeric nanoparticles for drug delivery applications. global health management  journal. 2017; 1(2): 31‐6.    global health management journal  www.publications.inschool.id  published by  original research article issn 2580-9296 (online) development of size-tunable polymeric nanoparticles for drug delivery applications komkrich sawasdee 1, ployphailin choksawad 1, sopida pimcharoen 2, kanlaya prapainop1,* 1 department of biochemistry, faculty of science, mahidol university, bangkok, thailand. 2 samsenwittayalai school, rama vi road, bangkok, thailand. *corresponding author. email: kanlaya.pra@mahidol.edu article info abstract article history: submitted 16 october 2017 accepted 27 october 2017 background: poly lactide-co-glycolide (plga) nanoparticles (nps) have been widely used in drug delivery applications because of their excellent properties such as biocompatibility, and biodegradability along with the ability to deliver hydrophobic drugs, increase drug bioavailability and improve drug absorption to targeted cells in both oral and parenteral administrations. the plga nps can be synthesized using an emulsion solvent evaporation method. each parameter during synthesis plays a role in the formation of nanoparticles and can affect np size; important factors for successful development of a drug delivery system. aims: the aim of this study was to prepare different sizes of plga nps by investigation of four factors (molecular weight, mw) of plga, emulsifier concentrations, organic solvent type and power of ultrasonication) involved in plga nanoparticle synthesis. methods: plga nanoparticles were prepared by an emulsion solvent evaporation method. size and size distribution were analyzed by dynamic light scattering and polydispersity index (pdi). results: the effect of four parameters: plga mw, emulsifier concentrations, solvent types, and amplitude of ultrasonication on plga nps preparation were evaluated. changing one parameter results in different sizes of plga nps that varied from 150300 nm. pdi which is an indicator for determination of size distribution of nps, varied with an overall value <0.2. conclusion: mw of plga polymer, emulsifier concentration, type of organic solvent and power of ultrasonication affect the size and size distribution of plga nps. keywords: drug delivery polymeric nanoparticles tunable size of nanoparticles © 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 cancer is a worldwide health problem with millions of people suffering from this disease in both economically developed countries and developing countries [1]. the current strategies for treatment of cancer include surgery, radiation, immunotherapy or chemotherapy. the chemotherapeutic drug is administered intravenously can spread to accumulate in offtargeted tissues or organs leading to undesirable side effects. to solve these problems, anti-cancer drug loaded nanoparticles have gained extensive attention to use as an effective drug delivery system to specific target sites [1, 2]. polymeric nps have unique properties including stability, biocompatibility and ease of surface chemistry modification [3, 4]. therefore these nanoparticles have been used in drug delivery global health management journal, 2017, vol. 1, no. 2  32      systems to protect drugs from bioand chemical degradation which also help to increase drug stability. in addition, the nanoparticle surface can be further modified for specific targeting purposes. for example, nps are conjugated with specific antibodies against cancer cells and used to deliver anti-cancer drugs for therapeutic purpose [5]. poly lactide-co-glycolide (plga) is one of the polymers that can form nanoparticles [6]. this linear copolymer can be hydrolyzed into the two non-toxic monomers: lactic acid and glycolic acid [7], therefore, plga has been approved for use in biomedical applications such as drug delivery by the united states food and drug administration (fda) and european medicine agency (ema) [8, 9]. in order to develop a successful drug carrier system, the size of nps is a key factor especially in cancer therapy [1, 2]. several reports show that size and size distribution of nps play important role in term of in vivo biodistribution, biological fate and toxicity [10]. smaller particles have relatively higher uptake efficiency to the targeted cells compared to larger particles but have smaller inner space for drug entrapment [11]. in addition, the drugs in the small nps are at or near the particle surface, leading to faster drug release compared to large particle size [12]. this faster release rate in smaller nanoparticles was also observed in a bovine serum albumin protein release model [13]. therefore, the small nps would be suitable for drug delivery that requires fast release rate whereas the large particles would be appropriate for drug that requires slow release rate. due to the importance of drug carrier size, the development of synthesis methods for preparation of different np sizes is important to provide the most optimal size and property to each specific drug delivery requirement [14]. this study focuses on development of tunable size of plga nps. four different parameters that might affect particle sizes (molecular weight of plga polymer, emulsifier concentrations, type of organic solvent and power of ultrasonication) are investigated. the overall scheme of plga nps synthesis is shown in figure 1. figure 1. schematic representation of general procedure of preparation of plga nanoparticle by emulsion solvent evaporation method. 33                                 global health management journal, 2017, vol. 1, no. 2        methods materials plga nps were prepared by a modification of emulsion solvent evaporation method as previously described [15,16]. four parameters were investigated: (i) size of plga polymer (60,000 g/mol and 80,000 g/mol), (ii) concentration of pva that acts as emulsifier (1-10 % (w/v)), (iii) type of organic solvent (etoac and dcm) and (iv) power of ultrasonication (10%, 35% and 38% amplitude). preparation of plga nps plga nps were prepared by a modification of emulsion solvent evaporation method as previously described [15, 16]. four parameters were investigated: (i) size of plga polymer (60,000 g/mol and 80,000 g/mol), (ii) concentration of pva that acts as emulsifier (1-10 % (w/v)), (iii) type of organic solvent (etoac and dcm) and (iv) power of ultrasonication (10%, 35% and 38% amplitude). preparation of plga nps using different molecular weight of plga a total of 50 mg of two different mw of plga polymer (60,000 and 80,000 g/mol) was dissolved in 0.5 ml etoac. the plga solution was added dropwise to 2 ml of pva dissolved in water under vortex. afterwards, the emulsion solution was treated with 3 cycles of 30 seconds pulse (38% amplitude). at the end of the cycles, the solution was quickly added into 25 ml of 0.3 % pva under stirring for 4 hours to evaporate the organic solvent. the plga nanoparticles were collected by centrifugation at 15,000 rpm for 15 minutes. after that, plga nanoparticles were washed for three times with deionized water and followed by lyophilization. preparation of plga nps using different emulsifier concentrations to study the effect of emulsifier concentrations, 50 mg plga polymer (60,000 g/mol) was dissolved in 0.5 ml etoac. the plga solution was added dropwise to 2 ml of different pva concentrations dissolved in water (1%, 5% and 10% (w/v)) under vortex. the mixture was emulsified, collected and stored using the same procedure as described above. preparation of plga nps using different organic solvent types to study the effect of organic solvent type, 50 mg plga polymer (60,000 g/mol) was dissolved in 0.5 ml of different organic solvents (etoac or dcm). the plga solution was added dropwise to 2 ml of 5% (w/v) pva dissolved in water under vortex. the mixture was emulsified, collected and stored using the same procedure as described above. preparation of plga nps using different power of ultrasonication to study the last parameter: the power of ultrasonication, 50 mg plga polymer (60,000 g/mol) was dissolved in 0.5 ml etoac. the plga solution was added dropwise to 2 ml of 5% (w/v) pva dissolved in water under vortex. the mixed solution was subsequently emulsified by sonication with 3 cycles of 30-second pulses (10%, 35% and 38% amplitude). the mixture was collected and stored using the same procedure as described above. characterization of particle size and pdi value nps were dispersed in milli q water at concentration of 0.1 mg/ml before characterization. the size and pdi value of the particles were analyzed using nanosizer 90 zs (malvern instrument ltd., malvern, uk) at 25c. all measurements were carried out as the average of value with triplicate measurements and at least 10 runs within each analysis. the results were reported as a mean of three independent readings  standard deviation. results plga np size and size distribution from different mw of plga in this experiment, the particles prepared by 60,000 and 80,000 g/mol plga have a size about 179 and 261 nm respectively (figure 2). both nps prepared by the two mw showed pdi values less global health management journal, 2017, vol. 1, no. 2  34      than 0.2 which indicated that the nps were monodispersed. figure 2. characterization of plga nps prepared using different molecular weight of plga. the 5% pva, etoac was applied to the reaction and 38% power of sonication was used. size (black bars, left yaxis) and pdi (white bars, right y-axis) values are presented. plga np size and size distribution from different emulsifier concentrations and organic solvent types the sizes of plga nanoparticles decreased when the pva concentration was increased (figure 3). using etoac as solvent (figure 3a), at 1% (w/v) pva, the particle size was about 259 nm. when the pva concentration was increased to 5% and 10% (w/v), the particle sizes were 179 and 176 nm, respectively. it was found that at 5% and 10% (w/v) pva the particle sizes were not significantly different. the pdi value that indicates nanoparticle size distribution showed the value less than 0.2 which suggested that plga nanoparticles prepared by these pva concentrations were monodispersed. similar results were also obtained from nps preparation using dcm as a solvent (figure 3b). nps size and pdi values prepared in etoac were smaller (170-220 nm) (figure 3a) than the particles that prepared in dcm (300-500 nm) (figure 3b). figure 3. characterization of plga nps prepared using different pva concentrations and different solvents. a) nps prepared using etoac, b) nps prepared using dcm. the 60,000 g/mol plga, and solvent were applied to the reaction and 38% power of sonication was used. size (black bar, left y-axis) and pdi (white bars, right y-axis) values are presented. plga np size and size distribution from different power of ultrasonication nps prepared by 38% sonication were of smaller size (179 nm) than particles prepared by 10% (246 nm). this result indicated that higher power of sonication induced the production of smaller size of nps. the pdi values from both conditions were less than 0.2 that represented monodispersity of nps (figure 4). 35                                 global health management journal, 2017, vol. 1, no. 2        figure 4. characterization of plga nps prepared by using different ultrasonication power. the 5% pva, 60,000 g/mol plga and etoac were applied to the reaction. size (black bars, left y-axis) and pdi (white bars, right y-axis) values are presented. plga np size after long storage in aqueous solution to use nps as a drug delivery system the stability of drug carrier is important. figure 5 illustrates examples of nps size after long storage in aqueous solution up to 7 months. the nps size remains similar to short storage time and no sign of aggregation was observed. this result suggested that the obtained plga nps are stable up to 7 months and has high potential for development as a drug carrier system. figure 5. characterization of plga nps prepared by using different pva concentrations and after long term storage. nps prepared using 60,000 g/mol plga, and etoac were applied to the reaction and 35% power of sonication was used. size after one week (black bars) and size after 7 months (white bars) are presented. discussion plga np size is easily tunable by simple changes in the synthesis parameters. with high mw of plga a larger particle size is produced because the long chain of polymer can induce larger oil droplets [17]. data show that pva can be used to stabilize emulsion and lead to formation of small and monodispersed particles [18, 19]. therefore, when increasing the concentration of pva the size of particles tend to decrease. in addition, organic solvent can affect the particles size of plga nps. the nps prepared by dcm were bigger than particles prepared by etoac. these results could be due to different properties of the solvent. dcm is a non-miscible solvent in water, unlike etoac. therefore, dcm has a higher surface tension in oil droplets from the emulsion step, resulting in larger nanoparticles [20]. apart from mw, emulsifier concentrations and organic solvent type, power of sonication can affect particle size. the power of sonication applied to the emulsion step can disrupt the surface tension of the larger oil drops to create a smaller oil drop which leads to formation of smaller particles as previously observed [21]. conclusion different sizes of plga nps were successfully prepared by changing each of four synthesis parameters. the factors that contribute to the achievement of desirable size are plga mw, pva concentrations, organic solvent type, and sonication power. the nps obtained are stable in aqueous solution, and therefore are suitable for further development as a drug carrier system for cancer treatment. acknowledgements this project was supported by mahidol university and faculty of science, mahidol university, development and promotion of science and technology talents project. this project was partially supported by cif grant, faculty of science, mahidol university. ks was supported by research assistantships, faculty of graduate studies, mahidol university. pc was supported by science achievement scholarship of thailand. sp was supported by development and promotion of science and technology talents project. global health management journal, 2017, vol. 1, no. 2  36      conflict of interests the authors have no conflict of interests. references 1. tabatabaei mirakabad fsn-k, kazem; akbarzadeh, abolfazl; yamchi, mohammad rahmati; milani, mortaza; zarghami, nosratollah; zeighamian, vahideh; rahimzadeh, amirbahman; alimohammadi, somayeh; hanifehpour, younes; joo, sang woo. plga-based nanoparticles as cancer drug delivery systems. asian pacific journal of cancer prevention. 2014;15(2):517-35. 2. dinarvand r, sepehri n, manoochehri s, rouhani h, atyabi f. polylactide-co-glycolide nanoparticles for controlled delivery of anticancer agents. international journal of nanomedicine. 2011;6:877-95. 3. marguet m, bonduelle c, lecommandoux s. multicompartmentalized polymeric systems: towards biomimetic cellular structure and function. chemical society reviews. 2013;42(2):512-29. 4. kumari a, yadav sk, yadav sc. biodegradable polymeric nanoparticles based drug delivery systems. colloids and surfaces b: biointerfaces. 2010;75(1):1-18. 5. kocbek p, obermajer n, cegnar m, kos j, kristl j. targeting cancer cells using plga nanoparticles surface modified with monoclonal antibody. journal of controlled release. 2007;120(1):18-26. 6. yin win k, feng s-s. effects of particle size and surface coating on cellular uptake of polymeric nanoparticles for oral delivery of anticancer drugs. biomaterials. 2005;26(15):2713-22. 7. zhou s, deng x, li x, jia w, liu l. synthesis and characterization of biodegradable low molecular weight aliphatic polyesters and their use in proteindelivery systems. journal of applied polymer science. 2004;91(3):1848-56. 8. danhier f, ansorena e, silva jm, coco r, le breton a, préat v. plga-based nanoparticles: an overview of biomedical applications. journal of controlled release. 2012;161(2):505-22. 9. lü j-m, wang x, marin-muller c, wang h, lin ph, yao q, et al. current advances in research and clinical applications of plga-based nanotechnology. expert review of molecular diagnostics. 2009;9(4):325-41. 10. alexis f, pridgen e, molnar lk, farokhzad oc. factors affecting the clearance and biodistribution of polymeric nanoparticles. molecular pharmaceutics. 2008;5(4):505-15. 11. singh r, lillard jw. nanoparticle-based targeted drug delivery. experimental and molecular pathology. 2009;86(3):215-23. 12. redhead hm, davis ss, illum l. drug delivery in poly(lactide-co-glycolide) nanoparticles surface modified with poloxamer 407 and poloxamine 908: in vitro characterisation and in vivo evaluation. journal of controlled release. 2001;70(3):353-63. 13. panyam j, dali mm, sahoo sk, ma w, chakravarthi ss, amidon gl, et al. polymer degradation and in vitro release of a model protein from poly(d,l-lactideco-glycolide) nanoand microparticles. journal of controlled release. 2003;92(1):173-87. 14. choi hs, liu w, misra p, tanaka e, zimmer jp, ipe bi, et al. renal clearance of nanoparticles. nature biotechnology. 2007;25(10):1165-70. 15. montalvo-ortiz bl, sosa b, griebenow k. improved enzyme activity and stability in polymer microspheres by encapsulation of protein nanospheres. aaps pharmscitech. 2012;13(2):632-6. 16. morales-cruz m, flores-fernández gm, moralescruz m, orellano ea, rodriguez-martinez ja, ruiz m, et al. two-step nanoprecipitation for the production of protein-loaded plga nanospheres. results in pharma sciences. 2012;2:79-85. 17. mittal g, sahana dk, bhardwaj v, ravi kumar mnv. estradiol loaded plga nanoparticles for oral administration: effect of polymer molecular weight and copolymer composition on release behavior in vitro and in vivo. journal of controlled release. 2007;119(1):77-85. 18. dutschk v, chen j, petzold g, vogel r, clausse d, ravera f, et al. the role of emulsifier in stabilization of emulsions containing colloidal alumina particles. colloids and surfaces a: physicochemical and engineering aspects. 2012;413(supplement c):23947. 19. sahoo sk, panyam j, prabha s, labhasetwar v. residual polyvinyl alcohol associated with poly (d,llactide-co-glycolide) nanoparticles affects their physical properties and cellular uptake. journal of controlled release. 2002;82(1):105-14. 20. mccall rl, sirianni rw. plga nanoparticles formed by singleor double-emulsion with vitamin e-tpgs. journal of visualized experiments : jove. 2013(82):51015. 21. bilati u, allémann e, doelker e. sonication parameters for the preparation of biodegradable nanocapsulesof controlled size by the double emulsion method. pharmaceutical development and technology. 2003;8(1):1-9. 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 formof 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 andmassive amounts of money have been saved by preventing diseases like polio, diphtheria tetanus and smallpox [3, 4], andmeasles immunization is estimated bywho 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 threemonths of 2019 the incidence ofmeasles worldwide has tripled comparedwith 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 themost contagious viruses around, the rise in the number of casesmay 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 solutionswe 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 turningmore andmore 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. simplemeasures that can be used tomake 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. wemust 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, especiallywhenwe involve families in research. in this context iwonder howmany 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 theworld’s population [13]. themechanisms 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, bockhl, clemens j, datta sk, john tj, lee bw, lolekha s, peltolah, 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 whohealth 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 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 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. 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.   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. 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.   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 s, guyatt h, omumbo j, shretta r, drake l, ouma j. situation analysis of malaria in school-aged children in kenya–what can be done? parasitology today. 2000;16(5):183-86. 2. jukes mch, drake lj, bundy dap. challenges for child health and nutrition. in: school health, nutritional and education for all: levelling the playing field. cab international publishing, cambridge, usa. chapter 2, pages 11-31. 2008 www.cabi-publishing.org 3. snow rw, craig mh, newton cr, steketee rw. the public health burden of plasmodium falciparum malaria in africa. fogarty international center, national institutes of health. working paper 11, disease control priorities project, bethesda, maryland, usa. pages 1-80 2003 4. jukes mc, pinder m, grigorenko el, smith hb, walraven g, bariau em et al. long-term impact of malaria chemoprophylaxis on cognitive abilities and educational attainment: follow-up of a controlled trial. plos clinical trials. 2006;1(4):e9 5. kihara m, carter ja, newton cr. the effect of plasmodium falciparum on cognition: a systematic review. tropical medicine and international health. 2006;11(4):386-97. 6. world health organization. world malaria report 2014. geneva, world health organization. 2014. 7. källander k, nsungwa-sabiiti j, peterson s. symptom overlap for malaria and pneumonia— policy implications for home management strategies. acta tropica. 2014;90(2):211-214. 8. mutabingwa tk. artemisinin-based combination therapies (acts): best hope for malaria treatment but inaccessible to the needy! acta tropica. 2005;95(3):305-15. 9. kilian ah, kabagambe g, byamukama w, langi p, weis p, von sonnenburg f. application of the parasight™-f dipstick test for malaria diagnosis in a district control program. acta tropica. 1999;72(3):281-93. 10. guthmann jp, ruiz a, priotto g, kiguli j, bonte l, legros d. validity, reliability and ease of use in the field of five rapid tests for the diagnosis of plasmodium falciparum malaria in uganda. transactions of the royal society of tropical medicine and hygiene. 2002;96(3):254-57. 11. world health organization. malaria 2015. geneva, world health organization. 2015. 12. abba k, deeks jj, olliaro pl, naing cm, jackson sm, takwoingi y et al. rapid diagnostic tests for diagnosing uncomplicated p. falciparum malaria in endemic countries. the cochrane library. jan 1 2011. 13. malaria consortium 2015; http://www.malariaconsortium.org/pages/112.ht m. accessed dec 30, 2016. 14. international artemisinin study group. artesenuate combinations for treatment of malaria: meta-analysis. the lancet. 2004;363(9402):9-17. 15. macnab aj, stewart d, gagnon f. health promoting schools: initiatives in africa. health education. 2014;114(4):246-59. 16. mukisa r, macnab aj, mutabazi s, steed r. teachers as agents of change: school-based diagnosis and treatment of malaria positively impacts child morbidity. in: proceedings of the international conference on applied science and health 2017 feb 22 (no. 1). http://publications.inschool.id/index.php/icash/a rticle/view/19 17. baum f, macdougall c, smith d. participatory action research. journal of epidemiology and community health. 2006;60(10):854-57. 18. 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):1759-62. 19. benjamin j, moore b, lee st, senn m, griffin s, lautu d et al. artemisinin-naphthoquine combination therapy for uncomplicated pediatric malaria: a tolerability, safety, and preliminary efficacy study. antimicrobial agents and chemotherapy. 2012;56(5):2465–71. 20. chandler ci, hall-clifford r, asaph t, pascal m, clarke s, mbonye ak. introducing malaria rapid diagnostic tests at registered drug shops in uganda: limitations of diagnostic testing in the reality of diagnosis. social science & medicine. 2011;72(6):937-44. global health management journal, 2017, vol. 1, no. 2  52      21. kyaabayinze dl, asiimwe c, nakanjko d, nabakooza j, counihan h, tibenderana jk. use of rdts to improve malaria diagnosis and fever case management at primary health care facilities in uganda, malaria journal. 2010;9(1):1. 22. mbonye ak, magnussen p, lai s, hansen ks, cundill b, chandler c et al. a cluster randomized trial introducing rapid diagnostic tests in registered drug shops in uganda: impact on appropriate treatment of malaria. plos one. 2015;10(7):e0129545. 23. fernando sd, rodrigo c, rajapaske s. the ‘hidden’ burden of malaria: cognitive impairment following infection. malaria journal. 2010;9(1):1. 24. white n, pukrittayakarnee s, hien tt, faiz ma, mokuolu oa, dondorp am. malaria. the lancet. 2014;383(9998):723-35. 25. fernando d, de silva d, wickremasinghe r. short-term impact of an acute attack of malaria on the cognitive performance of schoolchildren living in a malaria-endemic area of sri lanka. transactions of the royal society of tropical medicine and hygiene. 2003:97(6):633-9. 26. lasker rd, weiss es. broadening participation in community problem solving: a multidisciplinary model to support collaborative practice and research. journal of urban health. 2003;80(1):14-47. 27. commission on social determinants of health. closing the gap in a generation: health equity through action on the social determinants of health: final report of the commission on social determinants of health. world health organization, geneva. 2008. 28. brooker s, kabatereine nb, fleming f, devlin n. cost and cost-effectiveness of nationwide school-based helminth control in uganda: intracountry variation and effects of scaling-up. health policy and planning. 2008;23(1):24-35. 29. temperley m, mueller dh, njagi jk, akhwale w, clarke se, jukes mc et al. costs and costeffectiveness of delivering intermittent preventive treatment through schools in western kenya. malaria journal. 2008;7(1):1. 30. okello g, ndegwa sn, haliday ke, hanson k, brooker sj, jones c. local perceptions of intermittent screening and treatment for malaria in school children on the south coast of kenya. malaria journal. 2012;11(1):1. 31. fernando d, de silva d, carter r, mendis kn, wickremasinghe r. a randomized, doubleblind, placebo-controlled, clinical trial of the impact of malaria prevention on the educational attainment of school children. the american journal of tropical medicine and hygiene. 2006;74(3):386-93. 32. magnussen p, ndawi b, sheshe ak, byskov j, mbwana k. malaria diagnosis and treatment administered by teachers in primary schools in tanzania. tropical medicine and international health 2001;6(4):273-79. 33. drake tl, okello g, njagi k, halliday ke, jukes mc, mangham l et al. cost analysis of school-based intermittent screening and treatment of malaria in kenya. malaria journal. 2011;10(1):1. 34. fernando sd, gunawardena dm, bandara mr, de silva d, carter r, mendis kn et al. the impact of repeated malaria attacks on the school performance of children. the american journal of tropical medicine and 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 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. microsoft word 3. accepted original, siska evi martina, 9-12.docx cite this article as martina se, bratajaya cna, ernawati. dengue hemorrhagic fever: knowledge, attitude, and practice in palmeriam, jakarta, indonesia. global health management journal. 2018; 2(1): 9-12. global health management journal www.publications.inschool.id published by original research article issn 2580-9296 (online) dengue hemorrhagic fever: knowledge, attitude, and practice in palmeriam, jakarta, indonesia siska evi martina *, cicilia nony ayu bratajaya, ernawati sint carolus school of health sciences, indonesia. *corresponding author. email: evi_sastro@yahoo.com article info abstract article history: received 11 december 2017 reviewed 05 january 2018 received in revised form 14 february 2018 accepted 28 february 2018 background: dengue hemorrhagic fever (dhf) is the most rapidly spreading mosquito-borne viral disease in the world. it is an emerging disease, episodic and occurring annually. aims: this study was to examine the knowledge, attitude, and practice of community in palmeriam, jakarta regarding dengue hemorrhagic fever. methods: a community-based cross-sectional study was designed in this study between june to july 2016. purposive sampling was done to collect data from 148 respondents. results: this study found that average age was 47 years old, 75% were women, and 46.6% finished secondary high school. in another hand, 23.6% respondents had good knowledge, and 49.3% had a neutral attitude for preventing dengue hemorrhagic fever. the study found that 68.2% respondents had a mid-level of practice prevention dengue hemorrhagic fever and it can be improved. this study indicated that the community was quite familiar with dengue hemorrhagic fever, but there was confusion about water storage and environment effect. conclusion: health promotion program and community participation should improve dengue awareness. continuous campaign for enhancing the knowledge and attitude would result in better practice for dhf prevention. keywords: knowledge attitude practice dengue hemorrhagic fever © 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 dengue hemorrhagic fever (dhf) is recognized as emerging infectious diseases. dengue is a viral infection carried by the typical household mosquito (aedes aegypti) and becomes a health problem in tropical countries. in the world, there were about 50 million people infected dhf with 2.5% death reported annually [1]. world health organization (who) has declared that dhf to be endemic in south east asia [1]. tropical areas such as indonesia provide a climate that is conducive to the breeding of dengue-transmitting mosquitoes. since the first case of dhf was reported in 1968 to 2009, who declares indonesia as a country with the highest dhf cases in south east asia [1]. the geographical distribution of dhf has included urban and rural areas, making indonesia as the most rapidly expanding dengue viral disease [2]. jakarta is the capital city of indonesia with the highest incidence rate of dhf [3]. public health office of jakarta reported the incidence rates of dhf were 12,254 cases with 7 mortality in 2012 [3]. the highest incidence was found in palmeriam with 3,801 cases and 134 per 100,000 population, with a 0.08 mortality rate per 100,000 population. then palmeriam is one of the districts in east jakarta with doubling increased incidence rates from 2010 to 2014 [3]. the data showed that palmeriam is one of global health management journal, 2018, vol. 2, no. 1 10 the endemic areas that need attention for dhf prevention. the government of jakarta concerns for decreasing dhf cases by some programs such as chemical insecticidal control. however, the who and centers for disease control and prevention recommend limited reliance on insecticidal control and emphasis on community educational programs that emphasize communities responsibility in reducing vector breeding sites [4,5]. this recommendation is supported by prior research which found that community education was more effective in lowering dengue vector breeding sites than chemicals alone [6]. therefore, the communities should know prevention program of dhf. then, the effective prevention transmission of the dhf requires support, cooperation and participation by the community. the concept of knowledge, attitude, and practice, or is known as kap is a useful conceptual framework for assessing the level of awareness and prevention practices on dengue hemorrhagic fever (dhf) problems in the endemic community [7]. therefore, kap concept was applied to guide this study. the idea explained how knowledge, attitude, and practice deliver benefits to improve participation of communities for doing dhf prevention. this kap study was designed to identify human behavior related to what people know (knowledge), what people feel (attitude), and what people do (practice). therefore, it is essential to know the level of knowledge, attitude, and practice (kap) of the community concerning the dhf. there is limited kap study on dengue in communities in the urban area. it is important to conduct a kap study concerning dengue in urban communities because almost a quarter of dengue cases occur in the urban setting. therefore, through this study, we will define the level of knowledge, attitude, and practice concerning dhf among communities living at palmeriam district in jakarta, one of endemic areas in indonesia. the results will identify the real community situation of dhf prevention and the success of government program. methods the cross-sectional study was conducted between june to july 2016 in district 01 palmeriam, jakarta, indonesia. there were one hundred forty-eight (148) participants where the sample size was determined using slovin’s formula. the purposive sampling was employed within inclusion criteria including; aged 18 to 55 years old, living in district 01 palmeriam, jakarta, able to read, write, and communicate in indonesian, and willing to participate in this study. questionnaires employed in this study were composed of demographic information questionnaire and dhf knowledge, attitude, and practice (kap) questionnaire. the dhf kap was adapted from previous study [8]. the dhf kap questionnaire consisted of 39 items dividing into 3 variables; 1) an interval scale of knowledge (14 items), 2) a likert attitude scale (12 items), and 3) an interval scale to measure practice of prevention dhf (13 items). the internal consistency obtained cronbach’s alpha was knowledge = .79, attitude= .79, and practice of prevention dhf= .80. the study was approved by the head of research center in sint carolus school of health sciences and data was collected after obtaining permission and written consent from the head of public health care and head of the district. the researchers also provided participants information sheets. the participants signed an informed consent before getting questionnaires. participants took approximately 30 to 45 minutes to complete all questions. results all of the participants (148 participants) completed the questionnaire. table 1 describes the sociodemographics of the participants. the majority age of participants was ranged 21 to 44 years old (43.9%) where 75% participants were women, and 46.2% participants had a middle level of education and only 16.2% participants had a high level of education. table 1. distributions and frequencies of sociodemographic of the participants among (n=148) characteristics n % age adolescents (13-20 years) adult (21-44 years) pra-elderly (45-59 years) elderly (≥ 60 years) 4 65 50 29 2.7 43.9 33.8 19.6 gender women men 111 37 75 25 education level elementary school secondary high school university 55 69 24 37.2 46.6 16.2 11 global health management journal, 2018, vol. 2, no. 1 the knowledge in this study divided to 3 levels; low level, moderate level, and high level. as shown in table 2, we noted that most participants had moderate level of knowledge about dhf (45.9%) followed by low level (30.4), where only 23.6% participants had a high level of knowledge. even though the majority of participants had a neutral attitude of prevention dhf (49.3%), the study found that 40.6% participants had a negative attitude of prevention dhf. this study also identifies practice of prevention dhf among participants. only 16.9% participants had a high level of practice of prevention dhf, the most participants (68.1%) had a moderate level of practice of prevention dhf. this finding means that participants did not practice the prevention dhf regularly. table 2. distributions and frequencies of knowledge, attitude, and practice of prevention dengue hemorrhagic fever (n= 148) variables n % knowledge low (0-8 scores) moderate (9-11 scores) high (12-14 scores) 45 68 35 30.4 45.9 23.6 attitude negative (12-40 scores) neutral (41-46 scores) positive (47-60 scores) 60 73 15 40.6 49.3 10.1 practice prevention low (0-4 scores) moderate (5-6 scores) high (7-8 scores) 22 101 25 14.9 68.1 16.9 discussion in this study, only 45.9% of the participants had a moderate level of knowledge about dhf, and 30.4% of the participants had a low level. this refers the participants’ knowledge needs improvements. this finding supported by the previous study that mentioned the majority of participants had heard of dhf, however, the level of knowledge was low. the knowledge will be affected by the attitude and practice regarding dhf. a study in nepal found that the enhancing knowledge is the critical campaign to prevent dhf in the community [9,10]. previous studies show that the level of knowledge was different in some areas. the knowledge should concern the breeding mosquitoes of dhf [11, 12], causes of bite aedes aegypti [11,12,13,14], prevention program [15], signs and symptoms of dhf [12,16], dhf related to seasonal [12], and dhf management [9]. regarding attitude towards dhf control, 40.6% participants in this study was classified as having a negative attitude. this shows that the majority of people had a less perceived risk of dhf and supports toward dhf control. however, this result might also be partially influenced by characteristic individuals who did not perceive the benefit of dhf prevention. this finding similar to previous studies in laos and philippines [17,18]. this is the area needs attention for the modification of health promotion related dhf prevention. the finding reported the majority of participants (68.1%) had a moderate level of practice on prevention dhf. the good practice level will achieve a good knowledge level. the results corresponded with study in central nepal where people with low knowledge of dhf had less potential breeding sites in and around their houses than people with a good knowledge [19]. one of the reasons for middle practice levels attained in this study may be that many questions on practice level were related to daily practices for the control of other common mosquitoborne diseases in this area. in another hand, the previous study reported the most people who had a good attitude towards dhf prevention by monitoring mosquito larvae found half of the people said the obstacle was no time to monitor mosquito larvae [12]. therefore, there is an urgent needed for awareness program to raise the knowledge of people of this area regarding dhf. conclusion the success of the preventive practices of the dhf was strongly influenced by the knowledge and attitudes towards the prevention of dhf. knowledge about the causes of disease, signs and symptoms of dhf, breeding, and the prevention dhf needs to be improved in order for dhf prevention. government should support the communities to improve the knowledge, attitude and practice prevention dhf. acknowledgment the authors are grateful for all participants. we also appreciate sint carolus school of health sciences, indonesia for supporting this study. conflict of interests we certify that there is no actual or potential conflict of interest in relation to this article. global health management journal, 2018, vol. 2, no. 1 12 references 1. world health organization. comprehensive guidelines for prevention and control of dengue and dengue haemorrhagic fever. revised and expanded edition. india: searo technical publication series. 2011. 2. johansson ma, dominici f, glass ge. local and global effect of climate on dengue transmission in puerto rico. plos neglected tropical diseases, 2009; 3(2), p. 382. 3. departemen kesehatan. profil kesehatan dki jakarta. 2012. avilable from: www.depkes.go.id/resources/download/profil/prof il_kes_provinsi_2012/11%20profil_kes.prov. dkijakarta_2012.pdf 4. cdc cfdcap. dengue fever. colorado: cdc; 2005. available from: http://www.cdc.gov/ncidod/dvbid/dengue/dengueqa.htm. 5. who geneva. dengue hemorrhagic fever: diagnosis, treatment, prevention and control. geneva: world health organization; 1997. 6. espinoza-gómez f, hernández-suárez c, collcárdenas r. educational campaign versus malathion spraying for the control of aedes aegypti in colima, mexico. journal of epidemiology and community health. 2002; 56(2):148–52. 7. malhotra v, kaur p. the community knowledge, attitude and practice regarding dengue fever in field practice area of urban training health center of patiala. int j res dev health. 2014; 2(1): 19-26. 8. ahmed n. knowledge, attitude, and practice of dengue fever prevention among the people in male, maldives. master thesis, chulalongkorn university, thailand. 2007. 9. castro m, sanchez l, perez d, sebrango c, shkedy z, van der stuyft p. the relationship between economic status, knowledge on dengue, risk perceptions and practices. plos one, 2013; 8(12): e81875. 10. dhimal m, aryal kk, lamichane m, gautam i, singh sp, bhousol cl. knowledge, attitude, and practice regarding dengue fever among the healthy population of highland and lowland community in central nepal. plos one, 2014; 9(7): e102028. 11. koeraadt jmc, tueten w, sithiprasasna r, kijchalao u, jones wj, scott wt. dengue knowledge and practice and their impact on aedes aegypti populations in kampheng phet, thailand. j trop med. 2006;74 (4), 692-700. 12. nerlander l., chau tn, nguyen t. study on knowledge, attitudes, and practices of community members in tien giang and ho chi minch city with regards to dengue fever and climate change. international federation of red cross and red crescent societies. 2011. 13. malhotra v, kaur p. the community knowledge, attitude and practice regarding dengue fever in field practice area of urban training health center of patiala. int j res dev health.2014; 2(1): 19-26. 14. gunasekara tdcp, velathanthiri vgns, weeraskara mm, fernando ssn, peelewattage m, & fernando s. knowledge, attitudes and practices regarding dengue fever in sub-urban community in sri lanka. galle medical journal. 2012;17(1), 10-15. 15. itrat a, khan a, javaid s, kamal m, khan h, javed, s, et al. knowledge, awareness and practices regarding dengue fever among the adult population of dengue hit cosmopolitan. plos one.2008;3(7). 16. shuaib f, todd d, campebell-stennett d, ehiri j, jolly ep. knowledge, attitudes and practices regarding dengue infection in westmoreland, jamaica. west indian med. 2010; 59(2),139-146. 17. mayxay m, cui w, thammavong s, khensakhou k, vongxay v, inthasoum l, at al. dengue in peri-urban pak-ngum district, vientiane capital of laos: a community survey on knowledge, attitudes and practices. bmc public health. 2013;13:434. 18. yboa bc, labrage lj. dengue knowledge and preventive practices among rural residents in samar on provinces, philipines. am j public health res. 2013;1:47-52. 19. dhimal m, aryal kk, dhimal ml, gautam i, singh sp, et al. knowledge, attitude and practice regarding dengue fever among the healthy population of highland and lowland communities in central nepal. plos one.2014; 9(7). 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? 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. 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 christyanni1, dedi cahyo nusantoro2 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 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 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 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. 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 baby at conception : proposing a scientific hypothesis. 2015, 3(5); 664-668. 3. aasia khatoon khattak. female infanticide and killing women for giving birth to a baby girl. a case study of pakistan. proceedings of socioint14-international conference on social sciences and humanities. istanmbul, turki. 8-10 september 2014. 4. primacio, r; millot, h; jacob, c. early fetal sex determination using cell-free dna in microvolume of maternal plasma. journal of pregnancy and child health. 2017. (4);6. 5. hesketh therese & zhu whei xing. the consequences of son preference and sex selective abortion in china and other asian countries. canadian association medical journal. 2011; 183 (12): 1374-1377. 6. jain tarun, missmer as, gupta raina, hornstein md. preimplantation sex selection demand and preference in an infertility population. 7. eftekhaari, tasnim, nejatizadeh a, rajaei m, mahmoudi f. ethical considerations in sex selection. journal of education and health promotion. 2015 (4); 32. 8. stern, hj. preimplantation genetic diagnosis : prenatal testing for embryos finally achieving its potential. journal of clinical medicine. 2014 (3); 280-309. 9. w. dondorp et al. eshre task force on ethics and law 20: sex selection for non medical reasons. human reproduction. 2013; 28:6: 1448-1454. 10. human fertilization and embriology authority, “sex selection: choice and responsibility in human reproduction,” 2003. 11. r. baiduri, “the meaning and dimensions of work : women traders toba-batak (inang-inang) in medan, north sumatera, indonesia. international journal of humanities and social sciene. 2014; 4 (1): 66-74, 2014. 12. a. stark, “the matrilineal system of the minangkabau and its persistence throughout history : a structural perspective,” southeast asia : a multidisciplinary journal. 2013 (13) :1-13. 13. guiltomo cz. mapping gender prefferences and sex imbalances in indonesia. population studies: a journal of demography.2015. 14. budiyanti, rt, sulistyono, a, pujiyono. sex selection in indonesia : an ethical and legal perspective. eubios journal of asian and international bioethics. 2017 (january); 19-21. 15. bertens, k. etika biomedis. yogyakarta, indonesia, kanisius. 2011 16. mohan, rs. primum non nocere and neurosurgical management of brain tumors. 2005. nepal journal of neuroscience (2) : 95. 17. tom beauchamp/james childress. principle of biomedical ethics 7th edition. oxford university. 2013. 18. merino, s; aruanno me, gelpi rj, rancich, am. the prohibition of euthanasia and medical oaths of hippocratic stemma. acta bioethica. 2017. 23 (1): 171-178. 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. 
 10. hong, t.t. the health risk behavior of vietnamese adolescents: current status and the associated factors (analysis of national survey data on adolescents and young people in viet nam round 1 in 2003 and round 2 in 2009. phd thesis on sociology: ho chi minh national political academy, hanoi; 2013. 11. huong, n.m., anh, n.d. thematic report: the status of vietnamese adolescents and youth accessing and using mass media, second national survey of adolescents and youth in viet nam, the general department of population and family planning, hanoi. 2010. 12. huong, n.t. thematic report: mental health of adolescents and youth in vietnam. second national survey of adolescents and youth in viet nam, the general department of population and family planning, hanoi. 2010. 13. linh, l.c. thematic report: violence among vietnamese youth, national survey on adolescents and youth in vietnam. the general department of population and family planning, hanoi. 2010. 14. phuong, t.b., huong, n.t., nguyen thanh huong and et al. factors associated with health risk behavior among school children in urban vietnam. glob health action 2013. available at: http://www.globalhealthaction.net/index.php/gha/art icle/view/18876. 2013. [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 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 baby at conception : proposing a scientific hypothesis. 2015, 3(5); 664-668. 3. aasia khatoon khattak. female infanticide and killing women for giving birth to a baby girl. a case study of pakistan. proceedings of socioint14-international conference on social sciences and humanities. istanmbul, turki. 8-10 september 2014. 4. primacio, r; millot, h; jacob, c. early fetal sex determination using cell-free dna in microvolume of maternal plasma. journal of pregnancy and child health. 2017. (4);6. 5. hesketh therese & zhu whei xing. the consequences of son preference and sex selective abortion in china and other asian countries. canadian association medical journal. 2011; 183 (12): 1374-1377. 6. jain tarun, missmer as, gupta raina, hornstein md. preimplantation sex selection demand and preference in an infertility population. 7. eftekhaari, tasnim, nejatizadeh a, rajaei m, mahmoudi f. ethical considerations in sex selection. journal of education and health promotion. 2015 (4); 32. 8. stern, hj. preimplantation genetic diagnosis : prenatal testing for embryos finally achieving its potential. journal of clinical medicine. 2014 (3); 280-309. 9. w. dondorp et al. eshre task force on ethics and law 20: sex selection for non medical reasons. human reproduction. 2013; 28:6: 1448-1454. 10. human fertilization and embriology authority, “sex selection: choice and responsibility in human reproduction,” 2003. 11. r. baiduri, “the meaning and dimensions of work : women traders toba-batak (inang-inang) in medan, north sumatera, indonesia. international journal of humanities and social sciene. 2014; 4 (1): 66-74, 2014. 12. a. stark, “the matrilineal system of the minangkabau and its persistence throughout history : a structural perspective,” southeast asia : a multidisciplinary journal. 2013 (13) :1-13. 13. guiltomo cz. mapping gender prefferences and sex imbalances in indonesia. population studies: a journal of demography.2015. 14. budiyanti, rt, sulistyono, a, pujiyono. sex selection in indonesia : an ethical and legal perspective. eubios journal of asian and international bioethics. 2017 (january); 19-21. 15. bertens, k. etika biomedis. yogyakarta, indonesia, kanisius. 2011 16. mohan, rs. primum non nocere and neurosurgical management of brain tumors. 2005. nepal journal of neuroscience (2) : 95. 17. tom beauchamp/james childress. principle of biomedical ethics 7th edition. oxford university. 2013. 18. merino, s; aruanno me, gelpi rj, rancich, am. the prohibition of euthanasia and medical oaths of hippocratic stemma. acta bioethica. 2017. 23 (1): 171-178.   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. 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 education to the families of drug users: establishing safe family conversations yeyentimalla1*, agnescia clarissa sera2 1 department of nursing, poltekkes kemenkes palangka raya, indonesia 2 department of nutrition, poltekkes kemenkes palangka raya, indonesia *corresponding author’s e-mail: yeyentimalla@polkesraya.ac.id doi: 10.35898/ghmj-52941 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) family is the closest micro-system, owned by an individual. the relationship among the family members can be considered as the longest relationship an individual may have, from the time of pregnancy to the death of the age. even the drug survivors are still part of their families, unfortunately, with the incident of drug users, they are often having communication problem with their families. when clients or families experience relationship conflicts, but unable to resolve them, they need professionals help (shea, 1996; wahlroos, 1995). this has prompted the community service team of poltekkes kemenkes palangka raya consisted of two lecturers and three students, to share their knowledge and skills regarding an effective communication within families. the community service activity was held on october 17, 2020 at the galilee drug rebailitation center (hereinafter referred to as “panti”). figure 1. the community service team of the poltekkes kemenkes palangka raya mailto:alfeusmanuntung@gmail.com https://doi.org/10.35898/ghmj-52941 139 ghmj (global health management journal) 2022, vol. 5, no. 2 yeyentimalla & sera every month at the panti, there is a family support group (fsg) activity, as part of the therapeutic community program for drug users undergoing rehabilitation. in the fsg, the panti officers invite families, describe programs given their family members, build dialogue, and hope that the relationship will affect the success of rehabilitation (departemen sosial republik indonesia, 2002). therefore, in october’s fsg, panti invited the community service team so that families of drugs survivors would get an understanding of the affective function of family care. figure 2. mr. dodi ramosta sitepu, panti’s founder, share his experience to families of drug users having the first opportunity to speak to the family, mr. dodi ramosta sitepu, the founder and main leader of panti, shared his story of using drugs and recovery experience. mr. dodi said it is very important for the family to support its members who are undergoing rehabilitation at the panti. without family support, the panti’s efforts wasted. panti and families must work together to support the recovery of their family members. fsg exists for this purpose. in fsg, families attend seminars, discuss, and gather with family members who are residents of the panti at a group dinner. figure 3. yeyentimalla, leader of the community service team, explains about affective role of family care yeyentimalla & sera ghmj (global health management journal) 2022, vol. 5, no. 2 140 the next opportunity was given to the community service team providing health education about the role of family care. it aims to meet the psychological needs of its members. in a family, where the members are drug users, it is certainly important to balance control and warmth. the child’s need is to be loved while the parents need to be respected by their children. conversation in the family must be free from fear, obligation, and guilt. therefore, a family needs to build safe comfortable communication (eggerichs, 2014; olson, et al., 2014; silk, 2016; sillars, et al, 2004; thomas; 2015). figure 4. the mother of a drug user share the feelings and thoughts about the family care that triggers her son to take drugs the team showed empathy when parents of drugs user share feelings and thoughts about the family care that has been carried out so far. there is a recognition that their upbringing does not foster an independent and responsible attitude toward their children. the mother said she would change the conversation style in the family to be more concerned with the security needs of family members. figure 5. the students were involved in coordinating community service as a provision for them to become a vocational nurse 141 ghmj (global health management journal) 2022, vol. 5, no. 2 yeyentimalla & sera this activity also involved students to fulfill their learning needs to see and feel firsthand the process of community service, especially to the families of drug users. figure 6. ronald, panti’s mentor, asking a question in this good opportunity, ronald, one of panti’s mentors also expressed his view. based on his experience unsafe conversations in the family are not only experienced by children, but parents also experience them. he asked what invited all participants to put the problem proportionally. when fear arises, identify the feeling, identify the parts that make you afraid, and start having a conversation that promotes security for each person in the conversation. the team encouraged parents to start showing acceptance and trust in their children. everyone’s deepest need is to be accepted and trusted, we can generously fulfill it (olson, et al., 2014; chapman, 2012). figure 7. family dinner moment where residents have a quality time with their beloved one yeyentimalla & sera ghmj (global health management journal) 2022, vol. 5, no. 2 142 this photo essay records a 5-hour health education session for the families of drug users in order to help them in establishing safe family conversations among the family members. after the discussion was over, the rundown included hospitality and dinner together. while enjoying the foods, the panti residents joined the sharing session, and expressed their feelings missing their family and home. the residents want to connect hearts with their families. in the future, it is necessary to build a sustainable relationship for the success of the drug eradication program in our beloved country, indonesia. since the activity was held during the covid-19 pandemic, the team also showed concern by providing masks to each participant. consent the adults (identifiable) photographed have given their consent for their pictures to be used in the dissemination and publication of this research. conflict of interest none. acknowledgments the authors would like to thank for their cooperation with the management of the galilee foundation. references chapman, g. (2012). you’re speaking my language. nashville, usa: b & h publishing group. departemen sosial republik indonesia (2002). direktorat jenderal pelayanan dan rehablitasi sosial. metode therapeutic community (komunitas terapeutik) dalam rehabilitasi sosial penyalahgunaan napza. jakarta. eggerichs, e. (2014). love and respect in family. jakarta: light publishing. silk, d. (2016). keep your love on: connection, communication, and boundaries. jakarta: light publishing. sillars, a., canary, d., tafoya, m. (2004). communication, conflict, and the quality of family relationship. in a.l. vangelisti (editor). handbook of family communication. mahwah. new jersey: lawrence erlbaum associates. shea, s.c. (1996). wawancara psikiatri. seni pemahaman. y. asih, m. ester (editors). jakarta: penerbit egc. olson, d.h., defrain, j. skogrand, l. (2014). marriages and families. intimacy, diversity, strength. united states: mc graw-hill education. thomas, g. (2015). sacred parenting. michigan: zondervan, grand rapids. wahlroos, s. (1995). family communication: the essential for improving communication and making your relationship more loving, supportive, and enriching. mc.graw-hill. cite this article as: yeyentimalla, sera ac. health education to the families of drug users: establishing safe family conversations. ghmj (global health management journal). 2022; 5(2):138-142. doi:10.35898/ghmj-52941 https://doi.org/10.35898/ghmj-52941 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 ontherapy; 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 1million people a year, and perhaps closer to 3millionwhen 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 themorbiditymalaria 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 nowwidespread calls for innovation and implementation of programs to addressmalaria mortality and morbidity in school-age children. 2. method searcheswere undertaken of the published literature onmalaria 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 andmaterial familiar to the author. reviewwas 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 themain causes ofmortality due to infectious disease (worldhealth 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 infectedwith 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 andmalaney, 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). theworldhealthorganization (who) advocates early, accurate diagnosis ofmalaria andprompt, 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 thewhocommission 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 andworld 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 frommalaria 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 fromkenya indicate primary school studentsmiss 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 studywere poorer as the number ofmalaria 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 themagnitude 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 inugandan primary schools only 1 in 5 children knewwhat causedmalaria or if it can be prevented, what signs and symptoms suggest infection, andwhat 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 withmalaria receivedmanagement 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 ofwhoapprovedmethods, 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 onmalaria 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 aimofmaintainingprotective levelswithin 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, andmalaria 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 examiningwhy, 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-basedmalaria strategies conjointly. aghanaian 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 onmalaria management has beenwidely 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. falciparummalaria recommended bywho for useworldwide 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; themajor 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 casemanagement 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 secondmalawian 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 onmalaria 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 inmalawi. 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 fromuganda; 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 amajor 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-basedmalaria testing and treatment is undertaken in futurewill 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 schoolbasedmodels is needed in parallel. the efforts of major agencies made rdt and actmore affordable 14 macnab aj ghmj (global health management journal) 2020, vol. 4, no. 1 and hencemore available; the benefits of nowmaking 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. innovativeways are called for tomakewhoendorsed entitiesmore available to those in need, globally schools offermore 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 thewallenberg research centre at stellenboschuniversity and the hillman medical education fund (hmef), canada made the research and literature searches included here possible; these searches also contributed to other publications, book chapters and invited presentations on malaria prepared between 2018-2020. conflict of interest there is no conflict of interest. references abba, k., deeks, j. j., olliaro, p. l., naing, c.-m., jackson, s. m., takwoingi, y., donegan, s., and garner, p. (2011). rapid diagnostic tests for diagnosing uncomplicated p. falciparum malaria in endemic countries. cochrane database of systematic reviews, (7). afenyadu, g., agyepong, i., barnish, g., and adjei, s. (2005). improving access to early treatment of malaria: a trial with primary school teachers as care providers. tropical medicine & international health, 10(10):1065– 1072. agyepong, i. a., sewankambo, n., binagwaho, a., coll-seck, a. m., corrah, t., ezeh, a., fekadu, a., kilonzo, n., lamptey, p., masiye, f., et al. (2017). the path to longer and healthier lives for all africans by 2030: the lancet commission on the future of health in sub-saharan africa. the lancet, 390(10114):2803–2859. 15 ghmj (global health management journal) 2020, vol. 4, no. 1 macnab aj airhihenbuwa, c. o., makoni, s., iwelunmor, j., andmunodawafa, d. (2014). sociocultural infrastructure: communicating identity and health in africa. akweongo, p., agyei-baffour, p., sudhakar, m., simwaka, b. n., konaté, a. t., adongo, p. b., browne, e. n., tegegn, a., ali, d., traoré, a., et al. (2011). feasibility and acceptability of act for the community case management of malaria in urban settings in five african sites. malaria journal, 10(1):240. amexo, m., tolhurst, r., barnish, g., and bates, i. (2004). malaria misdiagnosis: effects on the poor and vulnerable. the lancet, 364(9448):1896–1898. ayi, i., nonaka, d., adjovu, j. k., hanafusa, s., jimba, m., bosompem, k. m., mizoue, t., takeuchi, t., boakye, d. a., and kobayashi, j. (2010). school-based participatory health education for malaria control in ghana: engaging children as health messengers. malaria journal, 9(1):98. barger, b., maiga, h., traore, o. b., tekete, m., tembine, i., dara, a., traore, z. i., gantt, s., doumbo, o. k., and djimde, a. a. (2009). intermittent preventive treatment using artemisinin-based combination therapy reduces malaria morbidity among school-aged children in mali. tropical medicine & international health, 14(7):784–791. bell, d., fleurent, a. e., hegg, m. c., boomgard, j. d., and mcconnico, c. c. (2016). development of new malaria diagnostics: matching performance and need. malaria journal, 15(1):406. benjamin, j., moore, b., lee, s. t., senn,m., griffin, s., lautu, d., salman, s., siba, p., mueller, i., and davis, t. m. (2012). artemisinin-naphthoquine combination therapy for uncomplicated pediatricmalaria: a tolerability, safety, and preliminary efficacy study. antimicrobial agents and chemotherapy, 56(5):2465–2471. birbeck, g. l., molyneux, m. e., kaplan, p. w., seydel, k. b., chimalizeni, y. f., kawaza, k., and taylor, t. e. (2010). blantyre malaria project epilepsy study (bmpes) of neurological outcomes in retinopathy-positive paediatric cerebral malaria survivors: a prospective cohort study. the lancet neurology, 9(12):1173–1181. boivin, m. j., bangirana, p., byarugaba, j., opoka, r. o., idro, r., jurek, a. m., and john, c. c. (2007). cognitive impairment after cerebral malaria in children: a prospective study. pediatrics, 119(2):e360–e366. brooker, s., kabatereine, n. b., fleming, f., and devlin, n. (2008). cost and cost-effectiveness of nationwide school-based helminth control in uganda: intra-country variation and effects of scaling-up. health policy and planning, 23(1):24–35. bundy,d., lwin, s., osika, j.,mclaughlin, j., andpannenborg, c. (2000). what should schools do aboutmalaria? parasitology today, 16(5):181–182. cairns, m., roca-feltrer, a., garske, t., wilson, a. l., diallo, d., milligan, p. j., ghani, a. c., and greenwood, b. m. (2012). estimating the potential public health impact of seasonal malaria chemoprevention in african children. nature communications, 3(1):1–9. chandramohan, d., webster, j., smith, l., awine, t., owusu-agyei, s., and carneiro, i. (2007). is the expanded programme on immunisation the most appropriate delivery system for intermittent preventive treatment of malaria in west africa? tropical medicine & international health, 12(6):743–750. clarke, s. e., jukes, m. c., njagi, j. k., khasakhala, l., cundill, b., otido, j., crudder, c., estambale, b. b., and brooker, s. (2008). effect of intermittent preventive treatment of malaria on health and education in schoolchildren: a cluster-randomised, double-blind, placebo-controlled trial. the lancet, 372(9633):127–138. clarke, s. e., rouhani, s., diarra, s., saye, r., bamadio,m., jones, r., traore, d., traore, k., jukes,m.c., thuilliez, j., et al. (2017). impact of a malaria intervention package in schools on plasmodium infection, anaemia and cognitive function in schoolchildren in mali: a pragmatic cluster-randomised trial. bmj global health, 2(2):e000182. cohee, l. m., chilombe, m., ngwira, a., jemu, s. k., mathanga, d. p., and laufer, m. k. (2018). pilot study of the addition of mass treatment for malaria to existing school-based programs to treat neglected tropical diseases. the american journal of tropical medicine and hygiene, 98(1):95–99. cohen, j. m., woolsey, a. m., sabot, o. j., gething, p. w., tatem, a. j., and moonen, b. (2012). optimizing investments in malaria treatment and diagnosis. science, 338(6107):612–614. counihan, h., harvey, s. a., sekeseke-chinyama,m., hamainza, b., banda, r., malambo, t., masaninga, f., and bell, d. (2012). community health workers use malaria rapid diagnostic tests (rdts) safely and accurately: results of a longitudinal study in zambia. the american journal of tropical medicine and hygiene, 87(1):57–63. de silva, p. m. and marshall, j. m. (2012). factors contributing to urban malaria transmission in sub-saharan africa: a systematic review. journal of tropical medicine, 2012. dicko, a., sagara, i., sissoko, m. s., guindo, o., diallo, a. i., kone, m., toure, o. b., sacko, m., and doumbo, o. k. (2008). impact of intermittent preventive treatment with sulphadoxine-pyrimethamine targeting the transmission season on the incidence of clinical malaria in children in mali. malaria journal, 7(1):123. 16 macnab aj ghmj (global health management journal) 2020, vol. 4, no. 1 dondorp, a. m., nosten, f., yi, p., das, d., phyo, a. p., tarning, j., lwin, k. m., ariey, f., hanpithakpong, w., lee, s. j., et al. (2009). artemisinin resistance in plasmodium falciparum malaria. new england journal of medicine, 361(5):455–467. drake, t. l., okello, g., njagi, k., halliday, k. e., jukes,m. c.,mangham, l., and brooker, s. (2011). cost analysis of school-based intermittent screening and treatment of malaria in kenya. malaria journal, 10(1):273. fernando, d., de silva, d., carter, r., mendis, k. n., and wickremasinghe, r. (2006). a randomized, doubleblind, placebo-controlled, clinical trial of the impact of malaria prevention on the educational attainment of school children. the american journal of tropical medicine and hygiene, 74(3):386–393. fernando, d., wickremasinghe, r., mendis, k., and wickremasinghe, a. (2003a). cognitive performance at school entry of children living in malaria-endemic areas of sri lanka. transactions of the royal society of tropical medicine and hygiene, 97(2):161–165. fernando, s., gunawardena, d., bandara, m., de silva, d., carter, r., mendis, k., and wickremasinghe, a. (2003b). the impact of repeated malaria attacks on the school performance of children. the american journal of tropical medicine and hygiene, 69(6):582–588. fernando, s. d., rodrigo, c., and rajapakse, s. (2010). the’hidden’burden of malaria: cognitive impairment following infection. malaria journal, 9(1):366. greenwood, b. (2006). intermittent preventive treatment–a new approach to the prevention of malaria in children in areas with seasonal malaria transmission. tropical medicine & international health, 11(7):983–991. group, i. a. s. et al. (2004). artesunate combinations for treatment of malaria: meta-analysis. the lancet, 363(9402):9–17. halliday, k. e., okello, g., turner, e. l., njagi, k., mcharo, c., kengo, j., allen, e., dubeck, m. m., jukes, m. c., and brooker, s. j. (2014). impact of intermittent screening and treatment for malaria among school children in kenya: a cluster randomized trial. the world bank. holding, p. a. and snow, r.w. (2001). impact of plasmodium falciparummalaria on performance and learning: review of the evidence. the american journal of tropical medicine and hygiene, 64(1_suppl):68–75. hotez, p. j., molyneux, d. h., fenwick, a., kumaresan, j., sachs, s. e., sachs, j. d., and savioli, l. (2007). control of neglected tropical diseases. new england journal of medicine, 357(10):1018–1027. houngbedji, c. a., prisca, b. n., hürlimann, e., yapi, r. b., silué, k. d., soro, g., koudou, b. g., acka, c. a., assi, s.-b., vounatsou, p., et al. (2015). disparities of plasmodium falciparum infection, malaria-related morbidity and access to malaria prevention and treatment among school-aged children: a national crosssectional survey in côte d’ivoire. malaria journal, 14(1):7. jukes, m. c., pinder, m., grigorenko, e. l., smith, h. b., walraven, g., bariau, e. m., sternberg, r. j., drake, l. j., milligan, p., cheung, y. b., et al. (2006). long-term impact of malaria chemoprophylaxis on cognitive abilities and educational attainment: follow-up of a controlled trial. plos clinical trials, 1(4). kihara, m., carter, j. a., and newton, c. r. (2006). the effect of plasmodium falciparum on cognition: a systematic review. tropical medicine & international health, 11(4):386–397. koukounari, a., estambale, b. b., njagi, j. k., cundill, b., ajanga, a., crudder, c., otido, j., jukes, m. c., clarke, s. e., and brooker, s. (2008). relationships between anaemia and parasitic infections in kenyan schoolchildren: a bayesian hierarchical modelling approach. international journal for parasitology, 38(14):1663–1671. kyabayinze, d. j., asiimwe, c., nakanjako, d., nabakooza, j., counihan, h., and tibenderana, j. k. (2010). use of rdts to improvemalaria diagnosis and fever casemanagement at primary health care facilities in uganda. malaria journal, 9(1):200. lalloo, d. g., olukoya, p., and olliaro, p. (2006). malaria in adolescence: burden of disease, consequences, and opportunities for intervention. the lancet infectious diseases, 6(12):780–793. lasker, r. d. and weiss, e. s. (2003). broadening participation in community problem solving: a multidisciplinary model to support collaborative practice and research. journal of urban health, 80(1):14–47. laxminarayan, r., chow, j., and shahid-salles, s. a. (2006). intervention cost-effectiveness: overview of main messages. in disease control priorities in developing countries. 2nd edition. the international bank for reconstruction and development/the world bank, pages 35–86. oxford university press. leighton, c. and foster, r. (1993). economic impacts of malaria in kenya and nigeria. citeseer. macnab, a. (2013). the stellenbosch consensus statement on health promoting schools. global health promotion, 20(1):78–81. macnab, a. (2020). school-based initiatives to reduce malaria morbidity and promote academic achievement in children. in aj, m., a, d., and c, p., editors, health in transition: translating dohad science to improve future health in africa. stellenbosch university press. macnab, a., mukisa, r., mutabazi, s., and steed, r. (2016). malaria in uganda: school-based rapid diagnostic testing and treatment. int j epidemiol, 45(6):1759–1762. 17 ghmj (global health management journal) 2020, vol. 4, no. 1 macnab aj macnab, a. j., gagnon, f. a., and stewart, d. (2014a). health promoting schools: consensus, strategies, and potential. health education. macnab, a. j., stewart, d., and gagnon, f. a. (2014b). health promoting schools: initiatives in africa. health education. magnussen, p., ndawi, b., sheshe, a., byskov, j., and mbwana, k. (2001). malaria diagnosis and treatment administered by teachers in primary schools in tanzania. tropical medicine & international health, 6(4):273– 279. matangila, j. r., mitashi, p., da luz, r. a. i., lutumba, p. t., and van geertruyden, j.-p. (2015). efficacy and safety of intermittent preventive treatment for malaria in schoolchildren: a systematic review. malaria journal, 14(1):450. mbonye, a. k., magnussen, p., lal, s., hansen, k. s., cundill, b., chandler, c., and clarke, s. e. (2015). a cluster randomised trial introducing rapid diagnostic tests into registered drug shops in uganda: impact on appropriate treatment of malaria. plos one, 10(7). mphwatiwa, t., witek-mcmanus, s., mtali, a., okello, g., nguluwe, p., chatsika, h., roschnik, n., halliday, k. e., brooker, s. j., andmathanga,d. p. (2017). school-baseddiagnosis and treatment ofmalaria by teachers using rapid diagnostic tests and artemisinin-based combination therapy: experiences and perceptions of users and implementers of the learner treatment kit, southern malawi. malaria journal, 16(1):318. mutabingwa, t. k. (2005). artemisinin-based combination therapies (acts): best hope for malaria treatment but inaccessible to the needy! acta tropica, 95(3):305–315. nankabirwa, j., brooker, s. j., clarke, s. e., fernando, d., gitonga, c. w., schellenberg, d., and greenwood, b. (2014a). malaria in school-age children in a frica: an increasingly important challenge. tropical medicine & international health, 19(11):1294–1309. nankabirwa, j. i., wandera, b., amuge, p., kiwanuka, n., dorsey, g., rosenthal, p. j., brooker, s. j., staedke, s. g., and kamya, m. r. (2014b). impact of intermittent preventive treatment with dihydroartemisininpiperaquine on malaria in ugandan schoolchildren: a randomized, placebo-controlled trial. clinical infectious diseases, 58(10):1404–1412. nonaka, d., kobayashi, j., jimba,m., vilaysouk, b., tsukamoto, k., kano, s., phommasack, b., singhasivanon, p., waikagul, j., tateno, s., et al. (2008). malaria education from school to community in oudomxay province, lao pdr. parasitology international, 57(1):76–82. okello, g., ndegwa, s. n., halliday, k. e., hanson, k., brooker, s. j., and jones, c. (2012). local perceptions of intermittent screening and treatment for malaria in school children on the south coast of kenya. malaria journal, 11(1):185. opoku, e. c., olsen, a., browne, e., hodgson, a., awoonor-williams, j. k., yelifari, l., williams, j., and magnussen, p. (2016). impact of combined intermittent preventive treatment of malaria and helminths on anaemia, sustained attention, and recall in northern ghanaian schoolchildren. global health action, 9(1):32197. pasha, o., del rosso, j., mukaka, m., and marsh, d. (2003). the effect of providing fansidar (sulfadoxinepyrimethamine) in schools on mortality in school-age children in malawi. the lancet, 361(9357):577–578. rennie, w., phetsouvanh, r., lupisan, s., vanisaveth, v., hongvanthong, b., phompida, s., alday, p., fulache, m., lumagui, r., jorgensen, p., et al. (2007). minimising human error in malaria rapid diagnosis: clarity of written instructions and health worker performance. transactions of the royal society of tropical medicine and hygiene, 101(1):9–18. rutebemberwa, e., kallander, k., tomson, g., peterson, s., and pariyo, g. (2009). determinants of delay in care-seeking for febrile children in eastern uganda. tropical medicine & international health, 14(4):472–479. sabot, o. j., mwita, a., cohen, j. m., ipuge, y., gordon, m., bishop, d., odhiambo, m., ward, l., and goodman, c. (2009). piloting the global subsidy: the impact of subsidized artemisinin-based combination therapies distributed through private drug shops in rural tanzania. plos one, 4(9). sachs, j. and malaney, p. (2002). the economic and social burden of malaria. nature, 415(6872):680–685. shillcutt, s., morel, c., goodman, c., coleman, p., bell, d., whitty, c. j., and mills, a. (2008). cost-effectiveness of malaria diagnostic methods in sub-saharan africa in an era of combination therapy. bulletin of the world health organization, 86:101–110. simba, d. o., warsame, m., kakoko, d., mrango, z., tomson, g., premji, z., and petzold, m. (2010). who gets prompt access to artemisinin-based combination therapy? a prospective community-based study in children from rural kilosa, tanzania. plos one, 5(8). simovska, v. and carlsson, m. (2012). health-promoting changes with children as agents: findings from a multiple case study research. health education. 18 macnab aj ghmj (global health management journal) 2020, vol. 4, no. 1 simwaka, b. n., simwaka, k., and bello, g. (2009). retrospective analysis of a school-based malaria treatment programme demonstrates a positive impact on health and education outcomes in mangochi district, malawi. journal of development effectiveness, 1(4):492–506. st leger, l. (2001). schools, health literacy and public health: possibilities and challenges. health promotion international, 16(2):197–205. tang, k.-c., nutbeam, d., aldinger, c., st leger, l., bundy, d., hoffmann, a. m., yankah, e., mccall, d., buijs, g., arnaout, s., et al. (2009). schools for health, education and development: a call for action. health promotion international, 24(1):68–77. temperley,m.,mueller, d. h., njagi, j. k., akhwale,w., clarke, s. e., jukes,m. c., estambale, b. b., and brooker, s. (2008). costs and cost-effectiveness of delivering intermittent preventive treatment through schools in western kenya. malaria journal, 7(1):196. thera, m. a., kone, a. k., tangara, b., diarra, e., niare, s., dembele, a., sissoko, m. s., and doumbo, o. k. (2018). school-aged children based seasonal malaria chemoprevention using artesunate-amodiaquine in mali. parasite epidemiology and control, 3(2):96–105. thiam, s., thior,m., faye, b., ndiop,m., diouf,m. l., diouf,m. b., diallo, i., fall, f. b., ndiaye, j. l., albertini, a., et al. (2011). major reduction in anti-malarial drug consumption in senegal after nation-wide introduction of malaria rapid diagnostic tests. plos one, 6(4). thuilliez, j., sissoko, m. s., toure, o. b., kamate, p., berthélemy, j.-c., and doumbo, o. k. (2010). malaria and primary education in mali: a longitudinal study in the village of doneguebougou. social science & medicine, 71(2):324–334. tipke, m., louis, v. r., yé, m., de allegri, m., beiersmann, c., sié, a., mueller, o., and jahn, a. (2009). access to malaria treatment in young children of rural burkina faso. malaria journal, 8(1):266. viner, r. m., ozer, e. m., denny, s., marmot, m., resnick, m., fatusi, a., and currie, c. (2012). adolescence and the social determinants of health. the lancet, 379(9826):1641–1652. visser, t., bruxvoort, k., maloney, k., leslie, t., barat, l. m., allan, r., ansah, e. k., anyanti, j., boulton, i., clarke, s. e., et al. (2017). introducing malaria rapid diagnostic tests in private medicine retail outlets: a systematic literature review. plos one, 12(3). vitor-silva, s., reyes-lecca, r. c., pinheiro, t. r., and lacerda, m. v. (2009). malaria is associated with poor school performance in an endemic area of the brazilian amazon. malaria journal, 8(1):230. von seidlein, l. (2014). the failure of screening and treating as a malaria elimination strategy. plos medicine, 11(1). walldorf, j. a., cohee, l. m., coalson, j. e., bauleni, a., nkanaunena, k., kapito-tembo, a., seydel, k. b., ali, d., mathanga, d., taylor, t. e., et al. (2015). school-age children are a reservoir of malaria infection in malawi. plos one, 10(7). white, n. j. (2005). intermittent presumptive treatment for malaria. plos medicine, 2(1). whitty, c. j., chandler, c., ansah, e., leslie, t., and staedke, s. g. (2008). deployment of act antimalarials for treatment of malaria: challenges and opportunities. malaria journal, 7(1):s7. who commission on social determinants of health and world health organization (2008). closing the gap in a generation: health equity through action on the social determinants of health: commission on social determinants of health final report. world health organization. wilson, a. l. et al. (2011). a systematic review and meta-analysis of the efficacy and safety of intermittent preventive treatment of malaria in children (iptc). plos one, 6(2). witek-mcmanus, s., mathanga, d. p., verney, a., mtali, a., ali, d., sande, j., mwenda, r., ndau, s., mazinga, c., phondiwa, e., et al. (2015). design, implementation and evaluation of a training programme for school teachers in the use of malaria rapid diagnostic tests as part of a basic first aid kit in southern malawi. bmc public health, 15(1):904. wongsrichanalai, c., barcus, m. j., muth, s., sutamihardja, a., and wernsdorfer, w. h. (2007). a review of malaria diagnostic tools: microscopy and rapid diagnostic test (rdt). the american journal of tropical medicine and hygiene, 77(6_suppl):119–127. world health organization (1992). malaria: a training guide for district health workers on malaria control in tropical africa, part 1. learner’s guide. world health organization (2013a). schistosomiasis: progress report 2001-2011, strategic plan 2012-2020. world health organization (2013b). what is a health promoting school? world health organization (2015). world malaria report 2015. world health organization and others (2011). malaria rapid diagnostic test performance: results of who product testing of malaria rdts: round 3 (2010-2011). 19 ghmj (global health management journal) 2020, vol. 4, no. 1 macnab aj cite this article as: macnab aj. global health initiatives to reduce malaria morbidity in schoolaged children. ghmj (global health management journal). 2020; 4(1):5-20. doi:10.35898/ghmj41495 20 introduction method background burden of disease in school-age children school-based intervention health education prophylaxis: regular administration of preventive drugs intermittent protective treatment (ipt) mass drug administration (mda) rapid diagnostic testing (rdt) and artemesinin combination therapy (act) developing a model for teacher-driven school-based care training cost future directions 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.   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 s, guyatt h, omumbo j, shretta r, drake l, ouma j. situation analysis of malaria in school-aged children in kenya–what can be done? parasitology today. 2000;16(5):183-86. 2. jukes mch, drake lj, bundy dap. challenges for child health and nutrition. in: school health, nutritional and education for all: levelling the playing field. cab international publishing, cambridge, usa. chapter 2, pages 11-31. 2008 www.cabi-publishing.org 3. snow rw, craig mh, newton cr, steketee rw. the public health burden of plasmodium falciparum malaria in africa. fogarty international center, national institutes of health. working paper 11, disease control priorities project, bethesda, maryland, usa. pages 1-80 2003 4. jukes mc, pinder m, grigorenko el, smith hb, walraven g, bariau em et al. long-term impact of malaria chemoprophylaxis on cognitive abilities and educational attainment: follow-up of a controlled trial. plos clinical trials. 2006;1(4):e9 5. kihara m, carter ja, newton cr. the effect of plasmodium falciparum on cognition: a systematic review. tropical medicine and international health. 2006;11(4):386-97. 6. world health organization. world malaria report 2014. geneva, world health organization. 2014. 7. källander k, nsungwa-sabiiti j, peterson s. symptom overlap for malaria and pneumonia— policy implications for home management strategies. acta tropica. 2014;90(2):211-214. 8. mutabingwa tk. artemisinin-based combination therapies (acts): best hope for malaria treatment but inaccessible to the needy! acta tropica. 2005;95(3):305-15. 9. kilian ah, kabagambe g, byamukama w, langi p, weis p, von sonnenburg f. application of the parasight™-f dipstick test for malaria diagnosis in a district control program. acta tropica. 1999;72(3):281-93. 10. guthmann jp, ruiz a, priotto g, kiguli j, bonte l, legros d. validity, reliability and ease of use in the field of five rapid tests for the diagnosis of plasmodium falciparum malaria in uganda. transactions of the royal society of tropical medicine and hygiene. 2002;96(3):254-57. 11. world health organization. malaria 2015. geneva, world health organization. 2015. 12. abba k, deeks jj, olliaro pl, naing cm, jackson sm, takwoingi y et al. rapid diagnostic tests for diagnosing uncomplicated p. falciparum malaria in endemic countries. the cochrane library. jan 1 2011. 13. malaria consortium 2015; http://www.malariaconsortium.org/pages/112.ht m. accessed dec 30, 2016. 14. international artemisinin study group. artesenuate combinations for treatment of malaria: meta-analysis. the lancet. 2004;363(9402):9-17. 15. macnab aj, stewart d, gagnon f. health promoting schools: initiatives in africa. health education. 2014;114(4):246-59. 16. mukisa r, macnab aj, mutabazi s, steed r. teachers as agents of change: school-based diagnosis and treatment of malaria positively impacts child morbidity. in: proceedings of the international conference on applied science and health 2017 feb 22 (no. 1). http://publications.inschool.id/index.php/icash/a rticle/view/19 17. baum f, macdougall c, smith d. participatory action research. journal of epidemiology and community health. 2006;60(10):854-57. 18. 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):1759-62. 19. benjamin j, moore b, lee st, senn m, griffin s, lautu d et al. artemisinin-naphthoquine combination therapy for uncomplicated pediatric malaria: a tolerability, safety, and preliminary efficacy study. antimicrobial agents and chemotherapy. 2012;56(5):2465–71. 20. chandler ci, hall-clifford r, asaph t, pascal m, clarke s, mbonye ak. introducing malaria rapid diagnostic tests at registered drug shops in uganda: limitations of diagnostic testing in the reality of diagnosis. social science & medicine. 2011;72(6):937-44. global health management journal, 2017, vol. 1, no. 2  52      21. kyaabayinze dl, asiimwe c, nakanjko d, nabakooza j, counihan h, tibenderana jk. use of rdts to improve malaria diagnosis and fever case management at primary health care facilities in uganda, malaria journal. 2010;9(1):1. 22. mbonye ak, magnussen p, lai s, hansen ks, cundill b, chandler c et al. a cluster randomized trial introducing rapid diagnostic tests in registered drug shops in uganda: impact on appropriate treatment of malaria. plos one. 2015;10(7):e0129545. 23. fernando sd, rodrigo c, rajapaske s. the ‘hidden’ burden of malaria: cognitive impairment following infection. malaria journal. 2010;9(1):1. 24. white n, pukrittayakarnee s, hien tt, faiz ma, mokuolu oa, dondorp am. malaria. the lancet. 2014;383(9998):723-35. 25. fernando d, de silva d, wickremasinghe r. short-term impact of an acute attack of malaria on the cognitive performance of schoolchildren living in a malaria-endemic area of sri lanka. transactions of the royal society of tropical medicine and hygiene. 2003:97(6):633-9. 26. lasker rd, weiss es. broadening participation in community problem solving: a multidisciplinary model to support collaborative practice and research. journal of urban health. 2003;80(1):14-47. 27. commission on social determinants of health. closing the gap in a generation: health equity through action on the social determinants of health: final report of the commission on social determinants of health. world health organization, geneva. 2008. 28. brooker s, kabatereine nb, fleming f, devlin n. cost and cost-effectiveness of nationwide school-based helminth control in uganda: intracountry variation and effects of scaling-up. health policy and planning. 2008;23(1):24-35. 29. temperley m, mueller dh, njagi jk, akhwale w, clarke se, jukes mc et al. costs and costeffectiveness of delivering intermittent preventive treatment through schools in western kenya. malaria journal. 2008;7(1):1. 30. okello g, ndegwa sn, haliday ke, hanson k, brooker sj, jones c. local perceptions of intermittent screening and treatment for malaria in school children on the south coast of kenya. malaria journal. 2012;11(1):1. 31. fernando d, de silva d, carter r, mendis kn, wickremasinghe r. a randomized, doubleblind, placebo-controlled, clinical trial of the impact of malaria prevention on the educational attainment of school children. the american journal of tropical medicine and hygiene. 2006;74(3):386-93. 32. magnussen p, ndawi b, sheshe ak, byskov j, mbwana k. malaria diagnosis and treatment administered by teachers in primary schools in tanzania. tropical medicine and international health 2001;6(4):273-79. 33. drake tl, okello g, njagi k, halliday ke, jukes mc, mangham l et al. cost analysis of school-based intermittent screening and treatment of malaria in kenya. malaria journal. 2011;10(1):1. 34. fernando sd, gunawardena dm, bandara mr, de silva d, carter r, mendis kn et al. the impact of repeated malaria attacks on the school performance of children. the american journal of tropical medicine and 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. 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. 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 in vitro inhibitory activity of dayak onion (eleutherine bulbosa mill.) essential oil against klebsiella pneumoniae 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 in vitro inhibitory activity of dayak onion (eleutherine bulbosa mill.) essential oil against klebsiella pneumoniae marwan hermawan, amanah amanah, nurbaiti nurbaiti faculty of medicine, university of swadaya gunung ja , cirebon, indonesia *corresponding author’s email: hermawanmarwan94@gmail.com abstract background: the cases of klebsiella pneumoniae infec on in west java province is s ll high. klebsiella pneumoniae bacterium can produce the extended spectrum beta lactamase enzyme leading to an bio cs resistant, so it is important to look for natural and inexpensive an bio c alterna ves; one of which is dayak onion plant (eleutherine bulbosa mill). the content found in dayak onion is believed to inhibit the growth of klebsiella pneumoniae bacteria. this study aims to determine the effec veness of dayak onion essen al oil on the growth of klebsiella pneumoniae bacteria. methods: this study was an experimental study with a post-test control group design using the culture of klebsiella pneumoniae on the mediamuller hinton agar in 7 groups. groups 1 to 5 (k1 to k5) were given sequen ally dayak onion essen al oil solu on in 10% dmso solvent with concentra ons of 50%, 25%, 12.5%, 6.25%, and 3.125%. group 6 (k6) was posi ve control (+) with 5 µg levofloxacin, and group 7 (k7) was nega ve (-) with 10% dmso. the treatment results were measured by the diameter of the host zone and the collected data were analyzed using one-way anova with appropriate post hoc analysis. results: the results showed that that there are differences in each group to inhibit the growth of bacteria (p <0.005). k1 are higher than k2, k3, k4, k5, and k7 with increasing concentra ons showed greater inhibi on. levofloxacin (k6) showed the highest inhibitory power. conclusion: the results showed that that there are differences in each group to inhibit the growth of bacteria (p <0.005). k1 are higher than k2, k3, k4, k5, and k7 with increasing concentra ons showed greater inhibi on. levofloxacin (k6) showed the highest inhibitory power. keywords: klebsiella pneumoniae, dayak onion essen al oil, bacterial inhibi on received: 26 april 2019 reviewed: 15 june 2019 revised: 1 july 2019 accepted: 12 july 2019 doi: 10.35898/ghmj-33458 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 indonesia is a country that has an increasing number of infectious diseases, one of which is a disease caused by the bacterium klebsiella pneumoniae. the latest estimate in 2014 in the west java province, the case of klebsiella pneumoniae infection was 48.1%, increasing by 3.1% compared to 2013 coverage of 45%. especially in cirebon, there are 95.62% of children under five diagnosed with klebsiella pneumonia infection (dinas kesehatan provinsi jawa barat, 2015). populations which are 146 mailto:hermawanmarwan94@gmail.com https://dx.doi.org/10.35898/ghmj-33458 hermawan m et al. ghmj (global health management journal) 2019, vol. 3, no. 3 susceptible to klebsiella pneumoniae infection are children less than 2 years old, adult over 65 years old and those who have health problems (malnutrition and immunological disorders) (budijanto and sutardjo, 2018; marcdante and kliegman, 2014). the klebsiella pneumoniae bacterium is a gram of negative bacterium that can cause nosocomial infections, infections of the respiratory system, and infections of the tract (budijanto and sutardjo, 2018). bacterial virulence factors that affect pathogenesis in the human body are polysaccharide capsules, endotoxin, cell wall receptors. the capsule structure functi (brooks et al., 2013). ons to protect bacteria from phagocytosis by polymorphonuclear granulocytes and prevent bacterial death by bactericidal serum. the presence of antigens in the capsule can increase bacterial pathogenicity treatment of klebsiella pneumoniae infection includes levofloxacin which belongs to the fluoroquinolone group which has a broad spectrum anti-bacterial effect. the action mechanism of levofloxacin is by inhibiting the dna-gyrase enzyme resulting in dna chain damage and causing bacteria to die. however, continuous antibiotics can resistance to bacteria because klebsiella pneumoniae is capable of producing extended spectrum beta lactamase (esbl) which can paralyze the work of various types of antibiotics (katzung et al., 2002; perhimpunan dokter paru indonesia, 2003). therefore, to reduce the occurrence of resistance to antibiotics, researchers use dayak onion essential oil as an alternative treatment dayak onion (eleutherine bulbosa mill.) is a plant originating from kalimantan which has an anti-bacterial effect (firdaus, 2014). the content of onion essential oil which is an important role in inhibiting bacterial growth is alkaloid that works by disrupting the peptidoglycan component (karou et al., 2006). flavonoids work in 3 ways: inhibiting nucleic acid synthesis, inhibiting cell membrane function and inhibiting energy metabolis (rijayanti, 2014). tannins work to inhibit the reverse transcriptase enzyme (firdaus, 2014). all compounds contained in dayak onion essential oils have their respective duties in inhibiting bacterial growth. previous research shows that dayak onion was able to inhibit the growth of staphylococcus aureus bacteria. therefore, this study aims to determine the effectiveness of dayak onion essential oil on the growth of klebsiella pneumoniae bacteria. 2. method this study was an experimental study with a post-test control group design. this experimental study was conducted in the microbiology laboratory of the faculty of medicine, swadaya gunung jati university, from january to february 2019. the material used was dayak onion (eleutherine bulbosa mill.) obtained from central kalimantan province. pure klebsiella pneumoniae bacteria were obtained from the microbiology laboratory of the faculty of medicine, university of indonesia. cultured bacteria were in mueller hinton media. as a solvent, dmso 10% and aquadest were used. for comparison, levofloxacin antibiotics were used. the tools used were vortex, ose, autoclave, incubator, test tube, micropipette, blue tip, test tube rack, burner and matches, and sterilized petri dishes. muller hinton agar (mha) media was made by mixing 38 grams of mueller hinton agar (mha) dissolved in 1 liter of distilled water, heated, stirred until homogeneous and sterilized using an autoclave at 1210 c, for 15 minutes. the klebsiella pneumonia suspension was cultured by incubating for 2-6 hours with a temperature of 37oc and turbidity was likened to the standard mc farland 0.5. essential oils of dayak onion (eleutherine bulbosa mill.) are obtained from the lansida herbal laboratory in yogyakarta, and the concentration of essential oils of dayak onion were 50%, 25%, 12.5%, 6.25%, and 3.125%, respectively, by adding 10% dmso solvent up to the volume expected. the concentration was chosen because previous research shows that the increasing concentration will make the inhibition zone bigger. however, the previous studies have not examined up to a concentration of 50%. the researchers used dayak onion essential oil of 50% compared to its half concentration, starting from 50%, 25%, 12.5%, 6.25% and 3.125%. as a comparison, the control (k6) was used in the form of a levofloxacin solution of crushed tablets of 1 mg into 5 ml of distilled water, while negative control (k7) has 10% dmso. the experimental procedure was carried out by culturing the suspended standard klebsiella pneumonia bacteria mc farland 0.5 on the homogeneous muller hinton agar (mha) 147 ghmj (global health management journal) 2019, vol. 3, no. 3 hermawan m et al. medium. the research subjects were grouped into 7 groups and made sumps in order to use a cork borer in the petri dish, then filled the well with k1 with essential oil solution with a concentration of 50%, k2 with a concentration of 25%, k3 with a concentration of 12.5%, k4 with a concentration of 6.25% , k5 with a concentration of 3.125%. as a control, k6 was given levofloxacin of 5 µg, and k7 was given 10% dmso. then incubated at 37℃ for 1 x 24 hours before the inhibition was observed. the potential for anti-bacterial was marked by the presence of a clear zone around and measured in millimeters in diameter. the data were obtained by using a statistical data processing computer program, i.e. one-way anova test, to test differences between groups. the data were examined for the normality of the distribution using the shapiro willik test, because the test results showed that the data were normally distributed. thus, the requirement for one-way anova was fulfilled. furthermore, the bonferroni post hoc test was used to see the difference in inhibitory power in each treatment group. 3. results measurements of inhibitory zones in bacteria were carried out after bacteria were incubated at 37℃ for 1 x 24 hours. differences in inhibition zones in all groups were analyzed using descriptive analysis. figure 1 shows the average difference in each treatment group. k1 k2 k3 k4 k5 k6 k7 16.5 12.75 12.5 9.25 7.5 20 1.62 figure 1. diameter inhibi on zone figure 1 shows the differences in mean inhibition zones in each group. k1 of onion essential oil with a concentration of 50%, k2 concentration of 25%, k3 concentration of 12.5%, k4 concentration of 6.25%, k5 concentration of 3.125%, k6 positive control, k7 of negative control. the inhibition of bacterial growth in each group was analyzed using the one-way anova test to see the difference in inhibition of bacterial growth between treatment groups. the one-way anova test results show that there are differences in inhibition zones with p-values of <0.05. at k1, administering essential oils of dayak onion with a concentration of 50% shows that there was a inhibition zone on bacterial growth with an average diameter of 16.50 mm. at k2, administering essential oils of dayak onion with a concentration of 25% obtained an average diameter of inhibition zone of 12.75 mm. at k3, administering essential oils of dayak onion with a concentration of 12.5% obtained the average diameter of the inhibition zone of 12.50 mm. at k4, administering essential oil of dayak onion with a concentration of 6.25% obtained an average inhibition zone diameter of 9.25 mm. at k5, administering dayak onion essential oil with a concentration of 3.125% obtained an average zone diameter the inhibition was 7.50 mm. at k6, administering levofloxacin of 5 µg obtained a mean diameter of the inhibition zone of 20 mm. meanwhile, at k7, the negative control of 10% dmso obtained an average diameter of the inhibition zone of 1.62 mm. the strongest inhibition was in positive control k7 with a 148 hermawan m et al. ghmj (global health management journal) 2019, vol. 3, no. 3 diameter inhibition zone of about 20 mm, followed by k1 using essential oil of dayak onion 50% with a diameter of inhibition zone 16.50 mm, followed by k2 using essential oil of dayak onions 25% with a diameter of 12.75 mm, and followed by k3 using essential oils of dayak onion 12.5% with a diameter of inhibition zone of 12.50 mm. inhibition in the medium category is found in k4 using essential oils of dayak onion 6.25% with diameter inhibition zones of 9.25 mm, followed by k5 using essential oils of dayak onion 3.125% with diameter inhibition zones of 7.50 mm, and the lowest inhibitory power was found in negative controls (k -) with the inhibitor zone diameter of 1.62 mm. all data in each group show that the data were normally distributed and homogeneous data. therefore, the data was carried out by post hoc bonferroni analysis to see differences between groups in inhibiting bacterial growth. table 1. the bonferroni post hoc test analyzes differences in inhibi on zones k1 k2 k3 k4 k5 k6 k7 k1 # k2 0.004 # k3 0.002 1.000 # k4 0.000 0.090 0.018 # k5 0.000 0.000 0.000 1.000 # k6 0.009 0.000 0.000 0.000 0.000 # k7 0.000 0.000 0.000 0.000 0.000 0.000 # table 1 shows that k1 compared with k2, k3, k4, k5, k6 and k7 are different in inhibiting bacterial growth (p <0.005). there was no significant difference in k3 compared to k2 in inhibiting bacterial growth (p = 1). there was no significant difference in k4 compared to k2 in inhibiting bacterial growth (p = 0.090) while k4 compared to k3 was different in inhibiting bacterial growth (p <0.005). k5 compared with k1, k2, k3 was different in inhibiting bacterial growth (p <0.005) while k5 compared to k4 had no significant difference in inhibiting bacterial growth (p = 1). k6 compared with k1, k2, k3, k4, k5 was different in inhibiting bacterial growth (p <0.005). k7 compared with k1, k2, k3, k4, k5, k6 was different in inhibiting bacterial growth (p <0.005). 4. discussion this study was carried out in 24 hours of treatment showing that the administration of positive control (k6) using levofloxacin of 5 µg had the strongest and most effective inhibitory effect with a diameter of 20 mm. previous research said levofloxacin inhibits important enzymes, topoisomerase, which is needed by bacterial cells for cell division dna. in addition, levofloxacin has bactericidal and bacteriostatic effects even with low doses which cause death in bacteria and inhibitory forces in petri dishes are formed (grillon et al., 2016; riahifard et al., 2017). the mechanism of action of the levofloxacin medicine is by inhibiting the dna-gyrase enzyme, resulting in damage to the dna chain and causing bacterial death (ganiswarna, 1995). however, the continuous use of levofloxacin can lead to antibiotic resistance because klebsiella pneumoniae is capable of producing extended spectrum beta lactamase (esbl) and klebsiella pneumoniae carbapenemase (kpc) which can paralyze the work of various types of antibiotics. the mechanism of action of esbl is by attacking penicillin and cephalosporin β-lactam ring bonds and producing penicillanic acid and chalcosporic acid so that antibacterial compounds are inactive while klebsiella pneumoniae carbapenemase (kpc) works as a self-protection cell wall from external threats (riahifard et al., 2017; ganiswarna, 1995). the treatment group k1 shows effective results with inhibition zone diameters of 16.50 mm when compared with k2 group with inhibition zone diameter of only 12.7 mm, k3 group with inhibition zone diameter of only 149 ghmj (global health management journal) 2019, vol. 3, no. 3 hermawan m et al. 12.5 mm, k4 group with inhibition zone diameter of only 9.25 mm, group k5 with inhibition zone diameter of only 7.5 mm, and group k7 with inhibition zone diameter of only 1.62 mm. these results are in accordance with previous studies stating that ethanol extract of dayak onions can inhibit microbes with minimal inhibitory concentrations and an inhibitory diameter of 14.49 mm (puspadewi et al., 2013). at a concentration of 15%, it can inhibit by 18.6 mm (novaryatiin et al., 2018). in this case, the higher the concentration, the wider the inhibitory zone. compounds that are thought to be contained in onion essential oil include flavonoids, alkaloids, tannins that have different working mechanisms. flavonoids have antibacterial properties in which the activity of flavonoids against bacteria is done by damaging bacterial cell walls consisting of lipids and amino acids. as a result, flavonoids are able to enter the cell nucleus bacteria and will react with dna and cause damage to the structure of the lipid dna, so that the bacteria will lysis and the cell will die (sari et al., 2015). besides, flavonoids also have immunomodulatory abilities that can increase the production of il-2 (interleukin 2) stimulating the proliferation and differentiation of t cells then th1 cells secrete ifn-γ (interferon gamma) which has the potential to activate macrophages (indrisari et al., 2017). the mechanism of action of alkaloids inhibits the formation of peptidoglycan so that the cell wall is not fully formed and causes cell death. while the tannin function inhibits the reverse transcriptase and dna topoisomerase enzymes. inhibition of the reverse transcriptase enzyme can cause no reverse transcription process to occur so that dna is not formed and the klebsiella pneumoniae bacterium will die (amanah et al., 2019). the characteristics of dayak onion essential oil are also known to have two solubility properties, namely hydrophilic and lipophilic, which are expected to have a significant effect on inhibiting bacteria. it is because their bioactive compounds affect bacterial cell walls making them more permeable and causing extensive leak from bacterial cells or the release of molecules and critical ions causing death in bacteria (ganiswarna, 1995; sari et al., 2015). gram negative bacteria easily absorb solutions, making it easier for solutes to enter the bacterial cell wall. the closer the bacteria are to the solute from the well which diffuses into the agar, and the more solute the substance becomes, the easier the bacteria will be killed by the substance (rustama et al., 2005). although, peptidoglycan in the cell wall of gram negative bacteria is not easily destroyed by onion essential oil. however, if the concentration of the substance is sufficiently concentrated, the bacteria will be killed. this research has been carried out and tried in accordance with the appropriate procedure, however it still has limitations, one of which is that the researchers do not know which active substance has the most anti-bacterial role in this dayak onion essential oil. 5. conclusion this study shows that the antibiotic levofloxacin has a wider inhibition zone diameter compared to the administration of dayak onion essential oil. dayak onion essential oil shows a smaller inhibition zone, however, the potential to inhibit it appears and cannot be ignored. for further research, it is recommended to isolate the active ingredient contained in dayak onion which is estimated to be equivalent to administer antibiotics. acknowledgments the authors would like to thank to all participants for participating in this study. conflict of interest there is no conflict of interest. 150 hermawan m et al. ghmj (global health management journal) 2019, vol. 3, no. 3 references amanah, a., pratamawati, t., taslimah, m., and primanagara, r. (2019). potential polysaccharide gel from durio zibethinus var. raja galuh rind extract towards klebsiella pneumoniae bacteria. in journal of physics: conference series, volume 1146, page 012029. iop publishing. brooks, g. f., butel, j. s., and morse, s. a. (2013). mikrobiologi kedokteran (medical microbiology). salemba medika, jakarta. budijanto, d. and sutardjo, u. (2018). data dan informasi profil kesehatan indonesia 2017 (indonesian data and health profile year 2017). dinas kesehatan provinsi jawa barat (2015). profil kesehatan provinsi jawa barat tahun 2015 (health profile of west java province). bandung: dinas kesehatan provinsi jawa barat, pages 1–72. firdaus, t. (2014). efektivitas ekstrak bawang dayak (eleutherine palmifolia) dalam menghambat pertumbuhan bakteri staphylococcus aureus (effectiveness of dayak onion extract (eleutherine palmifolia) in inhibiting the growth of staphylococcus aureus bacteria). ganiswarna, s. (1995). farmakologi dan terapi (pharmacology and teraphy). medical faculty, indonesia university, gaya baru jakarta, 471. grillon, a., schramm, f., kleinberg, m., and jehl, f. (2016). comparative activity of ciprofloxacin, levofloxacin and moxifloxacin against klebsiella pneumoniae, pseudomonas aeruginosa and stenotrophomonas maltophilia assessed by minimum inhibitory concentrations and time-kill studies. plos one, 11(6):e0156690, doi: 10.1371/journal.pone.0156690. indrisari, m., habibie, h., and rahimah, s. (2017). uji efek ekstrak etanol daun jarak pagar (jatropha curcas l.) terhadap titer imunoglobulin m (igm) dan imunoglobulin g (igg) pada tikus putih jantan (rattus norvegicus) (test of the effect of ethanol extract of jatropha curcas l on immunoglobulin m (igm) and immunoglobulin g (igg) titer in white male mice (rattus norvegicus). jurnal farmasi uin alauddin makassar, 5(4):244–250. karou, d., savadogo, a., canini, a., yameogo, s., montesano, c., simpore, j., colizzi, v., and traore, a. s. (2006). antibacterial activity of alkaloids from sida acuta. african journal of biotechnology, 5(2):195–200. katzung, b. g., masters, s., and trevor, a. j. (2002). farmakologi dasar dan klinik (basic and clinical pharmacology). ed, 12:939–947. marcdante, k. and kliegman, r. m. (2014). nelson essentials of pediatrics e-book: with student consult online access. elsevier health sciences. novaryatiin, s., pratiwi, a. m., and ardhany, s. d. (2018). uji daya hambat ekstrak etanol bawang dayak (eleutherine bulbosa (mill.) urb.) terhadap bakteri staphylococcus epidermidis (test of the inhibitory power of ethanol extract of dayak onion (eleutherine bulbosa (mill.) urb.) against staphylococcus epidermidis bacteria). anterior jurnal, 18(1):92–97. perhimpunan dokter paru indonesia (2003). pneumonia komuniti: pedoman diagnosis dan penatalaksanaan di indonesia (pneumonia community diagnosis and management guidelines). jakarta: balai penerbit fkui. puspadewi, r., adirestuti, p., and menawati, r. (2013). khasiat umbi bawang dayak (eleutherine palmifolia (l.) merr.) sebagai herbal antimikroba kulit (efficacy of dayak onion bulbs (eleutherine palmifolia (l.) merr.) as herbal antimicrobial skin). kartika: jurnal ilmiah farmasi, 1(1):31–37. riahifard, n., tavakoli, k., yamaki, j., parang, k., and tiwari, r. (2017). synthesis and evaluation of antimicrobial activity of [r4w4k]-levofloxacin and [r4w4k]-levofloxacin-q conjugates. molecules, 22(6):957. rijayanti, r. p. (2014). uji aktivitas antibakteri ekstrak etanol daun mangga bacang (mangifera foetida l.) terhadap staphylococcus aureus secara in vitro. jurnal mahasiswa pspd fk universitas tanjungpura, 1(1). rustama, m. m., rahayuningsih, s. r., kusmoro, j., and safitri, r. (2005). uji aktivitas antibakteri dari ekstrak air dan etanol bawang putih (allium sativum l.) terhadap bakteri gram negatif dan gram positif (antibacterial activity test of water extract and ethanol garlic (allium sativum l.) against gram negative bacteria and positive gram bacteria. biotika jurnal ilmiah biologi, 4(2). sari, k. et al. (2015). kandungan senyawa kimia dan aktivitas antibakteri ekstrak kulit buah alpukat (persea americana p. mill) terhadap bakteri vibrio alginolyticus (chemical compounds and antibacterial activity of avocado fruit extract (persea americana p.mill) against vibrio alginolyticus bacteria). jurnal kajian veteriner, 3(2):203–211. cite this article as: hermawan m, amanah a, nurbaiti n. in vitro inhibitory activity of dayak onion (eleutherine bulbosa mill.) essential oil against klebsiella pneumoniae. ghmj (global health management journal). 2019; 3(3):146-151. doi:10.35898/ghmj-33458 151 https://dx.doi.org/10.1371/journal.pone.0156690 introduction method results discussion conclusion 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 online health information-seeking behaviour: trends, influencing factors, ehealth literacy skills, benefits, and potential harms fina ratih wira putri1*, indri kusuma dewi2 1 poltekkes kemenkes palangka raya 2 poltekkes kemenkes surakarta *corresponding author’s email: finaratih.apt@poltekkes-palangkaraya.ac.id doi: 10.35898/ghmj-51592 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 number of internet users has increased rapidly in line with internet technology developments around the world. the internet’s accessibility allows the wider community to get information about various things quickly and in a variety of ways (wong and cheung, 2019). figure 1. health-related sites are increasingly in demand https://dx.doi.org/10.35898/ghmj-51592 11 ghmj (global health management journal) 2022, vol. 5, no. 1 putri & dewi in past years in the health sector, patients only received health information passively from the treating doctors. the internet provides the opportunity for patients to get information actively from various sources through search engines. health-related sites are increasingly in demand because patients and their families are increasingly aware of information available on the internet providing many alternatives in dealing with the health problems they face (barry et al., 2011). research conducted in the united states found that of the people who owned a gadget, 36% had mhealth app on their smartphone. of those who had the application, 60% stated that the mhealth application helped in achieving health behaviour targets, 35% stated that application helped solve health problems, and 38% reported that it was useful in improving the quality of discussions with doctors and seeking second opinions (bhuyan et al., 2016). the use of the internet is related to the communicative health literacy domain; patients have relatively better communication with related doctors to get explanations and information (xu et al., 2018). online health information-seeking behaviour (ohisb) correlates with several factors, such as demographic components, cognitive factors, internal factors, and external factors. based on demographic elements in the last decade, men have been found to be more likely to look for health information online than women. online health seekers tend to be younger, more educated, earn more, and have high-speed internet access at home and work. cognitive factors that affect ohisb are perceived benefits, perceived usefulness, perceived ease of use, and perceived behavioral control. meanwhile, influential internal factors include self-efficacy, experience using the internet, and trust. both factors have a positive and moderate effect. the external factor that plays the biggest role is the subjective norm. of the factors mentioned, the one with the largest effect size is the subjective norm, followed by perceived usefulness and attitude (wang, xiu, and shahzad, 2019). figure 2. demographic factors for ohisb i.e., men, younger, more educated, earn more, and have highspeed internet access putri & dewi ghmj (global health management journal) 2022, vol. 5, no. 1 12 the reasons for ohisb are to gather general information, to be active in personal healthcare, to research treatments or medication options, to self-diagnose, to identify people with similar experiences, and to find a doctor (kyriacou and sherratt, 2019). according to the results of a survey conducted by the world health organization (who) on ehealth, 29% of online health information-seekers used information obtained online to decide whether to see a doctor or come to an appointment at a regular consultation session. (barry et al., 2011). figure 3. the general public seeking information for disease identification based on symptoms and expressing doubts about the information, thus seeking a second opinion. figure 4. people reading health articles on the internet, ohisb need ehealth literacy 13 ghmj (global health management journal) 2022, vol. 5, no. 1 putri & dewi ehealth literacy is one of the supporting internal factors for ohisb along with using the internet and trust. according to valizadeh-haghi and rahmatizadeh (2018), ehealth literacy (health literacy) is the ability to search, find, understand, and use health information available from the internet and process it into knowledge to take into consideration in making decisions. in ehealth literacy, there are six supporting components. first, traditional literacy is essential literacy skills such as reading text, understanding written text, speaking, and writing. second is, information literacy, meaning a person can seek, obtain, and process the information acquired and transform it into knowledge. third, media literacy as a means of thinking critically about media content and considering issues such as the market, audience relations, and how the media want to convey messages. fourth, health literacy, which consists of the characteristics of patients who have adequate health literacy skills. this means being able to read and understand follow-up information services received in order to obtain the expected health outcomes. fifth is computer literacy, which is the ability to operate a computer or smartphone to solve problems. the last supporting component is scientific literacy, which requires one to put forward findings based on measurable and scientific research (norman and skinner, 2006). ohisb has both benefits and potential dangers. in terms of advantages, ohisb can promote a better understanding of health information, active patient involvement in health care, and a proactive patient response to health challenges. however, ohisb also raises concerns about potential dangers that may occur such as inaccurate, inadequate, or misleading online information. ohisb could spark the idea of starting an ineffective or potentially dangerous self-medication regimen. self-diagnosis and self-medication can also be triggered by ohisb. one of the things related to this issue is herbal product use (iverson, howard, and penney, 2008). research in iran showed that 54.5% of respondents had low digital health literacy scores. these low scores were found in recognizing the quality of health information circulating on the internet and using this information to make decisions (khademian, montazer, and aslani, 2020). another study revealed that although respondents did not have sufficient knowledge and skills to assess the quality of digital information, more than half of the respondents not only received information but also shared or recommended it to others (zhang et al., 2021). figure. 5 choosing a website reliable for health information on the internet, requiring literacy skills such as media literacy, scientific literacy, and health literacy putri & dewi ghmj (global health management journal) 2022, vol. 5, no. 1 14 consent the participants have given us consent to use their photos in this study. conflict of interest none references bhuyan, s. s., lu, n., chandak, a., kim, h., wyant, d., bhatt, j., … chang, c. f. (2016). use of mobile health applications for health-seeking behavior among us adults. journal of medical systems, 40(6). https://doi.org/10.1007/s10916-016-0492-7 barry, m. m., domegan, c., higgins, o., & sixsmith, j. (2011). a literature review on health information-seeking behaviour on the web: a health consumer and health professional perspective. iverson, s. a., howard, k. b., & penney, b. k. (2008). impact of internet use on health-related behaviours and the patient-physician relationship: a survey-based study and review. journal of the american figure 6. various information including alternative processing of herbal medicines, such as moringa leaf tea in the internet figure 7. moringa leaf tea processing method found in the internet https://doi.org/10.1007/s10916-016-0492-7 15 ghmj (global health management journal) 2022, vol. 5, no. 1 putri & dewi osteopathic association, 108(12), 699–711. https://doi.org/10.7556/jaoa.2008.108.12.699 khademian, f., montazer, m. r. a., & aslani, a. (2020). web-based health information seeking and ehealth literacy among college students. a selfreport study. investigacion y educacion en enfermeria, 38(1), 2216–0280. https://doi.org/10.17533/udea.iee.v38n1e08 kyriacou, a., & sherratt, c. (2019). online health information–seeking behavior by endocrinology patients. hormones, 18(4), 495–505. https://doi.org/10.1007/s42000-019-00159-9 norman, c. d., & skinner, h. a. (2006). ehealth literacy: essential skills for consumer health in a networked world. journal of medical internet research, 8(2). https://doi.org/10.2196/jmir.8.2.e9 valizadeh-haghi, s., & rahmatizadeh, s. (2018). ehealth literacy and general interest in using online health information: a survey among patients with dental diseases. online journal of public health informatics, 10(3). https://doi.org/10.5210/ojphi.v10i3.9487 wang, j., xiu, g., & shahzad, f. (2019). exploring the determinants of online health information-seeking behavior using a meta-analytic approach. sustainability (switzerland), 11(17). https://doi.org/10.3390/su11174604 wong, d. k. k., & cheung, m. k. (2019). online health information seeking and ehealth literacy among patients attending a primary care clinic in hong kong: a cross-sectional survey. journal of medical internet research, 21(3). https://doi.org/10.2196/10831 xu, x. y., yee, a., leung, m., & chau, p. h. (2018). health literacy , self-efficacy , and associated factors among patients with diabetes, 2(2), 67–77. https://doi.org/10.3928/24748307-20180313-01 zhang, d., zhan, w., zheng, c., zhang, j., huang, a., hu, s., & ba-thein, w. (2021). online health informationseeking behaviours and skills of chinese college students. bmc public health, 21(1), 736. https://doi.org/10.1186/s12889-021-10801-0 cite this article as: putri frw, dewi ik. online health information-seeking behaviour: trends, influencing factors, ehealth literacy skills, benefits, and potential harms. ghmj (global health management journal). 2022; 5(1):10-15. doi:10.35898/ghmj-51592 https://doi.org/10.7556/jaoa.2008.108.12.699 https://doi.org/10.17533/udea.iee.v38n1e08 https://doi.org/10.1007/s42000-019-00159-9 https://doi.org/10.2196/jmir.8.2.e9 https://doi.org/10.5210/ojphi.v10i3.9487 https://doi.org/10.3390/su11174604 https://doi.org/10.2196/10831 https://doi.org/10.1186/s12889-021-10801-0 https://dx.doi.org/10.35898/ghmj-51592 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 determinants of pre-diabetes on teenagers in palangka raya city 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 determinants of pre-diabetes on teenagers in palangka raya city ester inung sylvia*, gad datak, visia didin ardiyani health polytechnic of palangka raya (poltekkes palangka raya), indonesia *corresponding author’s email: esterinung@yahoo.co.id abstract background: pre-diabetes is a stage prior to diabetes mellitus (dm) and many studies in west countries found the risk factors of diabetes were mostly related to the nutri onal status of being overweight and obese. diabetes mellitus is not only experienced by adults but also by teenagers. they have the poten al for pre-diabetes because they may have unhealthy lifestyles such as smoking, consuming alcohol, high-calories, and junk foods and lack of physical ac vity. this study aims to determine the risk factors of pre-diabetes among senior high school students in palangka raya, central kalimantan, indonesia. methods: this study was a qualita ve study using a ques onnaire as an instrument for data collec on. it consists of a set of ques ons on diabetes risk. this research conducted in four public senior high schools in palangka raya with the total sample was 131 respondents have par cipated in this research. results: 25 respondents (19.1%) from a total sample of 131 par cipants suffered from pre-diabetes and 30.5% of respondents had a family with dm. some students (6.9%) had a smoking habit and 13% incidence of prediabetes in high school students related to these factors (r2: 0.13). only less than half of the total respondents (43.5%) had a normal bmi. as many as 39.7% of respondents were undernourished while the rest were overweight. conclusion: pre-diabetes factors on teenagers in palangka raya are female dominate had a history of dm, and being overweight. this study further leads to the importance of weight control that focusing on physical ac vity and dietary management as early precau ons. health educa on is required to suppress the number of risk factors for diabetes. keywords: pre-diabetes, palangka raya high school students, indonesia received: 14 may 2019 reviewed: 29 may 2019 revised: 16 june 2019 accepted: 6 july 2019 doi: 10.35898/ghmj-33455 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 urbanization and modernization have succesfully changed community’s lifestyles. this leads to shifting disease pattern from communicable to noncommunicable diseases. for example, in recent years, diabetes mellitus (dm) is known as one of the most chronic diseases in the world. according to indonesia’s national basic health research (2013), 6.9% of indonesian population suffered from diabetes (kemenkes, 2013). interestingly, diabetes mellitus is not only experienced by adults but also teenagers. according to indonesian peaditrician association (idai), the incidence of diabetes in children aged 018 years will be increased 7 times in 10 years (kemenkes, 2018). 117 mailto:esterinung@yahoo.co.id https://dx.doi.org/10.35898/ghmj-33455 ghmj (global health management journal) 2019, vol. 3, no. 3 sylvia ei et al. driven by economic development, nutrition transition, and increasingly sedentary lifestyles, the prevelence of diabetes were mostly started in young aged (chan et al., 2009). smoking, alcohol, consuming high-fat and calories meals as well as lack of physical activity contribute to the incidence of dm in teenagers (kemenkes, 2018; chan et al., 2009). moreover, many studies in west countries found the risk factors of diabetes were mostly related to nutritional status of being overweight and obese (chan et al., 2009; spurr et al., 2017). unfortunately, there are still limited studies related to prediabetes risk factors in high school students, especially in indonesia, which has a wide range of teenagers’ characteristics. a preliminary study needs to be done, taking an example of palangka raya, the most lively city in central kalimantan, indonesia, in which the prevalence of diabetes exceeded the national average (>0.7%). therefore, this study aims to identify prediabetes risk factors among high school students in palangka raya. this study is important to prevent further development towards diabetes through management at prediabetes stage. 2. method 2.1 respondents respondents were recruited using multistage random sampling from four public senior high schools in palangkaraya. minimum sample size (n=131) was calculated based on lameshow formula and considering the proportion of students lemeshow et al. (1990). eligible respondents were students aged 14-19 years old, male (n=53) or female (n=78) students. individuals who were sick during the survey were excluded. there were no drop outs in this study. written inform consent was obtained from participants prior to survey. 2.2 measurements this survey employed a questionnaire as an instrument for data collection. it consists of a set of questions on diabetes risk related items such as smoking, body mass index (bmi), physical activity (more than 30 minutes any physical activity at a time in a week), and also family history of diabetes. anthropometric measurements including height and weight were also taken to complete bmi calculation. bmi was calculated by using following formula: bmi = weight (kg) divided by height (m2). blood glucose measurement was carried out at prodia laboratory, palangka raya. the measurements were performed twice. first, the blood sample was taken after the respondents were fasting for 8-10 hours. after that, respondents consumed glucose water (as much as 75 grams of sugar were dissolved into 300 ml of water). the second blood sample was taken 2 hours after the consumption of concentrated glucose solution. respondents were diagnosed as prediabetes when their fasting plasma glucose level ranged at 100-125 mg/dl or once their oral glucose tolerance test ranged at 140-199 mg/dl. 2.3 data analysis descriptive data analysis was used to describe respondents’ risk factors, including age, gender, bmi, physical activity, smoking and family history of diabetes. chi square test was conducted to determine the relationships of risk factors (independent variable) and the incidence of prediabetes (dependent variable). odds ratio was calculated to measure the strength of the association between both variables. logistic regression was also conducted to study the effect of the incidence of prediabetes on glucose level, diet, physical activity, obesity, age and gender. 3. results table 1 shows 25 respondents (19.1%) from total sample of 131 students suffered from prediabetes and 30.5% respondents had family with dm. some students (6.9%) had smoking habit and most of respondents (69.5%) had physical activity of less than 3 times a week. only less than half of total 118 sylvia ei et al. ghmj (global health management journal) 2019, vol. 3, no. 3 respondents (43.5%) had a normal bmi. as many as 39.7% respondents were undernourished while the rest were overweight. table 1. overview of respondents’ characteris cs (n=131) variable n % non prediabetes 106 80.9 prediabetes 25 19.1 history of dm yes 40 30.5 no 91 69.5 smoking yes 9 6.9 no 122 93.1 physical ac vity < 3 mes 91 69.5 ≥ 3 mes 40 30.5 bmi normal 57 43.5 underweight 52 39.7 overweight 22 16.8 in details, according to table 2, prediabetes students were mostly female (25.6%). the amount of risk obtained from gender is 3.3 (95% ci: 1.2-9.5), meaning that female students are more at risk of prediabetes by 3.3 times compared to male students. this was confirmed by chi square test, which shows a signifancy value at gender variable (p < 0.05). table 2. bivariate analysis of prediabetes risk factors (n=131) variables non prediabetes prediabetes total or 95% ci p value n % n % n % gender male 48 90.6 5 9.4 53 100 3.3 (1.2-9.5) 0.021∗ female 58 74.4 20 25.6 78 100 history of dm no 77 84.6 14 15.4 91 100 2.1 (0.9-5.1) 0.104 yes 29 72.5 11 27.5 40 100 smoking habit yes 8 88.9 1 11.1 9 100 1.9 (0.2-16.4) 1.000 no 98 80.3 24 19.7 122 100 physical ac vity ≥ 3 mes 35 87.5 5 12.5 40 100 1.9 (0.7-5.9) 0.204 < 3 mes 71 71 20 22.0 91 100 bmi normal 47 82.5 10 17.5 57 100 1 119 ghmj (global health management journal) 2019, vol. 3, no. 3 sylvia ei et al. underweight 44 84.6 8 15.4 52 100 0.9 (0.3-2.4) 0.762 overweight 15 68.2 7 31.8 22 100 2.2 (0.7-6.8) 0.172 *significant at the p value 0.05 almost half of prediabetes students (44%) had a history of diabetes in their family. on the other hand, there were 27.3% respondents of nonprediabetes students had family with dm. or value shows that students with a family history of dm are 2.1 times more vulnerable suffered from prediabetes (95% ci: 0.9-5.1). students with smoking habits also shown differences in proportions. students who do not smoke are more likely to experience prediabetes (19.7%) than those who smoke (11.1%). this risk difference is 1.9 times (95% ci: 0.2-16.4), meaning that non-smokers have a higher risk of having 9 prediabetes compared to non-smokers. however, this risk is not proven significantly based on statistical tests (p>0.05). students with physical activity < 3 times a week, tend to experience prediabetes (22.0%) compared to students who do physical activity ≥ 3 times (12.5%). this risk difference is 1.9 times (95% ci: 0.7-5.9), meaning that students who do physical activity < 3 times a week are 1.9 times in risk of prediabetes than students who do physical activity ≥ 3 times in a week. but this risk is not proven statistically (p>0.05). bmi variables are made of dummy variables with normal bmi as a reference group. students who were thinner bmis were not at risk of having tgt levels of 0.9 times compared to students with a normal bmi (95% ci: 0.3-2.4). meanwhile, students whose bmi were overweight at risk of prediabetes 2.2 times compared to students with a normal bmi (95% ci: 0.7-6.8). however, it was not proven statistically (p>0.05). based on the results of bivariate analysis there were 4 variables with p values <0.25, namely gender, history of diabetes, physical activity, and bmi. the four variables were input into multivariate modeling using multiple logistic regression tests. the p values of four the variables that enter into the model were checked. if the value of p> 0.05, the variable were excluded from the model. after the variable were excluded, then the or value changes were examined to assess whether the variable is in the form of confounding of other variables or not. if the change in the value of or>10% then the variable is confounding. the excluded variable starts with the variable that had the largest p value. table 3. (not fixed)rela onship between gender, history of dm, physical ac vity, and bmi with the incidence of prediabetes, in public high school palangkaraya (n=131) variables model 1 model 2 model 3 or or or 95% ci 95% ci 95% ci sex female 3.4 3.1 3.7 male (1.1-10.5) (1.0-9.5) (1.2-11.2) history of dm no 2.2 1.5 2.2 yes (0.9-5.8) (0.5-4.6) (0.9-5.6) physical ac vity < 3 mes 1.5 2.3 ≥ 3 mes (0.5-4.7) (0.9-5.8) bmi normal 1 120 sylvia ei et al. ghmj (global health management journal) 2019, vol. 3, no. 3 underweight 1.2 (0.4-3.5) overweight 2.5 (0.8-8.2) n 131 131 131 r2 0.135 0.108 0.130 -2 loglikelihood 116.2015 118.577 116.654 table 3 shows the results of logistic regression hypothesis test. when the bmi variable was tried to be excluded there was a change in or values reaching >10%. therefore, variables with changes in or values>10% are re-entered into the regression equation. the physical activity frequency variable is excluded from the equation and the or value does not change>10% , this variable is excluded from the regression equation. so, the final result of the multiple logistic regression test states that gender variables, history of dm, and bmi affect the occurrence of prediabetes in students in all four public high school in the city of palangkaraya. the obtained value in model 2 is 0.130, which means that these variables can explain the incidence of prediabetes in high school students by 13%. 4. discussion the prevalence of prediabetes in the four public high school in palangkaraya city mostly occurs in female students compared to men, namely 9.4%. when viewed from gender, women are more likely to have diabetes than men. this is not certain yet, but if it is associated with bmi, women have the risk having a greater bmi than men. as the results of a study conducted by casapulla which showed that there was a significant relationship to bmi and gender where women had a higher bmi than men (casapulla et al., 2017). in addition, the monthly cycle syndrome and post-menopause make the distribution of body fat easily accumulated. but this is different from the results of the spurr study which showed no significant difference between men and women diagnosed with prediabetes, with a difference of 2% from the percentage mostly in men. previous research also mentions that teenage girls who are experience prediabetes are more obese than men with prediabetes (spurr et al., 2017). genetic factors are important factors in diabetes. abnormalities that transferred to their heir can directly affect beta cells and change their ability to recognize and spread insulin secretion stimuli. siperstein in waspadji stated in his study of diabetic patients it was found that 90% had abnormalities in the basal membrane of the muscle and similar abnormalities were found in 53% of non-diabetics whose parents had diabetes (spurr et al., 2017). the risk of prediabetes increases more in individuals who have a family history of diabetes than those without a history of diabetes (waspadji, 2009). the same thing was found in this study when viewed from a family history of diabetes there was a difference in the proportion of tgt levels between students who had a family history of diabetes and those who did not. the majority of prediabetes students had a history of diabetes in the family (27.5%) compared to those without a history of diabetes (15.4%). meanwhile, there were more students who did not have prediabetes also had no history of diabetes in the family (84.6%) compared to those who had a history of diabetes (72.5%). this is in line with previous studies that showed that a history of diabetes in the family is a major risk factor that causes abnormal blood sugar levels, which in turn causes the status of prediabetes. the prevalence of abnormal blood sugar levels is 1.9 times more likely in adolescents who have a family history of diabetes (al amiri et al., 2015). smoking habits are not a direct cause for an increase in blood sugar, but smoking and diabetes mellitus are a dangerous combination. cigarettes can increase the risk of diabetes. statements from previous studies show that respondents who used to and are still smoking both have a higher risk of developing diabetes, where smokers tend to have less physical activity and consumption of vegetables (spijkerman et al., 2014). this can also be seen from studies where more non-smoking students were seen to have more than normal levels of tgt (19.7%) compared to those who smoked (11.1%). this 121 ghmj (global health management journal) 2019, vol. 3, no. 3 sylvia ei et al. risk difference is 1.9 times (95%ci: 0.216.4), meaning that students who don’t smoke are more at risk of prediabetes compared to non-smokers. however, it was not proven significantly based on statistical tests (p>0.05). variables of physical activity carried out by students in four public high school in palangkaraya were mostly done only <3 times a week. the results showed that the risk of prediabetes was greater for students who did physical activity <3 times a week. according to soewondo and pramono (2011), physical activity has less intermediate to strong correlation with the condition of prediabetes. according to the researchers’ assumptions, physical activity is very useful for the use of glucose in one’s blood. individuals who lack activity tend to have obesity body proportions. obesity conditions will trigger an increase in insulin resistance in the muscles so that blood glucose cannot be used optimally by muscles as energy. this is in line with the results of puji’s research which states that physical activity can trigger the regulation and control of glucose levels in the blood so the researchers’ assumption that physical activity carried out <3 times a week can lead to prediabetes, which is characterized by increased levels of glucose in the blood (puji et al., 2017) as previously found that the risk of developing prediabetes will increase in adolescents who have sedentary activity and risk will decrease for those whose activities are medium and heavy (pandey et al., 2017). studies show that someone who is over 20% has a greater risk of developing diabetes mellitus, hypertension, coronary heart disease, stroke, arthritis, and cancer (cuasay et al., 2001). in this study showed that respondents with overweight bmi at risk of prediabetes were 2.2 times compared to students with normal bmi (95% ci: 0.7-6.8). in line with the research of adnan et al. (2013) that stated bmi has a relationship with blood sugar in diabetics. according to researchers increased bmi above normal can increase muscle insulin resistance which results in impaired use of blood glucose by muscles so that glucose in the blood becomes above normal. if this happens long enough and supported by other diabetes risk factors it will trigger the condition of prediabetes. the same case with widodo’s research, the result showed a relationship between bmi and the risk of developing diabetes in high school adolescents (widodo et al., 2017). this event can continue to diabetes if the trigger factors for diabetes are not handled properly. previous research stated that there was a significant relationship between bmi and adolescent prediabetes. the possibility is that every 1 kg / m2 exposure to bmi has an increase of 1,067 times the risk of prediabetes (pandey et al., 2017). one of them is bmi can be overcome by doing good physical activities such as exercise. during exercise glucose will be used as energy. physical activity is carried out 3 times a week with duration of 30-60 minutes each time can reduce these risk factors. this study further lead to the importance of an early precaution of preventing diabetes to all the students especially the one who had prediabetes by adding additional physical activities outside the obligatory physical education like extracurricular and to improve school health unit by collaborating with social insurance administration organization for prediabetes screening. also dietary management is also needed and doing physical activity or exercise minimum 3 times in a week with duration of 30-60 minutes. these behaviors can control the weight to maintain it in a normal range. 5. conclusion high school students in palangkaraya who are female, have a family history of dm, lack of physical activity, bmi in the category of overweight are more at risk of prediabetes. this study further leads to the importance of weight control that focusing on physical activity and dietary arrangements as early precautions. future research about health education to prevent diabetes is needed to suppress the number of risk factors of diabetes. conflict of interest there is no conflict of interest. 122 sylvia ei et al. ghmj (global health management journal) 2019, vol. 3, no. 3 references adnan, mulyati, t., and isworo, j. (2013). relationship between body mass index (bmi) and blood glucose levels in patients with t2dm in the outpatient room of tugurejo hospital semarang. al amiri, e., abdullatif, m., abdulle, a., al bitar, n., afandi, e. z., parish, m., and darwiche, g. (2015). the prevalence, risk factors, and screening measure for prediabetes and diabetes among emirati overweight/obese children and adolescents. bmc public health, 15(1):1298. casapulla, s. l., howe, c. a., mora, g. r., berryman, d., grijalva, m. j., rojas, e. w., nakazawa, m., and shubrook, j. h. (2017). cardiometabolic risk factors, metabolic syndrome and pre-diabetes in adolescents in the sierra region of ecuador. diabetology & metabolic syndrome, 9(1):24. chan, j. c., malik, v., jia, w., kadowaki, t., yajnik, c. s., yoon, k.-h., and hu, f. b. (2009). diabetes in asia: epidemiology, risk factors, and pathophysiology. jama, 301(20):2129–2140. cuasay, l. c., lee, e. s., orlander, p. p., steffen-batey, l., and hanis, c. l. (2001). prevalence and determinants of type 2 diabetes among filipino-americans in the houston, texas metropolitan statistical area. diabetes care, 24(12):2054–2058. kemenkes (2013). riskesdas. kemenkes (2018). hati-hati, anak pun bisa diabetes (be careful, children can get diabetes). http://www. depkes.go.id/article/view/18110100002/hati-hati-anak-pun-bisa-diabetes.html. (accessed on 1 november 2018). lemeshow, s., hosmer, d. w., klar, j., lwanga, s. k., organization, w. h., et al. (1990). adequacy of sample size in health studies. wiley, chichester. pandey, u., midha, t., rao, y. k., katiyar, p., wal, p., kaur, s., and martolia, d. s. (2017). anthropometric indicators as predictor of pre-diabetes in indian adolescents. indian heart journal, 69(4):474–479. puji, heru, and agus, s. (2017). aerobic exercise for reducing blood glucose levels in patients with t2dm in the bukateja purbalingga health center area. media ners journal, 1(2):49–99. soewondo, p. and pramono, l. a. (2011). prevalence, characteristics, and predictors of pre-diabetes in indonesia. medical journal of indonesia, 20(4):283–94. spijkerman, a. m., nilsson, p. m., ardanaz, e., gavrila, d., agudo, a., arriola, l., balkau, b., beulens, j. w., boeing, h., de lauzon-guillain, b., et al. (2014). smoking and long-term risk of type 2 diabetes: the epicinteract study in european populations. diabetes care, 37(12):3164–3171. spurr, s., bally, j., bullin, c., and trinder, k. (2017). type 2 diabetes in canadian aboriginal adolescents: risk factors and prevalence. journal of pediatric nursing, 36:111–117. waspadji, s. (2009). diabetes melitus: basic mechanism and rational management (management of integrated diabetes mellitus). faculty of medicine, university of indonesia, jakarta. widodo, d., retnaningtyas, e., and fajar, i. (2017). the risk factors of diabetes mellitus in adolescent senior high school in malang city. jurnal ners, 7(1):37–46. cite this article as: sylvia ei, datak g, ardiyani vd. determinants of pre-diabetes on teenagers in palangka raya city. ghmj (global health management journal). 2019; 3(3):117-123. doi:10.35898/ghmj-33455 123 http://www.depkes.go.id/article/view/18110100002/hati-hati-anak-pun-bisa-diabetes.html http://www.depkes.go.id/article/view/18110100002/hati-hati-anak-pun-bisa-diabetes.html introduction method respondents measurements data analysis results discussion conclusion 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 knowledge, attitudes, and hiv/aids risk behaviors of myanmar migrant workers in thailand ghmj (global health management journal) 2023, vol. 6, no. 2 indonesian scholars’ alliance open access original research antioxidant activity and consumer sensory perceptions of uru lewu (eleusine indica) formulations agnescia clarissa sera 1,* , prisilia oktaviyani 1 , tommi prayitno 2 1 department of nutrition, poltekkes kemenkes palangka raya, indonesia. 2 the national population and family planning board representative of central kalimantan, indonesia. *corresponding author’s email: agnescia@polkesraya.ac.id doi: 10.35898/ghmj-62962 abstract the dayak indigenous people of central kalimantan have traditionally used native plants as food and medicine to alleviate ailments, boost stamina, and extend life. one of these is the goosegrass or uru lewu plant (eleusine indica), which is thought to tighten female organs after birth. however, this has not been empirically confirmed. phytochemical examinations revealed that this plant boasts three chemicals with anticancer properties and two compounds with antioxidant properties because its bioactive component concentration can be formulated into herbal drinks, such as tea. three tea formulations were developed and evaluated on 100 consumer panelists to determine their sensory perceptions: f1 (100% uru lewu), f2 (80% uru lewu and 20% black tea), and f3 (60% uru lewu and 40% black tea). the ic50 values for uru lewu and black tea in the antioxidant activity test using the dpph technique were 133.77 mg/kg and 345.01 mg/kg, respectively. this suggests that uru lewu had nearly three times the antioxidant activity of black tea. uru lewu had moderate antioxidant activity (higher than black tea). based on the tea's color, aroma, and taste, the f3 tea formulation with 60% uru lewu and 40% black tea was the most chosen formulation by consumers. keywords: antioxidant, sensory, tea, goosegrass. received: 19 july 2023; revised: 15 august 2023; accepted: 25 october 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 central kalimantan, the indonesia's largest province, offers tropical rainforests rich in biodiversity, notably medicinal plants (aryadi, fithria, susilawati, & fatria, 2014). the indigenous dayak tribe of central kalimantan has recognized and used local plants as food and medicine for years to cure ailments, boost stamina, and prolong life (setyawan, 2010). additionally, for women, these herbs also serve as cosmetics, and the attractiveness of dayak females is frequently associated with the qualities of local kalimantan herbal plants. this understanding of central kalimantan's particular botanical qualities evolved into indigenous wisdom and passed naturally from generation to generation (julung, supiandi, ege, mahanal, & zubaidah, 2013). unfortunately, much research has not been done to document and investigate the wide range of advantages from these herbal plants (setyowati, 2012). it is certain that the forests of kalimantan house hundreds of herbal plant species with characteristics comparable to current medications (gunadi, oramahi, & tavita, 2017). as a result, the traditional medical wisdom based on these herbal constituents should be maintained and expanded through more empirical research. mailto:agnescia@polkesraya.ac.id https://doi.org/10.35898/ghmj-62962 67 ghmj (global health management journal) 2023, vol. 6, no. 2 sera, oktaviyani & prayitno researchers identified 17 different varieties of medicinal plants and forest plants with medical qualities by 2020. uru lewu (eleusine indica) is one of the herbs recommended for further study. uru lewu is thought to have characteristics that tighten a mother's feminine organs after giving birth. however, this is still limited to inherited cultural legacy, which has yet to be scientifically verified. even though the uru lewu plant has significant potential as biomedicine, it is frequently considered a nuisance. in addition to its benefits, uru lewu was chosen based on several characteristics, including the fact that it is simple to access and cultivate, that little study has been conducted on it, and that it has the potential to be transformed into a variety of derivative functional food products. the antioxidant activity of uru lewu (blended into a herbal tea) and its consumers' sensory perceptions were investigated in this study. 2. methods uru lewu plant was collected in murung raya regency, central kalimantan, indonesia. the branches and panicles were cleaned and washed to remove debris, such as soil and dust on the plants. the samples were subsequently dried in a food dehydrator at 40ºc (shown in figure 1). the drying process is crucial to maintain the chemical components in the plant. inadequate drying processes can harm the active chemicals in uru lewu. the drying process took 26 hours to achieve samples with less than 10% moisture content. with the lowest possible moisture level, mold and fungus could be avoided in the models. after drying, the samples were transported to pt saraswanti indo genetech's kan accredited laboratory in bogor, west java, indonesia to be evaluated for antioxidant activity using the dpph technique (2,2-diphenyl-1-picrylhydrazyl). the dried sample of uru lewu was transformed into three types of herbal tea formulations for the sensory impression test, namely f1: 100% uru lewu, f2: 80% uru lewu, 20% black tea, and f3: 60% uru lewu, 40% black tea. as black tea is a popular beverage among the general audience, uru lewu tea is the final product in this study. the consumer panelists were females aged 20 to 40 because postpartum women were the predominant consumers of this functional drink. the hedonic test was performed at the organoleptic laboratory of the nutrition department of poltekkes kemenkes palangka raya. the findings of the antioxidant activity tests were reported descriptively. the hedonic test data were tabulated and presented as a spider diagram to derive conclusions regarding consumers' sensory perceptions of uru lewu tea. 3. results and discussion a. antioxidant activity antioxidants are chemicals that help to inhibit the formation of free radicals in the form of reactive figure 1. uru lewu before and after dehydrated process sera, oktaviyani & prayitno ghmj (global health management journal) 2023, vol. 6, no. 2 68 oxygen species (ros). ros harms cells in the human body, causing pathogenic diseases and oxidative stress. antioxidants can neutralize ros via the antioxidant network mechanism. antioxidants are classified into two types: those created within the human body (endogenous) and those obtained outside the human body (exogenous). superoxide dismutase (sod), glutathione peroxidase (gsh px), coenzyme q10 (coq10), and catalase are examples of endogenous antioxidants (andarina & djauhari, 2017). in general, the number of endogenous antioxidants available will not be sufficient to neutralize the body's numerous ros sources. as a result, the body requires exogenous antioxidants from the diet. exogenous antioxidants are commonly acquired from plants and fruits high in vitamins a, c, and e, as well as the selenium mineral and phytochemical substances such as flavonoids, anthocyanins, lycopene, and polyphenols. the dpph (2,2-diphenyl-1-picrylhydrazyl) technique, which employs a uv-vis spectrophotometer, is a possible approach for determining a material's antioxidant activity (lung & destiani, 2017). dpph is a radical molecule that indicates the reduction process of antioxidant compounds by changing its color from purple to yellow. researchers frequently utilize this approach since it is straightforward with easy, rapid, and precise outcomes in polar and nonpolar solvents (julizan, 2019). vitamin c is frequently used as a comparative sample (control) in antioxidant activity assessments to establish the ic50 value, the concentration of a model that may block 50% of the free radical oxidation process. the stronger the antioxidant activity, the lower the ic50 value. antioxidant activity is defined as very strong if the ic50 value is less than 50 ppm, strong if the ic50 is between 50 and 100 ppm, moderate if the ic50 is between 100 and 150 ppm, weak if the ic50 is between 150 and 200 ppm, and very weak if the ic50 is greater than 200 ppm (jamiáh et al., 2018). table 1 antioxidant activity of uru lewu and black tea no. samples ic50 value (mg/kg) 1. uru lewu 133.77 2. black tea 345.01 as shown in table 1, the laboratory test suggests that uru lewu had nearly three times the antioxidant activity of black tea (uru lewu had a moderate antioxidant activity, but black tea had a low antioxidant activity). several studies shows that uru lewu from murung raya regency, central kalimantan contains flavonoids, isochaftoside, and gentiatibetine and triterpenoid 11-o-p-coumarylnepeticin. all three components exhibit antioxidant activity that might be used as an anticancer drug (bayliak et al., 2016; bourgou et al., 2017; firdaus et al., 2021). catechins, polyphenol derivatives, provide antioxidant content in black tea. b. sensory perceptions of uru lewu tea tea is a popular beverage, particularly among individuals living in asia. tea is typically made by steeping camelia sinensis leaves. other plants, such as dutch teak leaves, chinese teak leaves, cherry leaves, soursop leaves, moringa leaves, chinese almond leaves, dragon fruit peel, and others, are dried and steeped to produce tea. indonesia has four varieties of tea: black tea, green tea, oolong tea, and white tea. black tea has been fermented longer than other forms of tea, resulting in a darker color and a stronger scent. green tea is produced without the use of fermentation. tea shoots are collected and promptly cooked in an oven, roasted, or dried with hot steam. this is why the green tea variant is still green (lelita et al., 2013). oolong tea is classified as semi-fermented since it is dried for one day before being rolled and stored until the leaves turn black. furthermore, before the drying process begins, the fermentation process is halted by heating. white tea is made from young tea leaves that still have tiny hairs on them. the young leaves are dried immediately after being picked. because the drying process gives the tea a silvery white hue, white tea is also known as silver tea. 69 ghmj (global health management journal) 2023, vol. 6, no. 2 sera, oktaviyani & prayitno 1.00 2.00 3.00 4.00 5.00 warna aromarasa f1 f2 f3 color flavor aroma the type of tea utilized as a combination in this investigation was black tea. three types of beverage formulations were tested on the panelists: 100% uru lewu (f1), 80% uru lewu and 20% black tea (f2), and 60% uru lewu and 40% black tea (f3). the findings of organoleptic testing performed on 100 consumer panelists as shown in figure 2 below: a likert scale with a range of 1-5 is employed to express the panelists' sensory perception of the product, with a higher number indicating that the consumer favors the organoleptic features of the sample tasted. the third formulation, a mix of 60% uru lewu and 40% black tea is the most chosen beverage formulation by the panelists, with an average color of 4.09, scent of 4.37, and taste of 4.11. the panelists' least favorite beverage formulation was f1, with an average score on color, scent, and taste qualities of 3.24; 2.99; and 3.11, respectively. uru lewu f1 tea had an appeal similar to water (transparent and somewhat yellowish), whereas uru lewu f2 tea was pale yellow, and uru lewu f3 was traditionally reddish-brown. the f1 tea, made entirely of uru lewu, had a grassy aroma, but the f2 and f3 samples had a distinct scent of fragrance, which comes from a mixture of black tea. this appears to have influenced the panelists' preference for the f3 formulation (which contains 60% black tea and a stronger tea scent). f1 tea had a distinct taste of uru lewu grass, while f2 and f3 teas were slightly astringent. this astringent flavor is attributed to the catechin chemicals in tea formulations, with f3 tea being more astringent than f2. catechins are complex substances found in tea that are made up of epicatechin (ec), epicatechin gallate (ecg), epigallocatechin gallate (egcg), and gallocatechol (gc) (anjarsari, 2016). gallate compounds have a bitter and astringent flavor. the tannin components in tea also contribute to the bitter taste (wardani & fernanda, 2016). catechins are frequently related to tea's color, scent, and taste (anjarsari, 2016). catechin levels in black tea are mostly affected by the variety, age of the leaves, height at which they grow, and plucking method. the initial shoot of the tea leaf has more catechins than the subsequent leaf (anjarsari, 2016). however, processing, such as brewing with hot water, can lower the catechin level in black tea by up to 58% (karori et al., 2007). according to adawiyah et al. (2019), one of the most essential characteristics of tea beverages is their aroma. the higher the hedonic value of a cup of tea, the more aromatic its scent. f1 tea had a faint grassy scent in this investigation, but f2 and f3 teas had a fragrant black tea aroma. tea fragrance is a unique volatile scent produced throughout the tea-making process, such as during the fermentation and drying operations (arisudin et al., 2021). thus, a blend of black tea is still required to manufacture herbal tea derived from the uru lewu plant so that consumers may experience the refreshing, aromatic, and reddish-brown tone typical of tea. 4. conclusion uru lewu contains about three times the antioxidant activity of black tea. uru lewu had moderate antioxidant activity, but black tea had low antioxidant activity. this study concludes that 60% uru lewu and 40% black tea was the most popular formula based on the customers sensory perceptions. figure 2. uru lewu tea hedonic test results sera, oktaviyani & prayitno ghmj (global health management journal) 2023, vol. 6, no. 2 70 conflict of interest the authors declare no conflicts of interest, and no financial support. references adawiyah, d. r., azis, m. a., ramadhani, a. s., & chueamchaitrakun, p. (2019). perbandingan profil sensori teh hijau menggunakan metode analisis deskripsi kuantitatif dan cata (check-all-that-apply). jurnal teknologi dan industri pangan, 30(2), 161-172. andarina, r., & djauhari, t. (2017). antioksidan dalam dermatologi. jurnal kedokteran dan kesehatan: publikasi ilmiah fakultas kedokteran universitas sriwijaya, 4(1), 39-48. anjarsari, i. r. d. (2016). katekin teh indonesia: prospek dan manfaatnya. kultivasi, 15(2). arisudin, a., yahya, m., & erwanto, d. (2021). klasifikasi aroma teh dengan menggunakan sensor gas berbasis arduino uno. jasee journal of application and science on electrical engineering, 2(02), 115-127. aryadi, m., fithria, a., susilawati, s., & fatria, f. (2014). kearifan lokal masyarakat dayak terhadap tumbuhan berkhasiat obat di lahan agroforest kabupaten barito utara. jurnal hutan tropis, 2(3), 233–238. https://doi.org/10.20527/jht.v2i3.2250 bayliak, m. m., burdyliuk, n. i., & lushchak, v. i. (2016). effects of ph on antioxidant and prooxidant properties of common medicinal herbs. open life sciences, 11(1), 298–307. https://doi.org/10.1515/biol-2016-0040 bourgou, s., bettaieb rebey, i., mkadmini, k., isoda, h., ksouri, r., & ksouri, w. m. (2017). lc-esi-tof-ms and gc-ms profiling of artemisia herba-alba and evaluation of its bioactive properties. food research international, 99, 702–712. https://doi.org/10.1016/j.foodres.2017.06.009 firdaus, m., artanti, n., hanafi, m., & hanafi, m. (2021). phytochemical constituents and in vitro antidiabetic and antioxidant properties of various extracts of kenikir (cosmos caudatus) leaves. pharmacognosy journal, 13(4), 890–895. https://doi.org/10.5530/pj.2021.13.114 gunadi, d., oramahi, h. a., & tavita, g. e. (2017). studi tumbuhan obat pada etnis dayak di desa gerantung kecamatan monterado kabupaten bengkayang. jurnal hutan lestari, 5(2), 425–436. jami’ah, s. r., ifaya, m., pusmarani, j., & nurhikma, e. (2018). uji aktivitas antioksidan ekstrak metanol kulit pisang raja (musa paradisiaca sapientum) dengan metode dpph (2, 2-difenil-1-pikrilhidrazil). jurnal mandala pharmacon indonesia, 4(1), 33-38. julizan, n. (2019). validasi penentuan aktifitas antioksidan dengan metode dpph. kandaga–media publikasi ilmiah jabatan fungsional tenaga kependidikan, 1(1). julung, h., supiandi, m. i., ege, b., mahanal, s., & zubaidah, s. (2013). analisis sumber pengetahuan tradisional tanaman obat yang digunakan oleh masyarakat suku dayak desa. proceeding of biology education, 2(1), 67–74. karori, s. m., wachira, f. n., wanyoko, j. k., & ngure, r. m. (2007). antioxidant capacity of different types of tea products. african journal of biotechnology, 6(19). lelita, d. i., rohadi, r., & putri, a. s. (2013). sifat antioksidatif ekstrak teh (camellia sinensis linn.) jenis teh hijau, teh hitam, teh oolong dan teh putih dengan pengeringan beku (freeze drying). jurnal teknologi pangan dan hasil pertanian, 13(1), 15-30. lung, j. k. s., & destiani, d. p. (2017). uji aktivitas antioksidan vitamin a, c, e dengan metode dpph. farmaka, 15(1), 53-62. setyawan, a. d. w. i. (2010). biodiversity conservation strategy in a native perspective; case study of shifting cultivation at the dayaks of kalimantan. nusantara bioscience, 2(2), 97–108. https://doi.org/10.13057/nusbiosci/n020208 setyowati, f. m. (2012). etnofarmakologi dan pemakaian tanaman obat suku dayak tunjung di kalimantan timur. media litbang kesehatan, 20(3), 104–112. https://doi.org/10.22435/mpk.v20i3sept.789. wardani, r. k., & fernanda, m. h. f. (2016). analisis kadar kafein dari serbuk teh hitam, teh hijau dan teh putih (camellia sinensis l.). journal pharmasci (journal of pharmacy and science), 1(1), 15-17. cite this article as: sera, a.c., oktaviyani, p. & prayitno, t. (2023). antioxidant activity and consumer sensory perceptions of uru lewu (eleusine indica) formulations, 6(2). 66–70. https://doi.org/10.35898/ghmj-62962 https://doi.org/10.35898/ghmj-62962 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. (2018). manajemen sumber daya manusia (teori, konsep dan indikator). riau: zanafa publishing. andini, d. (2015). pengaruh kompetensi sumber daya manusia dan penerapan sistem akuntansi keuangan daerah terhadap kualitas laporan keuangan daerah pada satuan kerja perangkat daerah kabupaten empat lawang sumatera selatan. jurnal ekonomi kiat, 26(1), 65–82. ariandi, f. (2018). pengaruh metode pembayaran kompensasi terhadap kinerja tutor. jurnal perspektif, 16(1), 84–90. ariani, d., nugraha, t., & muhammad, i. (2020). analisa faktor penentu kepuasan kerja perawat pelaksana di instalasi rawat inap rsud langsa. j-kesmas: jurnal kesehatan masyarakat, 6(1), 23–37. https://doi.org/10.35329/jkesmas.v6i1.650 ariani, g. a. k. (2021). hubungan lingkungan kerja terhadap turnover intention perawat di rsu x denpasar. stikes bina usada bali. ariyanti, n. p. s., & suartina, i. w. (2021). pengaruh kompensasi terhadap turnover intention melalui job satisfaction pada pt. super horeca niaga denpasar. widya amrita: jurnal manajemen, kewirausahaan dan parwisata, 1(4), 1119–1129. deswarta, d., & mardiansah, a. (2021). pengaruh stres kerja dan kepuasan kerja terhadap turnover intention perawat rumah sakit prima pekanbaru. e-bisnis: jurnal ilmiah ekonomi dan bisnis, https://doi.org/10.35329/jkesmas.v6i1.650 9 ghmj (global health management journal) 2023, vol. 6, no. 1 amir, et. al. 14(2), 58–63. https://doi.org/10.51903/e-bisnis.v14i2.476 elizabeth, m. l. (2012). hubungan antara pelanggaran kontrak psikologis menurut perawat dengan intention to quit dan kepuasan kerja perawat rumah sakit x tahun 2011. universitas indonesia. fikry, m. d. (2021). implementasi business process reengineering untuk meminimalisir keluhan pelanggan. uin sunan ampel surabaya. gillies, d. a. (1996). manajemen keperawatan: suatu pendekatan sistem. rineka cipta: jakarta. halimah, t. n., fathoni, a., & maria, m. m. (2016). lingkungan kerja terhadap turnover intention pramuniaga di gelael supermarket (studi kasus pada gelael superindo kota semarang). journal of management, 2(2), 1–16. handoko, t. h. (2016). manajemen personalia dan sumberdaya manusia. bpfe. hasibuan, m. s. p., & hasibuan, h. m. s. p. (2016). manajemen sumber daya manusia. bumi aksara. hayes, l. j., o’brien-pallas, l., duffield, c., shamian, j., buchan, j., hughes, f., laschinger, h. k. s., & north, n. (2012). nurse turnover: a literature review–an update. international journal of nursing studies, 49(7), 887–905. https://doi.org/10.1016/j.ijnurstu.2011.10.001 herlambang, s. (2016). manajemen pelayanan kesehatan rumah sakit. yogyakarta: gosyen publishing. lusiati, a., & supriyanto, s. (2010). the impact of individual, job and organization factors on job satisfaction and turnover intentions of nurses. media jurnal administrasi kesehatan indonesia, 1(2). mardiana, i., hubeis, a. v. s., & panjaitan, n. k. (2014). hubungan kepuasan kerja dengan turnover intentions pada perawat rumah sakit dhuafa. manajemen ikm: jurnal manajemen pengembangan industri kecil menengah, 9(2), 119–130. https://doi.org/10.29244/mikm.9.2.119-130 mobley, w. h. (1986). pergantian karyawan: sebab-akibat dan pengendaliannya. pustaka binaman pressindo. irawan, b., & suroso, i. (2018). peran kualitas layanan dalam membangun kepuasan dan komunikasi dari mulut ke mulut pasien rawat jalan rsd. dr. soebandi jember. bisma: jurnal bisnis dan manajemen, 12(2), 191–203. https://doi.org/10.19184/bisma.v12i2.7889 pegia, z. s. p., & nuvriasari, a. (2021). pengaruh kepuasan kerja, lingkungan kerja, dan kompensasi terhadap turnover intention karyawan. jurnal ilmiah mahasiswa ekonomi manajemen, 6(4), 843– 856. pranowo, r. s. (2016). pengaruh kepuasan kerja, lingkungan kerja, dan kompensasi terhadap turnover intention karyawan dengan lama kerja sebagai variabel pemoderasi (studi kasus pada cv sukses sejati computama). skripsi. fakultas ekonomi, universitas negeri yogyakarta. prihanjana, i. p. i. (2013). rekomendasi menurunkan turnover rate karyawan menggunakan analisis faktor pendorong dan penarik. j. adm. kebijak. kesehat, 11(1), 38–43. purba, d. c., lengkong, v. p. k., & loindong, s. (2019). analisis pengaruh kepuasan kerja, motivasi kerja dan disiplin kerja terhadap kinerja karyawan pada perusahaan umum percetakan negara republik indonesia cabang manado. jurnal emba: jurnal riset ekonomi, manajemen, bisnis dan akuntansi, 7(1). https://doi.org/10.36987/ecobi.v7i2.1769 putra, i. d. g. d., & utama, i. w. m. (2017). pengaruh lingkungan kerja dan kepuasan kerja terhadap turnover intention di mayaloka villas seminyak. e-jurnal manajemen unud, 6(0), 5116–5143. putri, e. i. p., & irfani, a. (2020). pengaruh kepuasan kerja dan lingkungan kerja terhadap turnover intention di pt neuronworks indonesia. prosiding manajemen, 6(2), 802–808. ridwan, m., & jahrizal, j. (2020). pengaruh kompensasi dan kepemimpinana terhadap komitmen and turnover intention perawat rs syafira pekanbaru. jurnal tepak manajemen bisnis, 12(2), 320–336. robbins, s. p. (2003). perilaku organisasi. jakarta : gramedia (isbn : 979-683-105-8) saputra, a. t., & djastuti, i. (2021). analisis pengaruh person organization fit and person job fit terhadap turnover intention dengan work engagement sebagai variabel intervening (studi pada karyawan bpr bank surya yudha kantor pusat banjarnegara). diponegoro journal of management, 10(3). satar, y. p., & amran, y. (2013). faktor-faktor yang berhubungan dengan turnover intention perawat di brawijaya women and children hospital jakarta tahun 2013. surbakti, m. n. (2018). analisis pengaruh kompensasi, kepuasan kerja, komitmen dan lingkungan kerja terhadap turnover intention dengan stres kerja sebagai variabel intervening pada perawat rumah sakit mitra sejati medan. https://doi.org/10.51903/e-bisnis.v14i2.476 https://doi.org/10.1016/j.ijnurstu.2011.10.001 https://doi.org/10.29244/mikm.9.2.119-130 https://doi.org/10.19184/bisma.v12i2.7889 https://doi.org/10.36987/ecobi.v7i2.1769 amir, et. al. ghmj (global health management journal) 2023, vol. 6, no. 1 10 sutrisno, e., fatoni, a., & nawawi, h. (2010). manajemen sumber daya manusia (msdm). kencana prenada media group. jakarta. suwondo, d. i., & sutanto, e. m. (2015). hubungan lingkungan kerja, disiplin kerja, dan kinerja karyawan. jurnal manajemen dan kewirausahaan, 17(2), 145–154. https://doi.org/10.9744/jmk.17.2.145-154 suyono, t., girsang, e., nasution, a. n., & gusnawati, g. (2018). hubungan kompensasi dengan keinginan pindah kerja (turnover intention) tenaga perawat di rumah sakit swasta tipe c kota batam tahun 2018. scientia journal, 7(2), 133–137. wahyuni, w. (2021). hubungan kepuasan kerja perawat dengan turnover intention perawat . stikes ngudia husada madura. yuniasanti, r., & setyawan, f. b. (2016). kepuasan kerja pada tenaga penunjang akademik ditinjau dari dukungan sosial rekan kerja di universitas mercu buana yogyakarta. jurnal psikogenesis, 4(1), 25–40. https://doi.org/10.24854/jps.v4i1.515 zakaria, r., & astuty, i. (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 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 chalek juice: an alternative diet therapy of diabetes mellitus vinna maulidha yunianitamara*, erma nurjanah widiastuti, cucu rahayu, agnescia clarissa sera department of nutrition, poltekkes kemenkes palangka raya, indonesia *corresponding author’s email: vinnamaulidhay@gmail.com doi: 10.35898/ghmj-52939 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) diabetes mellitus (dm) is a chronic disease caused by insufficient amounts of insulin due to the malfunction of pancreatic organ (ministry of health of republic of indonesia, 2019; arsono, 2005). it will impact productivity, thereby reducing the quality of human resources. indonesia is among the 10 largest countries in the world with dm cases and is ranked 4th (damayanti, 2015; ministry of health of republic of indonesia, 2018; irawan, 2010). health treatment for dm requires expensive costs, especially for patients with complications. this encourages some people to look for herbal therapy, such as bitter melon (momordica charantia l) (ministry of health of republic of indonesia, 2014; katmo and pramono, 2006). figure 1 bitter melon (momordica charantia l) shown in figure 1, bitter melon or known in indonesia as pare, contains saponins, flavonoids, polyphenols, and alkaloids, which may improve pancreatic beta cells, thereby increasing insulin production (suiraoka, 2012). besides, bitter melon also contains charantin, an active antidiabetic substance that is believed to reduce blood sugar levels in the body. the decrease in blood sugar level is marked by lectin, carbohydratebinding proteins expressed on the surface of the body's cells (martínez-alarcón et al., 2018; tandra, 2013). this prompted the authors to create an alternative diet therapy formula named chalek juice, which stands for charantin and lectin. mailto:vinnamaulidhay@gmail.com https://doi.org/10.35898/ghmj-52939 129 ghmj (global health management journal) 2022, vol. 5, no. 2 yunianitamara et. al. as the name implies, bitter melon is dominated by bitter taste. it is mixed with cucumber, green apple and lemon to get a fresh and less bitter taste. to make chalek juice, there are six steps. first, wash the fruits and vegetables followed by cutting them into small pieces. to reduce the bitterness, soak the bitter melon into salt water for about 10 minutes (setiawan, 1993; rukmana, 2006), as shown in figure 3. figure 3 soaking process of bitter melon into salt water to reduce the bitterness the bitter melon, cucumber and green apple are crushed separately using a food processor. before mixing all the ingredients, bitter melon, cucumber and green apple are strained from their pulps. to get a glass of chalek juice (250 ml), mix 120 ml of bitter melon, 60 ml of green apple, 60 ml of cucumber and 20 ml of lemon juice, and mix it (figure 4). finally, the chalek juice is ready to drink. it is highly recommended to drink it at night before going to bed. figure 2. chalek juice made from a mixture of bitter melon, cucumber, green apple and lemon) yunianitamara et. al. ghmj (global health management journal) 2022, vol. 5, no. 2 130 figure 4. mixing all ingredients a glass of chalek juice contains 106 calories, 19.6 grams of carbohydrates, 4.1 grams of protein, 2.9 grams of fat, 2.4 grams of fiber, 60 mg of calcium and 42 mg of sodium. all ingredients used in the juice making are affordable and very easy to find at markets or convenient stores. figure 5. blood sugar level testing after two hours of consuming chalek juice in addition, bitter melon likely increases beta-cells or cells in the pancreas that function to produce insulin in the pancreas, and it is believed to help insulin secretion. this makes bitter melon often associated with diabetes (fuangchan et al., 2011). as shown in figure 5, we measured the blood sugar level in the participants after 2 hours consuming chalek juice. hasibuan and manurung (2020) state that bitter melon juice was significantly effective in reducing blood sugar levels in patients with type ii diabetes mellitus (p = 0.000). however, a research by gardiarini et al. (2018) using the hedonic test of the taste panel found that most of the panelists favored and really favored the bitter melon food (sautéed bitter melon) provided by the hospital. it is suggested, this innovation still needs to be improved in the future, especially its durability. this study found chalek juice only lasts a maximum of one week at cold temperatures and 30 minutes at a room temperature. consent the informants (identifiable) have given their consent for their pictures to be used in the publication of this research. 131 ghmj (global health management journal) 2022, vol. 5, no. 2 yunianitamara et. al. conflict of interest none. acknowledgments the authors would thank to the whole academic community of poltekkes kemenkes palangka raya who support the development of chalek juice. references arsono, s. (2005). diabetes melitus sebagai faktor risiko kejadian gagal ginjal terminal tesis. semarang: program pasca sarjana universitas diponegoro. damayanti, s. (2015). diabetes mellitus & penatalaksanaan keperawatan. yogyakarta: nuha medika fuangchan, a., sonthisombat, p., seubnukarn, t., chanouan, r., chotchaisuwat, p., sirigulsatien, v., ingkaninan, k., plianbangchang, p., & haines, s. t. (2011). hypoglycemic effect of bitter melon compared with metformin in newly diagnosed type 2 diabetes patients. journal of ethnopharmacology, 134(2), 422–428. https://doi.org/10.1016/j.jep.2010.12.045 gardiarini, p., setyawati, r., setyaningsih, a. (2018). pengembangan menu berbahan dasar pare sebagai menu diet khusus penderita diabetes melitus di rumah sakit. snitt-politeknik negeri balikpapan. 263-268. hasibuan, d.c., & manurung, d.m. (2020). efektifitas pare terhadap penurunan kadar gula darah pada penderita diabetes mellitus tipe ii. jurnal kesehatan ilmiah indonesia, 5 (2), 68-73. http://dx.doi.org/10.51933/health.v5i2.318 irawan, dedi. 2010. prevalensi dan faktor resiko kejadian diabetes mellitus tipe 2 di daerah urban indonesia (analisa data sekunder riskesdas 2007). thesis: universitas indonesia. katmo dan pramono, s. (2006). tingkat manfaat dan keamanan tumbuhan obat dan obat tradisional. yogyakarta: fakultas farmasi ugm. martínez-alarcón, d., blanco-labra, a., & garcía-gasca, t. (2018). expression of lectins in heterologous systems. international journal of molecular sciences, 19(2), 616. https://doi.org/10.3390/ijms19020616 ministry of health of republic of indonesia. (2014). situasi dan analisis diabetes. jakarta selatan : pusat data dan informasi. ministry of health of republic of indonesia. (2018). hasil utama riskesdas indonesia tahun 2018. jakarta: kemenkes ri. ministry of health of republic of indonesia. 2019. pusat data dan informasi kementerian kesehatan ri hari diabetes sedunia tahun 2018. jakarta: kemenkes ri. rukmana, r. (2006). budi daya pare. yogyakarta: kanisius. setiawan, iwan ade. (1993). pare dan labu. jakarta: pt penebar swadaya. suiraoka, ip. (2012). penyakit degeneratif. mengenal, mencegah dan mengurangi faktor resiko 9 penyakit degeneratif. yogyakarta : nuha medika. tandra, h. (2013). life healthy with diabetes (diabetes mengapa & bagaimana?). yogyakarta: rapha puslishing. cite this article as: yunianitamara vm, widiastuti en, rahayu c., sera ac. chalek juice: an alternative diet therapy of diabetes mellitus. ghmj (global health management journal). 2022; 5(2):128-131. doi:10.35898/ghmj-52939 https://doi.org/10.1016/j.jep.2010.12.045 http://dx.doi.org/10.51933/health.v5i2.318 https://doi.org/10.3390/ijms19020616 https://doi.org/10.35898/ghmj-52939 knowledge, attitudes, and hiv/aids risk behaviors of myanmar migrant workers in thailand ghmj (global health management journal) 2023, vol. 6, no. 2 indonesian scholars’ alliance open access guest editorial protecting the future: enriching reflections on the covid-19 pandemic from interdisciplinary research bayu mitra a. kusuma the ph.d. program in asia-pacific regional studies, college of humanities and social sciences, national dong hwa university, taiwan, r.o.c. *corresponding author’s email: 81090b006@gms.ndhu.edu.tw doi: 10.35898/ghmj-62959 abstract covid-19 spreads sporadically throughout the world at a high mortality rate. this virus caused a health crisis that forced the world health organization to declare it a global pandemic and caused various countries to implement massive social restrictions. until march 2023, there were 160,963 deaths because of covid-19, making indonesia the second highest in asia. indonesia’s lousy experience managing the covid-19 pandemic should raise awareness that a crisis can occur at any time. even though the current situation has improved a lot, preparedness and vigilance should not be neglected. no one can guarantee that a pandemic like covid-19 will not occur again. based on this situation, it is essential to look more deeply at the impact of the covid-19 pandemic and how scholars in various disciplines deal with it. to analyze future risks, interdisciplinary research is needed. this is a research approach that can link the main issues of the medical and health disciplines with other disciplines, such as the environment, social welfare, and public policy. keywords: future, covid-19 pandemic, interdisciplinary research. © 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. remembering the beginning it has been four years since humans have lived together with the corona virus disease (covid-19). the virus that first appeared in wuhan, people’s republic of china, spread sporadically throughout the world and transformed the face of human civilization. the high mortality rate has gripped the world in extreme fear in the fight against this virus. instantly, covid-19 caused a health crisis and other multidimensional crises, forcing the world health organization to designate it as a global pandemic in march 2020 (cucinotta & vanelli, 2020). consequently, covid-19 quickly became a prominent topic on various media platforms, beginning with scientific conversations and progressing to mysticism, hoaxes, and conspiracy theories. the uncontrolled spread of covid-19 forced various countries to implement massive social restrictions, including indonesia (djalante et al., 2020). community existence was altered when many regulations were implemented, such as disallowing gatherings, maintaining a distance when interacting, routinely washing hands, wearing facemasks in communal settings, taking hand sanitizer everywhere, and working remotely. initially, these rules were straightforward to follow. despite this, many people still disregard these regulations, believing they impinge upon their personal freedoms. this regulation is created to prevent the further spread of covid-19 and ensure proper treatment for those who have contracted the virus. mailto:81090b006@gms.ndhu.edu.tw https://doi.org/10.35898/ghmj-62959 55 ghmj (global health management journal) 2023, vol. 6, no. 2 kusuma, b.m.a insufficient awareness regarding the imposed social restrictions and health measures has led to the extensive transmission of covid-19. when the pandemic began, the death rate rose significantly because of a few factors, including patients refusing medical help due to the dishonor associated with covid-19, the public's lack of knowledge on oxygen saturation, and the indonesian health system not being adequately prepared for a crisis. until march 2023, it was recorded that confirmed cases in indonesia reached 6,740,404, with details of 6,575,775 recovered and 160,963 died (indonesian ministry of health, 2023). this statistic places the mortality rate of covid-19 in indonesia second in asia. 2. from experience to vigilance the bad experience of indonesia in dealing with the covid-19 pandemic should serve as a warning to all stakeholders that a health emergency can occur. the responsibility is not just with the government, but with all of society. although the world's condition has advanced considerably since this editorial was written, and many countries have decided that covid-19 is no longer a pandemic, but rather has become an endemic situation, like the common flu (aljazeera, 2022), it is still important to stay watchful and to be prepared. it is not possible to guarantee that a pandemic similar to covid-19 will not reoccur in the future. it ought to be acknowledged that covid-19 has changed into various variants, including alpha, beta, delta, gamma, and omicron. in principle, covid-19 can end if there is no more transmission, even though the virus continues to mutate. various sources stated that most dead victims had not received vaccinations, were over sixty, or had comorbidities. however, it is essential to remember that the omicron variant of covid-19 can still be transmitted even to people who have been vaccinated. early preventative measures like vaccinations are essential for controlling the omicron variant (ren et al., 2022). despite the double vaccinations, the body is still vulnerable to developing immunity; however, relying solely on defensive immunity is inadequate to improve the case. herd immunity is necessary to increase protection in the community. the covid-19 pandemic is not a transitory occurrence, nor can it be expected to bring about a swift return to normality. in the 21st century, there has not been an event whose scale and impact on human life are comparable to the impact of covid-19. we must learn from past pandemics, including the 19181920 spanish influenza (martini et al., 2019). unfortunately, the attitude of certain indonesian people during the covid-19 pandemic was still similar to that of the spanish influenza period. even though the period is 102 years, more than a century and the socio-economic conditions must have been very different. people who demonstrate a fatalistic attitude and seem to underestimate the magnitude of the global crisis cannot be justified and are detrimental to the public. 3. interdisciplinary research urgency the world is transitioning to a period of almost unrestricted utilization of technology. this changeover has provided certain advantages, such as more convenience to life, and created risks, such as technological threats. for example, even though there have been many studies that have concluded that covid-19 is caused by the transfer of viruses from animals to humans (shereen, 2020), we cannot deny that rumors have spread that covid-19 is a product of laboratory failure. this issue is rapidly disseminated through social media and accepted by certain social circles. humans live in a time full of risks, regardless of the morality of the situation. these risks usually remain unseen and unrecognized by the general population until they become major issues and have a pronounced impact. risk society is not a recent phenomenon. at least two scientists have popularized this term. a german scientist theorized this term ulrick beck (1992), through his work entitled risk society: towards a new modernity. british scientist anthony giddens again theorized the term (1999) through his work entitled risk and responsibility. the two scientists noted that society's social, spatial, and structural aspects remain in flux. for this reason, researchers must thoroughly investigate and reexamine social, ecological, and epidemiological susceptibilities and risks that could potentially arise. kusuma, b.m.a ghmj (global health management journal) 2023, vol. 6, no. 2 56 despite the current containment of covid-19, vigilance must still be maintained for the potential of new outbreaks in the future during a pandemic. to fully comprehend the consequences of the covid-19 pandemic, the potential ecological risks of further outbreaks, and how experts from multiple fields address the issue, interdisciplinary research is required. a single approach cannot resolve the current pandemic (zhao et al., 2022). the covid-19 pandemic has shown the importance of research in health management, public health, and health services. although research is necessary to connect medical and health issues to those from other disciplines, such as the environment, social welfare, and public policy, managing a pandemic will impact environmental resources, government policy, and the wider community. ghmj (global health management journal) is established to respond to this need. as a journal that concentrates on the health sphere, with a wide range of topics such as the environment, occupational safety, economics, technology, and bettering the quality of life, ghmj has been deemed an interdisciplinary journal that offers numerous solutions to intersectoral issues. the author believes ghmj has very high prospects as a reputable journal. hence, it is a great privilege for the author who has been trusted to compose a guest editorial for this edition. lastly, the authors would like to express their highest gratitude and appreciation for the trust and opportunity of the indonesian scholars’ alliance. this edition of ghmj will supply various perspectives that enhance the understanding of the covid-19 pandemic to safeguard human life in the coming years. happy reading! conflict of interest there is no conflict of interest. nothing to disclosure. references aljazeera. (2022). johnson lifts covid rules in england as omicron wave has peaked. aljazeera.com, january 19, 2022. https://www.aljazeera.com/news/2022/1/19/uk-johnson-lifts-covid-rules-england-omicron-wavepeaked. beck, u. (1992). risk society: towards a new modernity. translated by mark ritter. london: sage publications. https://us.sagepub.com/en-us/nam/risk-society/book203184. cucinotta, d. & vanelli, m. (2020). who declares covid-19 a pandemic. acta biomed, 91(1): 157-160. https://doi.org/10.23750/abm.v91i1.9397. djalante, r. et al. (2020). review and analysis of current responses to covid-19 in indonesia: period of january to march 2020. progress in disaster science, 6: 1-9. http://dx.doi.org/10.1016/j.pdisas.2020.100091. giddens, a. (1999). risk and responsibility. the modern law review, 62(1): 1-10. https://doi.org/10.1111/1468-2230.00188. indonesian ministry of health. (2023). covid-19 update. infeksi emerging kemenkes, march 16, 2023. https://infeksiemerging.kemkes.go.id/dashboard/covid-19. martini, m. et al. (2019). the spanish influenza pandemic: a lesson from history 100 years after 1918. journal of preventive medicine and hygiene, 60(1): e64-e67. https://doi.org/10.15167/24214248/jpmh2019.60.1.1205. ren, s. y. et al. (2022). omicron variant (b.1.1.529) of sars-cov-2: mutation, infectivity, transmission, and vaccine resistance. world journal of clinical cases, 10(1): 1-11. https://doi.org/10.12998/wjcc.v10.i1.1. shereen, m. a. et al. (2020). covid-19 infection: emergence, transmission, and characteristics of human coronaviruses. journal of advanced research, 24: 91-98. https://doi.org/10.1016/j.jare.2020.03.005. zhao, y. et al. (2021). is coronavirus-related research becoming more interdisciplinary? a perspective of cooccurrence analysis and diversity measure of scientific articles. technology forecast & social change, 175: 1-15. https://doi.org/10.1016/j.techfore.2021.121344. cite this article as: kusuma, b. m. a. (2023). protecting the future: enriching reflections on the covid-19 pandemic from interdisciplinary research. ghmj (global health management journal), 6(2). 54–56 https://doi.org/10.35898/ghmj-62959 https://doi.org/10.23750/abm.v91i1.9397 http://dx.doi.org/10.1016/j.pdisas.2020.100091 https://doi.org/10.1111/1468-2230.00188 https://doi.org/10.15167/2421-4248/jpmh2019.60.1.1205 https://doi.org/10.15167/2421-4248/jpmh2019.60.1.1205 https://doi.org/10.12998/wjcc.v10.i1.1 https://doi.org/10.1016/j.jare.2020.03.005 https://doi.org/10.1016/j.techfore.2021.121344 https://doi.org/10.35898/ghmj-62959 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 migang1*, evan kristianus migang2 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) 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 revitalizing a village for mental health in watershed area in central kalimantan, indonesia missesa department of nursing, poltekkes kemenkes palangka raya, indonesia *corresponding author’s e-mail: missesa@polkesraya.ac.id doi: 10.35898/ghmj-52951 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) mental health is a problem of disruption of one's self-control (stuart, 2013) which contributes to an individual mental state and degradation of cognitive function. as a result, one’s potential, and attitude might be affected, and they cannot cope with normal life stress within the environment, and the behavior disturbs the surrounding environment. prevention goals should be achieved by whole parties to decrease rates of mental health issues. the latest data in 2018 reported by the basic health research (riskesdas) show the number of people with mental disorders in central kalimantan reaching 4.4 per mile (ministry of health 2018). this prevalence was increased to 100% compared to data in 2013 which were only 0.9% (figure 1). figure 1. prevalence of mental disorders in indonesia mailto:missesa@polkesraya.ac.id https://doi.org/10.35898/ghmj-52951 missesa ghmj (global health management journal) 2022, vol. 5, no. 2 160 as shown in figure 2, most of the inhabitants in central kalimantan live in a residential area which is located close to the watershed (das). the geography of the watershed is a challenge for affordable health services, particularly in mental health services. patients with mental disorders who do not get health care services will have a high risk of experiencing recurrence due to withdrawal of medication (mubin, livana, 2019). there are needs to be solved by various parties to overcome this problem. mental healthcare delivery in this area is more likely to be effective and sustainable if supported by the secondary level of care in particular the local health department. photo source: https://www.triptrus.com/destination/397/sungai-kahayan figure 2. kahayan river in palangka raya city, central kalimantan province the concept of “desa siaga sehat jiwa” (healthy village) focuses on empowering communities and local health authorities to work together to improve mental health. hence people with mental disorders will become more independent (keliat, daulima, farida, 2011; sulaeman, karsidi, murti., kartono, waryana, hartanto., 2012.). mental healthcare implemented in healthy villages means that accessibility of mental health care is available near people’s houses. hence this can maintain their support systems and remain active in the village communities. a community-based mental health initiative has been conducted in cooperation with mental health nurses raising awareness of mental health. nurse educators at the health polytechnic palangka raya have an important role to play in raising awareness of mental health in village communities. in addition to the community-based mental health initiative, engagement with the community is crucial as a promotion strategy and enables knowledge transfer to people living in the marginalized area, particularly in the watershed area. as shown in figure 3, it is our initiative to be included as a community service which is part of the three core roles in higher education. we conducted an awareness campaign in menteng primary health care center, jekan raya district, palangka raya city based on the mental health reports of puskesmas menteng exhibited an increasing number of people with mental disorders, raising from 43 cases in 2017 to 74 cases in 2018. we delivered and facilitated a discussion session to revitalize the village in order to increase their awareness to mental health (figure 4). for the collaboration, to the meeting, we invite the village local 161 ghmj (global health management journal) 2022, vol. 5, no. 2 missesa stakeholders including the community leaders, health providers from the primary health care, soldiers, police, and community representatives. according to keliat, et al. (2010), the organizational structure of the healthy village can be organized through cross-sectorial and cross-program approaches. figure 3. mental health care awareness, delivered by lecturers of the nursing department of the palangka raya health polytechnic, moh. figure 4. discussion activity to form a “desa siaga sehat jiwa” (healthy village for mental health awareness) missesa ghmj (global health management journal) 2022, vol. 5, no. 2 162 at the beginning of the activity, each member of the community who attended the village meeting was given an opportunity to express their opinions about mental health problems within their environment. furthermore, they conveyed solutions to solve problems. one of the mental health awareness activities is to empower volunteers on mental health insights, and the detection of risks and disorders. volunteers for mental health services were recruited to allow access to mental health care hence it remains integrated and active in village communities through the presence of volunteers (figure 5). it consists of nurses from the primary health care centre, nursing lecturers, students, and alumni of the nursing department of the health polytechnic of the ministry of health, palangkaraya. it is important to alleviate people from excessive health expenditures related to seeking care such as transportation facilities located in urban areas, and loss of productivity. a designated training team was formed as an effort to transfer knowledge and reduce boundaries between educational institutions, service institutions, and the community (figure 6). figure 5. volunteer training activities figure 6. mental health volunteer training team 163 ghmj (global health management journal) 2022, vol. 5, no. 2 missesa to sustainably continue the forming of “desa siaga sehat jiwa”, a mutual agreement was signed by the stakeholders as a commitment to work together to create a healthy community in improving mental health in the villages (figure 7). figure 7. mutual agreement to form the “desa siaga sehat jiwa” a volunteer training was carried out for 5 (five) meeting days, 2 days of lecture meetings, followed by a question-and-answer session and role-play discussions. we also provided a general medical checkup during the home care services focusing on the mental health issues (figure 8a). all those activities were an integrated care for mental health in villages to establish a massive impact for marginalized people who suffered from mental health disorders. the sustainability of each health program thereafter continues to be evaluated and monitored through a proper documentation (figure 8b). (a) (b) figure 8. home visit by the volunteer and the training team including (a) general medical checkup, and (b) health evaluation and records for those with mental disorders integrating mental health and primary care services in a village is beneficial in which communities can get access to the care services close to them and the services can be a monitoring system which works as an early screening of mental health disorders. also the early screening system can increase social integration between the communities in the villages. in improving the mental health state of the villagers, a healthy village model for mental health is necessary to be implemented (nuryani, lindasari, and sofiah, 2020). community members can participate in voluntary works which are able to mobilize patients and their families who undergo routine care. it is important to set a more integrating mental health services with healthy village setting, to reduce the recurrence rate and patients will be active and productive. missesa ghmj (global health management journal) 2022, vol. 5, no. 2 164 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 trainers, volunteers, and all stakeholders for "desa siaga sehat jiwa" (dssj). references research and development agency of the ministry of health of the republic of indonesia. (2013). basic health research (riskesdas) 2013. jakarta: ministry of health of the republic of indonesia research and development agency of the ministry of health of the republic of indonesia.. (2018). basic health research (riskesdas) 2018. jakarta: ministry of health of the republic of indonesia. central kalimantan provincial health office (2012). central kalimantan community health profile years. palangka raya. keliat, b. a., panjaitan, r. u., riasmini, m., & mardella, e. (2010). model praktik keperawatan profesional jiwa. jakarta: penerbit buku kedokteran egc. keliat, b.a., daulima, n.h.c, & farida, p. (2011). manajemen keperawatan psikososial & kader kesehatan jiwa cmhn (intermediate course). jakarta : egc mubin, mf., livana, ph. (2019). the relationship between medication adherence and recurrence of paranoid schizophrenia patients. http://journal.stikeskendal.ac.id/index.php/far/article/view/493. nuryani, r., lindasari, s.w., sopiah, p.(2020). efforts to improve community mental health through the establishment of alert health mental villages (dssj). vol 5 no.4 syntax literate; jurnal ilmiah indonesia. stuart, g. w. (2013). principles and practice of psychiatric nursing .. st. louis missouri: mosby inc., an affiliate of elsevier inc. sulaeman, e.s, karsidi, r., murti., b, kartono. d.t, waryana w, hartanto., r. (2012). community empowerment model in health sector, study of alert village program. http://journal.fkm.ui.ac.id/kesmas/article/view/54. cite this article as: missesa. revitalizing a village for mental health in watershed area in central kalimantan, indonesia. ghmj (global health management journal). 2022; 5(2):159-164. doi:10.35898/ghmj-52951 http://journal.fkm.ui.ac.id/kesmas/article/view/54 https://doi.org/10.35898/ghmj-52951 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. ghmj (global health management journal) 2022, vol. 5, no. 2 indonesian scholars’ alliance open access perspectives politeknik kesehatan kemenkes palangka raya: health forum and international seminar the new normal : creating a pleasant virtual communication emotional awareness for fun digital communication yeyentimalla department of nursing, poltekkes kemenkes palangka raya, indonesia *corresponding author’s email: yeyentimalla@polkesraya.ac.id doi: 10.35898/ghmj-52931 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) improving digital communication skills is a necessity in the era of information technology, especially during the covid-19 pandemic, and after the pandemic has passed, this need remains. we have to adjust or we fall behind. nguyen et.al. (2021) finds the inability to communicate digitally before the pandemic can continue in pandemic times. someone who has a digital communication device does not necessarily make him capable of communicating digitally. while in the period of physical distancing, the choice of face-to-face communication switched to digital communication. many activities are run virtually and digitally. communication is all verbal and non-verbal behavior that emanates from someone that can be captured and interpreted by others (wahlroos, 2002). in this definition people can emit nonverbal behaviors that are less aware but have communication meaning, and can arise problems. in digital communication we must strengthen the skills of stringing words, that's the only effective way to share ideas and feelings (yeyentimalla, 2020). unlike the case with face-to-face communication that has three ways, i.e. words, intonation and body language (mc peat, 2010). what about the availability of emoticons and stickers in the whatsapp platform? can’t it be used to replace intonation and body language? it can indeed be used in the right situations so as to strengthen the words. however, overuse of emoticons and stickers makes messages less personal. we also become less than optimal in the way we are present and respond to the presence of others. humans are emotional creatures. we always feel first than we think about our feelings. the alignment of impulses in the brain reaches the limbic system first, we feel. then the impulses are processed in the cerebri cortex, we become able to think about our feelings. emotions first felt than thought is the workings of reflex movements so that we can survive (goleman, 2002). it's important to be able to do emotional animation consciously. emotional animation is an attempt to bring to life positively valued emotions such as pleasure, relief, compassion, empathy, gratitude, etc., and controlling negatively valued emotions such as anger, sadness, hate, disgust, etc. the idea of animate emotions is a conscious attempt to do something with emotion, i.e. recognize, use, understand and regulate it (goleman, 2002; yeyentimalla, 2019). mailto:yeyentimalla@polkesraya.ac.id https://dx.doi.org/10.35898/ghmj-52931 93 ghmj (global health management journal) 2022, vol. 5, no. 2 yeyentimalla a caricature taken from the book “pede bersama professor rajawali” (yeyentimalla, 2020) we need to improve communication skills to level four, which are safe and comfortable sharing feelings. the division of communication skills levels from gary chapman (2012) can be created in the form of an inverted pyramid. level one is ineffective for linking hearts, we have to jump to level four. the comfort of speaking to share feelings is the result of being created, not happening unconsciously. it’s important to be aware when speaking. emotional communication includes the art of self-revelation, showing acceptance, implying trust and trustworthiness, and confirming (yeyentimalla, 2019). the most visible technique that can be trained is confirmation. confirmation is effective for careful linking with partners. confirmation includes immediate recognition, positive feelings, responses asking for information, agreed response, supportive response (rakhmat, 2012). the act of disconfirming is not recommended because it weakens the relationship. disconfirming includes blank response, fleeting response, impersonal response, irrelevant response, interrupting response, contradictory response (incongruence response). it’s an example of a conversation where i (yeyen) consciously build a pleasant conversation, not just answer questions and the conversation is over. i make my friends talk to me comfortably. eva : bu yeyen, may i ask for a contact person to continue my study at ugm? yeyen : this is the contact of mbak rani, the administrative personnel of fk ugm. eva loves ugm, ya? welcome home. (emoticon smile) eva : yes, bu yeyen, thank you. my son was born in yogya. returning to yogya and ugm is like going home. (emoticon smile widely) i know that eva studied s2 at ugm, this knowledge i used to express support to eva. we continued the conversation in a happy mood. bechtle (2010) recommends that we find the sweet spot immediately so that the conversation develops and we enjoy it. the implementation of emotional intelligence for communication success in various social settings and fields of work has the support of much literature (di fabio & saklofske, 2018; schutte el al., 2013). when we use our human devices, especially emotions and are able to think about them, then we enjoy pleasant conversations and strengthen our relationships. yeyentimalla ghmj (global health management journal) 2022, vol. 5, no. 2 94 finally, the way we communicate is rooted in character, but character formation takes a long time. being aware to do emotional animation in every conversation is a simple short-term solution in fixing communication problems. in digital communication, making optimal the ability to string words is the right choice. references: bechtle, m. (2014). how to communicate with confidence. jakarta: nafiri gabriel. chapman, g. (2012). you’re speaking my language. nashville, usa: b & h publishing group. di fabio, a. and saklofske, d.h. (2018). emotional intelligence and youth career readiness. emotional intelligence in education: integrating research with practice, keefer, k.v., j. parker, d.a., and saklofske, d.h. eds. cham: springer, pp. 353–375. goleman, d. (2002). emotional intelligence. jakarta: pt gramedia pustaka utama. mc peat, s. (2010). e-book. mtd training: effective communication skills. united kingdom. nguyen, m.h., hargittai, e., marler, w. (2021). digital inequality in communication during a time of physical distancing: the case of covid-19. computers in human behavior 120 (2021) https://doi.org/10.1016/j.chb.2021.106717 rakhmat, j. (2012). psikologi komunikasi. bandung: cv remadja karya. schutte, n.s., malouff, j.m. and thorsteinsson, e.b. (2013). increasing emotional intelligence through training: current status and future directions. int. j. emot. educ., vol. 5, no. 1, pp. 56–72, 2013. wahlroos, s. (2002). family communication. jakarta: pt. bpk gunung mulia. yeyentimalla. (2019). revitalisasi komunikasi emosi dalam reintegrasi sosial keluarga penyintas narkoba. dissertation. yogyakarta: universitas gadjah mada. yeyentimalla. (2020) pede bersama professor rajawali: jurus jitu menyelesaikan studi. jakarta: pt gramedia pustaka utama. cite this article as: yeyentimalla. emotional awareness for fun digital communication. ghmj (global health management journal). 2022; 5(2):92-94. doi:10.35898/ghmj-52931 https://dx.doi.org/10.35898/ghmj-52931 ghmj (global health management journal) 2022, vol. 5, no. 2 indonesian scholars’ alliance open access perspectives politeknik kesehatan kemenkes palangka raya: health forum and international seminar the new normal : creating a pleasant virtual communication lessons on effective communication from taiwan government to combat covid-19 eva berthy tallutondok1,2, chia-jung hsieh3 1 national taipei university of nursing and health science, taiwan 2 faculty of nursing, universitas pelita harapan, banten 15811, indonesia 3 school of nursing, college of nursing, national taipei university of nursing and health science, taiwan *corresponding author’s email: evaberth@gmail.com, chiajung@ntunhs.edu.tw doi: 10.35898/ghmj-52933 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 2019 corona virus disease (covid-19) is airborne and highly transmissible, as well as extremely lethal. the greatest impact of the spread of the infection is on communication and social interaction. this condition is a serious concern for all nations, because it disturbs the order of human life in society, including in indonesia. the world was shocked by the speed of its spread and the extraordinarily high mortality rate. march 12, 2020 was the first day the who began announcing case counts country by country. that day, in one 24hour period, four new countries reported cases of covid-19, namely, french polynesia, turkey, honduras, and côte d’ivoire (who, 2020). the who warned that the symptoms could be severe and mortality was high, along with a rapid rate of transmission. although the who continued to share knowledge about patient care and hosted a discussion for clinicians via teleconference twice a week, its spread in the community could not be stopped (who, 2020). on that day alone, 118 countries reported about 125,000 confirmed cases to the who. indonesia reported a total of 34 confirmed cases to date, with 7 confirmed new cases, and one death, all of which were locally transmitted (who, 2020). indonesia is struggling to combat covid-19 and the government is using several different strategies to slow its spread in the community. despite these strategies, cases are continuing to skyrocket and the death rate is rising exponentially every day in indonesia, in contrast with taiwan, vietnam and new zealand, which have had greater success at controlling its spread. since march 2020, taiwan has had remarkable success eliminating local transmission over a period of five months (aspinwall, 2020). vietnam and new zealand have likewise achieved long periods without new local cases, at 100 and 102 days, respectively (everington, 2020). roughly three months later, on june 17, 2020, taiwan’s central epidemic command center (cecc) reported a total number of 74,699 suspected cases of covid-19, of which 73,775 tested negative. at that point, confirmed cases in taiwan numbered 445, of which 354 were imported, 35 were transmitted locally, with 36 cases among the crew of a navy ship abroad. of this total, 434 had been hospitalized in isolation wards and 7 people had died of the disease (taiwan centers for disease control, 2020). there were few (123) new cases, all imported, for five months with no local transmission until november, 2020, when the cecc mailto:evaberth@gmail.com mailto:chiajung@ntunhs.edu.tw https://dx.doi.org/10.35898/ghmj-52933 tallutondok & hsieh ghmj (global health management journal) 2022, vol. 5, no. 2 100 announced four more imported cases, this time from france, germany, the united kingdom, and the philippines. more recently, confirmed cases have reached 850 of which 751 recovered with still only 7 deaths on january 16, 2021 (cecc, 2021). in contrast to taiwan’s success, indonesia recorded the highest number of cases among asean nations on june 17, 2020, with 41,431 positive cases, and 2,276 covid-19 deaths, along with 1,241 new cases in a single day (azanella, 2020). in addition, indonesian medical physicians association tracked the death rate of health care professionals due to covid-19, reporting 252 deaths of physicians, 171 nurses, 64 midwives, 7 pharmacists, and 10 medical laboratory personnel, with the number of deaths increasing by five times since the first wave of the pandemic hit indonesia (antara, 2021). as of the time of this writing, the government’s latest estimated 1,037,993 positive cases and 29,331 deaths, while 647 health worker deaths due to covid-19. meaning that indonesia lost its population in a big city and the loss of health care workers due to covid-19 has also exacerbated the problem of distribution of health workers that has not changes evenly in the health care centers or hospitals. how can we explain the extraordinary gap in cases and deaths between indonesia and taiwan? why does taiwan have just 7 deaths while indonesia reported 14,348 deaths in the first week of november 2020? what strategy did taiwan’s government employ to combat covid-19? what lesson can be learned from taiwan to combat covid-19? it is a great challenge for an indonesian nursing student studying in taiwan to experience firsthand the stunning difference between indonesia and taiwan in the exposure and prevention of covid-19. the aim of this article is to identify lessons on effective communications strategy used by taiwan’s government that can affect government, health professionals, and population together to combat covid-19. findings and discussion 1. taiwan government strategy used to overcome or prevent transmission covid-19 wang, ng, & brook (2020) covid-19 occurred before the lunar new year celebration in january 2019, and around 2.71 million visitors from the mainland traveled to taiwan to celebrate with their families. the distance between wuhan and taiwan is close, and 850,000 taiwanese resided in china, with 404,000 working there (gardner, 2020). based on these facts, epidemiologists expected taiwan to have the second highest number of coronavirus cases after wuhan due to its proximity to and the number of flights between china and taiwan. yet taiwan became an outstanding success story in combatting the coronavirus (wang et al., 2020). what strategy did taiwan’s government use to combat covid-19 to protect the nation? wang is medicine and health research and policy from stanford university california mentioned that the government quickly response to covid-19 by recognizing the crisis and managing the crisis in nation. first, taiwan has been on constant alert and ready to act on epidemics arising from china ever since the severe acute respiratory syndrome (sars) epidemic in 2003. then, taiwan created a public health strategy to enable rapid response, starting with monitoring to identify emerging crises, managing the crisis, and educating the public by using communication and political leadership during an outbreak. also, the government had access to database and for tracking cell phone location data as part of contact tracing and enforcing quarantine, and proactive testing (wang, 2020). moreover, the government established the national health command center (nhcc) and the central epidemic command center (cecc) which were focused on direct communications among central, regional, and local authorities. besides that, the government used measures to gain control of the situation within five weeks from january 20 to february 24, 2020 like delaying the start of school after lunar new year and shutting down businesses like restaurants; mandating masks. moreover, taiwanese government based strategies on hospital data to combat covid-19 involved five important components, namely (1) border controls, (2) media communication tools and conferences, (3) establishing a distribution system for rationing medical masks and an online ordering mechanism, (4) travel occupational contact cluster-based rapid triage, outdoor clinics, and protective sampling devices, and (5) social distancing, postponing resumption of classes, 101 ghmj (global health management journal) 2022, vol. 5, no. 2 tallutondok & hsieh and banning large assemblies, such as religious festivals and concerts (chen et al., 2020). 2. taiwan policy and politics to control covid-19 in terms of pandemic policy and politics, communication through the media is important for social continuity and keeping communities intact. new technologies have disrupted traditional human habits and changed behaviors. for example, for communication, it becomes less common for people to meet and interact directly with other people face-to-face in the same time and place due to the emergence of new technologies such as portable social media. accustomed to looking at screens all day, people easily trust information that is untrue coming through electronic devices. democracies are debating the extent to which governments should be involved in controlling disinformation harmful to human and social health. more authoritarian governments control digital content without apology, suppressing falsehoods but also valid political criticism. jankowski in lievrouw and livingsstone (2006) describes a “virtual community” as incorporated in an environment that is not physically visible but has a virtual form. humans can also interact with each other virtually and form communities to facilitate sharing information. modern societies are described as information societies because people access to a great deal of information is necessary now for daily life. taiwan acted quickly as an independent country to combat covid-19 because it learned from the history and tragedy of severe acute respiratory syndrome (sars) in 2003 and the h1n1 pandemic of 2009 (su & han, 2020). without using coercive measures, the government organized a disciplined and comprehensive social response, including the public, the military and technology companies. for example, the soldiers took part in drills organized by the new taipei city to put in action “taiwan’s anti-coronavirus strategy” which utilizes a combination of proactive measures and technology in the form of analyzing phone data for contact tracing and monitoring people in quarantine and using online platforms to notify the public about specific risks. in addition, su and han describe how the government quickly organized strategies for controlling specific situations that might emerge and allocating resources to protect the public health. finally, both the cecc and other government officials employed culturally sensitive and transparent public communications and organized a comprehensive society-wide partnership that involved civil society organizations, schools, businesses, and technology platforms in taking precautions to prevent the virus’ potential spread (su and han, 2020). another strategy came from the communicable disease control act which was amended by the ministry of health and welfare in june 19, 2019. the law involves seven sections and each section outlines very clear general principles, and details of the disease control system, prevention of communicable diseases, disease control measures, quarantine measures, penal provisions, and supplementary provisions. for example, passengers who refuse to wear masks on public transport will be fined up to ntd 15,000. therefore, taiwan’s success in fighting covid-19 is due to seriousness of the government in handling the confirmed and suspected cases, the high level of organization and advance preparation and the level of public trust in the government in terms of preventing covid-19. seriousness was evidenced by the immediate formation of a disaster response team and by establishing a framework of disease control (yeh & cheng, 2020). yeh and cheng mentioned that centers for disease control (cdc) has the basic responsibility for public health governance and designing and carrying out major policy actions for tackling covid-19, namely (1) creating the central epidemic command center (cecc), (2) testing, tracking, and epidemiologic investigation, (3) travel restrictions, quarantine, and surveillance, (4) provisions for healthcare and healthcare worker protections, and (5) precautionary measures and travel history tracking. furthermore, the authors pointed out that taiwan’s government response is the synergistic result of many policies such as (1) centralized leadership and cecc professionalism, (2) democracy and political accountability, (3) civil society and social participation, and (4) ethical and legal considerations. the communication and politics in which government reassures and educates the public as a way of fighting misinformation, whether outright hoaxes or offering help analyzing and sorting through the deluge of facts, rumors, and disinformation that arise during any infodemic (wang, 2020). digital technology in modern society makes it possible to obtain and direct personalized information. however, the efficiency and tallutondok & hsieh ghmj (global health management journal) 2022, vol. 5, no. 2 102 automation of digital technology platforms sometimes enables hoaxes and disinformation that can interfere with an effective public response to health threats. in fact, low quality information is a threat to the nation if it is not followed and corrected in communities characterized by diversity and plurality, as in indonesia. if disinformation is not controlled, it will lead to public distrust of important information from the government; the global nature of disinformation is an emergency. for example, taiwan is using humor as a tool against coronavirus hoaxes (quito, 2020). these strategies have made taiwan successful in suppressing the number of cases of covid-19 in the country. 3. what lesson can be learned from taiwan to combat covid-19 the nightmare of sars in 2003 formed the national cultural character to become sensitive to the threat to life from a virus. in addition, the government’s rapid response to containing the covid-19 pandemic accelerated efforts to prevent community spread of virus. based on pfeiffer (2021, january 31st) mentioned that there are eight taiwan’s society-wide response in related to prevent covid-19, namely (1) many institutions, including schools, hospitals, businesses and monitoring employees and visitors taking temperature of everyone who enters the facility for screening for fever at entrances; (2) connecting travel data with national health insurance data, (3) large scale public gatherings and public transportation, meaning that everyone wears a surgical mask, whether or not they have cold symptoms. subway cars and buses are cleaned with disinfectant at the end of each run; (4) distributing surgical masks and preventing price gouging. initially people started buying up surgical masks leaving not enough for health workers. first the country stopped exporting masks. then they worked out of system to rotation them, limiting people to two masks per week, in order to ensure that health care workers have enough, when they step up production. people use their nhi card to buy masks so they do not cheat; (5) hospitals have reorganized work to prevent transmission and shut downs. in this situation as much as possible, teams of doctors and nurses stay on a single ward instead of rotating through the whole building. that way, if infection starts spreading on the ward, they can shut one ward down without closing the hospital. patients with the illness will be moved to medical observation or medial quarantine. the doctors and nurses working on that ward will stay home for two weeks to see if they develop symptoms. scheduling nursing shifts is a lot of work in ordinary times, so recognizing work according to these criteria is probably more complicated still. consequently, the number of both inpatients and outpatients have dropped; (7) use of covid-19 test kits fir check community spread of infection via throat and nose culture to see the symptoms and a travel history, and (8) taiwan’s central epidemic command center and national health insurance system as a model. the question that is indonesia ready? another important aspect of taiwan’s success involves using digitized data and high technology to counter hoaxes and disinformation contributing to the outstanding performance of the health professionals and the government in controlling covid-19 effectively and efficiently in taiwan. taiwan’s epidemic prevention measures meet public needs, including face mask regulations, mandatory quarantines for all arrivals, and contact tracing, and have been so successful that there was no verified case of local transmission of covid-19 in the first 176 days after the outbreak of covid-19. while vietnam, thailand, and new zealand also had long local case-free streaks of 100, 101, and 102 days, respectively, but all three records were broken by new outbreaks (everington, 2020). conclusion the strategy for preventing or mitigating the impact of the covid-19 pandemic varies widely among countries. however, taiwan has a strong public health foundation for combatting covid-19 through a coordinated response, especially in the areas of initial screenings, effective methods for isolation and quarantine, digital technology to identify potential cases, and universal use of masks. a limitation of this article is that it is based on limited experience from a short period in taiwan as an international student and observing community behavior of indonesians from far away. 103 ghmj (global health management journal) 2022, vol. 5, no. 2 tallutondok & hsieh acknowledgments we would like to thank the committee at the international seminar, poltekkes kemenkes palangka raya, and the participants who attend in seminar. we gratefully thank to ms. stefani pfeffer as an english editor and translator office of international education, national taipei university of nursing and health sciences references aspinwall, n. (2020). taiwan’s covid-19 success story continues as neighbors fend off new outbreaks: unlike countries like vietnam and new zealand, taiwan has managed to keep its five-month streak of no local covid-19 transmissions alive. [cite on the diplomat, september 11, 2020. https://thediplomat.com/2020/09/taiwans-covid19-success-story-continues-as-neighbors-fend-off-new-outbreaks/] azanella, l.a. (2020). tren kasus covid-19 meningkat di bulan juni, ini alasannya menurut ahli. editor: rizal setyo nugroho. kompas.com. 17/06/2020, 20:05 wib. baca: https://www.kompas.com/tren/read/2020/06/17/200500665/tren-kasus-covid-19-meningkat-di-bulan-juni-inialasannya-menurut-ahli?page=all. antara. (2021). 504 tenaga kesehatan di indonesia meninggal akibat covid-19. 2021. ed. persada, s. sabtu, 2 januari 2021 19:25 wib. [cite on https://nasional.tempo.co/read/1419545/504-tenaga-kesehatan-di-indonesia-meninggalakibat-covid-19/full&view=ok} chen, c. c., tseng, c. y., choi, w. m., lee, y. c., su, t. h., hsieh, c. y., . . . lin, c. y. (2020). taiwan governmentguided strategies contributed to combating and controlling covid-19 pandemic. front public health, 8, 547423. doi: 10.3389/fpubh.2020.547423 everington, k. (2020). white house has more coronavirus case than taiwan, new zealand, and vietnam. taiwan news. 2020/10/05.12:01. [cite on https://www.taiwannews.com.tw/en/news/4023311} gardner, l. (2020). update january 31: modeling the spreading risk of 2019-ncov. public health. johns hopkins. https://systems.jhu.edu/research/public-health/ncov-model-2/ jankowski, nw. (2006). creating community with media: history, theories, and scientific investigation. in: the handbook of new media: updated student edition. chapter 2. kamil. i. (2020). update 5 november: ada 54,306 kasus active covid-19 di indonesia. kompas.com – 05/11/2020, 16:06 wib. ed: krisiandi. https://nasional.kompas.com/read/2020/11/05/16062461/update-5-november-ada54306-kasus-aktif-covid-19-di-indonesia ministry of health and welfare. communicable disease control act. amended date: 20-06-19. https://law.moj.gov.tw/eng/lawclass/lawall.aspx?pcode=l0050001 quito, a. (2020). taiwan is using humor to quash coronavirus fake news _ quartz.pdf>. pfeiffer, s. (2021) shared an unpublished interveiw with dr. huang pai-tsan. cite: on january 31st, 2021. su, s. f., & han, y. y. (2020). how taiwan, a non-who member, takes actions in response to covid-19. j glob health, 10(1), 010380. doi: 10.7189/jogh.10.010380 taiwan center for disease control. (2021). cecc confirms 7 more imported covid-19 cases; cases arrive in taiwan from the philippines, indonesia, the us, russia, and south africa. jan 16, 2021. https://www.cdc.gov.tw/en/bulletin/detail/zac7io3hjejcsw0buyzt2g?typeid=158 taiwan today, 2021/01/09. taiwan’s coronavirus response features in bjm opinion. https://taiwantoday.tw/news.php?unit=10&post=181842 wang, c. j., ng, c. y., & brook, r. h. (2020). response to covid-19 in taiwan: big data analytics, new technology, and proactive testing. jama, 323(14), 1341-1342. doi: 10.1001/jama.2020.3151 who. (2020). coronavirus disease 2019 (covid-19) situation report – 52. who director-general’s opening remarks at the mission briefing on covid-19-12 march 2020. yeh, m. j., & cheng, y. (2020). policies tackling the covid-19 pandemic: a sociopolitical perspective from taiwan. health secur, 18(6), 427-434. doi: 10.1089/hs.2020.0095 cite this article as: tallutandok eb., hsieh cj. lessons on effective communication from taiwan government to combat covid-19. ghmj (global health management journal). 2022; 5(2):99-103. doi:10.35898/ghmj-52933 https://dx.doi.org/10.35898/ghmj-52933 ghmj (global health management journal) 2024, vol. 7, no. 1 indonesian scholars’ alliance open access research article the effect of physical activity on blood pressure in the community of tumbang tahai district, palangka raya, indonesia muhammad naufa anwar, riccardo hartoyo, i dewa gede sandhikarana, hendrykus theo damar widhiyanto, rian ka praja department of microbiology, faculty of medicine, universitas palangka raya, central kalimantan, indonesia. *corresponding author’s email: riankapraja@med.upr.ac.id doi: 10.35898/ghmj-71973 abstract background: cardiovascular diseases, including hypertension, pose significant health challenges globally. physical activity has long been recognized as a modifiable factor that can influence various aspects of cardiovascular health, including blood pressure. however, the relationship between physical activity and blood pressure is complex and can be influenced by various factors such as cultural and regional differences. aims: the primary objective of this research was to examine the association between physical activity and blood pressure using a quasi-experimental design. methods: this study utilized a quasi-experimental design with a one-group pre-test post-test approach. the sample was selected using a total sampling technique. the independent and dependent variables in this research were physical activity and blood pressure. data collection instruments employed in this study consisted of observation sheets, an aneroid sphygmomanometer, and a stethoscope. data analysis was performed using the wilcoxon test. results: this study showed that there was an association between physical activity and blood pressure. conclusion: this research sheds light on the relationship between physical activity and blood pressure. the findings underscore the importance of considering cultural and regional factors in designing health interventions. keywords: physical activity, blood pressure, hypertension. received: 20 november 2023, reviewed: 21 november 2023, revised: 14 march 2024, accepted: 03 april 2024. © 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 physical activity refers to any body movement generated by skeletal muscles that requires energy expenditure. insufficient physical activity is a risk factor for chronic diseases and is estimated to cause global mortality (world health organization, 2022). humans never cease to move, even during sleep, as the heart continues to pump blood throughout the body unconsciously. however, with the advancement of technology in various fields, awareness of the importance of physical activity for human health has diminished. increasing physical activity in individuals leads to a greater demand for oxygen-containing blood, which the heart meets by increasing blood flow. mailto:riankapraja@med.upr.ac.id https://doi.org/10.35898/ghmj-71973 anwar, et.al. , et.al. ghmj (global health management journal) 2024, vol. 7, no. 1 34 blood pressure is significantly influenced by several factors, including cardiac output, arterial tension, blood volume rate, and blood viscosity. blood pressure is typically expressed as the ratio of systolic pressure to diastolic pressure, with normal adult values ranging around 120/80 mmhg. lack of physical activity increases the risk of developing hypertension due to an increased risk of being overweight. individuals who engage in less physical activity tend to have a higher heart rate, causing the heart muscles to work harder with each contraction. the harder and more frequent the heart muscles have to pump, the greater the pressure imposed on the arteries. elevated blood pressure resulting from insufficient physical activity can lead to complications such as coronary heart disease, kidney function disorders, stroke, and more. hypertension can lead to permanent disability, sudden death, and fatal consequences. therefore, efforts to prevent and manage hypertension need to be carried out by increasing public awareness and adopting healthier lifestyles (kementerian kesehatan republik indonesia, 2019). data from the 2018 riskesdas (national basic health research) revealed that the prevalence of hypertension in central kalimantan reached 34.47%, compared to 26.7% in 2013, indicating a substantial increase within a 5-year period, which can be classified as high. data from the world health organization (who) in 2019 indicates that approximately 1.13 billion people worldwide suffer from hypertension, with two-thirds of cases occurring in low and middle-income countries. the prevalence of hypertension in indonesia reaches 34.1%, with a total of 63,309,620 cases. the 2018 basic health research reported a hypertension rate of 34.1% among individuals aged 18 and older. it stands at 31.6% for those aged 31-44, 45.3% for those aged 45-54, and 55.2% for those aged 55-64. among the 34.1% of the population with hypertension, only 8.8% are diagnosed with hypertension, 13.3% of diagnosed individuals do not take medication, and 32.3% of hypertensive individuals do not regularly take their prescribed medication. a significant 58% of hypertensive patients do not take medication because they feel healthy. this research aims to investigate the influence of physical activity on blood pressure (kementerian kesehatan republik indonesia, 2019). 2. methods this study is a quasi-experimental research with a one-group pre-test post-test design. the research was conducted in the tumbang tahai neighborhood, bukit batu sub-district, palangka raya city. the sample was selected using total sampling technique, consisting of 41 respondents. the independent and dependent variables in this study are physical activity and blood pressure. the research instruments used were observation sheets, an aneroid sphygmomanometer, and a stethoscope. data analysis was conducted using the wilcoxon test. 3. results the exploration of the study's outcomes is two-fold, delving into the intricate details of participant demographics and the consequential impact of physical activity on blood pressure within the community of tumbang tahai. together, these sections weave a comprehensive narrative, starting with participant characteristics and leading to a profound understanding of the impact of physical activity on blood pressure in the specified community context. 3.1 gender and age group distribution out of the 41 respondents who participated in this study, 29 (70.73%) were female, and 12 (29.27%) were male. there was 1 individual aged 17-25 years (2.44%), 4 individuals aged 26-35 years (9.76%), 8 individuals aged 36-45 years (19.51%), 12 individuals aged 46-55 years (29.27%), 11 individuals aged 56-65 years (26.83%), and 5 individuals aged >65 years (12.20%). 35 ghmj (global health management journal) 2024, vol. 7, no. 1 anwar, et.al. figure 1. gender distribution figure 2. age distribution 3.2 comparison of pre-post blood pressure results the analysis of the influence of physical activity on blood pressure in the community of tumbang tahai, as determined by the wilcoxon test, yielded a p value sig. (2-tailed) = 0.05. this result indicates that the p value is <0.05, thus rejecting h₀ and accepting h₁. therefore, it can be concluded that there is an influence of physical activity on blood pressure. this study was conducted on 41 respondents in the tumbang tahai neighborhood, with 29 females (70.73%) and 12 males (29.27%). based on the analysis using the wilcoxon test, a result of p value sig. (2-tailed) = 0.005 was obtained. this indicates that there is an influence of physical activity on blood pressure in the community of tumbang tahai. figure 3. the difference of pre-post and post-test result anwar, et.al. , et.al. ghmj (global health management journal) 2024, vol. 7, no. 1 36 4. discussion the present research investigates the relationship between physical activity and blood pressure within the community of tumbang tahai district, palangka raya, indonesia. the findings of this study contribute valuable insights into the potential impact of physical activity on blood pressure levels in a specific geographical context. physical activity involves any body movement generated by skeletal muscles that requires energy expenditure. regular physical activity can lead to various changes, such as strengthening the heart muscles, increasing its capacity, and ensuring strong and regular contractions. additionally, it can enhance the elasticity of blood vessels through relaxation and vasodilation, reducing fat accumulation and improving the contraction of the blood vessel walls. physical activity significantly affects blood pressure stability. individuals who are inactive in physical activities tend to have a higher heart rate, causing the heart muscles to work harder with each contraction. the harder the heart muscles work to pump blood, the greater the pressure on the arterial walls, leading to peripheral resistance and an increase in blood pressure. insufficient physical activity can also increase the risk of being overweight, which in turn raises the risk of hypertension (harahap et al., 2018; sihotang & elon, 2020). furthermore, the findings open avenues for future research exploring the mechanisms through which physical activity exerts its effects on blood pressure. molecular and physiological investigations could provide insights into the underlying pathways and help tailor interventions for optimal impact. practical implications of the study include the potential incorporation of community-based physical activity programs in public health initiatives aimed at preventing and managing hypertension in the tumbang tahai district. collaborative efforts involving local authorities, healthcare professionals, and community leaders can enhance the effectiveness and sustainability of such interventions. 5. conclusion in conclusion, this research sheds light on the relationship between physical activity and blood pressure in the specific context of tumbang tahai district, palangka raya, indonesia. the findings underscore the importance of considering cultural and regional factors in designing health interventions. this study contributes to the growing body of evidence supporting the role of physical activity in promoting cardiovascular health and encourages further exploration of tailored interventions for diverse populations. conflict of interest the authors declare no conflicts of interest for the results. references harahap, r. a., rochadi, r. k., & sarumpae, s. (2018). pengaruh aktivitas fisik terhadap kejadian hipertensi pada laki-laki dewasa awal (18-40 tahun) di wilayah puskesmas bromo medan tahun 2017. jurnal muara sains, teknologi, kedokteran dan ilmu kesehatan, 1(2). https://doi.org/10.24912/jmstkik.v1i2.951 kementerian kesehatan republik indonesia. (2019). laporan nasional riset kesehatan dasar 2018 lembaga penelitian dan pengembangan kesehatan. sihotang, m., & elon, y. (2020). hubungan aktivitas fisik dengan tekanan darah pada orang dewasa. chmk nursing scientific journal, 4(2), 199–204. retrieved from http://cyber-chmk.net/ojs/index.php/ners/article/view/787 world health organization. (2022). the global status report on physical activity 2022. cite this article as: anwar, m.n., hartoyo, r., sandhikarana, i.d.g., widhiyanto, t.d., praja, r.k. (2024). the effect of physical activity on blood pressure in the community of tumbang tahai district, palangka raya, indonesia. ghmj (global health management journal), 7(1). 33–36. https://doi.org/10.35898/ghmj-71973 https://doi.org/10.24912/jmstkik.v1i2.951 http://cyber-chmk.net/ojs/index.php/ners/article/view/787 https://doi.org/10.35898/ghmj-71973 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 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 roomwith 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. (1986). a synactive model of neonatal behavioral organization: framework for the assessment of neurobehavioral development in the premature infant and for support of infants and parents in the neonatal intensive care environment. physical & occupational therapy in pediatrics, 6(3-4):3–53. artana, i. w. d. (2016). luaran bayi kurang bulan late preterm. sari pediatri, 14(1):62–6. aylott, m. (2006). the neonatal energy triangle. part2: thermoregulatory and respiratory adaption. paediatric nursing, 18(7):38. bayuningsih, r. (2011). efektifitas penggunaan nesting dan posisi prone terhadap saturasi oksigen dan frekuensi nadi pada bayi prematur di rumah sakit umum daerah bekasi. thesis. comaru, t. and miura, e. (2009). postural support improves distress and pain during diaper change in preterm infants. journal of perinatology, 29(7):504–507. efendi, d. and rustina, y. (2013). newborn individualized developmental care and assessment program (nidcap) terhadap hasil jangka panjang perkembangan bayi prematur: suatu telaah. jurnal keperawatan indonesia, 16(3):161–167. eichenwald, e. c. and stark, a. r. (2008). management and outcomes of very low birth weight. new england journal of medicine, 358(16):1700–1711. erb, k. and berman, s. (2009). buku ajar praktik keperawatan klinis edisi 5. egc, jakarta. ferrari, f., bertoncelli, n., gallo, c., roversi, m. f., guerra, m. p., ranzi, a., and hadders-algra, m. (2007). posture and movement in healthy preterm infants in supine position in and outside the nest. archives of disease in childhood-fetal and neonatal edition, 92(5):f386–f390. gouna, g., rakza, t., kuissi, e., pennaforte, t., mur, s., and storme, l. (2013). positioning effects on lung function and breathing pattern in premature newborns. the journal of pediatrics, 162(6):1133–1137. guyton, a. c. and hall, j. (1990). fisiologi manusia dan mekanisme penyakit (edisi 3). egc, jakarta. hegner, b. (2003). asisten keperawatan suatu pendekatan proses keperawatan. egc, jakarta. hendricks-muñoz, k. d., prendergast, c. c., caprio, m. c., and wasserman, r. s. (2002). developmental care: the impact of wee care developmental care training on short-term infant outcome and hospital costs. newborn and infant nursing reviews, 2(1):39–45. hockenberry, m. j. and wilson, d. (2018). wong’s nursing care of infants and children-e-book. elsevier health sciences. irva, t. s., hasanah, o., and ginting, r. (2016). studi kasus: pengaruh posisi dan pijat dapat meningkatkan berat badan bayi berat lahir rendah di ruang perinatologi rsud arifin achmad propinsi riau. jurnal ners indonesia, 6(1):1–8. kahraman, a., başbakkal, z., yalaz, m., and sözmen, e. y. (2018). the effect of nesting positions on pain, stress and comfort during heel lance in premature infants. pediatrics & neonatology, 59(4):352–359. 25 ghmj (global health management journal) 2020, vol. 4, no. 1 deviana m et. al. khashu, m., narayanan, m., bhargava, s., and osiovich, h. (2009). perinatal outcomes associated with preterm birth at 33 to 36 weeks’ gestation: a population-based cohort study. pediatrics, 123(1):109–113. maynard, v., bignall, s., and kitchen, s. (2000). effect of positioning on respiratory synchrony in non-ventilated pre-term infants. physiotherapy research international, 5(2):96–110. ng, s. t., jiang, x., and chong, h. s. (2017). baby monitoring mat based on fiber optic sensor. us patent 9,572,517. pantiwati, i. (2010). bayi dengan berat badan lahir rendah. nuha medika, yogyakarta. pfohl, r. l. and uphold, j. d. (1991). vital signs monitoring system. us patent 5,010,890. picheansathian, w., woragidpoonpol, p., and baosoung, c. (2009). positioning of preterm infants for optimal physiological development: a systematic review. jbi evidence synthesis, 7(7):224–259. setyaningsih, n. y. d. and wahyunggoro, o. (2015). pemilihan lampu sebagai pemanas pada inkubator bayi. semnasteknomedia online, 3(1):4–3. shapiro-mendoza, c. k., tomashek, k. m., kotelchuck, m., barfield, w., weiss, j., and evans, s. (2006). risk factors for neonatal morbidity and mortality among “healthy,” late preterm newborns. seminars in perinatology, 30(2):54 – 60, doi: 10.1053/j.semperi.2006.02.002. tomashek, k. m., shapiro-mendoza, c. k., weiss, j., kotelchuck, m., barfield, w., evans, s., naninni, a., and declercq, e. (2006). early discharge among late preterm and term newborns and risk of neonatal morbidity. seminars in perinatology, 30(2):61 – 68, doi: 10.1053/j.semperi.2006.02.003. optimizing care and outcomes for late preterm (near-term) infants: part 2. trihono, p. p., windiastuti, e., pardede, s. o., endyarni, b., and alatas, f. s. (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 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 how education on nutrition increases knowledge of hypertension among the adolescents retno ayu hapsari* department of nutrition, poltekkes kemenkes palangka raya, indonesia *corresponding author’s email: retno@hapsari.com doi: 10.35898/ghmj-51601 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) globally, who states that about 40% of the adult population aged ≥25 years are diagnosed with hypertension. hypertension itself is the leading cause of death, which is about 45% of deaths in the world due to cardiovascular disease (world health organization, 2013). based on the 2017 indonesian health profile, the national prevalence of high blood pressure was 30.9% and the prevalence increased with age (kemenkes ri, 2018). at central kalimantan, in 2017 as many as 25.64% of the population aged ≥18 years suffered from hypertension (dinkes provinsi kalimantan tengah, 2018). figure 1 checking blood pressure regularly since adolescence is important in the early detection of hypertension mailto:retno@hapsari.com https://dx.doi.org/10.35898/ghmj-51601 59 ghmj (global health management journal) 2022, vol. 5, no. 1 hapsari furthermore, in palangka raya city the number of patient visits with hypertension increased quite sharply in the last five years where females (61.54%) were higher than males (38.46%) (dinkes kota palangka raya, 2018). several studies have shown that hypertension can occur since adolescence and its prevalence has increased over the last few decades, but many have not realized that it is one of the main causes of hypertension in later life (chen & wang, 2008; kelly & magnussen, 2014; muntner, he, cutler, wildman & whelton, 2004). riskesdas (baseline health research) reported that 8.7% of adolescents aged 15-24 years experienced elevated blood pressure (departemen kesehatan, 2008). adolescence is a transformation from childhood to adulthood where there is a social transition in growth and lifestyles affecting the type of disease in adolescents (soetjiningsih, 2004). unhealthy lifestyles in adolescents include alcohol consumption, smoking, excessive sodium consumption, high-stress levels and lack of physical activity can cause cardiovascular diseases such as hypertension (cordente-martinez, garciasoidän, sillero-quintana & stirling, 2009). lifestyle modification particularly weight management for overweight and obese believes in having a beneficial effect in lowering blood pressure among adolescents (genovesi et al., 2018). for implementing a suitable healthy lifestyle, adolescents should have adequate knowledge, particularly the risk factors of hypertension and ways to improve nutrition practices in daily life. thus, it is essential to provide adolescents with the necessary knowledge through nutrition education to prevent the occurrence of hypertension in later life. the project aims to examine the improvement of knowledge about hypertension in adolescents through nutrition education. (a) (b) the project was performed at senior high school in palangka raya. inclusion respondents’ criteria included age 15-18 years, 10 th -12 th grade, both female and male adolescents. anthropometric measurements (height and weight) were conducted to teach students to determine their nutritional status. nutrition education was carried out through audio-visual aids and leaflet both individually and as a group. a questionnaire evaluating nutrition knowledge consisted of 15 items. the questionnaire was given to all students before the figure 2 demonstrating height measurement in adolescence correctly to calculate nutritional status precisely (a); a student measures body weight correctly regularly as one way to self-monitor nutritional status (b) hapsari ghmj (global health management journal) 2022, vol. 5, no. 1 60 nutrition education was delivered to obtain pre-test scores. then, at the end of the session, the questionnaire was re-administered to all the students to obtain post-test scores. correct responses were expressed in percentage. the classification of knowledge level was categorised into 3 levels, namely "good/high" (score 71-100%), "intermediate" (score 51-70%) and "poor" (score 0-50%) (yusof, chia & hasni, 2014). the significance of the change in knowledge was analyzed using paired t-test. the success in providing nutrition education was determined from the differences in the results score of the knowledge of adolescents before and after nutrition education. (a) (b) there was 40 student who volunteered for this project. most students were females at 68% while males at 32%. students learned how to self-monitor nutritional status. the average imt/u was 21.1  2.5 and the nutritional status according to z-score imt/u was -0.1  0.9. however, approximately 10% of students indicated overweight. being overweight or obese is directly proportional to the increased risk of developing hypertension resulting in cardiovascular diseases (sánchez-zamorano, salazar-martinez, anaya-ocampo, & lazcano-ponce, 2009). the nutritional status of obesity in adolescents is a modifiable risk factor to reduce the risk of developing hypertension in the future. it is in line with previous research which shows that there is a significant relationship between obesity nutritional status and the incidence of adolescent hypertension (fitriana, lipoetoe, & triana, 2012; kaprina, 2012). the ministry of health of the republic of indonesia has produced an incredibly interesting infographic containing important information about hypertension. these infographics can be compiled and used as a nutrition resource in providing nutrition education about hypertension. infographics demonstrating visually appealing might be easier to understand, memorable, more persuasive, and relay information easily (balkac & ergun, 2018). figure 3 providing nutrition education about hypertension to adolescents individually (a); providing nutritional education about hypertension to adolescents as a group (b) 61 ghmj (global health management journal) 2022, vol. 5, no. 1 hapsari figure 4 compilation of infographics on hypertension used as a resource in nutrition education knowledge is the result of knowing that is obtained from the process of understanding the nutrition education material that has been delivered. 40 high school students received nutrition education both individually and in groups. nutrition knowledge about hypertension improved greatly among students. almost all students (95%), with sufficient and good levels of knowledge, assuredly understand the nutrition education material provided. the mean score of students before receiving nutrition education (pre-test) was 65.9  12.0, while the mean score of students after receiving nutrition education (post-test) was 77.5  11.9. the paired ttest showed the result of p = 0.000 which indicated there were differences in the level of knowledge of students before and after receiving nutrition education. furthermore, implementing nutrition education to students were apparently improve students’ nutrition knowledge effectively (rajikan & esmail, 2020). in summary, it was undoubtedly important to provide early knowledge about hypertension to adolescents considering adolescents were vulnerable to unstable behavioural lifestyle changes. this integrated adolescent figure 5 the proportion of students' knowledge levels before and after receiving nutrition education hapsari ghmj (global health management journal) 2022, vol. 5, no. 1 62 nutrition education program might significantly improve nutrition-related knowledge among students. figure 6 nutrition education about hypertension in adolescents is an early step in preventing hypertension. adolescent students involved in interactive and engaging nutrition education increase their knowledge of hypertension. conflict of interest none. references balkac, m., & ergun, e. (2018). role of infographics in healthcare. chinese medical journal, 131(20), 2514. chen, x., & wang, y. (2008). tracking of blood pressure from childhood to adulthood: a systematic review and meta–regression analysis. circulation, 117(25), 3171-3180. cordente-martinez, c. a., garcia-soidän, p., sillero-quintana, m., & stirling, j. r. (2009). correlations between the blood pressure and other health variables in spanish adolescents. international journal of adolescent medicine and health, 21(4), 635-652. departemen kesehatan. (2008). laporan hasil riset kesehatan dasar (riskesdas) indonesia tahun 2007. jakarta: departemen kesehatan republik indonesia. dinkes kota palangka raya. (2018). profil kesehatan kota palangka raya tahun 2017. palangka raya: dinas kesehatan kota palangka raya. dinkes provinsi kalimantan tengah. (2018). profil kesehatan provinsi kalimantan tengah tahun 2017. palangka raya: dinas kesehatan provinsi kalimantan tengah. fitriana, r., lipoetoe, n. i., & triana, v. (2012). faktor risiko kejadian hipertensi pada remaja di wilayah kerja puskesmas rawat inap sidomulyo kota pekanbaru. jurnal kesehatan masyarakat, 7(1). genovesi, s., orlando, a., rebora, p., giussani, m., antolini, l., nava, e. et al. (2018). effects of lifestyle modifications on elevated blood pressure and excess weight in a population of italian children and adolescents. american journal of hypertension, 31(10), 1147-1155. kaprina, m. t. (2012). asupan tinggi lemak dan aktivitas olahraga sebagai faktor risiko terjadinya hipertensi obesitik pada remaja awal. semarang: universitas diponegoro. kelly, r. k., & magnussen, c. g. (2014). epidemiology of elevated blood pressure in youth and its utility for predicting adulthood outcomes: a review. world journal of hypertension, 4(4), 29-36. kemenkes ri. (2018). profil kesehatan indonesia tahun 2017. jakarta: kementerian kesehatan republik indonesia. muntner, p., he, j., cutler, j. a., wildman, r. p., & whelton, p. k. (2004). trends in blood pressure among children and adolescents. jama, 291(17). 63 ghmj (global health management journal) 2022, vol. 5, no. 1 hapsari rajikan, s. & esmail, s. (2020). nutrition education to improve nutrition knowledge, attitude and practice among yemeni school children. trends applied sci. res., 15 (3), 207-213 sánchez-zamorano, l. m., salazar-martinez, e., anaya-ocampo, r., & lazcano-ponce, e. (2009). body mass index associated with elevated blood pressure in mexican school-aged adolescents. preventive medicine, 48(6), 543-548. soetjiningsih. (2004). tumbuh kembang remaja dan permasalahannya. jakarta: sagung seto. world health organization. (2013). a global brief on hypertension: silent killer, global public health crisis: world health day 2013. geneva: world health organization. yusof, a., chia, y. c., & hasni, y. m. (2014). awareness and prevalence of mammography screening and its predictors-a cross sectional study in a primary care clinic in malaysia. asian pacific journal of cancer prevention, 15(19), 8095-8099. cite this article as: hapsari ra. how education on nutrition increases knowledge of hypertension among the adolescents. ghmj (global health management journal). 2022; 5(1):58-63. doi:10.35898/ghmj-51601 https://dx.doi.org/10.35898/ghmj-51601 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 progressive muscle relaxation therapy to reduce stress levels in diabetic patients syam’ani* department of nursing, poltekkes kemenkes palangka raya, indonesia *corresponding author’s email: syam_ani@polkesraya.ac.id doi: 10.35898/ghmj-52938 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 number of diabetics worldwide is currently estimated to be around 190 million. by 2025, this number is projected to increase to more than 330 million, with the majority of cases being type 2 diabetes. type 2 diabetes is one of the major public health problems in both developing and developed countries in the asia pacific region. incidence of type 2 diabetes is growing worldwide, possibly due to lifestyle changes, associated with adoption of more western habits such as sedentary, obesity, or an unbalanced diet (ashari, 2012). . figure 1. number of people with diabetes by idf region, 2013. mailto:syam_ani@polkesraya.ac.id https://doi.org/10.35898/ghmj-52938 syam’ani ghmj (global health management journal) 2022, vol. 5, no. 2 122 it cannot be denied that the psychological impact of diabetes mellitus has been felt by sufferers since the doctor's diagnosis. patients begin to experience psychological disorders including stress on themselves related to treatment and medication that must be undertaken (tjokroprawiro, 2006). when a person is faced with a stressful situation, the stress response can be in the form of an increase in the hormone adrenaline which can eventually convert glycogen reserves in the liver into glucose. continuously high blood glucose levels can lead to complications of diabetes. in addition, the factor of the length of time suffering from diabetes is also a factor that can affect the stress level of diabetics. according to renata (2008) stress can decrease productivity, pain and mental emotional disturbances. emotional mental disorder is a condition that indicates the individual is experiencing an emotional change that can develop into a pathological state if it continues. figure 2. one of the psychological impacts of diabetes is stress figure 2. head ache, feeling anxious and feeling unhappy is some of symptoms of stress 123 ghmj (global health management journal) 2022, vol. 5, no. 2 syam’ani symptoms that contribute a lot to mental emotional disorders include frequent headaches, lack of appetite, feeling anxious, feeling unhappy, being unable to do useful things in life, disturbing daily work and finding it difficult to enjoy daily activities, difficulty sleeping, easy fear, trembling hands, disturbed digestion, frequent crying, difficulty making decisions, feeling worthless and easily tired (sri, 2010). this emotional stress condition requires proper handling so as not to fall into a more severe condition. one of them is through progressive muscle relaxation therapy. relaxation is a technique in behavioral therapy to reduce tension and anxiety. this technique can be used by patients without the assistance of a therapist and they can use it to reduce the everyday tension and anxiety experienced at home. relaxation is a technique that everyone can use to create inner mechanisms in a person by forming a good personality, eliminating various forms of chaotic thoughts due to one's helplessness in controlling one's ego, making it easier for a person to control himself, save the soul and provide health to the body. progressive muscle relaxation techniques are relaxation techniques that are done by focusing on the contraction and relaxation of the muscles of the body. figure 4. warming up step before the progressive muscle relaxation therapy figure 3. the author (syam’ani) giving explanation about progressive muscle relaxation to participants syam’ani ghmj (global health management journal) 2022, vol. 5, no. 2 124 progressive muscle relaxation is one of the easiest and most widely used relaxation techniques. this procedure gets relaxation in the muscles through two steps, namely by applying tension to a muscle group, and stopping the tension then focusing attention on how the muscle relaxes, feels a relaxed sensation, and tension (setyohardi, 2011). this opinion is also reinforced by the opinion of jacobson who stated that when anxious, muscles experience tension, a person can reduce anxiety by learning how to relax muscle tension. this progressive muscle relaxation requires physical and mental components (varvolgi & darviri, 2011). relaxation can also reduce subjective tension and affect other physiological processes. muscle relaxation and deep breath relaxation go along with mental relaxation. subjective feelings of anxiety can be reduced or eliminated by indirect suggestions or removing and eliminating the autonomic component of those feelings (resti, 2014). figure 5. demonstration and re-demonstration the steps of progressive muscle relaxation therapy to the participants the results of this study indicate that after being given progressive muscle relaxation therapy, there was a decrease in the number of diabetics who experienced stress, where before the intervention, there were 25 people with moderate stress (92.6%) and 2 people with severe stress (7,4%), while after the intervention decreased to 9 people (33.3%) had no stress, and 18 people (66.7%) had moderate stress. 125 ghmj (global health management journal) 2022, vol. 5, no. 2 syam’ani relaxation can only occur when the mind and body are calm, when the brain's rhythm changes from beta (alert) to alpha (relaxed). this condition causes anxiety to decrease and blood flow to the muscles decreases, otherwise blood flows to the brain and skin, giving a feeling of warmth and calm. progressive muscle relaxation techniques combined with deep breathing relaxation techniques work to reduce stress by activating the parasympathetic nervous system and stopping the sympathetic nervous system. if the sympathetic system is inhibited, this process will decrease so that the cortisol hormone decreases, this causes a decrease in the process of gluconeogenesis (new glucose formation) which is actually prepared to increase blood glucose levels in stressful situations (as a source of energy to deal with stressful situations). figure 7. the author, the participants and the facilitators feeling relaxed and happy as an indicator that stress levels have decreased figure 8. measurement of stress levels after therapy syam’ani ghmj (global health management journal) 2022, vol. 5, no. 2 126 physiologically relaxation exercises will reverse the effects of anxiety that involve the parasympathetic part of the central nervous system. relaxation therapy exercises will inhibit the increase in sympathetic nerves, so that the hormone that causes body dysregulation can be reduced in number. the parasympathetic nervous system, which has the opposite function of the sympathetic nerves, will slow down or weaken the work of the internal organs of the body. the result is a decrease in heart rate, breathing rhythm, blood pressure, muscle tension, metabolic rate, and the production of stress-causing hormones. as the levels of stress-causing hormones decrease, the whole body begins to function at a healthier level with more energy for healing, restoration, and rejuvenation. the combination of progressive muscle relaxation therapy and deep breathing relaxation is one of the stress management systems where the hope is that after doing this exercise the stress experienced by the respondents can decrease. the emotional problems usually experienced by diabetics are stress, sadness, worry about the future, thinking about long-term complications that might arise, feeling afraid to live with dm, feeling discouraged by the treatment program. that must be endured, worried about changes in blood sugar levels and bored with routine maintenance that must be undertaken. this if not followed up immediately will make the stress condition experienced by people with diabetes will get worse. based on the results of the research that has been done, it can be concluded that there is an effect of a combination of progressive muscle relaxation therapy and deep breathing on the stress level of diabetics. consent the informants (identifiable) photographed have given their consent for their pictures to be used in the publication of this research. figure 9. evaluation after intervention of progressive muscle relaxation to the diabetics 127 ghmj (global health management journal) 2022, vol. 5, no. 2 syam’ani conflict of interest none. acknowledgments the authors wish to thank mrs. tutik (the group leader of prolanis bpjs kesehatan) and mr. sopian (the leader of facilitator) for their hospitality and generosity in the implementation of therapy when the authors visited the project site at prolanis bpjs kesehatan, palangka raya city, central kalimantan. references ashari, irwan. (2012). prevalensi diabetes mellitus tipe 2 dan aterosklerosis. http://www.dokterirga.com. jamaluddin, muhammad. (2007). skripsi penelitian : strategi coping stres penderita diabetes dengan self monitoring sebagai variable mediasi, uin malang. renata komalasari, skp, (2008). buku ajar keperawatan jiwa, egc,jakarta resti, i. b. (2014). teknik relaksasi otot progresif untuk mengurangi stres pada penderita asma. jurnal ilmiah psikologi terapan. setyoadi, kushariyadi. (2011). terapi modalitas keperawatan pada klien psikogeriatrik. salemba medika. jakarta. sri idaiani. (2010) analisis gejala gangguan mental emosional penduduk indonesia. http://www.indonesia.digitaljurnal.org. susilo. (2011). cara jitu mengatasi diabetes melitus (kencing manis), andi, jakarta. tjokroprawiro, a. (2006). hidup sehat dan bahagia bersama diabetes melitus. gramedia pustaka utama, jakarta varvolgi & darviri. (2011). stress management techniques: evidence-based procedures that reduce stress and promote health. health and science journal. wulandari, p. y. (2006). efektivitas senam hamil sebagai pelayanan pre natal dalam menurunkan kecemasan menghadapi persalinan pertama. fakultas psikologi universitas airlangga surabaya who. (2008). global prevalence of diabetes. http://www.who.int/diabetes/facts/en/diabcare0504.pdf. cite this article as: syam’ani. a progressive muscle relaxation therapy to reduce stress levels in diabetic patients. ghmj (global health management journal). 2022; 5(2):121-127. doi:10.35898/ghmj-52938 http://www.dokterirga.com/ http://www.indonesia.digitaljurnal.org/ http://www.who.int/diabetes/facts/en/diabcare0504.pdf https://doi.org/10.35898/ghmj-52938 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 ghmj (global health management journal) 2024, vol. 7, no. 2 indonesian scholars’ alliance open access research article determinants of fish consumption in east kalimantan, indonesia: health knowledge, socio-economic factors, and sustainable fishing and culturing practices nurul ovia oktawati and handayani boa* faculty of fisheries and marine sciences, mulawarman university, jalan gunung tabur, kampus gunung kelua, samarinda, east kalimantan, indonesia *corresponding author’s e-mail: boahandayani123@gmail.com doi: 10.35898/ghmj-72996 abstract background: fish consumption preferences vary among communities. the issue of fish consumption achievement of east kalimantan residents which has decreased compared to 2019 has encouraged the government to intensify programs, especially considering socio-economic factors for liking to consume fish. in this study, the issue of fish consumption is also associated with the residents’ knowledge of the benefits of fish nutritional content for health. aims: this recent study aims to investigate the appreciation of east kalimantan residents for the health of fish consumption benefits and to analyze factors which influence the fish consumption of east kalimantan residents. methods: data collection was done through a questionnaire completed by 160 people in 10 regency and city sites in east kalimantan with purposive random sampling method during january to march 2024. also employing multiple linear regression (mlr) is in data analysis. results: most of east kalimantan residents (85%) appreciate the benefits of fish consumption for their health, even though there are still residents (15%) who lack information and knowledge about its benefits. the residents’ understanding and knowledge cover fish as a rich source of omega-3 fatty acids, high-quality protein, and related with reducing risk of heart disease, stroke, and certain types of cancer. the most residents (90%) approve that the fish protein content is of high quality of protein and vitamins-mineral. in the analysis, all variables that build this model have amounting to 82% (r2) affected into fish consumption residents. partially, age, income, fish price, ethnic, education, and fish substitute variables significantly influence the fish consumption of east kalimantan residents at p<0.05. except, the status at the family variable, it has not influence partially to fish consumption of residents. conclusion: residents who understand and know of fish consumption benefit for health are high. the research findings indicate that various variables (age (x1), income (x2), fish price (x3), ethnic (d2), education (d3), and fish substitute (d4) variables) significantly influence the fish consumption of east kalimantan residents. hence, to stimulate awareness of fish consumption, the government has to support the residents through more measurable programs for the increase of fish consumption such as socializing the benefit of fish consumption for health and fish eating program. keywords: fish consumption, health knowledge, socio-economic factors, sustainable fishing & culturing practices. received: 12 july 2024, reviewed: 22 july 2024, revised: 23 august 2024, accepted: 26 august 2024. © 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:boahandayani123@gmail.com https://doi.org/10.35898/ghmj-72996 https://orcid.org/0009-0004-4350-0360 https://orcid.org/0000-0003-3618-7615 93 ghmj (global health management journal) 2024, vol. 7, no. 2 oktawati & boa 1. introduction east kalimantan is one province in indonesia that has length of coastline amounting to 3.893,15 km (dkpkaltim, 2022), having the mahakam river area and length are around 980 km and 85.236 km2, as well as, having several the lakes (bps-kukar, (2023); bps-kaltim, (2023)) that provide fishery production. here, the natural resources used by a community also describe their socio-economic situation. boa et al. (2023) also assessed that culturing potency (ponds) in east kalimantan provide still production and profitable in the next 25 years. hence, based on this potential area provided for fisheries sector growth, the societies in east kalimantan have a big opportunity to consume fishes at their daily meals. according to tran et al. (2017), fast aquaculture growth can be increasing of fish consumption because there was the install of fish supply. to make it happen, environmental factors have to support. environmental factors for fish production can be determined from the quality of the aquatic environment, water volumes and discharge regimes, the degree of pollution from industrial and domestic effluents, pond type (or reservoir), including the proposed methods and technological recommendations (olena et al., 2021), as well as, climatic situation that related by temperature and oxygen levels (osei et al., 2021). then, fisheries policies that have benefits for fisheries or for the marine ecosystems upon which fisheries depend are realized (stewart, 2016). as well as, fish market accessibility can be a fish consumption reason even though far from water areas and fisheries. recently, residents’ fish consumption level in provinces of indonesia in 2022 is shown at fig. 1, namely 57.27 kg/capita/year. in east kalimantan, there was a drastic decline in the level of fish consumption from 2019 to 2020, even the current level of fish consumption in 2022 (58.51 kg/capita/year) increased but it was still below that of 2019 (60.12 kg/capita/year), and this figures is contrary to the government's expectations regarding the improvement in fish consumption figures which should continue every year. figure 1. fish consumption figures of east kalimantan and indonesia, 2022 in fig. 2, provinces in java island are lower than other provinces in indonesia; particularly daerah istimewa yogyakarta with the lowest level of fish consumption, 35.57 kg/capita/year. it has been noted that the highest residents’ fish consumption level is in maluku province, amounting to 79.49 kg/capita/year. such as provinces in kalimantan island, residents’ fish consumption level are also high, those fish consumption figures (kg/capita/year) are 51.34, 65.52, 57.95, 58.52, and 72.75 for west kalimantan, south kalimantan, central kalimantan, east kalimantan, and north kalimantan, respectively (kkp-republikindonesia, 2023). 0 10 20 30 40 50 60 70 fish consumption figures of indonesia (kg/capita/year) fish consumption figures of east kalimantan (kg/capita/year) 58.51 kg/capita/year 57.27 kg/capita/year 60.12 kg/capita/year oktawati & boa ghmj (global health management journal) 2024, vol. 7, no. 2 94 . figure 2. fish consumption figures of indonesia each province, 2022 the jawa ethnic’s fish consumption level in this jawa island is one of assumptions of the study as the lack fish consumption group in indonesia, as well as, jawa ethnic is the highest population density in indonesia knew. even, in the certain jawa region, the younger generation tend not to want to consume fish due to marine pollution reason (anyanwu et al., 2023). the recent study in yogyakarta mentioned that six factors of fish consumption barriers, which are the preferences of family members, processing methods of fish, distribution and availability, myths and knowledge, costs or prices, and tastes (wijaya et al., 2022), convenience, accessibility, healthy concern (wenaty et al., 2018), where nutritional benefits and availability are the most common reasons to eat locally caught fish (shaw et al., 2023). the current review from panchakarla et al. (2023); qayoom et al., (2020) stated that nutritional benefits of fish on human health are important for metabolism and hormone function because the essential elements found in fish such as omega-3 fatty acids, iodine, selenium, vitamin d, taurine, and carnitine, also, vitamins (fat soluble vitamins and several members of vitamin b complex), and minerals (phogat et al., 2022), it means that fish are a significant source of nutrients (naeem & selamoglu, 2023). particularly, fish freshwater consumption can reduce cardiovascular disease rates and certain types of cancer (mielcarek & socha, 2022). because fish nutrition and its benefits are really important, people must know about the food preference chosen, then, they develop habits and behavior in their daily lives to consume healthy food, such as eating fish. supported by the recent research result, it is known that the factor related to the subject's eating habits is nutritional knowledge, because knowledge is the basis for forming attitudes (jauziyah et al., 2021; ratih et al., 2022). against the background of the relatively high potential for fish availability and production in east kalimantan from the production of fish cultivation and fishing activities, increasing public knowledge about the benefits of fish for health, supporting government programs regarding fish-eating programs, as well as, to increase fish consumption figures of east kalimantan, that a study of fish consumption in the people of east kalimantan is deemed necessary. the research objectives are 1) to investigate the appreciation of east kalimantan residents for health of fish consumption benefits and 2) to analyze factors that influence the fish consumption of east kalimantan residents. in this study, there is high consumption on fish predicted basis on several factors of the socioeconomic status affecting. their consumption on fish is due to their well knowledge on fish benefit for health predicted that supported by important sustainable fishing and culturing where important sustainable fishing and culturing is discussed. the conceptual framework of the study is as shown in fig. 3. i have displayed it below, where the research of this study can bring down a recommendation for improvement of fish consumption figures in east kalimantan. 65.93 47.09 46.65 46.75 35.57 48.61 64.87 40.8 40.76 38.83 48.33 51.37 65.52 57.95 58.51 72.75 68.43 66.18 37.02 79.49 68.15 53.29 55.61 75.98 75.33 46.52 66.1 69.53 67.36 73.38 74.84 42.52 43.68 53.65 0 10 20 30 40 50 60 70 80 90 fish consumption figures of indonesia (kg/capita/year) 95 ghmj (global health management journal) 2024, vol. 7, no. 2 oktawati & boa figure 3. the conceptual framework of the study 2. methods study site and time the study site is in east kalimantan. data collection was 3 months in 2024, namely from january to march. sampling technique respondent were taken 160 people, where the sample that taken using the purposive random sampling method in all regency and city sites in east kalimantan province, namely 10 regency and city sites. nasution, (2003) conveyed that purposive sampling involves selecting samples based on the researcher’s judgment, where the purposive random sampling method is often chosen due to considerations such as time, labor, and budget constraints (arikunto & suharsimi, 2010). in this study, amounting to 16 people randomly was taken in each one regency or city sites. they were selected accidentally when buying fish at fish peddlers, grocery store, and traditional night market in weekend, where weekend was the day to gather with family (family days) assumed and became the limitation of research respondents. data collection method primary and secondary data are employed for this study. the primary data is gathered from east kalimantan’s residents through a questionnaire and in-depth interviews (online and offline). the secondary data are collected from relevant statistical data of the related government and private institution sources, and the research reports. analytical techniques the multiple linear regression (mlr) is applied to estimate strength of correlation between dependent and independent variables of fish consumption of east kalimantan’s citizen. residents’ fish consumption (y) is dependent variable, and age (x1), income (x2), fish price (x3), status in the family (d1), ethnic (d2), education (d3), and fish substitute (d4) are independent variables. d1, d2, d3, and d4 are dummy variables particularly to cover the influence of the characteristics of the residents in this study. where, the dummy variables have 2 categories, namely 1 and 2. the dummy variables consist of status at the family (1 = husband/wife, 0 = child/other), ethnic (1 = non jawa, 0 = jawa), education (1 = high at smu and more, 0 = elementary school and junior high school), and fish substitute (1 = fresh/non-processed food, 0 = processed food), where 1 shows the influence of the dummy variables toward the fish consumption. fish consumption fish consumption benefit for health factors affecting fish consumption important sustainable fishing and culturing high fish consumption figures included socioeconomic status, fish market accessibility, cultural influences, government policies, promoting sustainable consumption, and environmental factors oktawati & boa ghmj (global health management journal) 2024, vol. 7, no. 2 96 operational definitions to support the research, operational definitions in this study scope are below. 1. fish consumed are all types of fish, including shrimp, shells, crabs, and squid, including canned fish, dried fish, smoked fish, salted fish, bekasam, and pindang fish 2. residents have a salary or income, and older than 18 3. husband or wife at the family category are the person who takes a decision at their family or household for fish consumption 4. ethnic category basis on fish consumption figures history in indonesia for low and high figures group particularly in jawa and outside jawa island area compered 5. having education 9 years are low level group (elementary school and junior high school), otherwise those with more than 9 years are high level 6. fish substitute displays information on non-processed foods and processed foods of indonesian foods such as fresh meat, eggs, chicken, duck, bird, canned meat, tempeh, tofu, frozen food (meat ball, sausage, nuggets, etc.), side dishes, etc. 7. non-processed food of fish substitute is non-fish products without canning, salting, fermentation, drying, freezing, pasteurizing, smoking, heating, and cooking for production, otherwise, processed foods of fish substitute refer to any food that's changed from its natural state (there is process steps) before cooking or eating by residents. 3. results and discussion socioeconomic status of residents and driving fish consumption overall resident ages are in productive ages included (19-62 years) who distribute in regency of berau, west kutai, kutai kartanegara, east kutai, mahakam ulu, paser, panajam paser utara, balikpapan, bontang, and samarinda city. in table 1, amounting to 54% of residents in this study are female, and the maintaining 45% male. their dominant ethnic are non jawa (non-javanese) (79%) such as bugis, banjar, kutai, makassar, paser, dayak, mandar, madura, minahasa, manado, batak, minang, buton, banua, bajau, and melayu berau. then, most education of them (75%) is high level (from senior high school and more), where, the amount of husband and wife (their status at the family) are 25% respectively, 43% child, and 7% the others. also, they populate area of near river, lake, coastal, and the markets (68%), where their access gets fish for consumption are easier than the other places assessed. the average income this study is approximately idr4.4 million/month, which is still higher than regional minimum wage of east kalimantan province (idr3.01 million/month) determined by government (bps-kaltim, 2023). table 1. socioeconomic status of east kalimantan residents in the field no characteristics amount percentage 1. gender male female 74 86 45% 54% 2. ethnic non jawa jawa (javanese) 126 34 79% 21% 3. education high (senior high school/university/diploma) low (primary school/junior high school) 120 40 75% 25% 4. status at the family husband wife child the others 40 40 70 10 25% 25% 43% 7% 5. residence near river, lake, coastal, and market area the others 109 51 68% 23% 6. the average of income idr4.4 million/month 97 ghmj (global health management journal) 2024, vol. 7, no. 2 oktawati & boa fish market accessibility is well facilitated, and there are fish peddlers, grocery store, and traditional night market provided. also, this situation is profited by topography of east kalimantan that crossing sea and coastal, river, ponds, and lake as potency of fish production central. coastal length of east kalimantan is 3,925 km, and the length of the mahakam river is 920 km. the three largest lakes in east kalimantan are jempang, melintang, and semayang lake, covering an area of ±15,000 ha, ±11,000 ha, and ±13,000 ha, respectively. in the field, suffering from worms parasites and itching are cultural influences trusted by javanese if consume fish, added fishy smell to fish push jawa ethnic’s people to reduce fish consumption. this is interesting to discuss because the javanese are the largest tribe in indonesia, while on the other hand the fish eating campaign is being promoted by government and other institutions. in case of jawa ethic in east kalimantan, they tend to adapt to the surrounding community and environment. based on this situation, integrated projects and policies are needed to encourage sustainable fish consumption and support sustainable fishing and aquaculture activities. fish consumption benefit for health high fish consumption has also been related with people's habits and behaviors, added a study also mentioned that creating those intentions toward fish consumption are started and determined from attitude, social norms, perceived behavioral control, information, and knowledge and habits (arsil et al., 2019). the same thing also happened in the results of this study, where residents’ fish consumption in this study is relatively high, amounting to 58.1 kg/capita/year. also, the residents’ fish consumption is higher than fish consumption of national figures, which are 57.27 kg/capita/year. although, the fish consumption level is slightly below east kalimantan figures (58.51 kg/capita/year), their consumption on fish is still comparable. research result from utri-khodadady & glabska, (2023) mentioned that female, older than 18, underweight, living in an urban environment, from a region far away from the sea and from comprehensive schools provided a higher share of correct answers than other subgroups (p<0.05) about knowledge concerning fish-consumption benefits. based on the survey, most residents approve the benefit of fish consumption (85%) and 15% of them is found un-known and the lack information the benefit of fish consumption for health in detail. among those most residents who know the benefit of fish consumption for health, are 6% of them know fish as a rich source of omega-3 fatty acids, which are essential for heart, brain, and eye health, then, 90% of residents know fish provide high-quality protein, and important vitamins and minerals like vitamin d, vitamin b12, and selenium. as well as, 4% of them know that regularly eating fish linked to a reduced risk of heart disease, stroke, and certain types of cancer (fig.1). it is line with sajeev et al. (2021), the fish consumption variables are highly associated with health values with a note, there is the projects and policies integrated considered. figure 1. residents understanding and knowing on fish consumption benefit for health in addition, eicosapentaenoic (epa) and docosahexaenoic acid (dha) and selenium (se) and methylmercury (mehg) at the selected fish species content are critical components of fish and having health benefit value positively (cardoso et al., 2018). contrary, besides those positive impacts for health, the other 85% 15% benefits of fish consumption for health (residents understanding) know un-know 6% 90% 4% residents knowing on fish consumption benefit for health omega-3 fatty acids protein and vitamins disease prevention know (85%) oktawati & boa ghmj (global health management journal) 2024, vol. 7, no. 2 98 research also mentioned any health risk from cd (cadmium) intake from fish that having a potential risk for children health (arifin & falahudin, 2017), also getting the risk of hg (mercury) intake when consumes the certain fish species. nevertheless, from corriere della sera (newspaper) information emphasizes health still benefits more than possible risks (pasquare et al., 2013). in the field, the residents consume the selected fish from both freshwater and saltwater especially that dominate east kalimantan waters, those fishes types are snakehead, tilapia, goldfish, parrot fish, gourami fish, catfish, shrimp, and mujair. then, milkfish, tiger shrimp, vannamei, white shrimp, mackarel tuna group, skipjack tuna, crab, anchovy, puffer fish, trakulu fish, layang fish, first fish, biji nangka fish, and squid are from the sea and brackish water consumed. about fish substitute, 85% of the residents selected higher consumption to meat, lamb, egg, tempe, tofu/tahu, chicken, and mushroom with fresh/non-processed food than the processed food. factors influencing of residents’ fish consumption all variables in the model are important variables that having a influencing into fish consumption residents (r2=82%). it can be seen in the anova table that simultaneously all predictors are able to predict the resident fish consumption significantly (f=33.014; p<0.05). significant differences in fish consumption are found among age group, income, fish price, ethnic groups, education groups, as well as between fish substitutes (ρ<0.05) except status at the family variables has not influence partially to fish consumption. then, basis on the positive linear relationship of the fish consumption equation at the coefficient (y = -7.009 + .121 x1 + .429 x2 + .092 x3 + .205 d1 + 1.468 d2 + 1.448 d3 + 1.114 d4) (table 2), where, if age, income, fish price are improvement to 1 year, 1 idr/kg, and 1 idr/month respectively hence the fish consumption increase 0.121, 0.428, and 0.092 kg/capita/year as well. then, interpretation of dummy variables, are non-jawa ethnic, high education (senior high school or university/diploma/collage), and fish substitutes (fresh/non-processed food) influence the fish consumption positively. about vif (variance inflation factor) is less than 10. the amount is expected, meaning there is no correlation among the independent variables (x1, x2, x3, d1, d2, d3, d4) at multiple regression model because multicollinearity case in regression must be avoided (in collinearity case is better). then, there is no autocorrelation found because durbin-watson (dw) is 1.642 (between du and 4–du, where in dw table; α=5%, du = 1.8063). autocorrelation case must also be avoided even though the measurement of all variables is carried out simultaneously at the same time. overall, age, income, fish price, status at the family, ethnic, education and fish substitute variable are fit in this residents’ fish consumption model. table 2. coefficients and regression of residents’ fish consumption model coefficients a anova (regression) unstandardized coefficient t sig b std.error f sig (constant) -7.009 1.192 -5.878 .000 33.014 .000b age (x1) .121 .036 3.311 .002 income (x2) .429 .119 3.600 .001 fish price (x3) .092 .023 4.049 .000 status at the family (d1) .205 .649 .316 .753 ethnic (d2) 1.468 .558 2.632 .011 education (d3) 1.448 .567 2.556 .014 fish substitute (d4) 1.114 .540 2.062 .044 r square .816 vif (variance inflation factor) for collinearity check <10 durbin-watson (dw) for autocorrelation check (du < dw < 4 – du) 1.642 a. dependent variable: residents’ fish consumption (y) b. predictors: (constant), d4, d2, d3, x3, x1 d1, x2 it is similar with case in bali province, the age of 45-49 years was an independent variable that affects the level of fish consumption (widihastuti & arthatiani, 2020). also, can et al. (2015) mentioned that significant differences in fish consumption were also found among age groups, gender groups, and education groups, as well as between marital statuses. where, fish price and the availability of favorite fish are factor influencing fish 99 ghmj (global health management journal) 2024, vol. 7, no. 2 oktawati & boa purchase and consumption behavior (m v et al., 2023), and the other research result also mentioned that lower domestic prices can increase fish consumption (tran et al. (2017), nevertheless, a reasonable increase in fish prices accompanied by the quality and freshness of the fish is not a problem for consumers in east kalimantan found. furthermore, the status at the family variables as mentioned above has no affect significantly at the regression. it means that both husband and wife are not dominant to take a decision in a family for fish consumption, even the research result from retnowulandari (2018); david (1994) conveyed a wife is equal to the rights and position of the husband in the family life and in social life, where joint husband-wife decisionmaking patterns are the common norm. then, the family status as the child (adult daughter or son) or someone who lives the same household can also determine their meals preference type for consumption like fish. it is related with they have a role getting their own income, further they have an authority to make opinion and decision at the family. in similar vein, income and asset ownership strength in the family can impact to economic strength assets, communication, problem solving, social support, family cohesion, and religious support strength at the family (orthner et al., 2003). the high consumption of fish by non-javanese tribal communities is an important factor influencing the fish consumption figures in east kalimantan province. however, there are found that those who are javanese and live outside java tend to follow the fish eating culture and habit of the people in the area where they live. many studies state that education is assimilated with a person's knowledge level like education level of most residents who consuming high fish in this study. such as affecting household fish consumption expenditure in indonesia, where the length of schooling (education level of homemakers case) is at a significance level of 5 percent (ningsih et al., 2022). through nutrition education intervention, fish consumption of the residents is good met, but it is not meaningful that resident education in the field is higher than people at the others place if for reason of the fish consumption level. then, fish substitute has opportunity to move fish for consumption. in fact, residents tend select fresh/non-processed food for preferences of fish substitute because they do cooking process by themselves for keep quality food, nutrition, and taste. important sustainable fishing and culturing generally, several the integrated the projects and policies have to be considered for the increase of fish consumption of residents in east kalimantan. we can work towards a sustainable future for fish consumption, ensuring that marine resources are managed responsibly and effectively for generations to come through implementing key points for sustainable fishing and culturing. based on in-depth interview to east kalimantan residents related important sustainable fishing and culturing, there is eight key points found, namely regulation and quotas, sustainable aquaculture practices, ecosystem based management, certification and traceability, research and innovation, consumer education and awareness, community involvement and socioeconomic considerations, and international cooperation. 1. regulations and quotas establish and enforce fishing quotas, where governments should set and enforce catch limits based on scientific assessments to prevent overfishing and allow fish populations to recover. seasonal and area closures, namely implementing closed seasons and protected areas can help safeguard breeding grounds and juvenile fish, ensuring long-term population health. 2. sustainable aquaculture practices species selection, namely choose species that are resilient, have low environmental impact, and do not require high levels of wild-caught fish for feed. feed efficiency, namely use sustainable and efficient feed sources, such as plant-based or insect-based feeds, to reduce pressure on wild fish stocks. water quality management, namely implement systems to monitor and manage water quality, reducing pollution and disease outbreaks. 3. ecosystem-based management by catch reduction, namely develop and use fishing gear that minimizes by catch of non-target species and juvenile fish, ensuring more selective fishing practices. oktawati & boa ghmj (global health management journal) 2024, vol. 7, no. 2 100 habitat protection, namely protect critical habitats such as coral reefs, mangroves, and sea grass beds that support fish populations and biodiversity. 4. certification and traceability eco-labels and certifications, where encourage consumers to choose seafood certified by organizations like the marine stewardship council (msc) or aquaculture stewardship council (asc), which adhere to strict sustainability standards. traceability systems, namely implement traceability systems to track the origin of seafood products, ensuring they come from sustainable sources and reducing the risk of illegal, unreported, and unregulated (iuu) fishing. 5. research and innovation technological advancements, namely invest in research and development of new technologies that improve fishing efficiency, reduce environmental impact, and enhance aquaculture practices. alternative aquaculture systems, namely explore alternative systems like integrated multi-trophic aquaculture (imta) and recirculating aquaculture systems (ras) that have lower environmental footprints. 6. consumer education and awareness public awareness campaigns, namely educate consumers about the importance of sustainable seafood choices through campaigns and labeling initiatives. responsible consumption, namely promote responsible consumption habits, such as diversifying seafood choices to include underutilized species and reducing waste. 7. community involvement and socioeconomic considerations support for local communities, namely ensure that fishing regulations and aquaculture practices support the livelihoods of local fishing communities and promote fair labor practices. co-management approaches, namely engage local communities in fisheries management decisions, fostering a sense of ownership and responsibility for sustainable practices. 8. international cooperation global agreements and partnerships, where strengthen international cooperation through agreements and partnerships that promote sustainable fishing practices and combat iuu fishing. data sharing and research collaboration, namely encourage the sharing of data and collaborative research efforts to improve the understanding and management of fish stocks globally. overall, for improvement of fish consumption figures, the government has to support the residents through more measurable programs that integrated into the projects and policies. 3. conclusion to answer the first aim, understanding and knowing of east kalimantan residents on fish consumption benefit for the health show high (85%) and the remaining 15% is un-know for sure. those health benefits cover fish as a rich source of omega-3 fatty acids, high-quality protein, and related with reducing risk of health disease, stroke, and certain types of cancer. where, among health benefits, most residents know that fish provide highquality protein, important vitamins and minerals like vitamin d, vitamin b12, and selenium. further, to answer the second aim, in analysis, all variables that build this model have amounting to 82% (r2) affected into fish consumption residents. partially, age (x1), income (x2), fish price (x3), ethnic (d2), education (d3), and fish substitute (d4) variables significantly influence the fish consumption of east kalimantan residents at p<0.05, and having strong regression. except, the status at the family variable, it has not influence partially to fish consumption of residents. hence, to stimulate awareness of fish consumption, the government has to support the residents through more measurable programs for the increase of fish consumption such as socializing the benefit of fish consumption for health and fish eating program. also, besides socioeconomic status has a role in fish consumption measurable, fish market accessibility, cultural influences, government policies, promoting sustainable consumption, and environmental aspect implicitly are also the drive of fish consumption. then, the 101 ghmj (global health management journal) 2024, vol. 7, no. 2 oktawati & boa increase of important sustainable fishing and culturing in east kalimantan should be noticed especially making programs that integrated into the projects and policies. conflict of interest the authors declare no conflict of interest for the results. references anyanwu, o., folta, s., zhang, f., chui, k., chomitz, v., kartasurya, m., & naumova, e. (2023). fish—to eat or not to eat? a mixed-methods investigation of the conundrum of fish consumption in the context of marine pollution in indonesia. international journal of environmental research and public health, 20, 5582. https://doi.org/10.3390/ijerph20085582 arifin, z., & falahudin, d. (2017). contribution of fish consumption to cadmium and lead intakes in coastal communities of west kalimantan, indonesia. marine research in indonesia, 42, 1-10. https://doi.org/10.14203/mri.v42i1.154 arikunto, & suharsimi. (2010). prosedur penelitian suatu pendekatan praktik. rineka cipta, jakarta. arsil, p., ardiansyah, & yanto, t. (2019). consumers’ intention and behaviour towards fish consumption: a conceptual framework. iop conference series: earth and environmental science, 255, 012006. https://doi.org/10.1088/17551315/255/1/012006 arthatiani, f., luhur, e., wardono, b., & yulisti, m. (2021). socio-economic determinants of preserved fish consumption in java island: susenas data analysis 2019. iop conference series: earth and environmental science, 870, 012046. https://doi.org/10.1088/1755-1315/870/1/012046 boa, h., suwannathep, s., gunawan, b. i., & bunnag, b. (2023). assessing the impact of mangroves in traditional shrimp farming in the mahakam delta using a cost benefit analysis. journal of sustainability science and management, 18(4), 44-56. https://doi.org/http://doi.org/10.46754/jssm.2023.04.004 bps-kaltim. (2023). kalimantan timur province in figures 2023. bps statistic of kalimantan timur province. bps-kukar. (2023). kutai kartanegara regency in figures, 2023. bps statistics kutai kartanegara regency. can, m., gunlu, a., & can, h. (2015). fish consumption preferences and factors influencing it. food science and technology, 35, 339-346. https://doi.org/10.1590/1678-457x.6624 cardoso, c., bernardo, i., bandarra, n. m., louro martins, l., & afonso, c. (2018). portuguese preschool children: benefit (epa+dha and se) and risk (mehg) assessment through the consumption of selected fish species. food chem toxicol, 115, 306-314. https://doi.org/10.1016/j.fct.2018.03.022 david, f. p. (1994). the roles of husband and wives in household decision-makiing. bahandian, 42(1), 15. dkp-kaltim. (2022). statistic report of marine and fisheries of east kalimantan province. department of maritime affairs and fisheries. east kalimantan. jauziyah, s., nuryanto, n., tsani, a. f. a., & purwanti, r. (2021). pengetahuan gizi dan cara mendapatkan makanan berhubungan dengan kebiasaan makan mahasiswa universitas diponegoro. journal of nutrition college 10(1), 10. https://doi.org/10.14710/jnc.v10i1.30428 %& 72 kkp-republikindonesia. (2023). marine and fisheries in figures 2023. pusat data statistik dan informasi kementerian kelautan dan perikanan. ministry of fisheries and maritime affairs. m v, s., ramesha, t., narayanaswamy, c., & gopika, r. (2023). factors influencing fish purchase and consumption behaviour of koraga and soliga tribes, karnataka, india. indian journal of extension education, 59, 86-90. https://doi.org/10.48165/ijee.2023.59418 mielcarek, k., & socha, k. (2022). freshwater fish consumption in the prevention of diseases. acta poloniae pharmaceutica drug research, 79, 325-331. https://doi.org/10.32383/appdr/150863 naeem, m., & selamoglu, z. (2023). fish as a significant source of nutrients. 6, 1-14. https://doi.org/10.35841/aajphn.6.4.156 nasution, s. (2003). metode penelitian naturalistik kualitatif (bandung). tarsito. library. fis. uny. ac. id/opac/index. php. ningsih, s. k., afifah, e. n., & lubis, f. r. a. (2022). the effect of housewives' education level on fish consumption expenditure in indonesia. harmoni sosial jurnal pendidikan ips, 9(1). https://doi.org/doi:https://doi.org/10.21831/hsjpi.v9i1.28808 olena, h., paraniak, r., kutishchev, p. s., paraniak, n., hradovych, n., matsuska, o., rudenko, o., lytvyn, n., gutyj, b., & maksishko, l. (2021). the influence of environmental factors on fish productivity in small reservoirs and transformed waters. 176-180. https://doi.org/10.15421/2021_27 orthner, d. k., jones-sanpei, h., & williamson, s. a. (2003). family strength and income in households with children. journal of family social work, 7(2), 5-23. https://doi.org/10.1300/j039v07n02_02 osei, v. s., forrester, g., clottey, m. n. k., mcmanus, m. c., & collie, j. (2021). the influence of environmental factors and fishing effort on demersal fish species in ghanaian waters. regional studies in marine science, 46. https://doi.org/10.1016/j.rsma.2021.101858 panchakarla, s., tandle, a., meshre, s., kawade, s. s., & gedam, s. p. (2023). a review on nutritional benefits of fish on human health. chronicle of aquatic science, 1(4), 14. pasquare, f. a., bettinetti, r., fumagalli, s., & vignati, d. a. (2013). public health benefits and risks of fish consumption: current scientific evidence v. media coverage. public health nutr, 16(10), 1885-1892. https://doi.org/10.1017/s1368980012004302 https://doi.org/10.3390/ijerph20085582 https://doi.org/10.14203/mri.v42i1.154 https://doi.org/10.1088/1755-1315/255/1/012006 https://doi.org/10.1088/1755-1315/255/1/012006 https://doi.org/10.1088/1755-1315/870/1/012046 https://doi.org/http:/doi.org/10.46754/jssm.2023.04.004 https://doi.org/10.1590/1678-457x.6624 https://doi.org/10.1016/j.fct.2018.03.022 https://doi.org/10.14710/jnc.v10i1.30428 https://doi.org/10.48165/ijee.2023.59418 https://doi.org/10.32383/appdr/150863 https://doi.org/10.35841/aajphn.6.4.156 https://doi.org/doi:https:/doi.org/10.21831/hsjpi.v9i1.28808 https://doi.org/10.15421/2021_27 https://doi.org/10.1300/j039v07n02_02 https://doi.org/10.1016/j.rsma.2021.101858 https://doi.org/10.1017/s1368980012004302 oktawati & boa ghmj (global health management journal) 2024, vol. 7, no. 2 102 phogat, s., dahiya, t., jangra, m., kumari, a., & kumar, a. (2022). nutritional benefits of fish consumption for humans: a review. international journal of environment and climate change, 1443-1457. https://doi.org/10.9734/ijecc/2022/v12i121585 qayoom, u., mushtaq, z., mir, s., & gul, s. (2020). health benefits of eating fish. ratih, d., ruhana, a., astuti, n., & bahar, a. (2022). alasan pemilihan makanan dan kebiasaan mengkonsumsi makanan sehat pada mahasiswa unesa ketintang. jurnal tata boga, 11(1), 11. retnowulandari, w. (2018). a review of the “head of the family” concept from the family law, gender perspective. shs web of conferences, 54, 02008. https://doi.org/10.1051/shsconf/20185402008 sajeev, m. v., radhakrishnan, a., mohanty, a. k., joshy, c. g., akber ali, v. p., gopika, r., mathew, s., & ravishankar, c. n. (2021). factors influencing the fish consumption preferences: understandings from the tribes of wayanad, kerala. indian journal of extension education, 57(4), 23-27. https://doi.org/10.48165/ijee.2021.57405 shaw, s., he, x., haban, a., tomasallo, c., & meiman, j. (2023). a focus group study of fish consumption behaviors among asian women in milwaukee, wisconsin. preventive medicine reports, 36, 102528. https://doi.org/https://doi.org/10.1016/j.pmedr.2023.102528 stewart, b. (2016). fisheries policy. in (pp. 46-56). tran, n., rodriguez, u. p., chan, c. y., phillips, m., mohan, c., henriksson, p., koeshendrajana, s., suri, s., & hall, s. (2017). indonesian aquaculture futures: an analysis of fish supply and demand in indonesia to 2030 and role of aquaculture using the asiafish model. marine policy, 79, 25-32. https://doi.org/10.1016/j.marpol.2017.02.002 utri-khodadady, z., & glabska, d. (2023). analysis of fish-consumption benefits and safety knowledge in a populationbased sample of polish adolescents. nutrients, 15(23). https://doi.org/10.3390/nu15234902 wenaty, a., mabiki, f., chove, b., & mdegela, r. (2018). fish consumers preferences, quantities of fish consumed and factors affecting fish eating habits a case of lake victoria in tanzania. international journal of fisheries and aquatic studies, 6(6), 6. widihastuti, r., & arthatiani, f. (2020). factors that influence the level of fish consumption in tabanan regency, bali province. iop conference series: earth and environmental science, 521, 012023. https://doi.org/10.1088/17551315/521/1/012023 wijaya, t., farlianto, f., & mamengko, r. (2022). barriers factor analysis of fish consumption behavior in the special region of yogyakarta and central java. agriekonomika, 11, 1-10. https://doi.org/10.21107/agriekonomika.v11i1.12993 cite this article as: oktawati, n. o., & boa, h. (2024). determinants of fish consumption in east kalimantan, indonesia: health knowledge, socio-economic factors, and sustainable fishing and culturing practices. ghmj (global health management journal), 7(2), 92–102. https://doi.org/10.35898/ghmj-72996 https://doi.org/10.9734/ijecc/2022/v12i121585 https://doi.org/10.1051/shsconf/20185402008 https://doi.org/10.48165/ijee.2021.57405 https://doi.org/https:/doi.org/10.1016/j.pmedr.2023.102528 https://doi.org/10.1016/j.marpol.2017.02.002 https://doi.org/10.3390/nu15234902 https://doi.org/10.1088/1755-1315/521/1/012023 https://doi.org/10.1088/1755-1315/521/1/012023 https://doi.org/10.21107/agriekonomika.v11i1.12993 https://doi.org/10.35898/ghmj-72996 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. ndona2 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. 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 roles of educators in diabetes mellitus prevention and management for type 2 diabetes mellitus patients at pahandut public health care, palangka raya city alfeus manuntung*, agnes dewi astuti department of nursing, poltekkes kemenkes palangka raya, indonesia *corresponding author’s email: alfeusmanuntung@gmail.com doi: 10.35898/ghmj-52936 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) diabetes mellitus type 2 is the most common endocrine disease and the most common form of diabetes. the results of research conducted at the hasanuddin university teaching hospital using data from 2014-2018 show that there are four factors that influence the prediction of dm patient status, namely; fasting blood glucose (gdp), ldl cholesterol, triglycerides, and body weight (ente et al., 2020). diabetes mellitus (dm) type 2 requires medical care and self-management education to prevent acute complications and reduce the risk of chronic complications. the american diabetes association (ada) defines dm as a chronic disease that requires independent dm management and education in order to prevent acute and chronic complications (care & suppl, 2020). diabetes mellitus management requires 4 pillars, namely medical nutrition therapy, medicine, exercise and health education. one of the steps that nurses can take is to provide proper health education to patients in order to increase patient independence so that diabetes management is optimal (simamora et al., 2021). nurses act as diabetes educators for the community in an effort to improve health status through health education because diabetes educator as providing direct patient care and have direct influence in care and services that people with diabetes receive (rinker et al., 2018). figure 1 number of dm patients in palangka raya city (2006-2020) mailto:alfeusmanuntung@gmail.com https://doi.org/10.35898/ghmj-52936 111 ghmj (global health management journal) 2022, vol. 5, no. 2 manuntung & astuti in palangka raya city, people with diabetes who come and seek treatment at the puskesmas increased quite sharply in the last 6 years, this is shown by increase in people with diabetes in the period 2006-2020. in 2020 happens a significant increase in the number of 7,615 cases of people with diabetes mellitus, this shows that health promotion has not been able to reduce the number of people with diabetes mellitus in the city of palangka raya. the proportion of people with diabetes is generally of productive age, this is influenced by: risk factors for diabetes mellitus which are generally found in productive age. the risk of diabetes mellitus includes an unhealthy lifestyle such as a poor diet tend to have excess calories, lack of activity (exercise) and obesity which will have an impact on on decreased productivity, increased dependence of patients on family and community and the need for high costs for treatment (dinas kesehatan kota palangka raya, 2021). according to the central kalimantan statistics agency in 2016, diabetes mellitus (dm) is the 5th most common disease of the 10 most common diseases in central kalimantan province. the results of the initial data collection in the work area of the pahandut public health care, palangka raya city, showed that the level of community involvement in self-care for people with dm was still relatively low. this happens because sufferers often ignore or are not aware of the dangers of dm for their lives. puskesmas as the primary health care provider can carry out home visit to diabetes mellitus patients to reduce complications and improve the quality of life for diabetes patients. this activity was attended by 20 people with dm in the working area of the pahandut health center on jalan rindang banua, palangka raya city. figure 2 the health education in pahandut health care on jalan rindang banua, palangka raya city health education activities have started with checking blood sugar, blood pressure, weight and height. then health education is carried out using leaflet media about the prevention and management of dm. figure 3 check blood sugar diabetes patient as a monitoring effort in controlling dm manuntung & astuti ghmj (global health management journal) 2022, vol. 5, no. 2 112 figure 4 check blood pressure diabetes patient as a monitoring effort in controlling dm figure 5 check weight and height diabetes patient as a monitoring effort in controlling dm after check the examination of blood sugar, blood pressure and weight in dm patients have been completed, then an assessment of the level of knowledge was carried out by given a knowledge questionnaire for all participants present. the results of the data collection found as many as 20 people aged around 30-59 years and had suffered from dm for more than 1 year and 12 people (60%) with blood sugar >200 mg/dl, 14 people (70%) regularly took antidiabetic drugs while 6 people (30%) no longer take drugs because they feel bored. the results of the pretest also found that there were 9 people (45%) who scored >56 (less knowledge). this shows that dm sufferers still do not have adequate knowledge and management in handling their health problems, so that these conditions make dm sufferers unable to take care of themselves optimally. based on these data, the material has been delivered for 20 minutes using lcd and microphone media. furthermore, a question and answer discussion session was given which allowed all participants to actively ask questions in conveying the obstacles or problems they faced in overcoming their health problems. health education activities regarding the prevention and management of acute and chronic complications of dm is one of the efforts in controlling dm disease especially on the diabetes mellitus management requires 4 (banerjee et al., 2020; efendi et al., 2021; indaryati, 2018; simamora et al., 2021). 113 ghmj (global health management journal) 2022, vol. 5, no. 2 manuntung & astuti figure 6 health education activities figure 7 discussion session from this activity, some data related to the knowledge of dm sufferers were obtained after health education was carried out, namely the post-test results showed 17 people (85%) scored >56. this comparison of the level of knowledge before and after health education is a short-term evaluation of increasing knowledge which is expected to also improve the ability of dm patients in preventing and managing dm against acute and chronic complications by regularly consuming healthy foods (low glucose), increasing physical activity in the form of sports activities (physical activity for 20-30 minutes performed 3-4 times a week can increase insulin so that blood glucose levels decrease), using diabetes medication in accordance with the right dose safely and regularly, as well as monitoring blood glucose independently, maintaining weight, not smoking and avoiding cigarette smoke, and avoid increasing blood pressure and cholesterol, will support diabetics to stay healthy and reduce the risk of complications of diabetes mellitus. the majority of participants were enthusiastic and felt excited to be able to change a healthier lifestyle so that they could control their blood sugar throughout their lives. health education by dm educators is one of the planned efforts to influence other people, both individuals, groups and communities so that they can do what educators expect, especially for people with dm in improving their quality of life. counseling by dm educators to patients and their families is urgently needed to improve the management of type 2 dm by patients (ramadhan et al., 2018). chronic complications from diabetes usually develop gradually and occur when diabetes isn't properly managed. the most principle of dm complications management is to regulate blood glucose levels so as to not damage the body's organs. uncontrolled high blood glucose levels over time will increase the danger of complications, manuntung & astuti ghmj (global health management journal) 2022, vol. 5, no. 2 114 namely serious damage to all or any organs of the body. by health education will reduce the incidence and/or worsening of diabetes-related complications, such as kidney (nephropathy), eye (retinopathy) and limb (lower) complications. health education can also improve lifestyle behaviors, improve lifestyle behaviors, reduce diabetes-related stress and reduce all-cause mortality (powers et al., 2020). diabetes management may be a lifelong responsibility. diabetes management requires initiative and regularity to always implement a healthy lifestyle for people with diabetes. people with dm must be able to prevent complications as early as possible independently and learn to evaluate themselves and make the right decisions in fulfilling their life needs, especially in emergency conditions. family involvement is also expected to assist dm sufferers in controlling their blood sugar levels such as assisting in providing information support, material support and support in medication adherence (sulistyowati & astuti, 2020). the higher the diabetic is able to manage blood glucose levels, blood pressure and blood fat levels, the lower the risk of dm complications. figure 8 dm educator team and dm sufferers in pahandut health care on jalan rindang banua, palangka raya city dm educator plays an active role in providing health services for the entire community in order to improve the health status of the community. dm educators can work together with other health teams to maximize health services. it is also necessary to empower families and communities in helping people with dm in overcoming their health problems, so that they can improve their quality of life for the better. consent the adults (identifiable) photographed 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 the entire team of dm educators and all dm patients in pahandut health care, palangka raya city. 115 ghmj (global health management journal) 2022, vol. 5, no. 2 manuntung & astuti references banerjee, m., chakraborty, s., & pal, r. (2020). diabetes self-management amid covid-19 pandemic. diabetes and metabolic syndrome: clinical research and reviews, 14(4), 351–354. https://doi.org/10.1016/j.dsx.2020.04.013 care, d., & suppl, s. s. (2020). improving care and promoting health in populations: standards of medical care in diabetes-2020. diabetes care, 43(january), s7–s13. https://doi.org/10.2337/dc20-s001 dinas kesehatan kota palangka raya. (2021). profil kesehatan kota palangka raya tahun 2020. dinas kesehatan kota palangka raya. efendi, p., buston, e., suryanti, s., susmita, r., & yuninsi, y. (2021). pengaruh implementasi 4 pilar penatalaksanaan diabetes mellitus terhadap pengetahuanpada penderita diabetes mellitus di puskesmas kandang kota bengkulu. journal of nursing and public health, 9(2), 74–80. https://doi.org/10.37676/jnph.v9i2.1803 ente, d. r., thamrin, s. a., arifin, s., kuswanto, h., & andreza, a. (2020). klasifikasi faktor-faktor penyebab penyakit diabetes melitus di rumah sakit unhas menggunakan algoritma c4.5. indonesian journal of statistics and its applications, 4(1), 80–88. https://doi.org/10.29244/ijsa.v4i1.330 indaryati, s. (2018). pengaruh diabetes self management education (dsme) terhadap self-care pasien diabetes melitus di rumah sakit kota palembang. jurnal kesehatan saelmakers perdana, 1(1), 44–52. powers, m. a., bardsley, j. k., cypress, m., funnell, m. m., harms, d., hess-fischl, a., hooks, b., isaacs, d., mandel, e. d., maryniuk, m. d., norton, a., rinker, j., siminerio, l. m., & uelmen, s. (2020). diabetes selfmanagement education and support in adults with type 2 diabetes: a consensus report of the american diabetes association, the association of diabetes care & education specialists, the academy of nutrition and dietetics, the american academy of family physicians, the american academy of pas, the american association of nurse practitioners, and the american pharmacists association. diabetes care, 43(7), 1636– 1649. https://doi.org/10.2337/dci20-0023 ramadhan, n., marissa, n., fitria, e., & wilya, v. (2018). pengendalian diabetes melitus tipe 2 pada pasien di puskesmas jayabaru kota banda aceh. media penelitian dan pengembangan kesehatan, 28(4), 239–246. https://doi.org/10.22435/mpk.v28i4.63 rinker, j., dickinson, j. k., litchman, m. l., williams, a. s., kolb, l. e., cox, c., & lipman, r. d. (2018). the 2017 diabetes educator and the diabetes self-management education national practice survey. the diabetes educator, 44(3), 260–268. https://doi.org/10.1177/0145721718765446 simamora, f., manurung, d. m., & ramadhini, d. (2021). pendidikan kesehatan 4 pilar penatalaksanaan dm pada penderita diabetes mellitus di desa manunggang jae kota padangsidimpuan. jukeshum: jurnal pengabdian masyarakat, 1(1), 7–11. https://doi.org/10.51771/jukeshum.v1i1.22 sulistyowati, r., & astuti, a. d. (2020). dukungan keluarga terhadap kepatuhan minum obat pada pasien dm tipe ii. jurnal surya medika, 6(1). https://doi.org/10.33084/jsm.v6i1.1339 cite this article as: manuntung a., astuti da. the roles of educators in diabetes mellitus prevention and management for type 2 diabetes mellitus patients at pahandut public health care, palangka raya city. ghmj (global health management journal). 2022; 5(2):110-115. doi:10.35898/ghmj-52936 https://doi.org/10.35898/ghmj-52936 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 the roles of jumantik-psn (larvae monitor) to prevent dengue hemorrhagic fever (dhf) natalansyah natalansyah department of nursing, poltekkes kemenkes palangka raya, indonesia *corresponding author’s email: tatathomas268@gmail.com doi: 10.35898/ghmj-51599 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 reported the dengue hemorrhagic fever (dhf) outbreak has now become a major threat to global public health. more than 2.5 billion people in the world are at risk of developing dengue fever, with the majority of 70% of the population living in the asia pacific region. compared to other regions, southeast asian countries are most seriously affected by dhf, the potential for the spread of dhf in southeast asian countries is due to many tourists going in and out of one country to another (ministry of health, 2007). figure 1 infographics of dengue cases in indonesia in 2020 mailto:tatathomas268@gmail.com https://dx.doi.org/10.35898/ghmj-51599 45 ghmj (global health management journal) 2022, vol. 5, no. 1 natalansyah dengue hemorrhagic fever (dhf) is a contagious disease and a major public health problem in indonesia. dhf is a disease caused by the dengue virus which belongs to the arthropod-borne virus, genus flavivirus. dhf is transmitted through the bite of mosquitoes from the genus aedes, especially aedes aegypsi or aedes albopictus. diseases can occur throughout the year and can affect all age groups. this disease is related to environmental conditions and community behavior (ministry of health, 2015). mild dengue fever can cause a high fever, rash, and muscle and joint pain. while severe dengue fever, also known as dengue hemorrhagic fever, can cause serious bleeding, a sudden drastic drop in blood pressure, and even death. according to the ministry of health (2020), this year the number of dengue cases in january july reached 71,633 cases, in 2019 the number of cases was higher at 112,954. likewise with the number of deaths, this year there were 459, while in 2019 there were 751 (ministry of health, 2019). various factors are related to the presence of larvae, including the implementation of psn dhf which is an activity to eradicate the vector of dhf which requires an active role from the community, then the breeding place (breeding place), and environmental factors are closely related to the presence of larvae is humidity, while the temperature is not relationship (mardiyani et al, 2010). figure 2 health education regarding dhf according to the ministry of health (2014) that in implementing the seven main activities of controlling dengue fever, five program development plans are determined which include: increasing community participation, reactivating the operational working group (pokjanal) of dhf at various administrative levels, encouraging mosquito nest eradication activities (psn) by schoolchildren and scouts, support vaccine development and improve the ability of human resources (hr) to control diseases originating from arboviruses (ministry of health, 2014). health education is a dynamic process of behavior change, the change process is not only the transfer of material or delivery of material from one person to another, but changes in health education occur because of the awareness of each individual or from a group of people themselves (mubarak, 2009). natalansyah ghmj (global health management journal) 2022, vol. 5, no. 1 46 figure 3 implementation of the lecture method in conducting health education on dhf schoolchildren can play an important role in controlling dengue fever in indonesia, among others, as supervisors of jumantik larvae and as implementers of mosquito nest eradication (psn) in their respective schools and homes. the number of elementary, junior high, and high school students are up to 20% of indonesia's population so if they can play a role in controlling dengue it will have a significant impact in reducing cases and deaths of dengue (ministry of health, 2014). a larvae observer (jumantik) is a person who checks periodically and continuously larvae and moves the community in implementing psn dhf. through larvae monitoring, it is hoped that the mosquito population that transmits dengue hemorrhagic fever and its larvae can reduce by increasing community participation in the psn dhf. where there is a jumantik, it can be seen that the density of aedes aegypti mosquito larvae periodically and continuously can be used as an indicator of the success of psn dhf in the community/environment for implementing psn dhf (ministry of health, 2006). figure 4 collecting data at the jumantik student's house 47 ghmj (global health management journal) 2022, vol. 5, no. 1 natalansyah larva monitoring students (sismantik) are the empowerment of elementary school students to become larva monitors. students come from these schools with an age range of 9-12 years, which is more precisely grade 5 elementary school students. students who have been able to read and understand what they read, see, and hear. they monitor larvae in the school environment. activities or tasks of larva monitoring students are carried out in rotating groups based on the class hygiene picket group (ministry of health, 2006). figure 5 activities to eradicate mosquito nests in water reservoirs facilities in carrying out activities to eradicate dengue hemorrhagic fever mosquito nests consist of facilities for cleaning the bath (scoop, soap, brush, water), facilities for closing water reservoirs, facilities for burying or storing used items, giving abate powder, giving fish. larva monitors, and so on. the provision of these facilities is a means of supporting the implementation of psn dhf activities (soekidjo, 2005). the psn dhf activity is an activity to eradicate the dengue vector which requires an active role from the community. several factors that influence the active role of the community in the implementation of psn dhf are according to research conducted by laksmono widagdo et al. (2008) which states that there is a relationship between social characteristics, namely education, employment, number of residents in the house, and average income with psn 3m plus, whereas age, knowledge and attitude, there is no relationship. research conducted by arif (2009) states that there is a relationship between knowledge and the implementation of psn dhf activities, while attitudes do not have a significant relationship. natalansyah ghmj (global health management journal) 2022, vol. 5, no. 1 48 figure 6 examination of larvae in the bath according to research conducted by mardiyani et al. (2010) states that there is a relationship between the rain channel which is not smooth and the existence of water containers with the presence of aedes aegypti larvae. this is also supported by research conducted by setyobudi (2011) which states that the existence of breeding placemats has a significant effect. it is quite significant for the presence of mosquito larvae. in the research area, it is stated that the presence of breeding places that are mostly infected with larvae in endemic and non-endemic areas of dhf is a bathtub. the bathtub is owned by almost the entire community. figure 7 jumantik student home environment according to research conducted by mardiyani et al. (2010) states that the environmental factor associated with the presence of larvae is humidity, while temperature has no relationship. according to suprijanto's research (2004) that there is a significant relationship between the amount, volume, lighting, materials, the influence of sunlight, cover, location, water conditions, use of abate, and fish maintenance in water reservoirs, and the presence of larvae. 49 ghmj (global health management journal) 2022, vol. 5, no. 1 natalansyah figure 8 community service activities in classroom 6 of sdn petuk katimpun community services at the community with a location in petuk katimpun kelurahan was carried out by lecturers together with the pustu officer on tuesday, october 16, 2018, at the study room-class 6 elementary school petuk katimpun. activities carried out from 08.30 to 10.00 am attended by the school community, teachers, students in grades 5 and 6 as many as 30 people, 2 puskesmas officers, 4 students of the iii semester d-iv nursing study program. figure 9 closing of the jumantik psn activities at elementary school petuk katimpun based on the results of statistical analysis, there was an increase in the average score of knowledge (1.57 x points) about dhf after being given counseling on community service activities. the results of community service are in line with the results of research by natalansyah et al. (2017), that there is a difference in the form of an increase from the average value before the intervention of 5.03 to 8.1 after the intervention with p. value: 0.0005 (p <0.05). this study is in line with research by zullaekah (2012) which shows that booklet media can increase knowledge about nutrition by 17.44 points (p = 0.001). kirkpatrick (2006) revealed that the second level of training evaluation is a type of evaluation that is relatively easy, usually using pre and posttests. natalansyah ghmj (global health management journal) 2022, vol. 5, no. 1 50 consent the children and adults (identifiable) photographed have given their consent for their pictures to be used in the publication of this research. references arif & sari, k. (2011). gastrointestinal disorders medical surgical nursing care application. jakarta: salemba medika. setyobudi, a. (2011). factors related to the presence of mosquito larvae in dbd endemic areas in sananwetan subdistrict, sananwetan sub-district, blitar city. retrieved from online http://journal.unsil.ac.id/jurnal/prosiding/9/930agus_30.pdf., accessed, 27 october 2020. ministry of health of the republic of indonesia. (2006). indonesia health profile: guidelines for the implementation and procedure of hospital medical records in indonesia. jakarta: ministry of health of the republic of indonesia ministry of health of the republic of indonesia. (2007). indonesia health profile: prevention and eradication of dengue hemorrhagic fever in indonesia. jakarta: ministry of health of the republic of indonesia. ministry of health of the republic of indonesia. (2014). indonesia health profile: beware of dhf in the transitional season. retrieved from http :// www. depkes.go.id/ article/print/15010200002/waspada-dbd-dimusimpancaroba.html, accessed on october 27, 2020. ministry of health of the republic of indonesia. (2014). infodatin: situation of dengue hemorrhagic fever in indonesia. jakarta: center for data and information, ministry of health of the republic of indonesia. ministry of health of the republic of indonesia. (2016). indonesia health profile 2015. jakarta: ministry of health of the republic of indonesia. suprijanto, d.s. (2004). factors associated with the existence of dengue hemorrhagic fever mosquito larvae in purwodadi village, grobogan regency. doctoral dissertation, diponegoro university. kirkpatrick, d.l. (2006). implementing the four levels. san francisco: berret-koehler publisher, inc. ministry of health of the republic of indonesia. (2018). indonesia health profile 2017. jakarta: ministry of health republic of indonesia. mardiyani., n., nugrahaningsih, a.p & aryanta, i.w.r.. (2010). relationship between environmental factors and community behavior with the presence of mosquito larvae that transmit dengue hemorrhagic fever (dhf) in the working area of puskesmas kuta utara. journal of ecothropic, 5(2), 93-97. mubarak, w.i. (2006). textbook of community nursing 2. jakarta: sagung seto. soekidjo, n. (2005). health promotion: theory and application. jakarta: rineka cipta. zulaikah, s. & wulandari, a. (2012). comparison between platelet count with automatic counting tool and indirect manual method. malang: malang health analyst academy. widagdo, w. (2008). nursing care for clients with nervous system disorders. jakarta: trans info media. cite this article as: natalansyah n. the roles of jumantik-psn (larvae monitor) to prevent dengue hemorrhagic fever (dhf). ghmj (global health management journal). 2022; 5(1):44-50. doi:10.35898/ghmj-51599 http://journal.unsil.ac.id/jurnal/prosiding/9/930-%20agus_30.pdf https://dx.doi.org/10.35898/ghmj-51599 ghmj (global health management journal) 2024, vol. 7, no. 3 indonesian scholars’ alliance open access research article turmeric topical application: an effective solution for reducing breast milk secretion delays in new mothers tri ratna ariestini1, christine aden1, berthiana1, harlyanti muthma’innah mashar2 1 department of nursing, poltekkes kemenkes palangka raya, indonesia. 2 department of nutrition, poltekkes kemenkes palangka raya, indonesia. *corresponding author’s e-mail: harlyanti@polkesraya.ac.id doi: 10.35898/ghmj-73998 abstract background: the problem of low coverage of exclusive breastfeeding is partly influenced by insufficient breast milk production. the percentage of exclusive breastfeeding in infants under six months of age in central kalimantan in 2020 was 52.98%. this percentage was among the lowest nationally. in 2021, the coverage of exclusive breastfeeding in infants under six months of age reached 56.8%, and in 2022 it did 60.5%. the figure in 2022 exceeded the set target, but several regencies/cities still had low coverage. insufficient breast milk supply impacts on the nutritional status of the child. low breast milk production also arises due to several other factors during breastfeeding, namely late initiation of breastfeeding, long breastfeeding time, sore nipples, breast pain and swelling, and inverted nipples. aims: the study sought to measure the level of success of turmeric topical application in shortening the time it takes to initiate breast milk secretion. methods: the study uses a true experimental posttest-only control group design. a subject of 50 mothers having full-term spontaneous deliveries and with normal breasts was used in the study. the sample was divided into two groups: control and intervention groups. the sample was selected using a matching process based on age, parity, and early initiation of breastfeeding. subjects who met the inclusion criteria were offered whether they were willing to be given turmeric compresses after the delivery process. subjects who were willing were included in the intervention group and those who were not willing were included in the control group. age and parity in the intervention group were all taken, while the control group was selected to match the intervention group. the intervention group was given a treatment with a turmeric compress on the breasts for six hours. all participants were then observed for time of breast milk secretion initiation. in this experiment, we didn't perform blinding, but we managed it by having the midwife administer the turmeric compress just once during the delivery process before sending the client home. following this, we recorded the results, specifically the initial breast milk release in both the intervention and the control group. results: the average time periods it took to initiate breast milk secretion in the intervention and control groups were 509.96 minutes (8.5 hours) and 1573.76 minutes (26.2 hours), respectively. there was a significant difference (p = 0.023) in the time of breast milk secretion initiation of 1063.8 minutes or 17.73 hours between both groups. conclusion: applying a turmeric compress on the breasts of postpartum mothers may shorten the time it takes to initiate breast milk secretion. keywords: turmeric compress; breast milk secretion; postpartum mothers; breastfeeding initiation. received: 05 august 2024, reviewed: 23 august 2024, revised: 21 september 2024, accepted: 13 october 2024. © 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:harlyanti@polkesraya.ac.id https://doi.org/10.35898/ghmj-73998 113 ghmj (global health management journal) 2024, vol. 7, no. 3 ariestini, et.al. 1. introduction breast milk is an ideal food for babies because it contains a number of ideal nutrients with a balanced composition that is beneficial for the growth and development of babies and the maintenance of their health. breast milk provides babies with calories, vitamins, minerals, and other nutrients that they need (utari & desvira, 2021). the world health organization (who) and unicef recommend that every baby be exclusively breastfed for at least six months after birth and that breastfeeding should continue for two years (maleki & youseflu, 2022). breastfeeding can be one of the first steps for babies to have a healthy life. breastfeeding is regarded as the most essential element in reducing newborn death rates, and it has many benefits for maternal health. however, despite these recommendations, only 37% of babies under six months of age are exclusive breastfeeding in lowand middle-income countries (haryanti et al., 2024; sharma & khadka, 2019). the government is expected to attain the exclusive breastfeeding coverage target in order to achieve the sustainable development goals (sdgs), one of which is to ensure a healthy life and promote the welfare of all levels of society at all ages (kementerian perencanaan pembangunan nasional, 2020). however, insufficient breast milk production often poses complications to the targeted coverage of exclusive breastfeeding. based on data from eppgmn in 2023, the exclusive breastfeeding coverage rate in 2023 was 58%. this figure still fell short of the 75% coverage target set in the 2023 health strategy plan, suggesting the need to increase the coverage rate to achieve optimal results. the percentage of exclusive breastfeeding in infants under six months of age in central kalimantan in 2021 reached 56.8%, and in 2022, it was 60.5%. although the coverage rate in 2022 exceeded the set target, several regencies/cities still had low coverage, including south barito murung raya (2%), palangka raya (18%), north barito (40%), sukamara (45%), and south barito (48%) (kementerian kesehatan ri, 2022). insufficient breast milk supply is a problem faced by some breastfeeding mothers due to low breast milk production, impacting on the nutritional status of the child (djanah & muslihatun, 2017). in addition to low breast milk production, this problem also arises due to several other factors during breastfeeding, namely late initiation of breastfeeding, long breastfeeding time, sore nipples, breast pain and swelling, inverted nipples, and redness (babakazo et al., 2022). breast milk production can be increased through both pharmacological and non-pharmacological therapies. mothers primarily prefer non-pharmacological therapies using traditional techniques with herbs because they are considered safer and with minimal side effects. these include consuming katuk leaves and using turmeric either by oral administration or topical application on the breasts (mayasari & jayanti, 2022). these traditional methods have been passed down through generations and are believed to be effective in stimulating milk production. katuk leaves, in particular, are known for their galactagogue properties that can help increase breast milk supply. similarly, turmeric is believed to have anti-inflammatory properties that can help with any pain or swelling in the breasts. by incorporating these natural remedies into their routine, mothers can potentially improve their breastfeeding experience and ensure their baby is getting the nutrition they need (becskei et al., 2020; maru et al., 2023). from observations and interviews with dayak mothers in central kalimantan, it was figured out that the local wisdom of the dayak tribe holds that turmeric applied to the breasts is efficacious in facilitating breast milk production as well as accelerating the release of breast milk. turmeric can be taken as herbal medicine drinks or applied topically. turmeric contains essential oils, curcuminoids, turmeone, galactagogue, and zingiberene, which have the potential to be anti-inflammatory, antibacterial, and antioxidant. the galactagogue compound can act as a stimulant to facilitate and increase breast milk production (ariescha & tryaningsih, 2019). the role of turmeric as a topical drug is thought to be closely related to its efficacy in facilitating blood circulation and inducing calmness, thus reducing the risk of stress during breastfeeding. the efficacy of turmeric in treating depression have long been known in chinese medicine. this is thought to play a role in facilitating the release of breast milk (ramaholimihaso et al., 2020). more research is required to fully understand the possible advantages and mechanisms of turmeric for breastfeeding women. ariestini, et.al. ghmj (global health management journal) 2024, vol. 7, no. 3 114 2. methods the research used an experimental posttest-only control group design. the measurements include the duration of the first release of breast milk and the time interval after delivery until the first release of liquid breast milk, not thick colostrum. it was examined by squeezing the nipple and checking whether the breast milk that was expressed was thin or thick. objective data were supported by subjective data on early signs of breast milk secretion, namely the breasts feeling full, tight, and painful. the research was carried out at the pahandut public health center. the sample size was calculated based on the results of research on the timing of breast milk expression with early initiation of breastfeeding (eibf) treatment. each of the intervention and control groups consisted of 25 people. the inclusion criteria were postpartum mothers delivering at term and spontaneously, having no problems with breasts (no history of surgery, infection, phototherapy, or nipple disorders), and showing willingness to be respondents. postpartum mothers who were sick, receiving treatment from a doctor, and taking breast-milk-stimulating drugs were excluded. a drop-out was marked by failure to carry out the intervention according to the research provisions. the intervention and control groups were matched in terms of age, parity, and early initiation of breastfeeding. before being divided into control and intervention groups, subjects who met the inclusion criteria were offered whether they were willing to be given turmeric compresses after the delivery process. subjects who were willing were included in the intervention group, and those who were not willing were included in the control group. age and parity in the intervention group were all taken, while the control group was selected to match the intervention group. the intervention was carried out only once after the delivery process. it was carried out by a midwife at the health center in the position of the subject, who was still being hospitalized and not yet home, so that the implementation of the intervention could be ensured to be consistent. the treatment was administered to the intervention group in the following steps: 1. four hours after giving birth, mothers in the intervention group had their breasts compressed with crushed turmeric. the turmeric used is fresh turmeric weighing 50 g for each breast. the turmeric is first ground and then compressed onto the breast. the turmeric compress was applied on the entire surfaces of their breasts, except the nipples. 2. the turmeric compress was applied for six hours, during which time the mothers were allowed to wear a bra as usual. 3. after six hours, the breasts were cleaned thoroughly with a piece of wet wipe, followed with a piece of dry tissue. 4. an evaluation of the time of the first secretion of breast milk (thin as opposed to thick breast milk) was carried out, followed by additional assessments of early signs of breast milk production, such as the breasts feeling full, firm, and painful. 5. these assessments were also conducted on the control group. the confounding variables controlled by analysis in this study were breast care and early breastfeeding initiation (imd). the early initiation of breastfeeding variable was not analyzed because all samples, both the intervention and the control group, were given imd, so they were matched. while breast care was analyzed with the results of the chi-square test with a p-value of 0.225 (> 0.05), this means that there is no statistically significant difference between breast care and the time of first breast milk release. initially, data collection related to the nutritional status of the subjects was carried out by measuring the body mass index, but this was not continued because the bias with the increase in maternal weight during pregnancy is greatly influenced by the physiological process of increased fluid accumulation during the pregnancy process. nutrition and stress levels of pregnant women were not measured in this study and are shortcomings of the study. the bivariate analysis determined the relationship between topical application of turmeric as an independent variable and the time of breast milk secretion initiation as a dependent variable. external variables including the baby's weight, the baby’s gender, and the mother's parity were also examined in their effects on the smoothness of breastfeeding as a dependent variable. the t-test was employed to determine the association between the independent and dependent variables. meanwhile, the chi-square test is used to assess the association between external variables and the dependent variable. in multivariate analysis, linear regression was utilized. 115 ghmj (global health management journal) 2024, vol. 7, no. 3 ariestini, et.al. 3. results the distribution of participants by age, parity, breast care, and early initiation of breastfeeding can be seen in table 1. five individuals (20%) were < 20 years of age, and 11 (44%) fell within the age range of 20 to 35 years. the participants comprised eight primipara (32%) and 17 multipara (68%). at the intervention group, there were 10 individuals did breast care, while 15 did not. in the control group, six individuals did breast care, while 19 did not. breast care and early initiation of breastfeeding were controlled for the analysis. in both groups, 25 individuals initiated breastfeeding early. based on table 1, both intervention and control groups were the same because of the matching process carried out before intervention. table 1. distribution of research participants variable turmeric compress no turmeric compress n % n % age (year) <20 5 20 5 20 20 – 35 11 44 11 44 >35 9 36 9 36 total 25 100 25 100 parity primipara 8 32 8 32 multipara 17 68 17 68 total 25 100 25 100 breast care yes 10 40 6 24 no 15 60 19 76 total 25 100 25 100 early initiation of breastfeeding yes 25 100 25 100 no 0 0 0 0 total 25 100 25 100 as shown in table 2, this recent study showed that applying turmeric compresses to new mothers significantly sped up the time it took for their breast milk to start flowing. on average, mothers who used the turmeric compress began producing milk was 509.96 minutes (or in about 8.5 hours), while those who didn’t had to wait much longer— with an average time of 1573.76 minutes (or around 26 hours). the difference between the two groups was significant (p value = 0.023), meaning that there was a significant difference in the duration of first breast milk secretion between individuals applying the turmeric compress on their breasts and those who did not apply the turmeric compress. table 2. relationship between turmeric compress application and the first breast milk secretion duration group n mean (minute) standard deviation p value turmeric compress 25 509.96 309.46 0.023 no turmeric compress 25 1573.76 1420.09 mann-whitney test the results of the chi-square test for breast care and the time interval after delivery until the first release of liquid breast milk, not thick colostrum, can be seen in table 3. the chi-square test results show that the pvalue was > 0.05. it indicates that there was no significant difference between breast care and the time of first breast milk secretion. in other words, breast care did not affect the timing of breast milk secretion. because the bivariate test demonstrated that breast care had no effect on the time of first breast milk secretion, multivariate analysis was not conducted. this study's final outcome measured was the time of first breast milk release. the overall experience of breastfeeding or the success of exclusive breastfeeding up to 6 months has not been studied. ariestini, et.al. ghmj (global health management journal) 2024, vol. 7, no. 3 116 table 3. relationship between breast care and the time of first breast milk secretion breast care group p value turmeric compress no turmeric compress yes 10 6 0.225 no 15 19 total 25 25 4. discussion the research participants were postpartum mothers who gave birth at the pahandut public health center, palangka raya city, central kalimantan, indonesia. all of them were qualified to take part in the research until the end, and no one dropped out. throughout the study, the participants were provided with regular check-ins and support to ensure their well-being. the high level of participation and commitment of the participants contributed to the success of the research and the validity of the results obtained. the findings were able to accurately reflect the experiences and perspectives of the participants. this level of dedication from the participants highlights the importance of their voices being heard in research studies. the consistent support provided to them also reflects the ethical considerations taken by the researchers to prioritize the well-being of the participants. overall, the collaboration between the researchers and the postpartum mothers resulted in a successful study that truly captured the lived experiences and insights of this specific population. the distribution of research participants by age, parity, breast care, and early initiation of breastfeeding is shown in table 1. several researches revealed no significant association between maternal age and nursing self-efficacy levels. for instance, amini et al. (2019) discovered a weak link between the two. the relationship between the number of children in a family and the mother’s breastfeeding behavior is influenced by the family's perception on breastfeeding. new mothers who breastfeed their infants have much higher family attitudes or support than those who use mixed or artificial feeding. this suggests that family support and perceptions on breastfeeding play a crucial role in a mother's decision to breastfeed (bengough et al., 2022). breastfeeding duration is favorably associated to family size, birth order, maternal age, and the nutritional quality of the children (arif et al., 2021). mothers with larger families may have more experience and support from older children and other family members, leading to longer breastfeeding durations. previous breastfeeding experience was found be favorably connected with greater nursing self-efficacy scores. these factors can impact a mother's ability and readiness to breastfeed immediately after giving birth (li et al., 2021). breast care treatment, including oxytocin massage, can positively impact breast milk production by stimulating the release of the oxytocin hormone, leading to increased milk production. a study revealed that postpartum mothers who received oxytocin massage produced more milk compared to those who did not receive it. factors such as breast care treatment and oxytocin massage can contribute to higher breast milk production (hendriyani et al., 2019). some studies collected data on various factors that might affect the duration of breastfeeding, such as background data, antenatal and postnatal attitudes towards breastfeeding, breastfeeding intention, and postnatal support after discharge (gavine et al., 2022; naja et al., 2022). early breastfeeding shows a substantial favourable link with both exclusive breastfeeding and breastfeeding length, with the latter having the greatest benefit. knowledge about breastfeeding, birth history, and midwife's support also play a role in exclusive breastfeeding. mothers in urban regions are more likely to commence early breastfeeding and perform exclusive breastfeeding than those in rural areas (permatasari & syafruddin, 2016). early breastfeeding initiation has been demonstrated to boost exclusive breastfeeding rates in big groups. during the first month of the intervention, the rates of exclusive breastfeeding were already high, and they remained steady throughout the program, with significant increases observed over time. timely commencement and exclusive breastfeeding were key indicators in these programs, emphasizing the importance of establishing good infant feeding practices early on (fosu-brefo & arthur, 2015; patel et al., 2015). 117 ghmj (global health management journal) 2024, vol. 7, no. 3 ariestini, et.al. this study focuses on assessing the time of first breast milk release, not on the entire breastfeeding process or the amount of breast milk produced during breastfeeding. so the preparation factors before the lactation process that are commonly carried out by pregnant women, such as breast care and imd, are the main choices of researchers. nutritional factors during breastfeeding and emotional factors of mothers, such as postpartum blues, experience many changes during breastfeeding (lactation), so they are not the main choices of researchers. however, it is better to still be used as a confounding variable, including family support. because in this study it is not used as a confounding variable, it will be added to the statement in the discussion as a research deficiency. the results revealed that there was a considerable difference in the time of first milk secretion between the group of mothers who applied a turmeric compress on the breasts and those who did not (p < 0.05). mothers who had a turmeric compress applied on their breasts had their first breast milk come out faster than those who did not apply a turmeric compress. the average difference in breast milk release time was 1,063.8 minutes. it can be said that mothers who applied a turmeric compress for six hours after childbirth took less time to express breast milk for the first time (17.73 hours) compared to postpartum mothers without compresses. to ensure that the acceleration of breast milk production was indeed due to the influence of the turmeric compress, several variables that might acted as confounders were controlled. the age and parity variables were controlled through sample selection restrictions by matching. because all the participants practiced early initiation of breastfeeding, this variable was already controlled. lastly, the variable breast care was controlled through the chi-square analysis process. the results of the ci-square test for breast care and the time of first breast milk secretion can be seen in table 3. according to these results, there was no significant difference between breast care and the time to express breast milk (p > 0.05). in other words, breast care did not affect the timing of breast milk secretion. because the bivariate test of breast care showed no effect on the time of breast milk secretion, multivariate analysis was not conducted. this research used an intervention of a one-time six-hour turmeric compress, unlike people's custom in using turmeric compresses; typically turmeric compresses are applied all day long every two days to ensure the smooth release of breast milk. nonetheless, a significant difference was detected between the group of postpartum moms using a turmeric compress on their breasts and those who did not. if the intervention was carried out for a longer time, the first breast milk secretion might have occurred even earlier. turmeric is a spice plant that is often used in various dishes. it contains chemical compounds that have medicinal properties. the curcuminoids contained in turmeric consists of curcumin, 10% destoxycumin, and 1– 5% bisdesmethoxycurcumin. in addition, turmeric also contains essential oils, sesquiterpene ketones, 60% turmerontumeon, 45–55% vitamin c, 30% protein, 25% zingiberene, 8% starch, 3% carbohydrates, and 1–3% fat. other contents include mineral salts, iron, phosphorus, and calcium (el-saadony et al., 2023; megananda et al., 2024). turmeric massage can help increase breast milk production by stimulating oxytocin production, leading to contraction of myoepithelial cells and increased prolactin, hence increased milk production. turmeric can stimulate the anterior pituitary gland to release more prolactin, resulting in increased milk production. some chemical components of turmeric, such as curcumin, have an estrogenic effect and may also boost milk production. traditional birth attendants in the sumba tribe use turmeric oil paste to reduce stiff and painful breasts, which can help with milk flow. this is especially beneficial for breastfeeding mothers who may be experiencing low milk supply (martin et al., 2023; tarapandjang et al., 2024). additionally, turmeric is known for its anti-inflammatory effect, which can help reduce any swelling or discomfort in the breast tissue (el-saadony et al., 2023). this natural remedy has been passed down through generations and has been proven effective in aiding breastfeeding mothers. turmeric massage can be a beneficial and holistic approach to supporting breastfeeding and ensuring health (tarapandjang et al., 2024). the use of turmeric massage can promote relaxation and stress relief for breastfeeding mothers, which can further improve milk production (nasution et al., 2023). this traditional practice has been used for centuries in various cultures to support lactating women and promote overall health. incorporating turmeric massage into a breastfeeding routine can not only enhance milk flow but also offer a sensation of comfort and well-being for both the mother and the baby (modak et al., 2023). ariestini, et.al. ghmj (global health management journal) 2024, vol. 7, no. 3 118 early initiation of breastfeeding is crucial for newborns' health and is recommended within one hour of birth by the world health organization. mode of delivery, maternal knowledge, region of residency, receipt of breastfeeding instructions, and maternal education level are all connected with early commencement of breastfeeding (ahmed & salih, 2019; ahmed et al., 2019). these factors can impact a mother's ability and readiness to breastfeed immediately after giving birth. it is important for healthcare providers to address these influences and provide support to ensure that all newborns have the best possible start to life. by promoting early initiation of breastfeeding, we can improve the health outcomes for both the mother and the baby (asimaki et al., 2022; gavine et al., 2022). with proper support and guidance from healthcare providers, mothers can successfully initiate breastfeeding within the recommended timeframe. mothers who have received adequate education and information about breastfeeding are more likely to understand its importance and be motivated to start breastfeeding early. ultimately, ensuring that mothers have access to resources and support can help increase the rates of early initiation of breastfeeding, leading to improved health outcomes for newborns. the limitation of this study is that it has not included the variables of maternal nutrition, emotional factors, and family support. in the future, it is better to add these confounding variables. the suggestion for further research is not only to measure the time of the first breast milk release but also the amount of breast milk during lactation and the success of exclusive breastfeeding. conclusions may differ in populations with maternal conditions with nutritional disorders and emotional and hormonal imbalances that are not variables measured in this study. 5. conclusion this study showed that in the group that compressed the breasts with turmeric, breast milk came out faster than the group that did not compress the breasts. breast milk production was faster by 17.73 hours compared to those who did not compress the breasts with turmeric. there was a significant difference in the time of the first breast milk release between the group of postpartum mothers who compressed the breasts with turmeric and those who did not. turmeric might be recommended as an alternative for increasing breast milk production. turmeric has been demonstrated to relieve pain, reduce inflammation, lower blood pressure, and improve blood circulation in breastfeeding mothers. turmeric can stimulate the anterior pituitary gland to produce more prolactin to increase breast milk production. overall, using turmeric can be a natural and effective way to increase breast milk supply for breastfeeding mothers. its ability to stimulate prolactin production and its estrogenic effects make it a valuable supplement for those looking to increase breast milk production. in addition, other health benefits of turmeric make it a safe and beneficial choice for breastfeeding mothers who want to improve their overall well-being. further research should not only measure the time of the first breast milk release but also the amount of breast milk during lactation and the success of exclusive breastfeeding. in addition, it is advisable to add confounding variables such as maternal nutrition, emotional factors, and family support. acknowledgements the author would like to thank the midwives at the pahandut public health center who were directly involved in this research. our appreciation is also due to postpartum mothers who were willing to be research participants. conflict of interest there is no conflict of interest. nothing is to be disclosed. 119 ghmj (global health management journal) 2024, vol. 7, no. 3 ariestini, et.al. references ahmed, a. e., & salih, o. a. (2019). determinants of the early initiation of breastfeeding in the kingdom of saudi arabia. international breastfeeding journal, 14(1), 1-13. https://doi.org/10.1186/s13006-0190207-z ahmed, k. y., page, a., arora, a., & ogbo, f. a. (2019). trends and determinants of early initiation of breastfeeding and exclusive breastfeeding in ethiopia from 2000 to 2016. international breastfeeding journal, 14(1), 1-14. https://doi.org/10.1186/s13006-019-0234-9 amini, p., omani-samani, r., sepidarkish, m., almasi-hashiani, a., hosseini, m., & maroufizadeh, s. (2019). the breastfeeding self-efficacy scale-short form (bses-sf): a validation study in iranian mothers. bmc research notes, 12(1), 1-6. https://doi.org/10.1186/s13104-019-4656-7 ariescha, p. a. y., & tryaningsih, u. (2019). pengaruh pemberian daun bangun bangun (coleus ambonicus lour ) terhadap produksi asi. jurnal kebidanan kestra (jkk), 1(2), 23-28. https://doi.org/10.35451/jkk.v1i2.129 arif, s., khan, h., aslam, m., & farooq, m. (2021). factors influencing exclusive breastfeeding duration in pakistan: a population-based cross-sectional study. bmc public health, 21(1), 1-10. https://doi.org/10.1186/s12889-021-12075-y asimaki, e., dagla, m., sarantaki, a., & iliadou, m. (2022). main biopsychosocial factors influencing breastfeeding: a systematic review. maedica, 17(4), 955-962. https://doi.org/10.26574/maedica.2022.17.4.955 babakazo, p., bosonkie, m., mafuta, e., mvuama, n., & mapatano, m. a. (2022). common breastfeeding problems experienced by lactating mothers during the first six months in kinshasa. plos one, 17(10 october), 1-11. https://doi.org/10.1371/journal.pone.0275477 becskei, z., savić, m., ćirković, d., rašeta, m., puvača, n., pajić, m., dordević, s., & paskaš, s. (2020). assessment of water buffalo milk and traditional milk products in a sustainable production system. sustainability (switzerland), 12(16), 1-13. https://doi.org/10.3390/su12166616 bengough, t., dawson, s., cheng, h. l., mcfadden, a., gavine, a., rees, r., sacks, e., & hannes, k. (2022). factors that influence women's engagement with breastfeeding support: a qualitative evidence synthesis. maternal and child nutrition, 18(4). https://doi.org/10.1111/mcn.13405 djanah, n., & muslihatun, w. n. (2017). akupresur terhadap produksi asi pada ibu post partum. photon: jurnal sain dan kesehatan, 8(01), 73-77. https://doi.org/10.37859/jp.v8i01.533 el-saadony, m. t., yang, t., korma, s. a., sitohy, m., abd el-mageed, t. a., selim, s., al jaouni, s. k., salem, h. m., mahmmod, y., soliman, s. m., mo'men, s. a. a., mosa, w. f. a., el-wafai, n. a., abou-aly, h. e., sitohy, b., abd el-hack, m. e., el-tarabily, k. a., & saad, a. m. (2023). impacts of turmeric and its principal bioactive curcumin on human health: pharmaceutical, medicinal, and food applications: a comprehensive review. frontiers in nutrition, 9(january), 1-34. https://doi.org/10.3389/fnut.2022.1040259 fosu-brefo, r., & arthur, e. (2015). effect of timely initiation of breastfeeding on child health in ghana. health economics review, 5(1). https://doi.org/10.1186/s13561-015-0044-8 gavine, a., shinwell, s. c., buchanan, p., farre, a., wade, a., lynn, f., marshall, j., cumming, s. e., dare, s., & mcfadden, a. (2022). support for healthy breastfeeding mothers with healthy term babies. cochrane database of systematic reviews, 2022(10). https://doi.org/10.1002/14651858.cd001141.pub6 haryanti, h. a., aryati eko ningtyas, e., nurul widyawati, m., & sudirman. (2024). efektivitas kombinasi topikal gel jahe merah dan kapsul ekstrak daun katuk terhadap produksi asi ibu menyusui. jurnal keperawatan, 16(1), 273-282. hendriyani, f., suryaningsih, & suharto, a. (2019). effectiveness of oxytocin massage and breast care treatment on breast milk production. indian journal of forensic medicine and toxicology, 13(4), 1687-1691. https://doi.org/10.5958/0973-9130.2019.00550.4 kementerian kesehatan ri. (2022). profil kesehatan indonesia. kementerian kesehatan republik indonesia, jakarta. kementerian perencanaan pembangunan nasional badan perencanaan pembangunan nasional. (2020). pedoman teknis penyusunan rencana aksi tujuan pembangunan berkelanjutan (tpb)/sustainable development goals (sdgs). li, j., zhao, c., wang, y., wang, y. p., chen, c. y., huang, y., gao, y. q., fang, j., & zhou, h. (2021). factors associated with exclusive breastfeeding practice among mothers in nine community health centres in nanning city, china: a cross-sectional study. international breastfeeding journal, 16(1), 1-14. https://doi.org/10.1186/s13006-021-00416-x https://doi.org/10.1186/s13006-019-0207-z https://doi.org/10.1186/s13006-019-0207-z https://doi.org/10.1186/s13006-019-0234-9 https://doi.org/10.1186/s13104-019-4656-7 https://doi.org/10.35451/jkk.v1i2.129 https://doi.org/10.1186/s12889-021-12075-y https://doi.org/10.26574/maedica.2022.17.4.955 https://doi.org/10.1371/journal.pone.0275477 https://doi.org/10.3390/su12166616 https://doi.org/10.1111/mcn.13405 https://doi.org/10.37859/jp.v8i01.533 https://doi.org/10.3389/fnut.2022.1040259 https://doi.org/10.1186/s13561-015-0044-8 https://doi.org/10.1002/14651858.cd001141.pub6 https://doi.org/10.5958/0973-9130.2019.00550.4 https://doi.org/10.1186/s13006-021-00416-x ariestini, et.al. ghmj (global health management journal) 2024, vol. 7, no. 3 120 maleki, a., & youseflu, s. (2022). the effectiveness of aloe vera on relief of irritation and nipple pain in lactating women: systematic review and meta-analysis. obstetrics and gynecology international, 2022. https://doi.org/10.1155/2022/7430581 martin, n., yana, e., safitri, d. n., yunita, s., aritonang, p. z., harefa, n., kristianti, y. d., estiningtyas, q., adnani, s., & java, b. w. (2023). scoping review of breastfeeding mothers ' efforts to increase breast milk production. jurnal aisyah: jurnal ilmu kesehatan, 8(4), 1558-1573. https://doi.org/10.30604/jika.v8i4.2242 maru, t. d., wari, l. f., & fufa, a. j. (2023). milk handling practices , processing methods , and microbial quality. asian food science journal, 2(11), 22-45. https://doi.org/10.9734/afsj/2023/v22i12687 mayasari, s. i., & jayanti, n. d. (2022). efektifitas rebusan kunyit (curcuma domestica) untuk melancarkan produksi asi. seminar nasional kesehatan, 87-94. megananda, r. c., primiani, c. n., & anindhita, m. n. (2024). qualitative analysis of phytochemical compounds in turmeric powder as functional drink. biodidaktika : jurnal biologi dan pembelajarannya, 19(1), 7. https://doi.org/10.30870/biodidaktika.v19i1.18914 modak, a., ronghe, v., & gomase, k. p. (2023). the psychological benefits of breastfeeding: fostering maternal well-being and child development. cureus, 15(10). https://doi.org/10.7759/cureus.46730 naja, f., chatila, a., ayoub, j. j., abbas, n., mahmoud, a., abdulmalik, m. a., & nasreddine, l. (2022). prenatal breastfeeding knowledge, attitude and intention, and their associations with feeding practices during the first six months of life: a cohort study in lebanon and qatar. international breastfeeding journal, 17(1), 1-17. https://doi.org/10.1186/s13006-022-00456-x nasution, e., batubara, a., & pulungan, f. (2023). counseling on giving turmeric simplisia tea drinks to breastfeeding mothers in telaga sari village, tanjung morawa district, deli serdang regency. abdimas: jurnal pengabdian masyarakat, 6(1), 3285-3289. patel, a., bucher, s., pusdekar, y., esamai, f., krebs, n. f., goudar, s. s., chomba, e., garces, a., pasha, o., saleem, s., kodkany, b. s., liechty, e. a., kodkany, b., derman, r. j., carlo, w. a., michael hambidge, k., goldenberg, r. l., althabe, f., berrueta, m., … hibberd, p. l. (2015). rates and determinants of early initiation of breastfeeding and exclusive breast feeding at 42 days postnatal in six low and middle-income countries: a prospective cohort study. reproductive health, 12(2), s10. https://doi.org/10.1186/1742-4755-12-s2-s10 permatasari, t. a. e., & syafruddin, a. (2016). early initiation of breastfeeding related to exclusive breastfeeding and breastfeeding duration in rural and urban areas in subang, west java, indonesia. journal health research, 30(5), 337-345. ramaholimihaso, t., bouazzaoui, f., & kaladjian, a. (2020). curcumin in depression: potential mechanisms of action and current evidence-a narrative review. frontiers in psychiatry, 11(november), 1-16. https://doi.org/10.3389/fpsyt.2020.572533 sharma, i., & khadka, a. (2019). assessing the level of knowledge and practice of breastfeeding among factory working mothers in kathmandu, nepal. journal of health research, 33(1), 24-34. https://doi.org/10.1108/jhr-12-2018-0166 tarapandjang, d. s., trishinta, s. m., & ardiyani, v. m. (2024). cultural practices of breast care among breastfeeding mothers in the sumba tribe: a descriptive qualitative study. pediomaternal nursing journal, 10(1), 20-26. https://doi.org/10.20473/pmnj.v10i1.38413 utari, m. d., & desvira, n. (2021). efektivitas perawatan payudara terhadap kelancaran produksi asi pada ibu postpartum di rumah sakit pmc. menara ilmu, 15(2), 60-66. cite this article as: ariestini, t. r., aden, c., berthiana, b., & mashar, h. m. (2024). turmeric topical application: an effective solution for reducing breast milk secretion delays in new mothers. ghmj (global health management journal), 7(3), 112–120. https://doi.org/10.35898/ghmj-73998 https://doi.org/10.1155/2022/7430581 https://doi.org/10.30604/jika.v8i4.2242 https://doi.org/10.9734/afsj/2023/v22i12687 https://doi.org/10.30870/biodidaktika.v19i1.18914 https://doi.org/10.7759/cureus.46730 https://doi.org/10.1186/s13006-022-00456-x https://doi.org/10.1186/1742-4755-12-s2-s10 https://doi.org/10.3389/fpsyt.2020.572533 https://doi.org/10.1108/jhr-12-2018-0166 https://doi.org/10.20473/pmnj.v10i1.38413 https://doi.org/10.35898/ghmj-73998 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 no one should face breast cancer alone: breast cancer self examination and support group heti ira ayue*1,2, erina eka hatini1,2 1 department of midwifery, poltekkes kemenkes palangka raya, indonesia 2 pink care community central kalimantan, indonesia *corresponding author’s email: hetiiraayue@gmail.com doi: 10.35898/ghmj-51602 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) october is celebrated as a breast cancer awareness month to increase awareness, attention, and support for early detection and breast cancer treatment. estimates of cancer incidence and mortality produced by the international agency for research on cancer (iarc) breast cancer is the second leading cause of death the worldwide and it ranks first as cancer with the most cases in indonesia (figure 1). figure 1 number of cancer new cases the incidence of breast cancer in indonesia is estimated at 42.1 people per 100,000 population with an average death rate of 17 per 100,000 population (figure 2). breast cancer is still something that frightens most women, as a result, women are reluctant to do examinations and keep away from getting to know further about cancer so that many breast cancer cases are diagnosed at an already advanced stage (rasjidi, 2013) most of the mailto:hetiiraayue@gmail.com https://dx.doi.org/10.35898/ghmj-51602 65 ghmj (global health management journal) 2022, vol. 5, no. 1 ayue & hatini women are aware of breast cancer as a disease, but their in-depth knowledge of the cancer is lacking. therefore, providing more information and health education is important to increase awareness of breast cancer detection (liu et al., 2018) efforts to empower women through disseminating information and understanding the need for early detection of breast cancer (figures 2,3,4, and 5 ) need to be carried out continuously from various parties to encourage women to turn fear into awareness and care by detecting them. early cancer which is the best step so that the incidence of breast cancer can be detected at an earlier stage so that the morbidity and mortality due to breast cancer are reduced (ayue, n.d.) figure 2 breast self-examination education with leaflet in east central kalimantan figure 3 breast self-examination demonstration in parahangan village, kahayan tengah district, pulang pisau regency, central kalimantan ayue & hatini ghmj (global health management journal) 2022, vol. 5, no. 1 66 figure 4 simulated breast self-examination for a women group in kereng bangkirai palangka raya city figure 5 pink care community volunteers explained breast self-examination to couples at car free day location palangka raya city the use of intervention tools such as leaflets containing clear, precise information about breast cancer, signs, symptoms, risk factors, screening, and steps to carry out sadari is important in efforts to reduce mortality from breast cancer (ali an, foong jy, ying ch, 2019; rahman et al., 2019). another effort in dealing with breast cancer is the existence of a support group (figures 8, 9, 10, and 11). the role of a support group in the form of psychoeducation is proven to be beneficial for breast cancer patients and their companions, which has an impact on psychology and society in adapting to the conditions they are experiencing, the recovery process which ultimately improves health (cipolletta et al., 2019; chou et al., 2015). 67 ghmj (global health management journal) 2022, vol. 5, no. 1 ayue & hatini figure 6 breast cancer support group “pink care community” figure 7 pink care community volunteer training figure 8 pink care community volunteers have distributed 1000 leaflets breast self-examination at the car free day bundaran besar of palangka raya city ayue & hatini ghmj (global health management journal) 2022, vol. 5, no. 1 68 figure 9 visitation to breast cancer warrior by pink care community volunteers anxiety and depression are the most common conditions experienced by women with breast cancer. low emotional support and social networks are risk factors for more symptoms than some other psychological disorders (puigpinós-riera et al., 2018). support groups are effective at reducing psychological stress and supporting the quality of life for women with breast cancer (cipolletta et al., 2019). consent the women (identifiable) photographed have given their consent for their pictures to be used in the publication of this research. conflict of interest none. acknowledgments pink care community volunteers, warriors, and survivors of breast cancer of central kalimantan references ali an, foong jy, ying ch, a. n. (2019). effectiveness of intervention on awareness and knowledge of breast self-examination among the potentially at-risk population for breast cancer. asian oncology research journal, 2(1), 1–13. ayue, h. i. (n.d.). deteksi dini kanker payudara dengan pemeriksaan payudara sendiri (sadari) melalui pembentukan breast cancer awareness group di kelurahan kereng bangkirai kota palangka raya. chou, f.-y., lee-lin, f., & kuang, l. (2015). the effectiveness of support groups in asian breast cancer patients: an integrative review. asia-pacific journal of oncology nursing, 0(0), 0. https://doi.org/10.4103/23475625.162826 cipolletta, s., simonato, c., & faccio, e. (2019). the effectiveness of psychoeducational support groups for women with breast cancer and their caregivers: a mixed methods study. frontiers in psychology, 10(feb), 1– 8. https://doi.org/10.3389/fpsyg.2019.00288 liu, l. y., wang, y. j., wang, f., yu, l. x., xiang, y. j., zhou, f., li, l., zhang, q., fu, q. y., ma, z. b., gao, d. z., li, y. y., & yu, z. g. (2018). factors associated with insufficient awareness of breast cancer among women in northern and eastern china: a case-control study. bmj open, 8(2). https://doi.org/10.1136/bmjopen-2017-018523 puigpinós-riera, r., graells-sans, a., serral, g., continente, x., bargalló, x., domènech, m., espinosa-bravo, m., 69 ghmj (global health management journal) 2022, vol. 5, no. 1 ayue & hatini grau, j., macià, f., manzanera, r., pla, m., quintana, m. j., sala, m., & vidal, e. (2018). anxiety and depression in women with breast cancer: social and clinical determinants and influence of the social network and social support (dama cohort). cancer epidemiology, 55, 123–129. https://doi.org/10.1016/j.canep.2018.06.002 rahman, s. a., al-marzouki, a., otim, m., khayat, n. e. h. k., yousef, r., & rahman, p. (2019). awareness about breast cancer and breast self-examination among female students at the university of sharjah: a crosssectional study. asian pacific journal of cancer prevention, 20(6), 1901–1908. https://doi.org/10.31557/apjcp.2019.20.6.1901 rasjidi, i. (2013). buku ajar onkologi. egc. cite this article as: ayue hi, hatini ee. no one should face breast cancer alone: breast cancer self examination and support group. ghmj (global health management journal). 2022; 5(1):64-69. doi:10.35898/ghmj-51602 https://dx.doi.org/10.35898/ghmj-51602 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 supervision and transformational leadership styles on nurses’ compliance in prevention and control of infection risks at a hospital in kotamobagu, indonesia widya astuti*, tri ismu pujiyanto, susi nurhayati department of nursing, universitas karya husada, semarang, indonesia *corresponding author’s e-mail: widya.balqis19@gmail.com doi: 10.35898/ghmj-61928 abstract background: the quality of health services cannot be separated from the collaboration of all components of human resources, including nurses. transformational leadership supported by supervision can also improve the prevention and control of infection risk in order to optimize their work performance. supervision activities carried out by the head of the room might have a positive impact on nurse commitment. aims: the objective of this study is to analyze the influence of supervision and transformational leadership style on nurse compliance in infection risk prevention and control at gmibm (gereja masehi injili at bolaang mongondow) monompia general hospital, kotamobagu, indonesia. methods: this original research used an analytic observational with a quantitative approach and a cross sectional study design. a total of 72 nurses who worked at gmibm monompia kotamobagu general hospital, kotamobagu regency, indonesia, was selected in august 2022 using a total sampling technique based on the data from the human resources division. two combined questionnaires were distributed to define the leader supervision (20 questions) and the nurses’ compliance and their transformational leadership styles (18 questions) for prevention and control the infection risks. the results of this study were analyzed using spss software (univariate and bivariate parameters). results: this study shows that a sufficient supervision frequency (59.7%) among the participated nurses. we identify there were four transformational leadership styles among the nurses at the selected hospital: ideal influence (33.3%), inspirational motivation (27.8%), individual consideration (20.8%) and intellectual stimulation (18.1%). moreover, the majority of nurses performed good compliance in the preventing and controlling the infection risks (80.6%). the lack of compliance might be significantly resulted by the leader supervisions (p-value: 0.002). by the bivariate analysis, this study suggested that there is a relationship between transformational leadership style and compliance (p value: 0.001). we also noticed that the leader supervision and transformational leadership style are moderating variables to strengthen the nurse compliance (r square = 0.336). conclusion : this present study strongly suggested the hospital manager and head departments to pay attention to the two strong factors (supervision and transformational leadership style) affecting the nurses compliance in updating and implementing the prevention and risk control programs. keywords: supervision, transformational leadership style, nurses compliance received: 19 november 2022; revised: 15 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 the quality of health services cannot be separated from the collaboration of all components of resources, especially human resources (mulang, 2021). nursing human resources are one of the important resources and are spearhead to achieve hospital goals (clark et al., 2015). efforts to mailto:widya.balqis19@gmail.com https://doi.org/10.35898/ghmj-61928 astuti, pujiyanto, & nurhayati ghmj (global health management journal) 2023, vol. 6, no. 1 12 harmonize performance demands require highly committed human resources. one of the important elements in this effort is a leader who is able to influence and actively involve his subordinates in achieving hospital goals through an appropriate leadership style (lee & lee, 2022). a reformist leader is needed, capable of being the core driving force of change (transformation) so that good cooperation between leaders and subordinates is created (torfing et al., 2019). increased knowledge about transformational leadership style in preventing and controlling infection risk for nurse performance also increases after being given education about transformational leadership to the head of the hospital room (labrague et al., 2020). transformational leadership style can make followers feel trust, admiration, loyalty and respect for the leader and they are motivated to do more than was originally expected of them (ugwu et al., 2016). transformational leadership style is a leader who is able to inspire employees to prioritize organizational progress rather than personal interests, give good attention to employees and be able to change employee awareness in seeing old problems in new ways (vipraprastha et al., 2018). on the other hand, a person's commitment in the organization is the foundation needed to build a performance, so that the possible intervention is to develop a commitment to improve the performance of nurses in hospitals (heriyanto, 2021). a patient safety climate in the hospital built through transformational leadership that prioritizes patient safety to reduce unexpected events through supervision (alshyyab et al., 2019). continuous supervision or mentoring relationship continuum (mrc) can improve transformational leadership, enabling followers to build self-efficacy and self-confidence by accepting their environment with enthusiasm and positive emotions (reddy, 2014). the results of preliminary interviews in april may 2022 with the quality audit team and the nursing department at gmibm monompia hospital kotamobagu obtained data from 2022 on the results of patient identification accuracy of 75.40%, increasing effective communication 75.7%, increasing drug safety that needs to be improved. be wary of 77.15%, exact location certainty, right procedure, right patient surgery 75.50%, reducing the risk of infection related to hand hygiene health services as much as 55.67%. reinforced by the results of observations during the residency in december 2021, it was found that the supervision did not work because there was no continuous training by the gmibm monompia hospital, besides that the results also showed that the future target would be to increase the status for accreditation. therefore, it is necessary to analyze the influence of supervision and transformational leadership style on nurse compliance in infection risk prevention and control at gmibm monompia general hospital. 2. methods this original research used an analytic observational with a quantitative approach and a cross sectional study design. this study was conducted to determine the effect of supervision and transformational leadership style on nurse compliance in the prevention and control of infection risks. a total of 72 nurses who worked at gmibm monompia kotamobagu general hospital, kotamobagu regency, indonesia, was selected in august 2022 using a total sampling technique based on the data from the human resources division. the inclusion criteria including all nurses without any exception. nurses who did not attend at the time of survey were excluded. before conducting the research, the researcher will conduct an ethical test to obtain research permission from the karya husada university semarang. this research questionnaire is divided into 2 parts, such as part a (20 questions) which contains questions about supervision and part b (18 questions) which contains transformational leadership style and nurses' compliance in disease risk prevention and control. supervision is one part of the function of direction and supervision in nursing management and plays an important role to achieve an organizational goal. transformational leadership styles define the style to influence others (subordinates), create inspiring situations, and be able to read situations, solve problems, and be responsible. nurse compliance in the infection prevention and 13 ghmj (global health management journal) 2023, vol. 6, no. 1 astuti, pujiyanto, & nurhayati control program (ppi) is one of the benchmarks for the quality of hospital services which is measured periodically by the ppi committee to ensure a comprehensive nursing service. the results of this study were analyzed using spss software (univariate and bivariate parameters). 3. results respondent characteristics univariate analysis on the two distributed questionnaires shows that among the 72 nurses working at gmibm monompia general hospital, 43 respondents (59.7%) were sufficient in the prevention and control of infection risks, whilst the other 22 respondents were good (30.6%), and 7 respondents were poor (9.7%). we identify there were four transformational leadership styles among the nurses at the selected hospital: ideal influence (24 respondents or 33.3%), inspirational motivation (20 respondents or 27.8%), individual consideration (15 respondents or 20.8%) and intellectual stimulation (13 respondents or 18.1%). moreover, the majority of nurses performed good compliance in the preventing and controlling the infection risks (58 respondents or 80.6%), and only 14 respondents (19.4%) performed poor compliance (non-compliance). table 1. the general characteristics of the respondents variables (n=72) frequency percent supervision good 22 30.6 enough 43 59.7 poor 7 9.7 transformational leadership style ideal influence 24 33.3 inspirational motivation 20 27.8 intellectual stimulation 13 18.1 individual consideration 15 20.8 nurse compliance good 58 80.6 poor 14 19.4 bivariate analysis: factor affecting the nurses compliance by a bivariate analysis, we noted how supervision and transformational leadership style separately affecting the nurses compliance at gmibm monompia general hospital. from table 2, it is noted the type of leader supervision among the nurses with different performance. the data shows the higher number of nurses poorly perform if having poor leader supervision. it is indicated that the lack of compliance might be significantly resulted by the leader supervisions (p-value: 0.002). by the bivariate analysis, this study suggested that there is a relationship between transformational leadership style and compliance (p value: 0.001). we can see from the table 2, it seems that all of nurses (100%) with influence motivation for their transformational leadership style will result with good nurse compliance. however, if compare among nurses who have inspirational ideal as their leadership style, it tends to have higher number of nurses with poor compliance. it is suggested that the leader supervision and transformational leadership style are moderating variables to strengthen the nurse compliance (r square = 0.336). astuti, pujiyanto, & nurhayati ghmj (global health management journal) 2023, vol. 6, no. 1 14 4. discussion based on the results of this study, the distribution of the frequency of transformational leadership styles in preventing and controlling infection risk at gmibm monompia general hospital was 80.6% obedient in preventing and controlling infection risk. this study is in line with previously study on nurse compliance with the results showing that 90.0% of nurses' compliance was in the good category (faridha & milkhatun, 2020; noprianty & thahara, 2019). this study is different from the other study that the results showing that as many as 57.0% of nurses had poor compliance and 43.5% experienced sufficient compliance (pameswari et al., 2016). in another study it was also found that nurse compliance was worse than doctor compliance (kotwal & taneja, 2010). compliance is a form of human behavior that obeys the rules, orders that have been set, procedures and discipline that must be carried out (evangelista, 1999). formulates that compliance is influenced by two main factors, namely behavior causes and non-behavior causes (notoatmodjo, 2014). this knowledge will then be passed down in the form of attitudes or behavior of health workers in dealing with patients (lin et al., 2022). the one of the factors that influence nurse compliance is a good leadership style and good supervision of their work (klijn et al., 2022). compliance requires support in the form of shamans in the form of funds, time, and social housing that can foster compliance with the implementation of the rules that have been implemented (pakpahan et al., 2021). therefore, in realizing obedient or disobedient behavior starting from individual awareness of the stimulus, then eliciting a response in the form of attitude income which will lead to behavior in accordance with what is perceived, so that in the end obedient or disobedient behavior will emerge. based on the results of the chi square correlation statistic test are known that the significance is p = 0.002 (α: <0.05), which means the hypothesis is accepted. this proves that there is a relationship between supervision and nurse compliance in controlling infection risk at rsu gmibm monompia. this research is in line with previous study with the results of supervision research (p value = <0.001) and transformational leadership style (p value = 0.043) proves that there are differences and improvements in nurse performance before and after training (ningsih et al., 2020). supported by other research regarding the relationship between supervision and motivation with nurse compliance with hand washing in hospitals with the results of the study showing that there is a fairly strong relationship between the supervision of the head of the room and nurse compliance (parwa et al., 2019; yulianita et al., 2020). the supervision is a job that controls and directs staff, acting as a guide in an organization to achieve the goals to be achieved together (kadushin & harkness, 2014). it can be concluded that supervision is an activity that contains two dimensions of actors, namely there is a leader and there are staff or people to be supervised, both of whom have an equally important role in achieving common goals. table 2. bivariate analysis of supervision and transformational leadership style with nurse compliance variables nurse compliance p-value poor good n % n % supervisi poor enough good 4 10 0 71.1 23.3 0.0 3 33 22 42.9 76.7 100 0.002 transformational leadership style inspirational ideal influence motivation intellectual stimulation individual considerations 11 0 1 2 45.8 0.0 7.7 13.3 13 20 12 13 54.2 100 92.3 86.7 0.001 15 ghmj (global health management journal) 2023, vol. 6, no. 1 astuti, pujiyanto, & nurhayati based on the results of this study, it was found that the results of the chi square correlation statistic test indicated that the significance was p=0.001 (α: <0.05), which means the hypothesis is accepted. this proves that there is a relationship between transformational leadership style and nurse compliance in controlling infection risk at gmibm monompia general hospital. this study is in line with previous study showing that transformational leadership has a significant and positive effect on nurse performance and compliance (p = 0.001) (murtiningsih, 2017). the transformational leadership variable has a significant effect on performance, the leader's trust variable and the job satisfaction variable have a role as a mediating variable (feri et al., 2020). hospital managers in carrying out their duties must pay attention to transformational leadership styles that not only affect the performance of nurses but also increase the commitment of nurses to hospitals where nurses work in managing hospitals, which fosters commitment to employees in the organization where they work. 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 (ekaningsih, 2014; huber, 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 (feri et al., 2020; huber, 2018). 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). 5. conclusion in sum, this study shows that supervision and transformational leadership style have a significant relationship with nurse compliance in the prevention and control of infection risk. the results of this study might be applied in every hospital, and can be used as a reference for further research and can be developed into further research by including socio-demographic variables of health and socio determinants of health. the further study can be added more variables to adjust with socio-demographic and economic factors. because one's level of contentment differs from that of others and is difficult to quantify, there is no correlation between the two. conflict of interest there is no conflict of interest. nothing to disclosure. references alshyyab, m. a., fitzgerald, g., dingle, k., ting, j., bowman, p., kinnear, f. b., & borkoles, e. (2019). developing a conceptual framework for patient safety culture in emergency department: a review of the literature. the international journal of health planning and management, 34(1), 42-55. https://doi.org/10.1002/hpm.2640 clark, m., julmisse, m., marcelin, n., merry, l., tuck, j., & gagnon, a. j. (2015). strengthening healthcare delivery in h aiti through nursing continuing education. international nursing review, 62(1), 54-63. https://doi.org/10.1111/inr.12165 ekaningsih, a. s. (2014). the effect of transformational leadership on the employees' performance through intervening variables of empowerment, trust, and satisfaction (a study on coal companies in east kalimantan). european journal of business and management, 6(22), 111-117. evangelista, l. s. (1999). compliance: a concept analysis. nursing forum, 34(1), 5-12. https://doi.org/10.1111/j.1744-6198.1999.tb00230.x faridha, n. r. d., & milkhatun, m. (2020). hubungan pengetahuan dengan kepatuhan perawat dalam pelaksanaan pencegahan pasien jatuh di rumah sakit umum daerah pemerintah samarinda. borneo student research (bsr), 1(3), 1883-1889. https://doi.org/10.1002/hpm.2640 https://doi.org/10.1111/inr.12165 https://doi.org/10.1111/j.1744-6198.1999.tb00230.x astuti, pujiyanto, & nurhayati ghmj (global health management journal) 2023, vol. 6, no. 1 16 feri, s., rahmat, a., & supeno, b. (2020). pengaruh motivasi, gaya kepemimpinan transformasional dan budaya organisasi terhadap kinerja karyawan melalui kepuasan kerja sebagai variabel intervening studi pada pt. champion kurnia djaja technologies. inobis: jurnal inovasi bisnis dan manajemen indonesia, 4(1), 134-151. https://doi.org/10.31842/jurnalinobis.v4i1.172 heriyanto, m. (2021). effect of organizational culture on organizational commitment and nurse involvement as intervening variable: study at maternity hospital business in pekanbaru city, indonesia. international journal of science, technology & management, 2(5), 1848-1865. https://doi.org/10.46729/ijstm.v2i5.316 huber, d. l. (2018). leadership & nursing care management. 6th editio. 3251 riverport lane, st. louis missouri: elsevier. kadushin, a., & harkness, d. (2014). supervision in social work. columbia university press. https://doi.org/10.7312/kadu15176 klijn, e. h., de boer, n., & eshuis, j. (2022). leading frontline enforcers: how supervisors' leadership style impacts inspectors' enforcement style. public management review, 24(3), 398-417. https://doi.org/10.1080/14719037.2020.1833610 kotwal, a., & taneja, d. k. (2010). health care workers and universal precautions: perceptions and determinants of non-compliance. indian journal of community medicine: official publication of indian association of preventive & social medicine, 35(4), 526. https://doi.org/10.4103/0970-0218.74373 labrague, l. j., nwafor, c. e., & tsaras, k. (2020). influence of toxic and transformational leadership practices on nurses' job satisfaction, job stress, absenteeism and turnover intention: a cross‐sectional study. journal of nursing management, 28(5), 1104-1113. https://doi.org/10.1111/jonm.13053 lee, s. m., & lee, d. (2022). effects of healthcare quality management activities and sociotechnical systems on internal customer experience and organizational performance. service business, 16(1), 1-28. https://doi.org/10.1007/s11628-022-00478-9 lin, y.-y., yen, w.-j., hou, w.-l., liao, w.-c., & lin, m.-l. (2022). mental health nurses' tacit knowledge of strategies for improving medication adherence for schizophrenia: a qualitative study. healthcare, 10(3), 492. https://doi.org/10.3390/healthcare10030492 mulang, h. (2021). the effect of competences, work motivation, learning environment on human resource performance. golden ratio of human resource management, 1(2), 84-93. https://doi.org/10.52970/grhrm.v1i2.52 murtiningsih, m. (2017). pengaruh gaya kepemimpinan transformasional pada kinerja perawat rumah sakit islam siti aisyah madiun. jurnal manajemen dayasaing, 17(2), 54-66. ningsih, s. r., novita, r. v. t., & bandur, a. (2020). pengaruh supervisi dan gaya kepemimpinan transformasional terhadap kinerja perawat dalam kepatuhan hand hygiene dan pencegahan resiko jatuh di rsu gmibm monompia kotamobagu. media publikasi promosi kesehatan indonesia (mppki), 3(3), 236-243. https://doi.org/10.56338/mppki.v3i3.1231 noprianty, r., & thahara, g. k. d. (2019). healthcare workers knowledge, attitude, and availability of facilities toward compliance hand hygiene. indonesian journal of global health research, 1(1), 1320. https://doi.org/10.37287/ijghr.v1i1.2 notoatmodjo, s. (2014). ilmu perilaku kesehatan. rineka cipta. pakpahan, m., siregar, d., susilawaty, a., tasnim, t., ramdany, r., manurung, e. i., sianturi, e., tompunu, m. r. g., sitanggang, y. f., & maisyarah, m. (2021). promosi kesehatan dan perilaku kesehatan. yayasan kita menulis. pameswari, p., halim, a., & yustika, l. (2016). tingkat kepatuhan penggunaan obat pada pasien tuberkulosis di rumah sakit mayjen h. a thalib kabupaten kerinci. jurnal sains farmasi & klinis, 2(2), 116-121. https://doi.org/10.29208/jsfk.2016.2.2.60 parwa, d., krisnawati, m. s., & yanti, e. d. (2019). hubungan supervisi dan motivasi dengan kepatuhan perawat mencuci tangan di rsud. jurnal kepemimpinan dan manajemen keperawatan, 2(1), 28-32. https://doi.org/10.32584/jkmk.v2i1.281 https://doi.org/10.31842/jurnalinobis.v4i1.172 https://doi.org/10.46729/ijstm.v2i5.316 https://doi.org/10.7312/kadu15176 https://doi.org/10.1080/14719037.2020.1833610 https://doi.org/10.4103/0970-0218.74373 https://doi.org/10.1111/jonm.13053 https://doi.org/10.1007/s11628-022-00478-9 https://doi.org/10.3390/healthcare10030492 https://doi.org/10.52970/grhrm.v1i2.52 https://doi.org/10.56338/mppki.v3i3.1231 https://doi.org/10.37287/ijghr.v1i1.2 https://doi.org/10.29208/jsfk.2016.2.2.60 https://doi.org/10.32584/jkmk.v2i1.281 17 ghmj (global health management journal) 2023, vol. 6, no. 1 astuti, pujiyanto, & nurhayati reddy, c. k. (2014). guidelines for clinical research nurses about their self-leadership role in nursing practice at nursing units in the southern suburbs of cape town, western cape. sadeghi, a., & pihie, z. a. l. (2012). transformational leadership and its predictive effects on leadership effectiveness. international journal of business and social science, 3(7). torfing, j., sørensen, e., & røiseland, a. (2019). transforming the public sector into an arena for cocreation: barriers, drivers, benefits, and ways forward. administration & society, 51(5), 795-825. https://doi.org/10.1177/0095399716680057 ugwu, l. i., enwereuzor, i. k., & orji, e. u. (2016). is trust in leadership a mediator between transformational leadership and in-role performance among small-scale factory workers? review of managerial science, 10(4), 629-648. https://doi.org/10.1007/s11846-015-0170-z vipraprastha, t., sudja, i. n., & yuesti, a. (2018). the effect of transformational leadership and organizational commitment to employee performance with citizenship organization (ocb) behavior as intervening variables (at pt sarana arga gemeh amerta in denpasar city). international journal of contemporary research and review, 9(02), 20503-20518. https://doi.org/10.15520/ijcrr/2018/9/02/435 yulianita, h., hariyati, r. t. s., pujasari, h., komariah, m., & fitria, n. (2020). improving the quality of nursing documentation using supervision of the head of room. eurasian journal of biosciences, 14(2). cite this article as: astuti, w., pujiyanto, t.i., & nurhayati, s. (2023). the supervision and transformational leadership styles on nurses’ compliance in prevention and control of infection risks at a hospital in kotamobagu, indonesia. ghmj (global health management journal), 6(1), 11–17. https://doi.org/10.35898/ghmj-61928 https://doi.org/10.1177/0095399716680057 https://doi.org/10.1007/s11846-015-0170-z https://doi.org/10.15520/ijcrr/2018/9/02/435 https://doi.org/10.35898/ghmj-61928 https://doi.org/10.35898/ghmj-61925 storage stability of high fiber snack bar 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 storage stability of high fiber snack bar ivana aprilia pratiwi, varongsiri kemsawasd, thunnalin winuprasith* ins tute of nutri on, mahidol university, phu hamonthon, salaya, nakhon pathom, thailand *corresponding author’s email: thunnalin.win@mahidol.ac.th abstract background: recently, there has been considerable interest in increasing the dietary fiber content in food products because of inadequate dietary fiber consump on when considering the daily recommended intake. to increase dietary fiber intake, dietary fiber for fied foods are recommended. this study aimed to develop a high fiber snack bar (hfsb) using a combina on of jerusalem ar choke powder (jap) and low-fat desiccated coconut (lfdc) as sources of dietary fiber. methods: the changes in physicochemical and microbiological proper es, and sensory acceptability were measured during storage at 35 oc and 45 oc for 12 weeks. therefore, the shelf-life of the products was calculated by q10 test. results: the hfsb had a higher l* value (lightness) than control (c) due to the addi on of lfdc. total dietary fiber of the hfsbwas approximately 3.7 mes higher than that of the c formula. the l*, a*, and b* values of both c and hfsb were sta s cally significant different (p<0.05) a er storage. the total color different (�e) values of the hfsb were higher than those of the c formula due to inulin from jap, which par cipated in the maillard reac on. during storage, the moisture content (mc) and water ac vity (aw) of the hfsb remained more stable compared to those of the c due to the water-holding capacity of the fiber used. the aw of the c and hfsb during storage were in the range of 0.57to 0.60 and 0.53 to 0.57, respec vely. those ranges should be stable against microbial growth. higher storage temperature would increase the tbars values and decrease the ph (p<0.05) of the c and hfsb due to deteriora on. in terms of shelf-life calcula on, the c and hfsb snack bar could be kept in metalized polyester at 30 oc for 11 weeks. conclusion: the jap and lfdc exhibited great poten al for use as fiber ingredients. although the jap and lfdc influenced the physicochemical proper es and sensory acceptability, the shelf-life of both c and hfsbwas comparable. therefore, further studies should be conducted to extend the shelf-life of the formulated snack bar. keywords: snack bar, high fiber, jerusalem ar choke, low-fat desiccated coconut, shelf-life received: 8 may 2019 reviewed: 14 june 2019 revised: 26 june 2019 accepted: 19 july 2019 doi: 10.35898/ghmj-33456 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 many research articles have reported that dietary fiber consumption in children, adolescents, and adults is inadequate when considering the daily recommended intake (reicks et al., 2014). to increase the consumption of dietary fiber, food products can be fortified using various fiber ingredients. dietery fiber from conventional foods such as barley bran, oat bran, cereal, fruits, and vegetables, are commonly used as value added fiber ingredients since they provide health benefits (elleuch et al., 2011). the dietary fiber content in 100 g of jerusalem artichoke powder (jap) is approximately 71.10 g, 124 mailto:thunnalin.win@mahidol.ac.th https://dx.doi.org/10.35898/ghmj-33456 pra wi ia et al. ghmj (global health management journal) 2019, vol. 3, no. 3 including fructo-oligosaccharides and inulin (saengthongpinit and sajjaanantakul, 2005). jerusalem artichoke (helianthus tuberosus l.) is a versatile ingredient for food fortification because it has no bitter taste or odor. it has an off-white color and possesses the ability to improve food texture. accordingly, it could be applied in snack bars with palatable functional ingredients (praznik et al., 2002). for health benefits, soluble dietary fiber (sdf) promotes blood cholesterol reduction and glucose absorption in the intestinal tract (timm and slavin, 2008), whereas insoluble dietary fiber (idf) promotes water absorption and intestinal regulation by increasing the bulk of feces, thereby accelerating transit time through the gastrointestinal tract (hillman et al., 1983). therefore, other ingredients are needed which contain high insoluble dietary fiber to complement soluble dietary fiber. a by-product from coconut milk production, called low-fat desiccated coconut (lfdc), potentially contains 56.80 g of insoluble dietary fiber per 100 g of lfdc (ng et al., 2010). however, the addition of dietary fiber affects physicochemical properties such as water binding capacity, gelation, structure building, texture, and the color of the food product (foschia et al., 2013). in the market, there are often time lags between production, transportation, and consumption, which may lead to decreased quality in terms of the desirable attributes of the product such as odor, color, texture, and product safety (loveday et al., 2009). there are some factors that affect the deterioration of the product, such as ingredients, processing, packaging, and storage condition. the factors that may accelerate product deterioration are chemical reaction and temperature changing. the chemical reactions involve the reaction of rancidity, enzymatic, hydrolytic, as well as light-induced changes. temperature changing affects fat melting, crystal structure, and emulsion destabilization. these accelerating factors are usually used to monitor the changes in quality of products that occur under typical storage conditions (hough, 2006). for shelf-life prediction, product properties such as texture, water activity, moisture, ph, color, microbiology, rancidity and sensory attributes, can be used to calculate the shelf-life of products (altoaimi, 2011). the developed snack bar products were placed in metalized polyester, sealed, and kept in two controlled temperature chambers at 35 °c and 45 °c for 12 weeks following the accelerating shelf-life methods by mizrahi (2004). during storage, the products were sampled to measure any changes in quality. the objective of this study was to develop a high dietary fiber snack bar using jap and lfdc in addition to studying the changes occurring in the physicochemical and microbiological properties as well as sensory acceptability of the snack bar products in order to assess their shelf-life. 2. method 2.1 materials low-fat desiccated coconut (lfdc) was obtained from theppadungporn coconut co., ltd., thailand. jerusalem artichoke powder (jap) was purchased from saonfarm, thailand. the other ingredients for making the snack bar, including corn flakes, oat, butter, eggs, coconut sugar, honey, and salt, were purchased from local supermarkets in nakhon pathom, thailand. all chemical reagents and solvents used in this study were of analytical grade. 2.2 snack bar prepara on the control (c) formula was adapted from the research of panyeam (2007). the c formula contained the following ingredients by percentage: corn flakes (27%), oat (22%), butter (10.5%), egg white (8%), egg yolk (4%), coconut sugar (14%), honey (13%), salt (0.5%), and lecithin (0.5%). all ingredients were mixed together and molded into a bar shape (8 x 2.3 x 1.5 cm) then baked in an oven (axia built-in etn8a-mn, thailand) at 120 °c for 30 min. the amount of jap and lfdc mixture was added to the snack bar according to the regulations of food labeling, ec no. 1924/2006 of the european parliament. food product that contains dietary fiber (df) > 20% of daily value (dv) per serving or 5 g per serving can be classified as a “high dietary fiber product” (gilsenan, 2011). the lfdc and jap with the ratio of 1:1 were added into the c formula to formulate the high dietary fiber snack bar (hfsb). furthermore, 125 ghmj (global health management journal) 2019, vol. 3, no. 3 pra wi ia et al. the developed samples were packaged in a metalized polyester bag (5.5 x 3 x 12 cm) that was heat sealed. 2.3 proximate analysis of snack bar the chemical compositions, including carbohydrate, protein, fat, ash, and moisture content of the c and hfsb formula were analyzed according to the procedure of aoac (2016). soluble dietary fiber (sdf) and insoluble dietary fiber (idf) of the products were determined by aoac (2016) 991.42, 991.43 and (aoac, 2016) 991.42, respectively. fructans (inulin + fructo-oligosaccharides) was determined by the protocol of joye and hoebregs (2000). total dietary fiber (tdf) was determined by totaling sdf, idf and fructans. 2.4 shelf-life study the shelf-life of both c and hfsb formulas was studied using the q10 test. the products were stored at 35 °c and 45 °c for 12 weeks. the samples were checked every 2 weeks to measure their physicochemical properties including color, ph, water activity (aw), and moisture content (mc), and every 4 weeks for measuring thio-barbituric acid reactive substances (tbars), microbiological properties, and sensory acceptability using 30 panelists. then, the shelf-life was calculated using the following formula by considering total color difference (δe), overall acceptability, and difference from control (dfc). q10 = θs(t ) θs(t + 10) q1 = q0.1 10 q∆t = θs(t ) θs(t +∆t ) (1) when, θs(t ) = shelf-life at temperature t 0c (week) θs(t + 10) = shelf-life at temperature t+10 0c (week) q1 = rate of loss quality at temperature t 0c (week) q10 = rate of loss quality at temperature t+10 0c (week) ∆t = different between measured (t) and predicted temperature 2.5 physicochemical determina on of snack bar 2.5.1 water activity water activity (aw) of the jap and lfdc was measured using an aw meter at room temperature (25 °c) (aqua lab model 3te series 3b v 3.0, decagon devices inc., washington, usa). 2.5.2 moisture content moisture content (mc) of the jap and lfdc was determined by following the protocol of aoac (2016). 2.5.3 ph ph of jap and lfdc was determined by following the protocol of aoac (2016). the sample was ground using a blender (vkitch 565, china). subsequently, 5 g of sample was mixed with 45 ml of double distilled water in a 50-ml centrifuge tube, which was allowed to stand for 10 min before being centrifuged (hermle labortechnik gmbh, germany) at 6,000 rpm for 5 min. after that, the sample was filtered using filter paper (whatman no 1, ∅ ø 110 mm). the ph of the filtrate was directly measured at room temperature (25 °c) using a ph meter (waterproof pen meter, st10 ohaus, china). 126 pra wi ia et al. ghmj (global health management journal) 2019, vol. 3, no. 3 2.5.4 color the color of jap and lfdc was measured using a hunter lab digital colorimeter (colorflex ez, hunter associates laboratory, inc., reston, virginia) in cie-color system (l∗, a∗, b∗). the color parameters: l∗ represents lightness from black to white (0 to 100); a∗; from green (-) to red (+); and b∗; from blue (-) to yellow (+). the total color difference, deltae (∆e∗), was calculated with the following formula: ∆e∗ = √ (∆l∗)2 + (∆a∗)2 + (∆b∗)2 (2) 2.6 thio-barbituric acid reac ve substances (tbars) the level of rancidity in the snack bar was determined by measuring thio-barbituric acid reactive substances (tbars), according to the method of sinnhuber and tc (1977). the ground sample (200 mg) was weighed and transferred to a 50 ml-centrifuge tube. the blank sample was prepared using the same step without sample addition. then, three drops of tertiary butyl hydroxyl quinine (tbhq) and 3 ml of tba were added into the tubes, with and without sample. then, they were vortexed for 30 s. seventeen ml of tca-hcl reagent was added into the sample tubes before heating them in a waterbath (stirring water bath-swb-10l-1, saratoga, ca, usa) at 95 °c for 30 min. the sample tubes were then placed in an ice-bath for 5 min to stop the reaction. after that, 5 ml of chloroform was added and vortexed for 30 s before centrifugation (hermle labortechnik gmbh, germany) at 6,000 rpm for 10 min. the absorbance of the supernatant was measured at 532 nm using a uv-vis spectrophotometer (uv-1601 shimazu, japan). the tbars value is expressed as mg of malondialdehyde (mg mda) / kg sample, as calculated by the equation below: tbars value (mg mda/kg sample) = abs sample abs blank weight of sample × 46 (3) 2.7 microbiological analysis microbial properties was carried out according to bam method chapters 3, 8, and 4 for total plate count (tpc), yeast and mold and e. coli, respectively (food and drug administration division of mirobiology and association of official analytical chemists, 1998). 2.8 sensory test the sensory test was conducted using a 9-point hedonic scale and difference from control (dfc) method. this hedonic scale describes the appearance and overall liking. the lowest score is described as “extremely dislike” with 1 scoring point, while the highest score is described as “extremely like” with 9 scoring points. the dfc is described as “no difference” with 0 scoring points to “extremely different” with 6 scoring points. this method was used to determine the differences between the hfsb and c samples. 2.9 sta s cal analysis the results are reported as mean and standard deviation. all experiments conducted in this study, except dietary fiber and proximate analysis, were performed in triplicate. the dietary fiber and proximate analyses were performed in duplicate. data of the physicochemical properties of c and hfsb snack bar were analyzed by independent t-test. one-way analysis of variance (anova) and duncan’s multiple range test were used to establish the significance of differences (p < 0.05) among the mean values of physicochemical properties and sensory evaluation of the c and hfsb formulas during storage. statistical analyses were performed using spss program version 19.0 for windows (spss inc, chicago, il, usa). 127 ghmj (global health management journal) 2019, vol. 3, no. 3 pra wi ia et al. figure 1. appearance of control (c) snack bar during storage at 35 oc (1a) and at 45 oc (1b) every 4 weeks; appearance of high dietary fiber (hfsb) at 35 oc (1c) and hfsb at 45 oc (1d) every 4 weeks. 3. results 3.1 physicochemical proper es of freshly prepared control (c) and high dietary fiber snack bar (hfsb) color values, water activity (aw), moisture content (mc), and ph of the c and hfsb are shown in table 1. the hfsb had higher l* value (lightness) than the c formula. the b* value (yellowness) of the c was higher than that of the hfsb, which means the c was more yellow than the hfsb. there were statistically significant differences (p<0.05) in ph and mc between the c and hfsb. the ph the hfsb was 6.21, which was lower than that of the c (6.31). otherwise, mc of hfsb was 7.87%, which was higher than that of c (6.53). photographs showing the appearance of freshly prepared c and hfsb are presented in figure 1. table 1. color values (l∗, a∗, b∗), aw, mc, and ph of control (c) and high dietary fiber (hfsb) snack bar physical property c1 hfsb1 color l∗ 35.07±0.53 37.49±0.92∗ a∗ 5.94±0.29∗ 4.75±0.31 b∗ 15.61±0.31 14.74±0.53 aw 0.58±0.07 0.57±0.05 mc (%) 6.53±0.45 7.87±0.26∗ ph 6.31±0.02∗ 6.21±0.02 1results are reported as mean±sd of triplicate analysis. ∗means significantly different (p<0.05) in the same row. table 2 shows that c snack bar contained 1.81 g of dietary fiber per serving (44 g). this means the product was not able to be classified as a high dietary fiber product. however, the hfsb could claim to be a high dietary fiber product because it contained 6.78 g of dietary fiber per serving (>20% daily value per serving). 3.2 physicochemical proper es of control and high dietary fiber snack bar during storage color is one of the most important attributes related to quality, affecting consumer acceptability because it is the first thing that is clearly detected by consumers. however, a colorimeter instrument was used in this study in parallel with sensory test by humans to get accurate and quantitative results. higher storage temperature (45 oc) would accelerate the decrease in l* value and increase a* value, thereby decreasing lightness and increasing the redness of the products. it is clear that the l*, a*, and b* values were significantly different (p<0.05) after storage (figure 2). total color difference 128 pra wi ia et al. ghmj (global health management journal) 2019, vol. 3, no. 3 table 2. proximate values and dietary fiber content of control (c) and high dietary fiber (hfsb) snack bar (44g) nutrients c1 hfsb1 energy (kcal) 191.86 198.31 mc (g) 4.27 4.03 protein (g) 3.16 3.01 total fat (g) 5.83 6.95 carbohydrate (g) 31.69 30.94 ash (g) 0.92 0.84 tdf (g) 1.81 4.38 sdf (g) 0.72 1.00 idf (g) 1.09 3.38 inulin (g) nd 2.40 sum of inulin + tdf (g) 1.81 6.78 1results are duplicate analysis. samples were calculated in dry basis; nd: not determined. (�e) values of the c and hfsb kept at 35 oc were below 3.7 throughout storage time. on the other hand, the �e values of the c and hfsb kept at 45 oc were higher than 3.7 at week 6 and week 4 of storage, respectively (table 3). figure 2. l* (2a), a* (2b), and b* (2c) of control (c) and high dietary fiber (hfsb) snack bar during storage at 35°c and 45 °c for 12 weeks. different superscripts (a-f) mean significantly different (p<0.05) in the same line. the ph, aw, and mc values of the c and hfsb snack bar throughout storage period are presented in figure 3. the ph of the c and hfsb slightly decreased (p<0.05) throughout the storage time. however, the ph values of the snack bar formulas kept at 45 oc rapidly decreased compared to those of the formulas kept at 35 oc. the initial aw of the c and hfsb were 0.57 and 0.56, respectively. during storage, aw of the c and hfsb were in the ranges of 0.52-0.63 and 0.48-0.57, respectively. the initial mc of the c and hfsb were 5.73% and 7.76%, respectively. the mc of the c snack bar (p<0.05) increased significantly after storage, otherwise the mc of the hfsb remained more constant. 129 ghmj (global health management journal) 2019, vol. 3, no. 3 pra wi ia et al. table 3. total color difference (�e) of control (c) and high dietary fiber (hfsb) snack bar during storage at 35 °c and 45 °c for 12 weeks storage me (week) c hfsb 35 oc 45 oc 35 oc 45 oc 2 1.48±0.53d 1.72±0.29d 1.53±0.22c 2.02±0.78c 4 1.85±0.40cd 3.37±0.53c 1.87±0.97bc 4.68±0.64b 6 1.59±0.39d 7.69±0.18b 2.00±0.01bc 4.45±0.17b 8 3.23±0.99a 6.45±1.53ab 2.40±0.73bc 6.85±0.13a 10 2.75±0.39b 5.94±0.06a 3.63±0.08a 6.93±0.07a 12 2.43±0.47bc 7.57±0.62a 2.84±0.29ab 6.73±0.11a results are reported as mean±sd of triplicate analysis. different superscript (a-d) mean significantly different in the same column (p<0.05). figure 3. ph (3a), water ac vity (3b), and moisture content (3c) of control (c) and high dietary fiber (hfsb) snack bar at 35°c and 45 °c for 12 weeks. different superscripts (a-f) mean significantly different (p<0.05) in the same line. 130 pra wi ia et al. ghmj (global health management journal) 2019, vol. 3, no. 3 table 4. thio-barbituric acid reac ve substances (tbars) of control (c) and high dietary fiber (hfsb) snack bar during storage at 35 °c and 45 °c for 12 weeks storage me (weeks) c (mg mda/kg sample) hfsb (mg mda/kg sample) 35 oc 45 oc 35 oc 45 oc 0 0.019±0.001a 0.019±0.001b 0.022±0.001b 0.023±0.001b 4 0.019±0.001a 0.021±0.001a 0.024±0.002a 0.026±0.001a 8 0.019±0.001a 0.023±0.002a 0.023±0.001a 0.026±0.002a 12 0.020±0.001a 0.022±0.002a,* 0.023±0.001a 0.026±0.004a,* results are reported as mean±sd of triplicate analysis. different superscript (a-d) mean significantly different in the same column (p<0.05). ∗ means significant differences (p<0.05) in the same row. 3.3 thio-barbituric acid reac ve substances (tbars) of control (c) and high dietary fiber snack bar (hfsb) during storage thio-barbituric acid reactive substance (tbars) values of the c and hfsb after each week of storage are presented in table 4. the tbars values of the hfsb were higher than the c formula. furthermore, there was no statistically significant difference (p>0.05) in the tbars values of the c stored at 35 oc throughout the storage time. however, the tbars values of the c and hfsb kept at 45 oc increased gradually after storage from 0.019 to 0.022 and 0.023 to 0.026 mg mda/kg, respectively. the tbars values of the c and hfsb snack bars kept at 45 oc were significantly increased (p<0.05) at week 4, after which the values became constant until the end of storage. 3.4 microbiological test the microbiological results showed that yeast and mold and total plate count (tpc) were detected less than 10 cfu/g, while mpn e. coli was detected less than 2 in both c and hfsb during storage. 3.5 sensory evalua on the sensory scores of the c and hfsb kept at 35 oc are shown in table 5. the overall acceptability scores of the c and hfsb at week 12 were below 6 (neither like nor dislike). the dfc scores of the c formula were higher than 3 at week 4 and week 12. otherwise, the dfc scores of the hfsb were below 3 throughout the storage period. the sensory scores of the c and hfsb snack bar kept at 45 oc are presented in table 6. the dfc scores of the c and hfsb were higher than 3 at week 4. interestingly, the dfc scores of the c and hfsb were below 6 (neither like nor dislike) at week 8. thus, sensory evaluation of the developed snack bar at week 12 was not performed. 3.6 cut-off point parameter to determine the shelf-life of the snack bar, the selection of cut-off points which are associated with maximum deterioration should be considered. the lowest scores for the cut-off point were selected to calculate the shelf-life due to the quality and stability of the products that should be considered. the cut-off point for calculating the shelf-life of the c and hfsb snack bars at 35 oc and 45 oc were at 8 weeks and 4 weeks of storage, respectively (table 6). 131 ghmj (global health management journal) 2019, vol. 3, no. 3 pra wi ia et al. table 5. sensory evalua on of control (c) and high dietary fiber (hfsb) snack bar during storage at 35 °c for 12 weeks storage me (weeks) appearance overall acceptability dfc c hfsb c hfsb c hfsb 0 7.20±1.06a 6.40±1.45a 7.07±1.11a 6.83±1.14a 4 6.73±0.86a 6.27±1.52a 6.30±0.95b 6.27±1.38ab 3.10±1.51a 2.70±1.11a 8 7.03±1.03a 6.80±1.21a 6.00±1.43b 6.70±0.79a 2.77±1.25a 2.30±1.09a 12 6.60±1.35a 6.06±1.76a 5.90±1.34b 5.93±1.70b 3.20±1.30a 2.70±1.34a nine-point hedonic scale (9= extremely like, 5= neither like nor dislike, 1= extremely dislike) dfc (difference from control): 0 = no difference, 6 = very large difference results are reported as mean±sd, n=30 different superscript (a-b) mean significantly different (p<0.05) in the same column. table 6. cut-off point parameter of control (c) and high dietary fiber (hfsb) snack bar during storage at 35 °c and 45 °c. sample parameter (weeks) cut-off point (weeks) ∆e overall acceptability dfc c-35 12 8 8 8 c-45 6 4 4 4 hfsb-35 12 8 12 8 hsfb-45 4 4 4 4 132 pra wi ia et al. ghmj (global health management journal) 2019, vol. 3, no. 3 4. discussion 4.1 physicochemical proper es of freshly prepared control (c) and high dietary fiber snack bar (hfsb) the l* value of hfsb was higher than c, expressed to be lighter, due to the addition of low-fat desiccated coconut (lfdc). there were statistically significant differences (p<0.05) in ph and mc between the c and hfsb. the ph of the hfsb was lower than that of the c. ozturk and serdaroglu (2018) reported that the addition of jap in food products would decrease ph due to the natural characteristics of the ingredient. however, the mc of the hfsb was higher than that of the c due to the moisture content from jap. in the proximate analysis, the c snack bar contained 1.81 g of dietary fiber per serving (44 g), meaning the product was not able to be classified as a high dietary fiber product. however, the hfsb could claim to be a high dietary fiber product because it contained 6.78 g of dietary fiber per serving (>20% daily value per serving) (gilsenan, 2011). it is clearly seen that the jap and lfdc successfully helped to increase the dietary fiber content in the hfsb. soluble dietary fiber (sdf) including inulin mostly came from the jap, whereas insoluble dietary fiber (idf) mostly came from lfdc. 4.2 physicochemical proper es of control and high dietary fiber snack bar during storage total color difference (�e) values of the c and hfsb kept at 35 oc were below 3.7 throughout the storage time. on the other hand, the �e values of the c and hfsb kept at 45 oc were higher than 3.7 at 6 and 4 weeks of storage, respectively. eliades et al. (2004) suggested that the acceptance limit of �e value is 3.7, which is clinically visible by human eyes beyond this value. the color alteration of the hfsb was faster than that of the c because the inulin content from jap participated in the maillard browning reaction, thereby reducing the lightness of the products (broyart et al., 1998). the higher storage temperature (45 oc) would accelerate the decrease in l* value and increase a* value, thereby decreasing lightness and increasing the redness of the products. high storage temperature affected the properties and quality of the products. sun-waterhouse et al. (2010) also observed that prolonged exposure to high temperature would have serious effects on the color of the product. maillard reaction plays an important role in the change in color, which is favored by high temperature and alkaline ph (loveday et al., 2009). the other factor is an excess of reducing sugar present in the product. pallavi and chetana observed that a snack bar with artificial sweeteners would be more stable than a snack bar with sugar as the equilibrium relative humidity was closer to normal ambient conditions, especially reducing sugar. reducing sugars such as all monosaccharides and some disaccharides, which were also used as ingredients in this experiment, increased the maillard reaction (yilmaz and toledo, 2005) as well as caramelization (ameur et al., 2008). maillard reaction produces several intermediate compounds such as hydroxymethylfurfural (hmf), methyl ketones, formic acid, and galactosyl-βpyranone from advanced maillard (cattaneo et al., 2008) in addition to brown-colored melanoidins (deeth, 2010). melanoidin is produced from the final stage of the maillard reaction, which establishes brown and dark pigmentation color (perez-locas and yaylayan, 2010). the hfsb could retain mc due to the high water-holding capacity (whc) of the fiber used (grigelmomiguel et al., 1999). in commercial products, mc of cereal bar was in a range between 8.00% and 10.06% (padmashree et al., 2012). theoretically, mc is the total amount of water present; the shifting of mc in a product will affect its texture (kong and singh, 2011). otherwise, aw is a key parameter used for determining the rate of many chemical reactions and also the microbial growth in food products (bchir et al., 2018). throughout the storage period, the aw of the c and hfsb was in the ranges of 0.52-0.63 and 0.48-0.57, respectively. aigster et al. (2011) observed the initial aw of granola and cereal bar was 0.69, which gradually increased to 0.77 during the storage time. however, the snack bars were packed with good oxygen, light, and moisture barrier properties. thus, the alteration in aw could be associated with starch retrogradation, which removes water instead of the migration of moisture through the packaging (silva et al., 2013). in fact, yeast and mold start to grow at aw in the 133 ghmj (global health management journal) 2019, vol. 3, no. 3 pra wi ia et al. range between 0.70 and 0.80 (rawat and darappa, 2015). the snack bar can normally be classified as a low moisture food product (lmf) due to the aw value being below 0.70. the low aw of the snack bar product would help to extend its shelf life (farakos et al., 2013). the ph values of the c and hfsb were slightly decreased (p<0.05) throughout the storage time. the ph values of snack bar formulas kept at 45 oc rapidly decreased more than those of products stored at 35 oc. the higher temperature could accelerate the deterioration of food products (elmlund, 2014). in food products, formic acid generated by the maillard reaction contributes to the decrease in ph during heat treatment (da silva et al., 2014; deeth, 2010). moreover, it should be noted that the decrease in ph may be a sign of microbial growth and chemical reaction. 4.3 thio-barbituric acid reac ve substances (tbars) of control and high dietary fiber snack bar during storage the tbars values of the c and hfsb snack bars kept at 35 and 45 °c for 12 weeks are shown in table 4. the tbars values of the hfsb were higher than those of the c throughout storage time because of the addition of jap and lfdc in the formulation. there was no statistically significant difference (p>0.05) in tbars values of the c at 35 oc during the storage time. however, the tbars values of the c and hfsb increased significantly (p<0.05) at 4 weeks of storage, after which the values became constant until the end of storage. trinidad et al. (2006) observed that proximate analysis of lfdc per 100 g of sample is as follows: 3.6% moisture, 3.1% ash, 10.9% fat, 12.1% protein, and 70.3% carbohydrates. otherwise, the proximate analysis of jap per 100 g sample is as follows: 3.39% moisture, 3.66% ash, 0.91% fat, 8.91% protein, and 83.13.3% carbohydrates (bui et al., 2016). it is clear that the fat content of the hfsb was higher than that of the c, at 6.95 and 5.83, respectively (see table 2). thus, fat from the lfdc and jap contributed to increase the tbars value because of lipid oxidation. lipid oxidation is one of the big problems in food products, where oxidative rancidity causes shelf life quality deterioration, including nutritional loss and toxic compound formation. lipid oxidation produces aldehyde compounds. thus, it can be detected as malondialdehyde (mda) as it is associated with off-flavors and aromas, which are usually found in meat products (ghani et al., 2017). table 4 shows that snack bar formulas kept at 45 oc had higher tbars values than those kept at 35 oc. this was probably due to lipid oxidation, which was expedited by several factors such as the presence of lipoxidase, peroxide, light, mc, and high temperature (chow, 1980). however, the tbars values of the c and hfsb snack bar were less than 0.05 mg mda/kg sample. the tbars values were less than the rancidity threshold (1–2 mg mda/kg sample) for food products, especially corn snacks (etemadian et al., 2018). 4.4 microbiological test the microbiological results showed that yeast and mold and total plate count (tpc) were detected less than 10 cfu/g, while mpn e. coli was detected at less than 2 for both c and hfsb during storage. based on the thai community product standard (tcps 709/2004), these formulated products were safe for consumption because yeast and mold was lower than 102 cfu/g and tpc was also lower than 1x103 cfu/g. 4.5 shelf-life determina on as mentioned previously, this research mainly aimed to develop a snack bar with high dietary fiber content to increase fiber intake. the product was carefully prepared using necessary hygienic steps to obtain a shelf-stable product. commercially, this product could be stored at room temperature (in thailand around 30 oc). for shelf-life prediction, the selection of a cut-off point should be considered, which is associated with the maximum deterioration. some parameters, such as color and sensory acceptability, should be considered because they are correlated to the quality of the product. total color difference (�e) and sensory scores tested by 30 panelists using 9-point hedonic scale and difference from control (dfc) test were used as cut-off points to calculate the shelf-life. the total color difference (�e) was considered at 3.7 as this level can be interpreted as a visible difference by human eyes 134 pra wi ia et al. ghmj (global health management journal) 2019, vol. 3, no. 3 (eliades et al., 2004). for the 9-point hedonic scale, the overall acceptability score should be higher than 6.0 (like slightly), meaning the product is accepted by panelists (giménez et al., 2012). based on freitas and costa (2006), the product will be rejected if the score for difference from control (dfc) is 3 or above. the q10 equation was used for predicting the product shelf-life at 30 oc. the shelf-life prediction for the c and hfsb snack bar stored at 30 oc was 11 weeks. padmashree et al. (2012) suggested that cereal snack bars packed in metallized polyester films have limited shelf-life of around 3 to 4 months. however, higher temperature during transportation and storage should also be considered due to the shelf-life of these products being shorter than that obtained from calculation. 5. conclusion jerusalem artichoke powder (jap) and low-fat desiccated coconut (lfdc) helped to increase the total dietary fiber by 3.7 times. thus, the developed high fiber snack bar (hfsb) could be classified as a high fiber food product. however, the addition of jap and lfdc contributes to certain changes in the physicochemical properties and stability of the snack bar. for shelf-life prediction by q10 test, the c and hfsb snack bar could be kept at 30 oc for 11 weeks. modified packaging should be considered in further experiments in order to help extend the shelf-life of the snack bar. acknowledgments the authors gratefully acknowledge to faculty of graduate studies, mahidol university for financial support. the authors also would like to thanks institute of nutrition, mahidol university for supporting the laboratory instruments. conflict of interest the authors declare that they have no conflict of interest. references aigster, a., duncan, s. e., conforti, f. d., and barbeau, w. e. (2011). physicochemical properties and sensory attributes of resistant starch-supplemented granola bars and cereals. lwt-food science and technology, 44(10):2159–2165. altoaimi, b. (2011). developing a gluten, soy, dairy, and nut free energy bar with a suggested haccp plan. ameur, l. a., rega, b., giampaoli, p., trystram, g., and birlouez-aragon, i. (2008). the fate of furfurals and other volatile markers during the baking process of a model cookie. food chemistry, 111(3):758–763. aoac (2016). official method of analysis. association of official analytical chemists, arlington, va. bchir, b., jean-françois, t., rabetafika, h. n., and blecker, c. (2018). effect of pear apple and date fibres incorporation on the physico-chemical, sensory, nutritional characteristics and the acceptability of cereal bars. food science and technology international, 24(3):198–208. broyart, b., trystram, g., and duquenoy, a. (1998). predicting colour kinetics during cracker baking. journal of food engineering, 35(3):351–368. bui, c. v., siriwatwechakul, w., tiyabhorn, w., wattanasiritham, t., limpraditthanont, n., and boonyarattanakalin, s. (2016). conversion of jerusalem artichoke tuber powder into fructooligosaccharides, fructose, and glucose by a combination of microwave heating and hcl as a catalyst. science & technology asia, pages 31–45. cattaneo, s., masotti, f., and pellegrino, l. (2008). effects of overprocessing on heat damage of uht milk. european food research and technology, 226(5):1099–1106. chow, k. (1980). storage problems of feedstuffs. in fish feed technology, chapter 13. fao, rome. da silva, e. p., siqueira, h. h., do lago, r. c., rosell, c. m., and vilas boas, e. v. d. b. (2014). developing fruit-based nutritious snack bars. journal of the science of food and agriculture, 94(1):52–56. 135 ghmj (global health management journal) 2019, vol. 3, no. 3 pra wi ia et al. deeth, h. (2010). improving uht processing and uht milk products. in improving the safety and quality of milk, pages 302–329. elsevier. eliades, t., gioka, c., heim, m., eliades, g., and makou, m. (2004). color stability of orthodontic adhesive resins. the angle orthodontist, 74(3):391–393. elleuch, m., bedigian, d., roiseux, o., besbes, s., blecker, c., and attia, h. (2011). dietary fibre and fibre-rich by-products of food processing: characterisation, technological functionality and commercial applications: a review. food chemistry, 124(2):411–421. elmlund, e. (2014). potential of light and temperature exploitation for accelerated shelf life studies (aslt) for sauces. etemadian, y., shabanpour, b., ramzanpour, z., shaviklo, a. r., and kordjazi, m. (2018). production of the corn snack seasoned with brown seaweeds and their characteristics. journal of food measurement and characterization, 12(3):2068–2079. farakos, s. s., frank, j., and schaffner, d. (2013). modeling the influence of temperature, water activity and water mobility on the persistence of salmonella in low-moisture foods. international journal of food microbiology, 166(2):280–293. food and drug administration division of mirobiology and association of official analytical chemists (1998). bacteriological analytical manual. association of official analytical chemists. foschia, m., peressini, d., sensidoni, a., and brennan, c. s. (2013). the effects of dietary fibre addition on the quality of common cereal products. journal of cereal science, 58(2):216–227. freitas, m. a. and costa, j. c. (2006). shelf life determination using sensory evaluation scores: a general weibull modeling approach. computers & industrial engineering, 51(4):652–670. ghani, m. a., barril, c., bedgood jr, d. r., and prenzler, p. d. (2017). measurement of antioxidant activity with the thiobarbituric acid reactive substances assay. food chemistry, 230:195–207. gilsenan, m. (2011). nutrition & health claims in the european union: a regulatory overview. trends in food science & technology, 22(10):536–542. giménez, a., ares, f., and ares, g. (2012). sensory shelf-life estimation: a review of current methodological approaches. food research international, 49(1):311–325. grigelmo-miguel, n., gorinstein, s., and martı́n-belloso, o. (1999). characterisation of peach dietary fibre concentrate as a food ingredient. food chemistry, 65(2):175–181. hillman, l., peters, s., fisher, a., and pomare, e. (1983). differing effects of pectin, cellulose and lignin on stool ph, transit time and weight. british journal of nutrition, 50(2):189–195. hough, g. (2006). sensory shelf-life testing. food qual prefer, 17(7-8):640–645. joye, d. and hoebregs, h. (2000). determination of oligofructose, a soluble dietary fiber, by high-temperature capillary gas chromatography. journal of aoac international, 83(4):1020–1025. kong, f. and singh, r. p. (2011). advances in instrumental methods to determine food quality deterioration. in food and beverage stability and shelf life, pages 381–404. elsevier. loveday, s. m., hindmarsh, j. p., creamer, l. k., and singh, h. (2009). physicochemical changes in a model protein bar during storage. food research international, 42(7):798–806. mizrahi, s. (2004). accelerated shelf-life tests. understanding and measuring the shelf-life of food, pages 318–339. ng, s., tan, c., lai, o., long, k., mirhosseini, h., et al. (2010). extraction and characterization of dietary fiber from coconut residue. j food agric environ, 8(2):172–177. padmashree, a., sharma, g. k., srihari, k. a., and bawa, a. s. (2012). development of shelf stable protein rich composite cereal bar. journal of food science and technology, 49(3):335–341. panyeam, p. (2007). formulaton of snack bars containing soy protein ingredients. perez-locas, c. and yaylayan, v. (2010). the maillard reaction and food quality deterioration. in chemical deterioration and physical instability of food and beverages, pages 70–94. elsevier. praznik, w., cieślik, e., and filipiak-florkiewicz, a. (2002). soluble dietary fibres in jerusalem artichoke powders: composition and application in bread. food/nahrung, 46(3):151–157. rawat, n. and darappa, i. (2015). effect of ingredients on rheological, nutritional and quality characteristics of fibre and protein enriched baked energy bars. journal of food science and technology, 52(5):3006–3013. reicks, m., jonnalagadda, s., albertson, a. m., and joshi, n. (2014). total dietary fiber intakes in the us population are related to whole grain consumption: results from the national health and nutrition examination survey 2009 to 2010. nutrition research, 34(3):226–234. saengthongpinit, w. and sajjaanantakul, t. (2005). influence of harvest time and storage temperature on characteristics of inulin from jerusalem artichoke (helianthus tuberosus l.) tubers. postharvest biology and technology, 37(1):93–100. 136 pra wi ia et al. ghmj (global health management journal) 2019, vol. 3, no. 3 silva, e. c. d., sobrinho, s., cereda, m. p., et al. (2013). stability of cassava flour-based food bars. food science and technology, 33(1):192–198. sinnhuber, r. o. and tc, y. (1977). the 2-thiobarbituric acid reaction, an objective measure of the oxidative deterioration occurring in fats and oils. journal of japan oil chemists’ society, 26(5):259–267. sun-waterhouse, d., teoh, a., massarotto, c., wibisono, r., and wadhwa, s. (2010). comparative analysis of fruit-based functional snack bars. food chemistry, 119(4):1369–1379. timm, d. a. and slavin, j. l. (2008). dietary fiber and the relationship to chronic diseases. american journal of lifestyle medicine, 2(3):233–240. trinidad, t. p., mallillin, a. c., valdez, d. h., loyola, a. s., askali-mercado, f. c., castillo, j. c., encabo, r. r., masa, d. b., maglaya, a. s., and chua, m. t. (2006). dietary fiber from coconut flour: a functional food. innovative food science & emerging technologies, 7(4):309–317. yilmaz, y. and toledo, r. (2005). antioxidant activity of water-soluble maillard reaction products. food chemistry, 93(2):273–278. cite this article as: pratiwi ia, kemsawasd v, winuprasith t. storage stability of high fiber snack bar. ghmj (global health management journal). 2019; 3(3):124-137. doi:10.35898/ghmj-33456 137 introduction method materials snack bar preparation proximate analysis of snack bar shelf-life study physicochemical determination of snack bar water activity moisture content ph color thio-barbituric acid reactive substances (tbars) microbiological analysis sensory test statistical analysis results physicochemical properties of freshly prepared control (c) and high dietary fiber snack bar (hfsb) physicochemical properties of control and high dietary fiber snack bar during storage thio-barbituric acid reactive substances (tbars) of control (c) and high dietary fiber snack bar (hfsb) during storage microbiological test sensory evaluation cut-off point parameter discussion physicochemical properties of freshly prepared control (c) and high dietary fiber snack bar (hfsb) physicochemical properties of control and high dietary fiber snack bar during storage thio-barbituric acid reactive substances (tbars) of control and high dietary fiber snack bar during storage microbiological test shelf-life determination conclusion 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. (2016). nursing workload: a concept analysis. journal of nursing management, 24(4), 449457. https://doi.org/10.1111/jonm.12354 amelia, n. l., & hersona, s. (2022). the effect of emotional intelligence on employee performance of pt. plastik karawang flexindo. enrichment: journal of management, 12(3), 1545-1551. begum, s., ashfaq, m., xia, e., & awan, u. (2022). does green transformational leadership lead to green innovation? the role of green thinking and creative process engagement. business strategy and the environment, 31(1), 580-597. https://doi.org/10.1002/bse.2911 behbahani, a. a. (2011). a comparative study of the relation between emotional intelligence and employee's performance. procedia-social and behavioral sciences, 30, 386-389. https://doi.org/10.1016/j.sbspro.2011.10.076 bosak, j., kilroy, s., chênevert, d., & flood, p. c. (2021). examining the role of transformational leadership and mission valence on burnout among hospital staff. journal of organizational effectiveness: people and performance. https://doi.org/10.1108/joepp-08-2020-0151 geun, h. g., & park, e. (2019). influence of emotional intelligence, communication, and organizational commitment on nursing productivity among korean nurses. journal of korean academy of community health nursing, 30(2), 226-233. https://doi.org/10.12799/jkachn.2019.30.2.226 https://doi.org/10.1111/jonm.12354 https://doi.org/10.1002/bse.2911 https://doi.org/10.1016/j.sbspro.2011.10.076 https://doi.org/10.1108/joepp-08-2020-0151 https://doi.org/10.12799/jkachn.2019.30.2.226 gaib, mendrofa, & dewi ghmj (global health management journal) 2023, vol. 6, no. 1 42 goleman, d. (2018). what makes a leader? in military leadership (pp. 39-52). routledge. https://doi.org/10.4324/9780429495007-4 hassan, s., mahsud, r., yukl, g., & prussia, g. e. (2013). ethical and empowering leadership and leader effectiveness. journal of managerial psychology. https://doi.org/10.1108/02683941311300252 hughes, l. c., chang, y., & mark, b. a. (2009). quality and strength of patient safety climate on medicalsurgical units. health care management review, 34(1), 19-28. https://doi.org/10.1097/01.hmr.0000342976.07179.3a hughes, p., & ferrett, e. (2011). introduction to health and safety at work. routledge. https://doi.org/10.4324/9780080970714 joullié, j.-e., gould, a. m., spillane, r., & luc, s. (2021). the language of power and authority in leadership. the leadership quarterly, 32(4), 101491. https://doi.org/10.1016/j.leaqua.2020.101491 kaslow, n. j., graves, c. c., & smith, c. o. (2012). specialization in psychology and health care reform. journal of clinical psychology in medical settings, 19(1), 12-21. https://doi.org/10.1007/s10880-0119273-0 kaur, s., & jiwan, t. (2014). an exploratory study to assess emotional intelligence and performance of students of selected nursing institute, ludhiana, punjab. asian journal of nursing education and research, 4(3), 346. king, c., rossetti, j., smith, t. j., smyth, s., moscatel, s., raison, m., gorman, r., gallegos, d., & watson, j. (2021). workplace incivility and nursing staff: an analysis through the lens of jean watson's theory of human caring. international journal for human caring, 25(4), 283-291. li, y., cao, f., cao, d., & liu, j. (2015). nursing students' post‐traumatic growth, emotional intelligence and psychological resilience. journal of psychiatric and mental health nursing, 22(5), 326-332. https://doi.org/10.1111/jpm.12192 mccloughen, a., & foster, k. (2018). nursing and pharmacy students' use of emotionally intelligent behaviours to manage challenging interpersonal situations with staff during clinical placement: a qualitative study. journal of clinical nursing, 27(13-14), 2699-2709. https://doi.org/10.1111/jocn.13865 mcqueen, a. c. h. (2004). emotional intelligence in nursing work. journal of advanced nursing, 47(1), 101108. https://doi.org/10.1111/j.1365-2648.2004.03069.x misto, mi., susanti, i. h., & sumarni, t. (2022). hubungan kecerdasan emosi dengan kinerja perawat di fasilitas pelayanan kesehatan kecamatan rembang kabupaten purbalinga. viva medika: jurnal kesehatan, kebidanan dan keperawatan, 15(2), 48-65. https://doi.org/10.35960/vm.v15i2.858 morrison, t. (2007). emotional intelligence, emotion and social work: context, characteristics, complications and contribution. the british journal of social work, 37(2), 245-263. https://doi.org/10.1093/bjsw/bcl016 murtiningsih, m. (2017). pengaruh gaya kepemimpinan transformasional pada kinerja perawat rumah sakit islam siti aisyah madiun. jurnal manajemen dayasaing, 17(2), 54-66. oktafiani, i. d. (2019). pengaruh high performance organization terhadap organizational attractiveness yang dimediasi oleh work engagement, affective organizational commitment, job satisfaction pada karyawan pt. indorama synthetics tbk jakarta. skripsi-2019. rahim, s. y. r., mas' ud, m., & maryadi, m. (2020). pengaruh kepemimpinan transformasional, budaya organisasi dan motivasi terhadap kinerja asn pada dinas pemberdayaan perempuan dan perlindungan anak kabupaten pangkep. jurnal magister manajemen nobel indonesia, 1(1), 141-153. rangki, l. (2019). hubungan kecerdasan emosional dengan tingkat stres kerja perawat di icu dan igd rsud kota kendari. jurnal kedokteran syiah kuala, 19(3). https://doi.org/10.24815/jks.v19i3.18118 ribeiro, n., yücel, i̇., & gomes, d. (2018). how transformational leadership predicts employees' affective commitment and performance. international journal of productivity and performance management. https://doi.org/10.1108/ijppm-09-2017-0229 romero, m., & barbera, e. (2011). quality of learners' time and learning performance beyond quantitative timeon-task. international review of research in open and distributed learning, 12(5), 125-137. https://doi.org/10.19173/irrodl.v12i5.999 ross, h., tod, a. m., & clarke, a. (2015). understanding and achieving person‐centred care: the nurse perspective. journal of clinical nursing, 24(9-10), 1223-1233. https://doi.org/10.1111/jocn.12662 sadeghi, a., & pihie, z. a. l. (2012). transformational leadership and its predictive effects on leadership effectiveness. international journal of business and social science, 3(7). simorangkir, a. c., pakpahan, b. a. s., & ariawan, s. (2021). the role of leadership in improving employee discipline. jurnal christian humaniora, 5(1), 125-132. https://doi.org/10.46965/jch.v5i1.623 https://doi.org/10.4324/9780429495007-4 https://doi.org/10.1108/02683941311300252 https://doi.org/10.1097/01.hmr.0000342976.07179.3a https://doi.org/10.4324/9780080970714 https://doi.org/10.1016/j.leaqua.2020.101491 https://doi.org/10.1007/s10880-011-9273-0 https://doi.org/10.1007/s10880-011-9273-0 https://doi.org/10.1111/jpm.12192 https://doi.org/10.1111/jocn.13865 https://doi.org/10.1111/j.1365-2648.2004.03069.x https://doi.org/10.35960/vm.v15i2.858 https://doi.org/10.1093/bjsw/bcl016 https://doi.org/10.24815/jks.v19i3.18118 https://doi.org/10.1108/ijppm-09-2017-0229 https://doi.org/10.19173/irrodl.v12i5.999 https://doi.org/10.1111/jocn.12662 https://doi.org/10.46965/jch.v5i1.623 43 ghmj (global health management journal) 2023, vol. 6, no. 1 gaib, mendrofa, & dewi soto-rubio, a., giménez-espert, m. d. c., & prado-gascó, v. (2020). effect of emotional intelligence and psychosocial risks on burnout, job satisfaction, and nurses' health during the covid-19 pandemic. international journal of environmental research and public health, 17(21), 7998. https://doi.org/10.3390/ijerph17217998 sun, h., wang, s., wang, w., han, g., liu, z., wu, q., & pang, x. (2021). correlation between emotional intelligence and negative emotions of front‐line nurses during the covid‐19 epidemic: a cross‐sectional study. journal of clinical nursing, 30(3-4), 385-396. https://doi.org/10.1111/jocn.15548 tampi, p. p., nabella, s. d., & sari, d. p. (2022). the influence of information technology users, employee empowerment, and work culture on employee performance at the ministry of law and human rights regional office of riau islands. enrichment: journal of management, 12(3), 1620-1628. tan, j. r. o., boersma, p., ettema, t. p., aëgerter, l., gobbens, r., stek, m. l., & dröes, r.-m. (2022). known in the nursing home: development and evaluation of a digital person-centered artistic photoactivity intervention to promote social interaction between residents with dementia, and their formal and informal carers. bmc geriatrics, 22(1), 1-15. https://doi.org/10.1186/s12877-021-02632-w thorn, l., & jensen, a. l. (2022). the self-managing nurse: a foucault-inspired discourse analysis. nordisk sygeplejeforskning, 12(2), 1-14. https://doi.org/10.18261/nsf.12.2.3 tj, h. w., tecoalu, m., colline, f., widjaja, d., & mannuela, r. (n.d.). the effect of intelligence quotient and emotional quotient on lecturer performance mediated by creativity. tsang, k. k., du, y., & teng, y. (2022). transformational leadership, teacher burnout, and psychological empowerment: a mediation analysis. social behavior and personality: an international journal, 50(1), 111. https://doi.org/10.2224/sbp.11041 wang, h.-f., chen, y.-c., yang, f.-h., & juan, c.-w. (2021). relationship between transformational leadership and nurses' job performance: the mediating effect of psychological safety. social behavior and personality: an international journal, 49(5), 1-12. https://doi.org/10.2224/sbp.9712 widarko, a., & anwarodin, m. k. (2022). work motivation and organizational culture on work performance: organizational citizenship behavior (ocb) as mediating variable. golden ratio of human resource management, 2(2), 123-138. https://doi.org/10.52970/grhrm.v2i2.207 yosiana, y., hermawati, a., & mas'ud, m. h. (2020). the analysis of workload and work environment on nurse performance with job stress as mediation variable. journal of socioeconomics and development, 3(1), 3746. https://doi.org/10.31328/jsed.v3i1.1326 cite this article as: gaib, j. h., mendrofa, f., & dewi, r. (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 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 ghmj (global health management journal) 2022, vol. 5, no. 2 indonesian scholars’ alliance open access perspectives politeknik kesehatan kemenkes palangka raya: health forum and international seminar the new normal : creating a pleasant virtual communication learning in the new normal: positive convergence of technology, quality, and sustainability merceditas o ang st. paul university, philippines *corresponding author’s email: angmerceditas@yahoo.com doi: 10.35898/ghmj-52932 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) all of us are affected by the covid-19 pandemic that caused disruptions in education, healthcare, economy, and travels. likewise, it is impacting the way we live, study, work, think, and interact. during this global crisis, we consider the health and well-being of people as most important. in fact, the medical doctors, nurses, and other healthcare professionals and clinicians who are front liners in the fight against the corona virus are now lauded as the new heroes in the coronial era. health education and mental health issues are crucial and relevant today as we navigate adverse situations, manage stress, cope with loss of jobs and loved ones, and deal with the quarantine fatigue. in the education sector, online learning has catapulted into the forefront due to the restriction of faceto-face classes. learning modalities have changed and education is transforming into the new normal. the quality and sustainability of technology-enabled learning is a major point of discussion. school leaders, policy makers, teachers, students, and parents, are all trying to make sense out of this unprecedented situation that needs unconventional wisdom. education in this new normal is challenging. hopefully, we can move forward with open minds, positive perspectives, and steadfast faith that we can make it. communication is very important and vital during this pandemic. we need to communicate clearly, positively, and effectively. in the digital platform of teaching and learning, the teacher needs to be creative and innovative in communicating, to get the interest and attention of the students, thus, make the learning process more engaging and interactive. learning in the new normal is full of challenges, particularly in terms of: a) quality of content, delivery and assessment of online learning; b) cost of investment in technology and digital infrastructure; c) lack of internet connectivity and electronic gadgets, and the digital divide issue; d) data privacy concerns and cybersecurity; e) training and up-skilling of the digital skills of teachers, staff and students, and teaching strategies in the new normal; f) financial constraints for salaries and school operations especially with decrease in enrolment; g) safety and mental health issues of students and employees; h) physical and geographical restrictions and health protocols; i) internship, on-the-job training, clinical immersion and laboratory classes; and j) industry linkages and employability of graduates. mailto:angmerceditas@yahoo.com https://dx.doi.org/10.35898/ghmj-52932 ang mo ghmj (global health management journal) 2022, vol. 5, no. 2 96 educators in the new normal need to communicate and exemplify the following: a. positive disposition and mindset that will help us to adjust to the disruptions, manage stress, and take care of our physical and mental health and well-being b. resilient attitude and skills to easily adapt to changes, cope with difficult situations, and bounce back amid setbacks c. agile approach in tasks and responsibilities that deliver efficient, effective, prompt, value-added and high impact results and services d. integral framework of transformative education anchored on quality teaching and learning, technological solutions, and sustainable development for a better future e. strategic management and leadership founded on connectivity to the institutional vision-mission, promote students’ and employees’ welfare, responsive to societal needs, and supportive of national and global peace and unity f. empathy and compassion towards the teachers, students, parents, healthcare front liners, law enforcers, workers, and all those who are affected by the covid-19 pandemic the education sector is tremendously affected and disrupted by the pandemic and so we need to rethink, re-imagine, and re-design our learning model, to come up with something that would be more adaptive to the transforming world today and tomorrow. the educational landscape is changing and re-shaping, and so we need to be creative, resilient, smart and innovative. remote teaching and online learning in the new normal can communicate a holistic and integral learning model that is effective and doable. learning in the new normal calls for a new way of teaching and communicating using digital platforms of the learning management system (lms), videoconferencing, teleconferencing, and any other modalities of technologyenabled learning. we need to communicate what is essential and positive, and stimulate the thinking process of the students, to come up with an interactive, engaging, and effective virtual learning in the new normal, the teaching and learning process revolves around three vital elements: technology, quality, and sustainability. technology has truly revolutionized the delivery of education, especially when internet was introduced. the cutting-edge educational technologies in the 4ir can facilitate the effective delivery of the lesson through interactive, adaptive, independent, and immersive learning, and virtual simulations. during this pandemic, classes continue through online learning, the flexible modality of both synchronous and asynchronous learning, the blended and hybrid delivery to suit the context of the learners and reach out to those with limited or no internet connectivity. with respect to teaching courses in medicine, nursing, pharmacy, medical technology, midwifery, and other health-related programs, the laboratory courses and clinical immersion in the hospitals are discouraged due to the risk of the corona virus. it is difficult to communicate and explain to the students online without the specimen that they can see and touch. at st. paul university philippines (spup), for example, we use 3d simulations and virtual reality. we have subscribed to the lecturio lms for the students taking up medicine, nursing, and allied health sciences courses. through the said learning platform, teachers and students may access an array of learning resources (video lectures), simulations (3d models), interactive assessments (quizzes), testing assets or test banks, and clinical/medical case scenarios for their academic engagement activities. for the laboratory experiments, spup subscribed to labster with its virtual laboratories in the different science courses. quality is a vital component of technology-enabled learning, particularly the content and delivery, authentic assessment of learning outcomes, process management of operations, and quality assurance. the transition from the in-face to online learning revolves around the quality of teaching and learning process and outcomes. the students and teachers are adjusting to the virtual learning environment. teachers have to establish good rapport with the students and empathize with the latter’s state of mental and psychological 97 ghmj (global health management journal) 2022, vol. 5, no. 2 ang mo well-being. the quality of relationship between teachers and students can boost learning engagement. this global pandemic is causing a lot of stress to students and their parents. likewise, the teachers and school administrators are pressured to ensure the quality of education in the online and flexible learning modalities. so, the quality of communication is important. the school leaders can inspire the teachers and students with caring words that communicate compassion, understanding, and willingness to help in these difficult times. a prevailing concern today is sustainability. the schools are confronted with problems like low enrollment, losses and financial constraints, complaints of students about internet connectivity, teachers’ lack of digital skills, expensive investment on technology, etc. school administrators and teachers are like walking on a tightrope during this pandemic, confronted with the uncertainty of the school re-opening, the availability of the vaccine for covid-19, adjusting and adapting to the changing technological frontiers that require new skills, and observing health and safety protocols. school leadership in a covid vuca world entails strategic resiliency, innovation, and sustainable development. to move forward, now more than ever, we need resiliency, strategy, courage, competence, openness and flexibility to adapt and adjust to the changes and disruptions going on, and learn to cope with inconvenience and difficulty. school leaders who display strategic resiliency would have the conviction and character to engage in reforms, paradigm shift, transition, transformation, and recovery effort. it is imperative to focus on sustainable development and innovation in order to survive and thrive in the present, and thus ensure that we would have a bright future. education and training systems need to keep pace with the new demands of labor markets that are continually challenged by technological disruption, demographic change, shifting business models, and the evolving nature of work. let me share a sustainable quality-based, technology-driven, education (sqte) framework which can be a useful guide for educators in the new normal and beyond. the sqte is a positive convergence and integration of quality pedagogy, technology as a learning modality, and sustainability through innovations and networking with stakeholders. a holistic education must be anchored on the basic tenet of lifelong education which is seamless, borderless, and a continuing development of the full potentials of the human person in both formal and informal setting. sustainability is a primary consideration especially when we deal with enrollment, salaries of teachers & personnel, employability of graduates, administrative concerns, and the survival and sustainable development of the school during this pandemic and beyond. to be sustainable, the school must network with the stakeholders and be responsive to their needs in context, particularly with the students, teachers, parents, alumni, and the community where they belong. also, we have to monitor the government policies and subsidies. we need to collaborate with partners in the academe and industry and match the skills of graduates with the demands of the labor market. school programs and endeavors must be aligned with the sustainable development goals (sdg) 2030 and the principles of education for sustainable development (esd). sustainability would entail continuing innovations, specialization and niche programs, strong connectivity and interface with the industry and civil society, research collaboration with local and international partners in the academe and industry, care for people and environmental environment, and global citizenship education. the quality of education is most important. a learner-centered interdisciplinary approach tends to evoke more interest and engagement. the quality of teaching and learning in whatever modality is influenced by the mindset of the teacher and students. that’s why, it is fundamental for the school to uphold its vision, mission, institutional goals and core values as embedded in the curriculum and instruction. this defines the unique quality and relevance of the school’s educational value proposition which can be its differentiation factor as well. intrinsic to quality would be training, research, the development of 21st century learning competencies, transformation and real-life application of knowledge and skills. our contemporary education ang mo ghmj (global health management journal) 2022, vol. 5, no. 2 98 is highly globalized, borderless and seamless, and we are moving fast into transnational education (tne) and internationalization, therefore, the universal application of knowledge and skills is the way to go, transcending geographical locations and cultural differences. the universal design for learning (udl) caters to all types of learners. in the context of the primacy now of machine learning and the increasing automation of jobs in the industry and changing working models, then we need to future-proof the quality of education not only to focus on 21st century professional competencies and adeptness of 4ir technologies but also to enrich the quality of education with values, ethics and spirituality, soft skills, research, resiliency and creativity, problem-solving and solution fluency, and other qualities of the human person that would make us superior from the humanoid robots and smart machines which is the trend in the future. technology is a tool that we can use in school to improve the quality of being human with the responsibility to uplift the quality of life and make the world better. the digital platform of learning is dominant during this pandemic. with millennial learners, technology-enabled learning is the way to go. since the labor market is fast changing due to new technologies, and the automation of jobs is displacing the traditional workforce, then we need to strengthen the soft skills as well as the hard skills of our graduates. amid the hype on technology and machine learning, we need to enrich our curriculum and instruction with values, spirituality and work ethics, so that our students and graduates become more responsible, well-adjusted, productive, and caring towards people and the environment. the impact of technology on learning is anchored on people engagement and mission-driven goals, quality and values embedded in the curriculum and instruction, and a sustainable roadmap of continuing innovations and lifelong learning towards better quality of life and work, today and tomorrow. cite this article as: ang mo. learning in the new normal: positive convergence of technology, quality, and sustainability. ghmj (global health management journal). 2022; 5(2):95-98. doi:10.35898/ghmj-52932 https://dx.doi.org/10.35898/ghmj-52932 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 ep en d en 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. 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 the effect of food presentation and ingredients modifications on patient’s leftovers at harapan insani medical center hospital dhini dhini1*, marini astrianoor2 1 department of nutrition, poltekkes kemenkes palangka raya, indonesia 2 harapan insani medical center, hospital pangkalan bun, iskandar 88, pangkalan bun, indonesia *corresponding author’s email: dinpraya@gmail.com doi: 10.35898/ghmj-51596 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 management of nutrition services at hospitals plays an important role in providing nutritional care to patients according to their specific conditions. it should be oriented to the needs and satisfaction of clients in the aspects of promotive, preventive, curative, rehabilitative to improve the quality of life. hospital nutrition service management includes outpatient nutrition care, inpatient nutrition care, food administration, research, and development. inpatient nutrition services start from nutrition assessment, nutrition diagnosis, nutrition intervention including planning, feeding, and nutrition counseling to nutrition monitoring and evaluation (kemenkes ri, 2013). improvement of meal presentation at a hospital setting can increase food intake, reduce waste food substantially and reduce readmission rate to hospital. (navarro et al., 2016). not all hospitals can implement food services with a systems approach, due to limited resources, especially in type c and d hospitals (bakri et al., 2018). to increase the food intake and at the same time reduce food waste, it is necessary to modify the taste and appearance of food. taste modification can be done through adding spices, coloring, and replacing or adding food ingredients. appearance modification of the food by changing food ingredients, shape, cooking techniques, serving utensils (wayansari, et al., 2018). based on preliminary research conducted at harapan insani hospital, of all the menus served, the most leftover food was fish-based dinner menus as much as 36.7%. this is because the patient has difficulty swallowing or is afraid of choking on the fishbone. in addition, the food presentation is less attractive. based on this background, the researchers studied the effect of food presentation and ingredient modification of fish-based dishes on food leftovers at harapan insani medical center hospital. harapan insani medical center hospital (previously a clinic), is located in pangkalan bun, kotawaringin barat regency, central kalimantan province, indonesia. it was established in september 2020 and now is classified as a type d hospital. the bed capacity is 20 with an average number of patients 15-20 people per day (before the covid pandemic). the food management system at harapan insani hospital uses a 10-day cycle menu, where cycle changes are carried out annually. https://dx.doi.org/10.35898/ghmj-51596 33 ghmj (global health management journal) 2022, vol. 5, no. 1 dhini & astrianoor this research was conducted in october 2020 with a total number of patients in the sapphire, emerald, and amethyst rooms as many as 8 people. with a purposive sampling technique, a sample of 5 people was determined. the inclusion criteria included being hospitalized for at least 2 days, 18 years old, willingness to be a respondent and a good level of awareness. while the exclusion criteria were patients with nasogastric tube and pregnant women with hyperemesis gravidarum table 1 shows the food preparation served at the observed hospital. the dish served before modification named ikan nila lepah timun was processed using a typical recipe from the kotawaringin barat district. in this dish, the nile tilapia is processed with herbs and cucumber vegetables, with presentation following figure 1.a. according to previous studies, the remaining food from this menu was 55%. patients claim that the menu is often consumed at home, so they feel bored. another patient admitted that it was difficult to separate the fish meat from the bones, which made them lazy to finish this meal. therefore, the researchers attempted to modify the menu by grinding fish meat and mixing it with additional seasonings shows at table 1.b. this dish was served in a bowl made from banana leaves, and is called ikan mangkukkan and be served as figure 1.b. table 1. food preparation at harapan insani medical center hospital before and after modification nila lepah timun fish (before modification) (a) ikan mangkkukan (after modification) (b) dhini & astrianoor ghmj (global health management journal) 2022, vol. 5, no. 1 34 (a) (b) the main spices used include shallots, garlic, lemongrass, turmeric, candlenut, ginger, galangal, pepper, salt, and sugar, following different other ingredients as showing at table 2. in this essay we also provide the cooking steps and the ware used to cook the both version of foods, before and after modification (refers to table 3). from our study, we found that, once ikan mangkukkan was served, there was no food left. in other words, the patient likes this food modification. the tolerance limit for hospital leftovers is ≤20% (rotua et al., 2018). thus, it can be concluded that modification of food presentation and ingredients positively affects patient acceptance and minimizes the leftovers at harapan insani medical center hospital. table 2. food ingredient used in this study nila lepah timun fish (before modification) (a) ikan mangkkukan (after modification) (b) ingredients amount ingredients amount nile tilapia 500 g nile tilapia (minced) 500 g cucumber 250 g pumpkin 250 g tomato 250 g egg 55 g lime juice 1 tablespoon cooking oil 25 g banana leaves (as a bowl) 5 leaves water 800 ml spices amount spices amount garlic 15 g garlic 15 g shallots 15 g lime leaves 1 g candlenut 15 g fiber creme 50 g turmeric 10 g turmeric 10 g ginger 10 g salt 15 g gallangal 5 g ground pepper 1 g salt 15 g coriander powder 2 g ground pepper 1 g coriander powder 2 g figure 1. food presentation of (a) before modification – nila lepah timun fish and (b) after modification – ikan mangkukkan 35 ghmj (global health management journal) 2022, vol. 5, no. 1 dhini & astrianoor table 3. cooking wares and cooking steps to prepare and present the food nila lepah timun fish (before modification) (a) ikan mangkkukan (after modification) (b) cooking wares cooking wares food processor food processor bowl bowl knife knife chopping board chopping board digital kitchen scales digital kitchen scales stove stove frying pan steam pan wooden spatula wooden spatula measuring cup measuring cup bowl scissors plates grater cooking steps cooking steps 1. clean 5 pieces or 500 grams of tilapia, give a squeeze of lemon juice 1. grind the nile tilapia fillets in a food processor 2. grind all the spices using a food processor 2. grind all the spices using a food processor 3. peel and clean cucumber, weigh 250 g, then cut lengthwise. weigh 250 g of red tomatoes, clean, and cut into pieces 3. mix the minced fish and ground spices, add fiber cream powder, and egg 4. saute the spices with cooking oil 4. grate 250 g of pumpkin. set aside 50 g of pumpkin shavings for garnish 5. add 800 ml of water along with the tilapia pieces 5. put the grated pumpkin into the fish mixture, mix well with the spices. 6. cook for 15 minutes 6. put in a bowl of banana leaves, spread out the dough, sprinkle the pumpkin shavings on top 7. add the cucumber and red tomatoes 7. steam for 30 minutes, remove from heat, and serve. 8. once cooked, remove from heat and serve with a sprinkling of fried onions. references bakri, b., intiyati, a., & widartika. (2018). sistem penyelenggaraan makanan institusi. jakarta: kemenkes ri. kementerian kesehatan republik indonesia. (2013). pedoman pelayanan gizi rumah sakit. jakarta: kemenkes ri. navarro, d.a., boaz, m., krause, i., elis, a., chernov, k., giabra, m. et al. (2016). improved meal presentation increases food intake and decreases the readmission rate in hospitalized patients. clinical nutrition; 35(5), 1153-1158. rotua, m., & siregar, r. (2013). manajemen sistem penyelenggaraan makanan institusi dasar. egc. cite this article as: dhini d & astrianoor m. the effect of food presentation and ingredients modifications on patient’s leftovers at harapan insani medical center hospital. ghmj (global health management journal). 2022; 5(1):32-35. doi:10.35898/ghmj-51596 https://dx.doi.org/10.35898/ghmj-51596 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; 2013. 2. moh indonesia. riset kesehatan dasar [basic health research] 2013. jakarta: moh indonesia; 2013. 3. putra igne, astuti d, widyastari da. prevalence and determinants of condom use among male adolescents in indonesia. int j adolesc med health. 2018. doi:10.1515/ijamh-2018-0141 4. de castro f, rojas mr, villalobos ha, allen lb, breverman ba, billings dl, uribe zp. sexual and reproductive health outcomes are positively associated with comprehensive sexual education exposure in mexican high-school students. plos one. 2018; 13(3):115. 5. moh indonesia. health law no. 36/2009. 6. susanto t, rahmawati i, wuryaningsih ew, saito r, syahrul, kimura r, tsuda a, tabuchi n, sugama j. prevalence of factors related to active reproductive health behavior: a cross-sectional study indonesian adolescent. epidemiol health. 2016;38. 39 global health management journal, 2019, vol. 3, no. 1 pradnyani et al. global health management journal. 2019; 3(1):31-39 7. azinar m. perilaku seksual pranikah berisiko terhadap kehamilan tidak diinginkan [primary sexual behaviors risk on unwanted pregnancy]. jurnal kesehatan masyarakat. 2013;8(2):153-160. 8. faturochman. sikap dan perilaku seksual remaja di bali [adolescents’ attitude and sexual behaviors in bali]. jurnal psikologi. 1992;(1):12-17. 9. suka ig , muninjaya aag, wiasti nm, kartika daas, aryastami k. pemberdayaan perarem untuk menurunkan angka hamil di luar nikah dan kawin usia muda di desa pengotan kabupaten bangli [empowerment of perarem to reduce premarital pregnancy and early married in pengotan village, bangli district]. buletin penelitian sistem kesehatan. 2013;16(3):275-281. 10. ippa of bali chapter. data kehamilan yang tidak diinginkan dan infeksi menular seksual [unwanted pregnancy and sexually transmitted infections data]. denpasar: ippa of bali chapter; 2015. 11. rahyani ky, utarini a, wilopo sa, hakimi m. perilaku seks pranikah remaja [premarital sexual behavior of adolescents]. jurnal kesehatan masyarakat nasional. 2012; 7(4): 180-185. 12. nurdjannah s. knowledge and behaviour about adolescent reproductive health in yogyakarta, indonesia. international journal of public health science. 2015;4(4): 326–331. doi: 10.11591/.v4i4.4754. 13. i̇şgüven p, yörük g, çizmeciğlu fm. educational needs of adolescents regarding normal puberty and menstrual patterns. jcrpe j clin res pediatr endocrinol. 2015; 7(4): 312-22. 14. yazıcı s, gulumser d, yıldız o, fatma y. the level of knowledge and behavior of adolescent male and female students in turkey on the matter of reproductive health. sex disabil. 2011; 29:217–227 15. nwaorgu oc, onyeneho ng, okolo m, obadike e, enibe g. reproductive health knowledge and practices among junior secondary school grade one students in enugu state: threat to achieving millennium development goals in nigeria. east afr j public health. 2008; 5(2): 5-11. 16. gul s, rubab b, ahmad n, iqbal u. herbal drugs for abortion may prove as better options in terms of safety, cost & privacy. a sci innov res. 2015; 4(2): 105-8. 17. wiriyana igna, hanim d, lestari a. pengetahuan, sikap dan tindakan hiv/aids anggota dan bukan anggota kelompok siswa peduli aids dan narkoba [knowledge, attitudes and practices of hiv/aids between members and non-members of students’ group with awareness of aids and drugs]. nexus kedokteran komunitas. 2017; 6(2): 45-53. 18. awang h, wong lp, jani r, low wy. knowledge of sexually transmitted diseases and sexual behavior among malaysian male youths. a biosoc sci. 2014; 46(2): 21424. 19. abdeyazdan z, sadeghi n. knowledge and attitude toward aids/hiv among senior school students in isfahan. iran j clin infect dis. 2008; 3(2): 93-8. 20. rahman m, mizanur m, kabir, shahidullah. adolescent knowledge and awareness about aids/hiv and factors affecting them in bangladesh. journal of ayub medical college.2009;21(3):3-6 21. bhatta dn. adolescent students' attitude towards premarital sex and unwanted pregnancy. health renaissance. 2013; 11(2): 145-9. 22. widyastuti esa. personal dan sosial yang mempengaruhi sikap remaja terhadap hubungan seks pranikah [personal and social factors influencing adolescent attitudes toward premarital sex]. jurnal promosi kesehatan indonesia.2009;4(2):75-85. 23. siramaneerat i, agushybana f, nugraha a, mungkhamanee s. knowledge, attitude, and behavior toward premarital sex among adolescents in indonesia. journal of health research. 2017;31(6):447–53. 24. rondini s, krugu jk. knowledge, attitude and practices study on reproductive health among secondary schools in bolgatanga, upper east region, ghana. afr j reprod health. 2009; 13(4): 51-66. 25. widyastari da, pimonpan i, zahroh s. “women won’t get pregnant with one sexual intercourse” misconceptions in reproductive health knowledge among indonesian young men. journal of health research.2015;29(1):63-69. 26. unesco, unfpa. youth and comprehensive sexuality education. new york: unesco, unfpa; 2011 27. chi x, hawk st, winter s, meeus w. the effect of comprehensive sexual education program on sexual health knowledge and sexual attitude among college students in southwest china. asia pac j public health. 2015; 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. 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 postpartummothers 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. (2017). binahong leaves ( anredera cordifolia tenore steen ) extract as an alternative treatment for perineal wound. belitung nursing journal, 3(6):778–783. akil, a., api, o., bektas, y., yilmaz, a. o., yalti, s., and unal, o. (2014). paracetamol vs dexketoprofen for perineal pain relief after episiotomy or perineal tear. journal of obstetrics and gynaecology, 34(1):25–28. ariani, s., loho, l., and durry, m. f. (2014). khasiat daun binahong (anredera cordifolia (ten.) steenis) terhadap pembentukan jaringan granulasi dan reepitelisasi penyembuhan luka terbuka kulit kelinci (the influences of binahong leaf in granulation tissue formation and epithelial regeneration of open wound healing of rabbit skin). jurnal e-biomedik, 1(2). borgelt, l. m., o’connell, m. b., and smith, j. (2010). women’s health across the lifespan: a pharmacotherapeutic approach. ashp. davidson, n. (1974). reeda: evaluating postpartum healing. journal of nurse-midwifery, 19(2):6–8. dewi, s. s., soemardini, s., and nugroho, f. a. (2016). hubungan tingkat konsumsi protein, zat besi (fe) dan zinc (zn) dengan kondisi penyembuhan luka perineum derajat ii pada ibu nifas (correlation between the consumption of protein, iron (fe) and zinc (zn) with second degree of perineal wound healing condition). majalah kesehatan fkub, 3(3):137–143. 114 karimah n et al. ghmj (global health management journal) 2019, vol. 3, no. 3 fithriyah, n., arifin, s., and santi, e. (2016). lumatan daun sirih merah (piper crocatum) terhadap lama penyembuhan luka bakar derajat ii pada kulit kelinci (cavia cobaya) (red betel leaf (piper crocatum) to the wound healing period of second degree burn on rabbits skin (cavia cobaya)). dunia keperawatan, 1(1):24–31. fouelifack, f. y., eko, f. e., ko’a, c., fouedjio, j., and mbu, r. (2017). treatment of perineal wounds during the post partum period: evaluation of whether or not antibiotic should be systematically prescribed. the pan african medical journal, 28:144–144. greenhalgh, d. g. (2003). wound healing and diabetes mellitus. clinics in plastic surgery, 30(1):37–45. gunanti, d. s. (2010). hubungan anemia dengan lama penyembuhan luka jahitan perineum pada ibu nifas di rs dr asmir salatiga tahun 2010 (assosiation between anemia and the period of perineal wound healing among postpartum mothers in dr asmir hospital, salatiga 2010). hartiningtiyaswati, s. (2010). hubungan perilaku pantang makanan dengan lama penyembuhan luka perineum pada ibu nifas di kecamatan srengat kabupaten blitar (correlation between abstaining from certain food with perineal wound recovery of postpartum mother in srengat subdistrict blitar). hill, p. d. (1990). psychometric properties of the reeda. journal of nurse-midwifery, 35(3):162–165. juliantina, f., citra, d., nirwani, b., nurmasitoh, t., and bowo, e. (2008). manfaat sirih merah (piper crocatum) sebagai agen anti bakterial terhadap bakteri gram positif dan gram negatif (the benefits of red betel leaves (piper crocatum) as an agent of antibacterial toward gram positive and gram negative bacteria). jurnal kedokteran dan kesehatan indonesia, 15:1–10. koca kutlu, a., çeçen, d., gürgen, s. g., sayın, o., and çetin, f. (2013). a comparison study of growth factor expression following treatment with transcutaneous electrical nerve stimulation, saline solution, povidoneiodine, and lavender oil in wounds healing. evidence-based complementary and alternative medicine, 2013. kusumowati, i. t. d., sujono, t. a., suhendi, a., da’i, m., and wirawati, r. (2012). korelasi kandungan fenolik dan aktivitas antiradikal ekstrak etanol daun empat tanaman obat indonesia (piper bettle, sauropus androgynus, averrhoa bilimbi, dan guazuma ulmifolia) (correlation phenolic content and antiradical activities of ethanol extract of plant drug indonesia leaves). pharmacon, 13(1):1–5. lindsay, p., bagness, c., and peate, i. (2018). midwifery skills at a glance. wiley-blackwell. marwoko, m. t. b. (2013). isolasi, identifikasi dan uji aktifitas senyawa alkaloid daun binahong (anredera cordifolia (tenore) steenis) (isolation, identification and test of activity of binahong leaf alkaloid compounds (anredera cordifolia (tenore) steenis)). chem info journal, 1(1):196–201. mercandetti, m. and cohen, a. (2012). wound healing, healing and repair. middleton, j. e. (2011). wound healing: process, phases and promoting. nova science publishers, new york. nisa, g. k., nugroho, w. a., and hendrawan, y. (2014). ekstraksi daun sirih merah (piper crocatum) dengan metode microwave assisted extraction (mae) (extraction of red betel leaf (piper crocatum) methods microwave assisted extraction (mae)). jurnal bioproses komoditas tropis, 2(1):72–78. o’reilly, b., bottomley, c., and rymer, j. (2012). essentials of obstetrics and gynaecology e-book. elsevier health sciences. r, n. (2017). perbedaan antara perawatan bersih kering dan rebusan daun sirih merah terhadap lama penyembuhan luka perineum pada ibu nifas (differences of clean dry care and red betel leaf decoction water on perineal wound recovery period of postpartum mothers). poltekkes kemenkes semarang, semarang. rohmin, a., octariani, b., and jania, m. (2017). faktor risiko yang mempengaruhi lama penyembuhan luka perineum pada ibu post partum (risk factor affecting the period of perineal wound healing in postpartum mothers). jurnal kesehatan, 8(3):449–454. said, s., taslim, n. a., and bahar, b. (2016). hubungan imt dan kadar albumin berhubungan dengan penyembuhan luka (body mass index and albumin level related to wound healing). jurnal keperawatan padjadjaran, 4(1). sari, p. i. a. (2019). pengaruh kemampuan vulva hygiene terhadap waktu penyembuhan luka perineum pada ibu postpartum primipara (the effect of vulva hygiene ability on the healing time of perineal wound in primiparous postpartum mothers). oksitosin: jurnal ilmiah kebidanan, 6(1):16–27. selawa, w., runtuwene, m. r., and citraningtyas, g. (2013). kandungan flavonoid dan kapasitas antioksidan total ekstrak etanol daun binahong [anredera cordifolia (ten.) steenis.] flavonoid content and total antioxidant capacity of ethanolic extract of binahong leaf (anredera cordifolia (ten.) steenis). pharmacon, 2(1). smith, l. a., price, n., simonite, v., and burns, e. e. (2013). incidence of and risk factors for perineal trauma: a prospective observational study. bmc pregnancy and childbirth, 13(1):59. suhermanto, m, s., and s, f. (2013). profil flavonoid, tanin, dan alkaloid dari ekstrak daun sirih merah (piper crocatum) (flavonoid, tannin, and alkaloid profiles of red betel leaf extract (piper crocatum). bogor agricultural institute, bogor. 115 ghmj (global health management journal) 2019, vol. 3, no. 3 karimah n et al. sulistyaningsih, a., haryadi, w., and swasono, r. (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 ghmj (global health management journal) 2024, vol. 7, no. 2 indonesian scholars’ alliance open access review children are losing lives in the name of culture: the health impacts of initiation schools in south africa tiisetso aubrey chuene department of student affairs, student health and wellness centre, university of limpopo, sovenga, 0727, south africa. *corresponding author’s e-mail: tiisetso.chuene@ul.ac.za doi: 10.35898/ghmj-72982 abstract background: on an annual basis, young boys lose their lives due to circumcisions performed at initiation schools across south africa. some of the initiates lose their manhood as a result of amputations and all these acts are done in the name of culture. over the last few years, there have been more media reports in south africa about improper traditional circumcisions coupled with poor health outcomes causing deaths of children admitted at initiation schools. aims: this article explores the health impacts of traditional initiation schools in south africa. methods: this review followed desktop approach through utilization of secondary data. systematic quantitative review technique was used to collect data. to get a better understanding of the context under investigation, desktop analysis was employed using the five steps of the data analysis process. results: the themes identified in this study include challenges associated with the practice in relation to children’s rights, ethical conflicts between traditional initiation practices and public health, commercialization of initiation schools, and complications associated with circumcision at initiation schools. conclusion: there is insufficient enforcement of the laws and a lack of public knowledge regarding the impact of initiation on children. even though south africa's national and local governments have made significant attempts to control the initiation practices and uphold children's rights, significant law enforcement is still required to shield children from unsafe cultural customs. in addition to the ineffective execution of existing rules and regulations, the traditional initiation sector is burdened by a lack of direct, continuous, and efficient supervision of the operations of initiation schools. keywords: supervision of initiation schools; losing lives; children; culture; male circumcision; enforcement of laws. received: 7 february 2024, reviewed: 11 march 2024, revised: 29 march 2024, accepted: 16 april 2024. © 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 in south africa, traditional initiation programs for the circumcision of men constitute a component of south africa's cultural heritage and are safeguarded by the constitution (south africa, 1996). traditional male circumcision is described by meissner and buso (2007) as rites of transition in adolescent's transition to manhood. this process is further described by dyke and mathew (2017) as the removal of the foreskin from the penis performed by traditional providers for cultural reasons. the custom of traditional circumcision is accepted and practiced in a varied south african community that is defined by multiple traditions. as a transition from childhood to manhood, traditional circumcision is performed by several cultural communities among males in south africa (mdhluli et al., 2021). according to douglas and maluleke (2018), initiation schools are cultural learning environments used to acquire information regarding social norms, masculine principles, and customary mailto:tiisetso.chuene@ul.ac.za https://doi.org/10.35898/ghmj-72982 chuene, t.a. ghmj (global health management journal) 2024, vol. 7, no. 2 38 traditions and rituals. young men who want to learn about their culture's values, beliefs, struggles, respect, and sense of responsibility might go to initiation schools that are cultural institutions (douglas et al., 2017). this occurs across a clear, predetermined timeframe and it can take place in wintertime or during the summertime. initiation is one of the oldest customs which is practiced by people from different cultural backgrounds (silverman, 2004). in south africa, this custom is followed by nguni a group which is inclusive of amaswati, amaxhosa, amandebele, and amazulu people. according to hammond-tooke and schapera (1974), numerous tribes in the country follow it as well, including the bapedi, the southern sotho people, tsongas, and vhavenda. according to douglas et al. (2017), traditional male circumcision is a sacred and seclusion-based procedure because initiates are not allowed to talk about the custom with non-initiates, and any who do will face harsh punishment from the community. initiates in a traditional circumcising society go through the initiation rituals so as to be given family and social obligations. males go through initiation rituals because they are a part of cultural customs within families and communities. the significance of initiation schools in south africa is highlighted by ndou-mammbona, and mavhandu-mudzusi (2022) who claim that adolescents who attend initiation schools receive education on social behaviour, cultural norms around marriage and courtship, and standards for societal duty. according to prusente et al. (2019), males are granted numerous benefits in the community that are linked to their level of maturity upon initiation. in addition, mohlaloka et al. (2016) state that initiates receive training and instruction on how to be independent and financially autonomous while still making place for the enrichment of less fortunate members of the community. through initiation schools, the initiates also acquire the concepts of accountability, humanity, respect, and resoluteness (douglas & maluleke, 2018). according to mohlaloka et al. (2016), initiation schools provide adolescents with the skills they will need as adults. these competences align with the official educational framework of south africa, which seeks to give adolescents the principles, understanding, and abilities needed for self-actualization and significant engagement in society (department of basic education, 2011). the benefits of initiation schools are numerous; however, there are disadvantages as well. on an annual basis, young boys lose their lives due to circumcisions performed at initiation schools across south africa. during the last 15 years, 858 boys are thought to have died while attending initiation schools, and numerous others have been hospitalized with severe injuries (centre for human rights, 2021). these occurrences amount to a violation of the rights to life, health, physical security, and dignity that the republic of south africa's 1996 constitution protects. in the eastern cape province, 11 of the 10 794 boys who attended initiation school in 2022 died during the winter initiation season while 23 of the 51 601 boys died during the summer initiation season (kamnqa, 2023). some of the initiates lose their manhood because of amputations and all these acts are done in the name of culture. over the last few years, there have been more media reports in south africa about improper traditional circumcisions coupled with poor health outcomes causing deaths of children admitted at initiation schools (commission for gender equality, 2021). some of the children die at initiation schools annually because of going to unlicensed initiation schools, while others flee their homes and join initiation schools operated by people who are not qualified to execute traditional surgeries and who lack the ability to offer the initiates with professional care after surgery. young initiates die as a result. this article therefore focuses on traditional male initiation schools which are a topic of concern in the country due to several issues such as deaths, sending children to initiation schools against their will, and in certain situations, sending them without parental permission. while this raises concerns about the children's human rights, the situation is made worse by unfavorable health outcomes that ultimately lead to uncontrolled complications. 2. methods the review and analysis of secondary data constitute the basis of this conceptual paper. the researcher used a purposive sampling strategy to collect secondary data. to guide this review, the primary question was: what is the impact of traditional initiation schools in south africa? the question was developed using the population, intervention, comparator, and outcome (pico) framework (schardt et al., 2007). using techniques outlined by pickering et al. (2015), a comprehensive literature review was carried out to ascertain the scope of academic research on initiation schools in south africa. no limitations on research design were imposed in order to guarantee that all pertinent studies were included. therefore, the incorporation of mixed-methods, qualitative, and quantitative content that was categorized to evaluate the dimension, comprehensive manner, and diversity of literature on the subject was made possible by the use of systematic quantitative review technique. this form of review was shown to be appropriate for summarizing and quantifying the body of research that has already been done, as well as for identifying gaps in knowledge. the review was concluded following the preferred reporting items for systematic reviews and meta-analyses (prisma) model (moher et al., (2015). 39 ghmj (global health management journal) 2024, vol. 7, no. 2 chuene, t.a. to find pertinent studies, different electronic databases such pubmed, google scholar, sabinet, jstor, ebscohost, and institutional electronic theses and dissertations repositories were systematically searched. the following search terms, either alone or in combination, were used to search for available literature on initiation schools: “initiation schools”, “traditional male circumcision”, “health impacts”, “culture”, “supervision of initiation schools”, “children rights”. the inclusion criteria were articles related to initiation schools and traditional circumcision of males. data with ambiguous characteristics and not full paper articles were excluded. review was limited to the english language and focused predominantly on south africa. due to historic relevance of the topic, no restrictions in terms of publication date, however research published in the last 20 years were given priority. the retrieved data was analyzed thematically to find both analytical and descriptive themes. to further get a better understanding of the context under investigation, desktop analysis was employed using the five steps of the data analysis process: familiarization, thematic framework identification, organizing, mapping process, and interpretation of the results (crowe et al., 2011). themes of commonality were discerned, and recommendations were made. 3. literature review theoretical perspective vygotsky's sociocultural theory (1931) served as the foundation for this review of health impact of initiation schools in south africa. vygotsky's sociocultural theory is used in conjunction with social constructionism and as a frame to examine the socio-cultural theory. according to vygotsky and cole (1978), the development of a person can be comprehended through looking at their own social norms. each clan is distinct from the others since each has a unique culture. every clan has an impression of kinship as a result of the principles, standards, and practices, such as initiation schools, because they have meanings associated with them and are how individuals in an ethnic community are recognized. vygotsky (1931) argues that social behavior occurs in a cultural setting served as the foundation for the sociocultural viewpoint on learning and development. in south africa, communities believe that initiation signify the change from a particular phase of life to another. therefore, one can assume that initiation signify a duty to watch over youngsters during their transition from childhood to adulthood. given this, initiation schools continue to be a significant aspect of most african communities. according to vygotsky and cole (1978), the socio-social environment offers the individual a variety of tasks and interacts with actuality using the instruments that are provided. this suggests that involvement in initiation schools and interactions with parents, who serve as the custodians of culture, exert a greater impact on the conceptualizations of the majority of male youngsters. such custodianships are transferred to caretakers known as "baditi" throughout the initiation school period, where the initiates are entirely dependent on them. the initiate's operations are initiated by "baditi" by teaching them what to expect during the process of initiation. the author evaluated the integration of the social constructionism viewpoint in that manner. therefore, employing sociocultural theory to explore various individual's cultural and social lives helps author get an overview of the things they value and the faith they hold to. in order to comprehend beliefs about culture, the author employed socio-cultural theory to concentrate on the social custom of male initiation school. according to gergen (1985), social constructionism is a theoretical perspective that holds that an individual's existence is a result of cultural and interpersonal interactions. while acknowledging the role of genetically inherited traits, the idea places more of a focus on examining how society has impacted culture and the lives of individuals. the theory of social constructionism was chosen as an additional matric theory due to its capacity to generate a collectively formed perspective that serves as the foundation for commonly held views about realities. this additional theory therefore provided the notion that adolescents who receive training in initiation schools acquire expected social behaviors that are required by many society individuals. on the other hand, carstens (1982) argue that initiation plays a role in the creation of masculinity because it cultivates an aggressive and powerful representation of the man, which serves to maintain and promote maleness. social constructionism strongly aligns with the ideas of mfecane (2013), who contends that several masculinities may occur in a particular cultural environment. mfecane (2013) believes that although it is important to think about how an unequal system is perpetuated by studying members of the group with power, there is a remote possibility of ever overturning the current gender balance without being aware of its flaws and restrictions. though social constructivists contest this, initiation gives young males authority over women, uninitiated men, and men circumcised at hospitals. hatfield (2010) challenges culturally accepted notions of masculinity, arguing that they make men be seen as the only competent providers. men who are portrayed in this way perpetuate discrimination and ignore the abilities of women and marginalized masculinities. chuene, t.a. ghmj (global health management journal) 2024, vol. 7, no. 2 40 the importance of initiation schools in south africa the main goal of initiation schools is to help prepare adolescents for the transition from adolescence to adulthood. numerous cultural groups in south africa, including the pedi, venda, tsonga, ndebele, xhosa, and basotho perform rituals of initiation with characteristics that are unique in a variety of ways, such as the definition of circumcision, the rituals held prior to and following initiation procedures, the participants in the rites of passage, and the roles they play (aids foundation of south africa, 2012; rathebe, 2018). male initiation rituals are used to emphasize the value of respect for one's own manhood, self-assurance, authentic cultural identification, character development, and acceptance of one's own particular african culture. the social and cultural training provided at initiation schools in respect to the obligations and responsibilities of what it means to be considered a "man" is among the elements considered to be significant. traditional circumcision is performed for cultural motives as a tradition and a transitional process into manhood (mdhluli et al., 2021; makgopa 2005). cultural understanding of male circumcision in south africa is to lower the dangers of human immunodeficiency virus (hiv) and other sexually transmitted infections (stis). this implies that despite the fact that there are additional elements that are more important, circumcision has served as the emphasis in numerous ethnic groups' views on how to "save sex." one of the most important practices that has been scientifically shown to lower the risk of stis, including hiv/aids, human papillomavirus, gonorrhea, syphilis, and herpes, and to name a few, is male circumcision (dyke & mathew, 2017). according to research, male circumcision lowers the likelihood of stis by offering males approximately 60% protection against hiv exposure (prodger & kaul, 2017). according to dyke and mathew (2017), majority of men and teenagers desire or undergo circumcision for a variety of reasons such as medical factors, sexual reasons, cultural customs, cosmetic considerations, and religious considerations. according to mdhluli et al. (2021), certain communities no longer practice circumcisions have an interest in adopting it as a method of hiv/aids prevention. leclerc-madlala (2002) asserts that certain tribal groups now perform circumcision as an hiv preventive measure rather than as a cultural tradition. according to a study by froneman and kapp (2017), the customary circumcision of males helps to lower hiv infections. this is supported by makgopa (2005) who highlighted that circumcision is linked to a lower risk of urinary tract infection, hiv infection, penile cancer, and other stis. ndou-mammbona (2023) asserts that individuals have a chance to use initiation schools for instilling positive behaviours and for effective hiv prevention because the initiates pay attention to everything that is being taught throughout the initiation period. on the contrary, mutombo et al. (2015) argue that male circumcision cannot completely prevent hiv infection because circumcised men are still susceptible to the virus and can spread it to their partners. leclerc-madlala (2002) also disagrees with these assertions and believes that the process may be harmful to one's sexual, emotional, or psychological well-being. key legislation frameworks and national policies governing south african initiation schools the children's act (38 of 2005) was enacted by the parliament in order to give effect to the rights of children as stated in section 28 of the constitution (south africa, 1996). the act aims to offer legal defence against male circumcision performed without consent. provisions of the children's act emphasize the need to uphold a child's cultural attachments, and the act's foundational principle is that the child's best interests must be prioritized. as stated in section 12 (1), all children have the right to be free from religious, cultural, and social customs that are detrimental to their health. additionally, according to section 7, a child has the right to be a member of any cultural group they so choose. section 12 (10) of the act stipulates that the development phase and maturity of a child must be taken into account while regulating the protection of children's rights in cultural customs, including male circumcision. the children's act no. 58 of 2005 appropriately regulates the circumcision of boys under the age of eighteen. under chapter 2 of the children's act, section 8(a) forbids circumcision and the application of circumstances that might jeopardize the health of children under the age of sixteen. the customary initiation act no. 2 of 2021, which was recently passed by south africa, addresses concerns related to the initiation of boys and young men in particular. registration, permission, restrictions, age and circumcision, discipline and instruction, water, cleanliness, food, healthcare, alcohol and drug usage, and procedures for handling an initiate's death are among the main topics covered in chapter 4 of the customary initiation act. according to the national policy on customary practice of initiation, an initiation school needs to be registered in line with its guidelines. children attending unregistered initiation schools shall be considered abducted and the applicable laws must be upheld in such cases (department of cooperative governance and traditional affairs, 2015). in order to accomplish the aforementioned goals, the provincial governments must set up provincial initiation coordinating committees and the national government, in accordance with the new customary initiation act no. 2, 2021, formed the national initiation oversight committee. these committees' job is to make sure all initiation schools follow the law. the act states that anybody in charge of any initiation school 41 ghmj (global health management journal) 2024, vol. 7, no. 2 chuene, t.a. that violates the law by having unregistered staff members and management may face legal action. the traditional health practitioners act no. 22 of 2007 and the customary initiation act no. 2 of 2021 both permit prosecution of unregistered traditional surgeons. nowadays, traditional surgeons must register with the appropriate provincial departments of health as is mandated by law. according to chapter 11 of the south african constitution (1996), a traditional leadership that upholds a traditional legal system and was legally recognized prior to the constitution's adoption shall remain such authority and continue to fulfill and maintain the rights and responsibilities entrusted to it in line with the rules and regulations in force, subject to any amendments or repeals of those rules and regulations by an appropriate leadership. legislation controlling traditional circumcision has been passed by a number of provinces. some examples of legislation from provinces include among others the limpopo circumcision schools act no. 6 of 2016. in the free state province there is initiation schools health act no. 1 of 2004 in place, and the eastern cape has the application of health standards in traditional circumcision act. the national policy on customary practice of initiation in south africa and the application of health standards in the traditional circumcision act no. 6 of 2001 were anticipated to be in line with these provincial laws. various provincial laws control the environmental, medical, and social components of the initiation schools. there are additional laws in place to protect traditional leadership's values and to guarantee that it is treated with respect and dignity and such laws include the traditional leadership and governance framework amendment act no. 41 of 2003 which establishes recognizes traditional councils. it also acknowledges the state's obligations to uphold, safeguard, and advance the traditional authority in a way that is consistent with the constitution. 4. results the results of this review highlight that initiation schools have negative impact on the health and wellbeing of initiates and such impacts are discussed below: traditional circumcision-related complications at south african initiation schools in south africa, the practice of traditional circumcision at initiation schools is unfortunately linked to a severe health catastrophe. for example, according to a study by mdhuli et al. (2021), some of the initiates' health has been compromised due to improper circumcision that resulted in gangrene and septic wounds. these complications are also linked to traditional surgeons' lack of training and expertise, which results in improper surgery. additionally, according to banwari (2015), there is a significant likelihood that circumcision performed at initiation schools will result in major negative outcomes, including death. anike et al. (2013) concurs with banwari (2015) by highlighting that are higher chance of traditional male circumcision-related complications such as excessive bleeding, gangrenous penis, sepsis, and septicemia, permanent disability from glans or shaft amputation, dehydration, urinary retention, stenosis, fistulae, loss of penile sensitivity, oedema of the glans penis and to the worst-case scenario death of the initiates. as per the republic of south africa's constitution (1996), everyone has the right to life. therefore, culture cannot take superiority over the right to life. dehydration is one of the complications that initiates encounter at the initiation schools. douglas and maluleke (2018) concluded that during the first two weeks of the initiation process, traditional male circumcision initiates experience dehydration due to restrictions on drinking water and eating certain foods like fruit and vegetables. this is considered as an endurance test as well as a way to minimize frequent urination and weeping of the circumcised wound (douglas & maluleke, 2016). nwanze and mash (2012) state that initiates receive this kind of training as a way to be resilient, self-disciplined, and strong. complications from traditional circumcision occur across south african provinces. for example, in eastern cape province, thousands of young people have been hospitalized, hundreds have had their penile amputations performed, and hundreds have lost their lives due to traditional circumcision throughout the past 20 years (kepe, 2010). douglas et al. (2017) argues that the traditional leaders who are thought to be the guardians of cultural practices and the impacted communities are all gravely impacted by this increase in initiates death rates from the initiation schools. with the majority of the complications ending up in hospitals, the initiation schools' increased number of complications puts pressure on the health system which is already overburdened. for instance, between june 2006 and june 2013, the eastern cape department of health recorded 5,035 circumcision initiates admitted to hospitals, 453 death cases, and 214 penile amputations (eastern cape statistics, 2013). traditional male circumcision continues to be recognized in many african tribes as an essential, even sacred, cultural ritual meant to prepare young men for the duties of adulthood. sadly, a lot of these initiates are exposed to behaviors that have negative health effects. in south africa, initiation schools for circumcision enroll hundreds of young people annually. regretfully, certain individuals who undergo traditional circumcision frequently encounter complications that necessitate medical attention (anike et al., 2013). according to chuene, t.a. ghmj (global health management journal) 2024, vol. 7, no. 2 42 moslemi et al. (2011), some complications frequently call for surgery as a solution, which comes at a significant cost to the healthcare budget. complications including gangrene, septicemia, dehydration, pneumonia, thrombosis, and congestive heart failure are the leading causes of common deaths (meel, 2010). another problem is that hospitalization for circumcised initiates is considered culturally inappropriate (behrens, 2013). contact with conventional medical hospitals is seen by some as going against the norm. according to douglas and maluleke (2018), deaths are a common aspect of initiation schools due to factors such as unfavorable environmental conditions, improper circumcisions, dehydration, unbalanced dietary intake and mistreatment by traditional attendants. regarding environmental hygiene and the definition of safe and healthy procedures, rathebe (2018) argue that there is a knowledge gap among the owners of initiation schools. sithole (2024) reported that the eastern cape department of co-operative governance and traditional affairs have revealed that at least 34 initiates lost their lives during the 2023 initiation season. the same province saw over 31 deaths during the december 2021 initiation period, which was already more than twice as much as the 14 fatalities from the previous initiation season. commercialization of initiation schools because of lack of employment the practice of getting circumcised was never intended to be financially profitable. it was customary to give the traditional nurse and the surgeon some of the meat that was killed during the initiation as a thank-you gift. this has evolved through time, becoming increasingly commercialized, with certain individuals now benefiting greatly from the custom. even well-known and licensed traditional surgeons also referred to as legal traditional surgeons, demand payment from the initiates' families (douglas & hongoro, 2018). traditional male circumcision was only held in the winter and was performed for free of as a community programme by authorities from traditional office. the traditional male circumcision is currently structured looking at the school holidays, making the winter and summer breaks the suitable seasons for new initiates to attend. a profit-driven commercial element has taken control of what had been initially a free service, leading to the establishment of numerous initiation schools under no supervision from traditional authorities (douglas, 2013). initiation schools that are not endorsed nor regulated are widely believed to have multiplied. the overwhelming majority of these schools do not follow cultural norms or the customary practice of setting up schools in remote locations far from villages. the findings by mdhluli et al. (2021) show that initiation schools are susceptible to misuse by opportunistic individuals without employment as well as employed individuals who want to add to their inadequate salaries in order to survive, destroying and weakening a highly respected cultural practice. as a cultural tradition and extra hiv protection measure, traditional circumcision is still performed in initiation schools in south africa and is still accepted and practiced there. however, to the detriment of this cultural practice, many dishonest organizations or individuals establish initiation schools to further their own economic objectives. economic troubles and a lack of job opportunities appear to be the primary reason for certain individuals turning to desperate measures to make a living. the founding of initiation schools was once considered sacrilege because it included invoking ancestors. however, some people nowadays overlook the cultural significance and consider it as a chance to make money instead. therefore, initiation schools are vulnerable to misuse by opportunistic unemployed individuals and some employed individuals who seek to add to their inadequate salaries to survive, weakening and damaging a highly regarded cultural tradition. in south africa, indigenous knowledge practitioners continue to undertake and pass down customary procedures including circumcision as initiation (makgopa, 2005). however, the tradition of circumcision has been criticized and questioned by some individuals as well as media reports. according to reports in the media, there are a lot of unlicensed initiation schools being run by dishonest people who don't respect the sacredness of this cultural rite but are instead only interested in making money. this has several negative health effects, including the eventual death of initiators. but there have been a lot of alarming stories about how unethical professionals are spreading. problems associated with the circumcision practice in relationship to children’s rights the state is required by the constitution's section 7(2) to defend, uphold, and fulfil the rights of children. this emphasizes that the state has a constitutional duty to control initiations and safeguard children from potentially life-threatening circumstances. in actuality, though, the constitution does not ensure that children's interests will be protected. according to section 12(9)(a) of the act, a child who is above 16 years old may undergo circumcision provided they have given their consent. additionally, it is explicitly stated in the act that male children below the age of 16 are not allowed to have circumcision. it is thus argued that, in spite of these clauses, young children are nonetheless coerced into initiation with complete indifference to their rights. there are two exceptions to 43 ghmj (global health management journal) 2024, vol. 7, no. 2 chuene, t.a. the act's rules regarding male circumcision under the age of sixteen: religious circumcision and medical circumcision (section 12(8)). this implies that unless it is done for medical or religious grounds, the act does not support the circumcision of minors. however, there are societies that promote, coerce, or even hijack children under the age of sixteen to attend initiation. under section 12 (10) of the children's act, a child has the option to decline circumcision based on their age, developmental phase, and level of understanding. however, most young boys lack the bravery to refuse due to pressure from their peers, societal judgment, as well as individual beliefs (bosman-sadie et al., 2010). the inference for parents is that they are breaking the law and breaching their child's rights when they make their kids undergo traditional circumcision without their will. although there are no consequences for breaking this clause, anyone who does so including physicians runs the risk of being sued for damages under common law by the child who had the treatment done in violation of the act (morei, 2017). according to children's act regulation 5(1)(d), cultural circumcision should only be performed by a medical professional or someone who is knowledgeable about the relevant social and cultural customs and has received the necessary training. comparable regulations apply to religious circumcision, which can be carried out by a physician or a member of the relevant church who has received the necessary training (children's act regulation 6(1)). nonetheless, circumcision is still performed at random on young children attending initiation schools, some of whom have been abducted. it is argued that the laws and regulations governing initiation schools and circumcision are completely disregarded in some areas. conflicts between public health standards and initiation practices there are ethical tensions between traditional initiation practices and public health that cannot be overlooked. the regulation of traditional initiation rituals has been the subject of legislation, and most recently, a law governing the safety and well-being of these rituals was passed in south africa (south africa, 2018). according to douglas (2013), operators of initiation schools believe that medical experts frequently impose health regulations and procedures without taking cultural differences into account. they find this to be quite arrogant considering the majority of the healthcare workers who operate in rural regions are black africans, who are supposed to protect and uphold african culture. every south african citizen has a right to a healthy, secure, and safe environment, as stated in the country's 1996 constitution. to guarantee that the customary initiation rituals are carried out in secure, healthy, and ethical way, stakeholders should be involved in initiation school practices. in accordance with the law governing initiation schools, the authority given to traditional leaders constitutes one of the groups having the power to address issues relating to initiation ceremonies and initiation schools. these authorities include selecting traditional healers for initiation schools, addressing mistreatment reports, mediating disputes in initiation schools, and creating organizations to defend the rights of initiates. to ensure rational practices in initiation schools, the participation of the following stakeholders is essential: the department of health, south african police services, the department of social development, and municipalities. in south africa, traditional initiation affairs incorporate a variety of stakeholders, but functioning, active involvement and visibility are still required. the health and sanitation at initiation schools are compromised since there will always be a fear of participating fully. according to douglas and maluleke (2018), it is challenging to prosecute or detain traditional surgeons who break the rules since the government is never willing to tamper with customs. the necessity for active, aggressive engagement and visibility persists despite the fact that all relevant parties participate in south africa's traditional initiation rituals. the environment for well-being and sanitation in initiation schools is perpetually compromised by apprehension of participating aggressively. traditional access rules that prevent different stakeholders from actively participating in initiation schools are the first issue cited by the commission for the promotion and protection of the rights of cultural, religious, and linguistic communities. these rules are in place to safeguard traditional revered customs, cultural education, and rites of passage. unauthorized initiation schools that are not listed on municipal registers present the second challenge. these institutions, which are not acknowledged by the traditional authority, are a major cause of initiate fatalities, as well as pneumonia, dehydration, and genital amputations. based on the above complications, it is worth arguing that the health of initiates should not be sacrificed in the name of preserving south african cultural beliefs. this conundrum necessitates a drastically altered compliance strategy. 5. conclusion although culture is an essential component of african customs that is difficult to replace, children's health and safety come first. even though south africa's national and local governments have made significant attempts to chuene, t.a. ghmj (global health management journal) 2024, vol. 7, no. 2 44 control the initiation practices and uphold children's rights, significant law enforcement is still required to shield children from unsafe cultural customs. the health of initiates should not be compromised in the name of preserving south african cultural customs. this conundrum necessitates a drastically altered compliance strategy. even though everyone has the freedom to engage in cultural activities of their preference, cultural rights cannot be exercised in a way that is incompatible with the rights of children. thus, in accordance with clause 7(2) of the constitution, the state needs to step in and preserve the safety of initiates. due to the rise in recorded deaths, catastrophic infections, and unlawful entry into initiation schools, all of which occur within the current legal framework, the authors therefore contend that there is insufficient enforcement of the laws and a lack of public knowledge regarding the impact of initiation on children. the rules and regulations, official standards and codes of conduct that govern initiation and circumcision processes have been disregarded by those operating the initiation schools because there is ineffective law enforcement. in addition to the ineffective execution of existing rules and regulations, the traditional initiation sector is burdened by a lack of direct, continuous, and efficient supervision of the operations of initiation schools. it should be kept in mind that monitoring and assessing the unfavorable practices at these schools is an enormous task because the custom in question is cloaked in secrecy and sacredness. therefore, legislation alone will not be enough to solve the problems caused by initiation school operations; substantial efforts are required. as a result, this paper suggests the following recommendations: training workshops for all stakeholders there is still a need for strong, active engagement and transparency in traditional initiation matters, notwithstanding the multiplicity of stakeholders involved in south african traditions. since initiation schools fall under the jurisdiction of the traditional chiefs and their council(s), providing them with ongoing legal education and training would equip them with the knowledge and abilities necessary to oversee the initiation schools in an efficient and compliant manner. training workshops aimed at all stakeholders must be held annually prior to the start of the initiation period. by training stakeholders, the intended objectives of successfully governing traditional behaviours are likely to be achieved, as communities are likely to promote these programs if they receive support. in this sense, the government ought to be involved in assisting initiation school programs financially and with training. active collaboration among stakeholders to preserve the cultural significance and improve the safety of initiates, different stakeholders such as traditional healers, the house of traditional leaders, the traditional surgeons, government officials from national and provincial government departments, such as the departments of cooperative governance and traditional affairs, social development, health, and the south african police service and local municipalities, members of local community policing forums, the community, and other stakeholders should work together in enforcing the regulations governing the operations of initiation schools. effective collaboration amongst the stakeholders can help minimize death rates and diseases that can be prevented. it can also guarantee that all necessary services are provided within the initiation schools. in undertaking such initiatives, it is imperative to acknowledge the delicate boundary that exists between the need to guarantee safe healthcare practices and personal freedom to preserve cultural customs. additionally, this paper also suggest that the commission for gender equality collaborate tightly with other pertinent organizations to guarantee that national and local governments establish the monitoring and oversight mechanisms required to safeguard the rights of initiates, ensuring that they receive the customary practices of circumcision and initiation in safe and secure settings that do not infringe upon their human, sexual, or reproductive health rights. incorporate initiation processes into the school curricula everything that is taught at initiation schools ought to be included in the curricula of primary schools, starting with the foundation phase, where life skills are taught. in this sense, teachers who completed the initiation school might be quite helpful. this recommendation aims to rethink the institution's function rather than completely dismantle it, as education and development offer a viable solution. reflect on the custom in the author's opinion, traditional circumcision is no longer the best option for children due to its complications. although initiation schools are cultural spaces where young men learn cultural values, rules, adversity, respect, and responsibility, the author believe that their original purpose of shaping men into better members of society has been superseded. even though the initiation tradition was well-practiced in the past, it is no longer relevant 45 ghmj (global health management journal) 2024, vol. 7, no. 2 chuene, t.a. in the modern day because there are medical facilities like hospitals and clinics where it may be performed safely. for this reason, the author advises the government to start thinking carefully about the traditional initiation and evaluate its rationale. the purpose of initiation schools is to develop young boys into men rather than being known for causing fatalities and must therefore be carried out in a setting that the children are comfortable with; if not, the custom should be outlawed because it infringes on their rights. research research which focuses more on health education for initiates and stakeholders in initiation schools requires immediate attention. the primary areas to focus on should include: hydration quality; the hygienic state of cooking areas; the sterilization techniques used on circumcision instruments; the detrimental impacts of adverse weather conditions on initiates; and the level of compliance with general health and medical care risk waste regulations. implementation and strengthening of the health promotion programs provincial houses of traditional leaders should collaborate with municipalities and other stakeholders, particularly parents, teachers, and school administrators, to carry out successful community education awareness campaigns. the author suggests that to reach the full participation of the community and prevent health-related issues, those planning programs on health promotion must be attentive to the cultural traditions linked with initiation schools. thus, the results of this study support douglas's (2013) recommendation to put the developed health promotion program into action. the success of health promotion programs can be achieved through collaboration with skilled circumcision practitioners under the guidance of health promotion practitioners who are culturally orientated. since they are qualified to lead programs and function as community promoters at the primary level of prevention, the health promotion practitioners in this situation will be valuable in helping to promote health promotion initiatives in collaboration with the traditional leaders. conflict of interest there is no conflict of interest. references aids foundation of south africa. (2012). culture and health programme, initiation schools-baseline report. 2012. available at: https://www.aids.org.za/wp-content/uploads/2018/02/culture-health-programme-final-report.pdf (accessed 30 december 2023) anike, u., govender, i., ndimande, j. v., & tumbo, j. (2013). complications of traditional circumcision amongst young xhosa males seen at st lucy's hospital, tsolo, eastern cape, south africa. african journal of primary health care & family medicine, 5(1), 1-5. https://hdl.handle.net/10520/ejc136756 banwari, m. (2015). dangerous to mix: culture and politics in a traditional circumcision in south africa. african health sciences, 15(1): 283-287. https://doi.org/10.4314/ahs.v15i1.38 behrens, k. g. (2013). traditional male circumcision: balancing cultural rights and the prevention of serious, avoidable harm. south african medical journal, 104(1), 15-16. https://doi.org/10.7196/samj.7493 bosman-sadie, h., corrie, l., & swanepoel, e. j. (2010). a practical approach to the children's act. lexisnexis. carstens, p. (1982). the socio-economic context of initiation ceremonies among two southern african peoples. canadian journal of african studies, 16(3), 505-522. https://doi.org/10.1080/00083968.1982.10804010 centre for human rights. (2021). press statement: centre for human rights calls for in-depth study and action to prevent deaths arising from customary initiation practices. available at: https://www.chr.up.ac.za/news-archive/2771-pressstatement-centre-for-human-rights-calls-for-in-depth-study-and-action-to-prevent-deaths-arising-from-customaryinitiation-practices (accessed 25 march 2024) commission for gender equality. (2021). illegal initiation schools in south africa: assessing risks to boys and young men. available at: https://cge.org.za/wp-content/uploads/2021/07/cge-report-on-illegal-initiation-schools.pdf (assessed 30 december 2023) crowe, s., cresswell, k., robertson, a., huby, g., avery, a., sheikh, a., (2011). the case study approach. bmc medical research methodology, 11(1), 100-108. https://doi.org/10.1186/1471-2288-11-100 department of basic education. (2011). curriculum and assessment policy statement. grades 10-12. life orientation. pretoria: government printers department of cooperative governance and traditional affairs. (2015). policy on customary practice of initiation in south africa. pretoria: government printers. https://www.aids.org.za/wp-content/uploads/2018/02/culture-health-programme-final-report.pdf https://hdl.handle.net/10520/ejc136756 https://doi.org/10.4314/ahs.v15i1.38 https://doi.org/10.7196/samj.7493 https://doi.org/10.1080/00083968.1982.10804010 https://www.chr.up.ac.za/news-archive/2771-press-statement-centre-for-human-rights-calls-for-in-depth-study-and-action-to-prevent-deaths-arising-from-customary-initiation-practices https://www.chr.up.ac.za/news-archive/2771-press-statement-centre-for-human-rights-calls-for-in-depth-study-and-action-to-prevent-deaths-arising-from-customary-initiation-practices https://www.chr.up.ac.za/news-archive/2771-press-statement-centre-for-human-rights-calls-for-in-depth-study-and-action-to-prevent-deaths-arising-from-customary-initiation-practices https://cge.org.za/wp-content/uploads/2021/07/cge-report-on-illegal-initiation-schools.pdf https://doi.org/10.1186/1471-2288-11-100 chuene, t.a. ghmj (global health management journal) 2024, vol. 7, no. 2 46 douglas, m., & maluleke, t. x. (2018). traditional male circumcision: ways to prevent deaths due to dehydration. american journal of men's health, 12(3), 584-593. https://doi.org/10.1177/1557988316628545 douglas, m. (2013). an intervention study to develop a male circumcision health promotion programme at libode rural communities in the eastern cape province, south africa (doctoral dissertation), walter sisulu university. douglas, m., & hongoro, c. (2018). the consideration of socioeconomic determinants in prevention of traditional male circumcision deaths and complications. american journal of men’s health, 12(3) 597-607. https://doi.org/10.1177/1557988316638157 douglas, m., maluleke, t. x., manyaapelo, t., & pinkney-atkinson, v. (2017). opinions and perceptions regarding traditional male circumcision with related deaths and complications. american journal of men's health, 12(2), 453-462. https://doi.org/10.1177/1557988317736991 dyke, t., & mathew, t. h. (2017). male circumcision as a remedy to sexually transmitted infections amongst youths in the limpopo province of south africa. indilinga african journal of indigenous knowledge systems, 16(2), 276-287. eastern cape statistics. (2013). health presentation on hiv/ aids programme of safe circumcision june/july season report. https://pmg.org.za/committee-meeting/16354/ (accessed 06 january 2024). froneman, s., & kapp, p. a. (2017). an exploration of the knowledge, attitudes and beliefs of xhosa men concerning traditional circumcision. african journal of primary health care & family medicine, 9(1), 1-8. https://doi.org/10.4102/phcfm.v9i1.1454 gergen, k. j. (1985). social constructionist inquiry: context and implications. in the social construction of the person. new york, ny: springer new york, 3-18. hammond-tooke, w.d. & schapera, i. (1974). the bantu speaking peoples of southern africa. london: routledge and kegan paul. hatfield, e. f. (2010). “what it means to be a man”: examining hegemonic masculinity in two and a half men. communication, culture & critique, 3(4), 526-548. https://doi.org/10.1111/j.1753-9137.2010.01084.x kamnqa, s. (2023). feature: the complexities of traditional and medical circumcision in the eastern cape. available at: https://www.spotlightnsp.co.za/2023/07/27/feature-the-complexities-of-traditional-and-medical-circumcision-in-theeastern-cape/ (accessed 25 march 2024) kepe, t. (2010). ‘secrets’ that kill: crisis, custodianship and responsibility in ritual male circumcision in the eastern cape province, south africa. social science & medicine, 70(5), 729-735. https://doi.org/10.1016/j.socscimed.2009.11.016 leclerc-madlala, s. (2002). on the virgin cleansing myth: gendered bodies, aids and ethnomedicine. african journal of aids research, 1(2), 87-95. https://doi.org/10.2989/16085906.2002.9626548 makgopa, m. m. (2005). inexperienced adults’ reliance on extrinsic product attributes to judge the quality of major household appliances (doctoral dissertation), university of pretoria. mdhluli, t. d., matshidze, p. e., kugara, s. l., vuma, l., & mawere, j. (2021). an investigation into the commercialisation of initiation schools: a case of eastern cape, south africa. hts teologiese studies/theological studies, 77(2), 1-8. https://doi.org/10.4102/hts.v77i2.6157 meel, b. l. (2010). traditional male circumcision-related fatalities in the mthatha area of south africa. medicine, science and the law, 50(4), 189-191. https://doi.org/10.1258/msl.2010.010017 meissner, o., & buso, d. l. (2007). traditional male circumcision in the eastern cape-scourge or blessing? south african medical journal, 97(5), 371-373. mfecane, s. (2013). can women ‘refuse’condoms? dilemmas of condom negotiation among men living with hiv in south africa. culture, health & sexuality, 15(3), 269-282. https://doi.org/10.1080/13691058.2012.729159 moher, d., shamseer, l., clarke, m., ghersi, d., liberati, a., petticrew, m., ... & prisma-p group. (2015). preferred reporting items for systematic review and meta-analysis protocols (prisma-p) 2015 statement. systematic reviews, 4, 1-9. https://doi.org/10.1186/2046-4053-4-1 mohlaloka, s. m. b., jacobs, l., & de wet, n. c. (2016). insights from traditional initiation teachers (basuwe) on the influence of male traditional initiation (lebollo) on the behaviour of schoolboys. perspectives in education, 34(2), 19-32. https://doi.org/10.18820/2519593x/pie.v34i2.2 moslemi, m. k., abedinzadeh, m., & aghaali, m. (2011). evaluation of epidemiology, safety, and complications of male circumcision using conventional dissection surgery: experience at one center. open access journal of urology, 83-87. https://doi.org/10.2147/rru.s17913 morei, n. (2017). cultural practices and children’s rights: the case of male initiation in south africa. africology: journal of pan african studies, 10(2), 1-20. mutombo, n., maina, b. & jamali, m., (2015). male circumcision and hiv infection among sexually active men in malawi. bmc public health, 15(1), 1-9. https://doi.org/10.1186/s12889-015-2384-z https://doi.org/10.1177/1557988316628545 https://doi.org/10.1177/1557988316638157 https://doi.org/10.1177/1557988317736991 https://pmg.org.za/committee-meeting/16354/ https://doi.org/10.4102/phcfm.v9i1.1454 https://doi.org/10.1111/j.1753-9137.2010.01084.x https://www.spotlightnsp.co.za/2023/07/27/feature-the-complexities-of-traditional-and-medical-circumcision-in-the-eastern-cape/ https://www.spotlightnsp.co.za/2023/07/27/feature-the-complexities-of-traditional-and-medical-circumcision-in-the-eastern-cape/ https://doi.org/10.1016/j.socscimed.2009.11.016 https://doi.org/10.2989/16085906.2002.9626548 https://doi.org/10.4102/hts.v77i2.6157 https://doi.org/10.1258/msl.2010.010017 https://doi.org/10.1080/13691058.2012.729159 https://doi.org/10.1186/2046-4053-4-1 https://doi.org/10.18820/2519593x/pie.v34i2.2 https://doi.org/10.2147/rru.s17913 https://doi.org/10.1186/s12889-015-2384-z 47 ghmj (global health management journal) 2024, vol. 7, no. 2 chuene, t.a. ndou-mammbona, a. a., & mavhandu-mudzusi, a. h. (2022). could vhavenda initiation schools be a panacea for hiv and aids management in the vhembe district of south africa? curationis, 45(1), 1-10. https://doi.org/10.4102/curationis.v45i1.2356 ndou-mammbona, a. a. (2023). exploring initiation schools' impact on hiv and aids management in the vhembe district of south africa: an ethnography. health sa gesondheid, 28, 1-9 nwanze, o., & mash, r. (2012). evaluation of a project to reduce morbidity and mortality from traditional male circumcision in umlamli, eastern cape, south africa: outcome mapping. south african family practice, 54(3), 237-243 pickering, c., grignon, j., steven, r., guitart, d., & byrne, j. (2015). publishing not perishing: how research students transition from novice to knowledgeable using systematic quantitative literature reviews. studies in higher education, 40(10), 1756-1769. https://doi.org/10.1080/03075079.2014.914907 prodger, j. l., & kaul, r. (2017). the biology of how circumcision reduces hiv susceptibility: broader implications for the prevention field. aids research and therapy, 14(1), 1-5. https://doi.org/10.1186/s12981-017-0167-6 prusente, s., khuzwayo, n., & sikweyiya, y., (2019), ‘exploring factors influencing integration of traditional and medical male circumcision methods at ingquza hill local municipality, eastern cape: a socio-ecological perspective’, african journal of primary health care & family medicine 11(1), 1-11. https://doi.org/10.4102/phcfm.v11i1.1948 rathebe, p. c. (2018). the role of environmental health in the basotho male initiation schools: neglected or restricted? bmc public health, 18(1), 1-8. https://doi.org/10.1186/s12889-018-5936-1 schardt, c., adams, m. b., owens, t., keitz, s., & fontelo, p. (2007). bmc medical informatics and utilization of the pico framework to improve searching pubmed for clinical questions. 6, 1–6. https://doi.org/10.1186/1472-6947-7-16 silverman, e. k. (2004). anthropology and circumcision. annual review of anthropol, 33, 419-445. https://doi.org/10.1146/annurev.anthro.33.070203.143706 sithole, s. 2024. outcry over 34 initiation-season deaths in eastern cape. available at: https://www.iol.co.za/saturdaystar/news/outcry-over-34-initiation-season-deaths-in-eastern-cape-2fe533cc-5494-4bd9-ad18-41c476db87d8 (accessed 06 january 2024) south africa. (1996). the constitution of the republic of south africa. pretoria: government printer. available from: https://www.gov.za/documents/constitution/constitution-republic-south-africa-1996-04-feb-1997 (accessed 05 february 2024). south africa. (2018). customary initiation bill, b7. government gazette no. 4149. pretoria: government printer. vygotsky, l.s., 1931, ‘chapter 12: imagination and creativity in the adolescent’, in the pedology of the adolescent from volume 4 of the collected works of l.s. vygotsky, transl. f. smolucha, pedagogika, moscow, 1984. vygotsky, l. s., & cole, m. (1978). mind in society: development of higher psychological processes. cambridge, ma: harvard university press. cite this article as: chuene, t.a. (2024). children are losing lives in the name of culture: the health impacts of initiation schools in south africa. ghmj (global health management journal), 7(2). 37–47. https://doi.org/10.35898/ghmj-72982 https://doi.org/10.4102/curationis.v45i1.2356 https://doi.org/10.1080/03075079.2014.914907 https://doi.org/10.1186/s12981-017-0167-6 https://doi.org/10.4102/phcfm.v11i1.1948 https://doi.org/10.1186/s12889-018-5936-1 https://doi.org/10.1186/1472-6947-7-16 https://doi.org/10.1146/annurev.anthro.33.070203.143706 https://www.iol.co.za/saturday-star/news/outcry-over-34-initiation-season-deaths-in-eastern-cape-2fe533cc-5494-4bd9-ad18-41c476db87d8 https://www.iol.co.za/saturday-star/news/outcry-over-34-initiation-season-deaths-in-eastern-cape-2fe533cc-5494-4bd9-ad18-41c476db87d8 https://www.gov.za/documents/constitution/constitution-republic-south-africa-1996-04-feb-1997 https://doi.org/10.35898/ghmj-72982 ghmj (global health management journal) 2024, vol. 7, no. 3 indonesian scholars’ alliance open access editorial non-communicable diseases: opportunities to promote future health during the first 1000 day of life andrew john macnab * department of pediatrics, university of british columbia, canada. * the stellenbosch institute for advanced study (stias), wallenberg research center at stellenbosch university, south africa. * editor in chief, global health management journal, yayasan aliansi cendekiawan indonesia thailand, indonesian scholars' alliance (inschool). *corresponding author’s email: ajmacnab@gmail.com doi: 10.35898/ghmj-731003 given as a keynote speech at the 1st cirebon international health symposium, faculty of medicine, universitas swadaya gunung jati, indonesia, 31 august 2024. abstract the developmental origins of health and disease (dohad) framework now underlies the evolution and epigenetics of many non-communicable diseases that develop in adult life. type 2 diabetes, obesity, hypertension, heart disease and stroke in particular have links back to events during the first 1000 days of life, and as the world is witnessing an epidemic of these conditions, identifying measures able to contribute to reducing the potential for these ncds to develop in our aging populations becomes all the more important. parental health at conception and good maternal health and nutrition throughout pregnancy are known to be integral to normal infant development and health in later life, but more recently the central importance of infant nutrition that achieves healthy weight gain has become recognized. in this context, achieving growth patterns for infants that avoid either the onset of obesity or development of stunting during the first 1000 days of life appears to be an achievable goal with significant potential for the avoidance of many ncds in later life. hence the relevance of health promotion initiatives to share this knowledge among health care providers and educate parents on the benefits of optimal infant nutrition. keywords: developmental origins of health and disease; exclusive breast feeding; first 1000 days of life; obesity; stunting. published: 25 september 2024. © 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) editorial the progressive advance of non-communicable diseases (ncds) has resulted in a significant and growing global epidemic which is having devastating health and economic consequences. ncds are chronic diseases and often of long duration; the main forms are type 2 diabetes, cardiovascular diseases that cause high blood pressure, heart attacks and stroke, some types of cancer and respiratory diseases like chronic obstructive pulmonary disease, and asthma (world health organization, 2023). while these are diseases that have an increased incidence in aging populations, many ncds are highly preventable or modifiable, as they result from a combination of genetic, physiological, environmental and behavioral factors, with five major epidemiological risk factors being common: tobacco use, physical inactivity, mailto:ajmacnab@gmail.com https://doi.org/10.35898/ghmj-731003 https://publications.inschool.id/index.php/ghmj/announcement/view/32 https://publications.inschool.id/index.php/ghmj/announcement/view/32 macnab, a.j. ghmj (global health management journal) 2024, vol. 7, no. 3 110 harm from alcohol consumption, poor diet and air pollution. the epidemic of ncds poses devastating health consequences for individuals, families and communities, and threatens to become and unmanageable burden for health systems. worldwide ncds affect an estimated two billion people; low and middle income countries (lmics) bear the biggest burden, with more than three quarters of global ncd deaths occurring in lmics. reducing the burden of ncds is an important investment. in addition to providing better health, improving quality of life and reducing the incidence of premature death, the financial benefit would also be considerable. the extent of health budget expenditure on care for the increasing numbers of patients with type 2 diabetes is an example; these costs are increasing to such an extent that in africa the care for diabetics in the population threatens to consume the whole health care budget in some countries by 2030. another measure of the unchecked rise in ncds on the african continent is that it is estimated that deaths from diabetes will soon be greater than those for malaria. the who has identified several cost-effective, high-impact ncd-related interventions that could save millions of lives in lmics, but headway to improve the situation is poor worldwide, as the necessary measures are either not being implemented or their scale up is inadequate. at the same time, although ncds remain the largest cause of premature death globally, health promotion initiatives and interventions to curb their advance only receive a small proportion of preventive care budgets. there is now clear evidence that a range of adverse early life events can predispose an individual to increased risk of developing ncds in later life, and also that this risk can be passed to future generations. awareness of this form of programming underlies the concepts of the developmental origins of health and disease (dohad), and explains the potential for defined life events to underlie the development of many ncds. dohad concepts focus particularly on the first 1000 days of life and three specific periods. 1) conception (including periconceptual health of the father as well as the mother), 2) pregnancy (particularly maternal nutrition, and vitamin and trace element provision during the first three months when fetal structures are formed) and, 3) infant nutrition up to the end of the second year of life (where the pattern of weight gain should avoid both excessive weight gain, and gradual weight loss leading to stunting of growth). the optimal way to avoid excessive weight gain and stunting is exclusive breastfeeding (ebf) for the first six month of life (yan et al., 2014; horta et al., 2015). ebf is defined as giving infants breast milk only with no additional food or drink, except for the addition of medications, oral rehydration salts and vitamins as needed, and has multiple other well-known benefits for both mother and infant. the adequacy of an infant’s nutritional status is best monitored by plotting weight at regular intervals on a who growth chart. the infant’s weight at birth places her/him on a centile curve and from then on weight gain should follow the curve of that same centile. small babies should not be overfed with the intention of making them grow more quickly, and large babies should not be limited in their calorie intake. excessive weight gain with weight moving upwards across the weight centile predisposes an infant to obesity and an increased risk of being overweight and developing type 2 diabetes in later life. inadequate weight gain and a downward fall across the centiles lead to stunting of growth which predisposes the infant to cardio metabolic effects in adult life, which increase the risk of obesity, diabetes, coronary artery disease, hypertension and stroke. however, it must be recognized, that not every mother who wants to breast feed can do so, and, even for those who can, that a full 6 months of ebf may not be possible. the need to supplement breastfeeding with formula and situations where just formula is fed are also a reality, so, in parallel with promoting ebf and encouraging breastfeeding the need to monitor weight gain in every infant needs to be understood. regardless of how they are fed, it is important to monitor weight gain in all infants so as to avoid any of them becoming either overweight or stunted. importantly, the next generation of parents needs to be the target group for interventions aimed at optimizing health during the first 1000 days of life; hence adolescence is a critical opportunity for health promotion related to prevention of ncds (tohi et al., 2022). while antenatal care, postnatal maternal support and monitoring each infant’s weight gain remain important, focusing health promotion on these phases risks missing important 111 ghmj (global health management journal) 2024, vol. 7, no. 3 macnab, a.j. opportunities during the dohad relevant time periods of preconception and the first three months of fetal growth when a mother may not realize that she is pregnant. so it is important for health care providers, parents and educators to engage with adolescents to promote the future health of their children in anticipation of future conception. school-based programs offer an opportunity to promote health; lifestyles and behaviors likely to break the cycle of ncds, and who has estimated that over a billion children worldwide have the potential to benefit from effective health promotion programs in schools (macnab. 2019). but finding creative ways to educate is necessary because school programs based on facts and approaches that may be clear and obvious to adults will probably be of little interest, or seem to have no obvious relevance, to high school pupils. in a study in africa it was found that facts about the burden of diabetes in adult life or the problem of cost to the health care system were meaningless to teenagers, but, in contrast, there was definite interest in learning dohad-related facts that increased the chances of their future child being healthy (macnab & mukisa, 2018). this was because the prime motivator for future parents wanting to learn more was coming to understand that when they have a healthy child she/he will earn more in their lifetime than someone who is unhealthy. because they are the next generation of parents, adolescents must be considered a priority group for advancing knowledge based on dohad science, and in particular for promoting the benefits of exclusive breast feeding as a way to avoid overweight or stunting in infancy. but, ideally, because of the urgency of the ncd epidemic, a whole community approach will occur where there is a special focus on engaging with adolescents, as this offers most hope for breaking the ncd disease cycle. there is no doubt that the current ncd epidemic is jeopardizing the health, wellbeing and survival of millions of people globally, and in addition, threatens to overwhelm the ability of some countries to provide essential health care for the whole population. consequently, it is now a priority for all of us to seek ways to raise awareness of about ncds, the potential for dohad-related approaches to contribute to breaking the cycle, and work to contribute to local community and national strategies to prevent and control ncds in the future. you can learn more about ncds and initiatives to prevent them or modify their consequences, dohad concepts, the benefits of breastfeeding and school-based programs to promote heath through online updates from the who. references horta, b. l., loret de mola, c., & victora, c. g. (2015). long‐term consequences of breastfeeding on cholesterol, obesity, systolic blood pressure and type 2 diabetes: a systematic review and meta‐analysis. acta paediatrica, 104, 30-37. https://doi.org/10.1111/apa.13133. macnab, a.j. (2019). the stellenbosch consensus statement on health promoting schools. global health promotion. 20(1), 78-81. https://doi.org/10.1177/1757975912464252. macnab, a.j., & mukisa, r. (2018). priorities for african youth to engage in the dohad agenda. journal of developmental origins of health and disease. 9(1), 15-19. https://doi.org/10.1017/s2040174417000423. world health organization. (2023). noncommunicable diseases https://www.who.int/news-room/factsheets/detail/noncommunicable-diseases. tohi, m., bay, j. l., tu’akoi, s., & vickers, m. h. (2022). the developmental origins of health and disease: adolescence as a critical lifecourse period to break the transgenerational cycle of ncds—a narrative review. international journal of environmental research and public health, 19(10), 6024. https://doi.org/10.3390/ijerph19106024. yan, j., liu, l., zhu, y., huang, g., & wang, p. p. (2014). the association between breastfeeding and childhood obesity: a meta-analysis. bmc public health, 14, 1-11. https://doi.org/10.1186/1471-2458-14-1267. cite this article as: macnab, a.j. (2024). non-communicable diseases: opportunities to promote future health during the first 1000 day of life. ghmj (global health management journal), 7(3). 109–111. https://doi.org/10.35898/ghmj-731003 https://doi.org/10.1111/apa.13133 https://doi.org/10.1177/1757975912464252 https://doi.org/10.1017/s2040174417000423 https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases https://doi.org/10.3390/ijerph19106024 https://doi.org/10.1186/1471-2458-14-1267 https://doi.org/10.35898/ghmj-731003 ghmj (global health management journal) 2023, vol. 6, no. 2 indonesian scholars’ alliance open access research article risk factors for severe stunted among children aged 2-5 years with stunting in pontianak city, indonesia linda suwarni1,* , selviana1, vidyastuti1, asrul abdullah1, pranowo adi2 1 faculty of health science, universitas muhammadiyah pontianak, kalimantan barat, indonesia. 2 the national population and family planning board representative of west kalimantan, indonesia. *corresponding author’s email: linda.suwarni@unmuhpnk.ac.id doi: 10.35898/ghmj-62965 abstract background: stunting is still a major public health in developing countries, including indonesia. there are many predictors that might contribute to stunting, including child factors, mother factors, household factors, and community. this study focuses on children and mother level. aims: this study aimed to examine the factors associated with severe stunted among children aged 2 to 5 years old. methods: this study uses primary data in pontianak city, indonesia the data has been collected from january to february 2023. respondents were selected by total sampling method. univariate, bivariate, and multivariate have been done using stata 17. results: the analysis data revealed that 75.98% of children were stunted and 24.20 were severe stunted. the factors including low birth weight and birth interval were found significantly associated with severe stunted, other independent variables did not have a correlation for being severe stunted. conclusion: according to children’s factors and maternal factors, the variables of low birth weight and birth interval were found to correlate with being severe stunted. keywords: stunted; severe stunted; children under five; pontianak city. received: 28 october 2023 reviewed: 6 november 2023 revised: 9 november 2023 accepted: 21 november 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 stunting among children under five years old is a significant public health issue globally, including in indonesia and asian countries (correa, 2022; mengesha et al., 2021). stunting is defined as a condition where a child's height or length is significantly below the average for their age (de onis & branca, 2016). stunting is thought to afflict about one-third of children under five worldwide, with a higher frequency in south asian and sub-saharan african low-resource nations (mengesha et al., 2021). stunting among children under five years old is a significant public health issue in indonesia and asian countries (umar & darajat, 2022). stunting is defined as a child's length or height being below the acceptable standard values for their age (de onis & branca, 2016). in indonesia, 30.8% of children under five experience stunting (umar & darajat, 2022). a number of clusters can be used to group elements related to stunting, such as mailto:linda.suwarni@unmuhpnk.ac.id https://doi.org/10.35898/ghmj-62965 https://orcid.org/0000-0003-0862-4881 suwarni, et.al. ghmj (global health management journal) 2023, vol. 6, no. 2 82 environmental factors, fetal growth restriction and preterm birth, adolescent motherhood and short birth intervals, maternal nutrition and infection, and child nutrition and infection (danaei et al., 2016). it is associated with long-term consequences such as poor cognitive development, increased risk of chronic diseases, and reduced economic productivity (lartey, 2015). understanding the factors related to severe stunting is crucial for developing effective interventions to address this problem. numerous researches conducted in various nations have examined these variables, offering insightful information about the factors that contribute to severe stunting in children under the age of five. according to one nigerian study, severe stunting in children under five was strongly correlated with elements including maternal education, home affluence, and access to improved drinking water sources (akombi et al., 2017). similarly, a study in rwanda identified risk factors for stunting, including household wealth, maternal education, and access to improved sanitation facilities (nshimyiryo et al., 2019). these findings highlight the importance of socioeconomic factors in determining the prevalence of severe stunting. stunting in children under two years old was linked to maternal education, occupation, age at pregnancy, socioeconomic circumstances, and nutritional quality of pregnant women, according to another study done in indonesia (susyani et al., 2022). this suggests that improving maternal education and socioeconomic conditions can play a crucial role in preventing severe stunting in early childhood. according to a study conducted in nepal, stunting and severe stunting in children under the age of five were linked to variables like maternal education, household affluence, and birth problems (tiwari et al., 2014). this highlights the importance of addressing both maternal and environmental factors in preventing severe stunting. the role of maternal factors in stunting was also highlighted in a study conducted in ghana, which found that young maternal age was a risk factor for child undernutrition (wemakor et al., 2018). similarly, a study in ethiopia reported that the quantity, frequency, and type of supplementary feeding, birth weight, sex, birth order, and disease conditions like diarrhea were strongly associated with stunting among under-five children (fikadu et al., 2014). additionally, research from zambia and bangladesh revealed that variables like the child's age and sex, the mother's age and educational attainment, her wealth, the availability of an improved drinking water source, the length of her breastfeeding, and her place of residence were predictive of stunting in children under five (chowdhury et al., 2021; mzumara et al., 2018). these findings emphasize the importance of addressing multiple factors at the individual, household, and community levels to prevent severe stunting. in addition to socioeconomic and maternal factors, other studies have identified specific risk factors for severe stunting. for example, a study in ethiopia found that children from educated and malnourished mothers, as well as those from less wealthy mothers, were more likely to be severely stunted (hailu et al., 2020). according to a different study conducted in rwanda, there is a higher chance of childhood stunting if a child has diarrhea, is male, older than 11 months, has a child impairment, and has two children under five (kalinda et al., 2023). environmental factors, such as sanitation and access to clean water sources, have also been identified as important determinants of severe stunting. a study in zimbabwe highlighted the low micronutrient density and poor protein quality in cereal-based diets as contributing factors to stunting in resource-poor settings (kairiza et al., 2020). similarly, a study conducted in bangladesh discovered a substantial correlation between stunting, wasting, and underweight in children under five and the availability of toilets, drinking water sources, residential locations, and socioeconomic position (chowdhury et al., 2021). in the indonesian context, in order for nations to realize their full potential for productivity, stunting must be reduced, according to the world bank's human capital project. indonesia's goal is to further reduce stunting to 14 percent by 2024. the country's coordinated efforts have reduced stunting rates 83 ghmj (global health management journal) 2023, vol. 6, no. 2 suwarni, et.al. from 31.4 percent in 2018 to 21.6 percent in 2022 (world bank, 2023). government and non-profit organizations are collaborating to establish a program related to reducing the number of stunting among children in indonesia. unicef indonesia reported the double burden of malnutrition as a major program that needs to be solved immediately. in fact, in 2018 3 of 10 children under 5 years were stunted and 1 of 10 were wasted (unicef indonesia, 2023). moreover, an issue of overweight and obesity are also concerning. among children of primary school age, 20% of them are overweight and 15% are obese (unicef indonesia, 2023). furthermore, two million children under 5 years suffer from severe acute malnutrition. in a specific area of pontianak, west kalimantan province, compared to national data, in 2021 the prevalence of stunted children was 24.4% (pemprof kalbar, 2023). according to a study conducted in east nusa tenggara, children's age, mothers' level of education, and living in a rural location are the main causes of stunting (suratri et al., 2023). overall, the factors related to severe stunting among children under 5 years old are multifaceted and include socioeconomic factors, maternal factors, environmental factors, and specific risk factors. addressing these factors requires a comprehensive approach that includes improving maternal education, socioeconomic conditions, access to healthcare services, and environmental sanitation. additionally, interventions should focus on promoting optimal breastfeeding practices, improving the quality and diversity of children's diets, and providing access to clean water sources. by addressing these factors, it is possible to reduce the prevalence of severe stunting and improve the health and well-being of children under 5 years old. this study aimed to explore the risk factors of severe stunted and severe stunted in pontianak city, west kalimantan province, indonesia. 2. methods study design this study used a cross-sectional time frame. the data collection has been done in 10 villages in 6 subdistricts in pontianak city, west kalimantan province where stunting is the focus. those locations such as parit tokaya, benua melayu laut, tambelan sampit, banjar serasan, saigon, tanjung hilir, tanjung hulu, parit mayor, siantan hulu dan sungai jawi. the data was collected during january to february 2023. total sampling was used to select the respondents who were mothers of children aged 2 to 5 years old with diagnosed stunting. the final respondents who completely joined the interview were 687 mothers with children aged 2-5 years old. measurement the dependent variable of this study is nutritional status which has two categories, such as stunted and severe stunted. to define severe stunted, authors used cut-off based on who recommendation length/height-for-age <−3 sd of the median, and stunted used length/height-for-age ≤−2 sd and ≥−3 sd of the median. the independent variable of this study includes the children's level and mother's level. the tool used in this study is a closed questionnaire. statistical techniques data analysis in this study includes univariate, bivariate, and multivariate. univariate was used to describe the general information of respondents that presented in frequency and percentage. bivariate analysis was done using chi-square in order to test each independent variable and dependent variable. multivariate analysis in this study is binary logistic regression because the dependent variable consists of dummy categories. ethical clearance all the analysis was done by using stata 17. this study including instruments and all procedure has been approved by ethical clearance no: 010/kepk-fikes/ um pontianak/ 2023. suwarni, et.al. ghmj (global health management journal) 2023, vol. 6, no. 2 84 3. results the general characteristics of respondents univariate analysis in this study explains the frequency distribution of children with stunting characteristics and the potential predictors. in table 1. among all stunted children, there are 165 of 687 children who were severely stunted (24.20%). according to the birth interval between childbirth and the previous birth, it was revealed that the majority of children were born in intervals of 2 years or more with another birth (73.80%). moreover, the gestation data showed the majority of children were born at enough months of gestation (93.16%). the mother reported that the children were born with enough or more birth weight (83.84%) and enough birth height (55.75%). based on the mother’s history of chronic lack of energy, the mother reported did not have (87.34%). the majority of mothers practiced exclusive breastfeeding (80.20%) and were in age less than 20 years old or more than 35 years old when pregnant (80.35%). furthermore, it also described that most of the mothers had a weight of 150 cm or higher (66.81%), did not have a history of anemia (65.36%), and did not complete all immunizations (56.62%). table 1. the general information of children variables (n=687) frequency percentage stunting severely stunted 165 24.20 stunted 522 75.98 birth interval < 2 years 180 26.20 ≥ 2 years 507 73.80 premature when born yes 47 6.84 no 640 93.16 low birth weight yes 111 16.16 no 576 83.84 birth height < 48 cm 304 44.25 ≥ 48 cm 383 55.75 history of chronic lack of energy yes 87 12.66 no 600 87.34 exclusive breastfeeding yes 136 19.80 no 551 80.20 age when pregnant (year) < 20th or >35th 552 80.35 20-35 135 19.65 mother’s height < 150 cm 228 33.19 ≥ 150 cm 459 66.81 mother’s history of anemia yes 238 34.64 no 449 65.36 complete all immunization no 389 56.62 yes 298 43.38 total 687 100.0 85 ghmj (global health management journal) 2023, vol. 6, no. 2 suwarni, et.al. the correlation between each independent variable and stunted table 2 below shows the result of the chi-square test by bringing each potential predictor associated with severe stunted. it showed that some variables including birth interval, premature birth, low birth weight, and birth height have strong associations (p-value <0.001) with severe stunted. moreover, another variable has a moderate association (p-value <0.01), including exclusive breastfeeding, and a low association (p-value <0.05) including the history of chronic lack of energy. however, some other variables were not significantly associated with nutritional status (p-value>0.05), including age when pregnant, mother’s height, history of anemia, and completeness of immunizations. table 2. the result of bivariate analysis using the chi-square test variables nutritional status p-value severe stunted (%) stunted (%) birth interval < 0.001*** < 2 years 61 (33.89) 119 (66.11) ≥ 2 years 104 (20.51) 403 (79.49) premature when born < 0.001*** yes 27 (57.45) 20 (42.55) no 138 (21.56) 502 (78.44) low birth weight < 0.001*** yes 62 (55.86) 49 (44.14) no 103 (17.88) 473 (82.12) birth height < 0.001*** < 48 cm 95 (31.25) 209 (68.75) ≥ 48 cm 70 (18.28) 313 (81.72) history of chronic lack of energy 0.014* yes 30 (34.48) 57 (65.52) no 135 (22.50) 465 (77.50) exclusive breastfeeding 0.006** yes 45 (33.09) 91 (66.91) no 120 (21.78) 431 (78.22) age when pregnant (year) 0.586 < 20th or >35th 135 (24.46) 417 (75.54) 20-35 30 (22.22) 105 (77.78) mother’s height 0.814 < 150 cm 56 (24.56) 172 (75.44) ≥ 150 cm 109 (23.75) 350 (76.25) mother’s history of anemia 0.730 yes 59 (24.79) 179 (75.21) no 106 (23.61) 343 (76.39) complete all immunization 0.085 no 103 (26.48) 286 (73.52) yes 62 (20.81) 236 (79.19) *p-value <0.05, **p-value <0.001, ***p-value <0.001 multivariate analysis table 3 below describes the result of multivariate analysis using binary logistic regression. it was shown that, after adjusting to all independent variables, compared to children with enough birth weight, the variables of having low birth weight were 4.26 times more likely and strongly associated with severe stunted (p-value <0.001). additionally, compared to children born with 2 year or more birth interval, children born with less than a 2-year birth interval had a 45% increasing probability of having severe stunted. however, after adjusting to all predictors the variables of premature when born, birth height, history of chronic lack of energy, exclusive breastfeeding, age when pregnant, mother’s height, mother’s history of anemia, and completeness of immunizations were found not significantly associated suwarni, et.al. ghmj (global health management journal) 2023, vol. 6, no. 2 86 with having severe stunted (p-value>0.05). table 3. the result of multivariate analysis using binary logistic regression variables aor 95% confidence interval (lower – upper) p-value birth interval (ref: ≥ 2 years) < 2 years 0.55 0.37 – 0.81 0.002** premature when born (ref: no) yes 1.91 0.93 – 3.92 0.080 low birth weight (ref: no) yes 4.26 2.55 – 7.13 0.000*** birth height (ref: ≥ 48 cm) < 48 cm 1.22 0.81 – 1.84 0.334 history of chronic lack of energy (ref: no) yes 1.64 0.95 – 2.84 0.075 exclusive breastfeeding (ref: yes) no 1.51 0.96 – 2.38 0.074 age when pregnant (year) (ref: 20-35) < 20th or >35th 0.68 0.41 – 1.21 0.131 mother’s height (ref: ≥ 150 cm) < 150 cm 0.94 0.63 – 1.41 0.757 mother’s history of anemia (ref: no) yes 0.94 0.63 – 1.41 0.757 complete all immunizations (ref: yes) no 1.33 0.91 – 1.97 0.143 *p-value <0.05, **p-value <0.001, ***p-value <0.001 lr chi2 (10) = 85.73 prob > chi2 = 0.000 pseudo r2 = 0.1132 log likelihood = -335.86 4. discussion according to the result in the previous section, the factors associated with severe stunted was low birth weight and birth interval. this finding was in line with the studies in developing countries (danaei et al., 2016). several factors have been identified as being associated with stunting among children under five years old. fetal growth restriction and preterm delivery, teen pregnancy and short birth intervals, environmental factors, maternal nutrition and infection, and child nutrition and infection are some of the clusters into which these factors might be divided (danaei et al., 2016). maternal nutrition and infection play a crucial role in the development of stunting, as poor maternal nutrition and infections during pregnancy can lead to fetal growth restriction and preterm birth, which are risk factors for stunting (danaei et al., 2016). teenage motherhood and short birth intervals are also associated with stunting, as these factors can lead to inadequate maternal nutrition and care during pregnancy (danaei et al., 2016). child nutrition and infection are important factors in the development of stunting. inadequate nutrition, including insufficient intake of essential nutrients, can contribute to stunting (marume et al., 2023). additionally, frequent infections, such as diarrheal and worm infections, can impair nutrient absorption and utilization, leading to stunting (marume et al., 2023). stunting is also influenced by environmental variables, including hygienic conditions, access to clean water, and cleanliness habits. lack of access to sanitary facilities and clean water can raise the risk of illnesses, which can lead to stunting (shofifah et al., 2022). other factors associated with stunting include low birth weight, low socioeconomic status, inadequate breastfeeding practices, and poor dietary quality (marume et al., 2023). due to its reflection of insufficient fetal growth and development, low birth 87 ghmj (global health management journal) 2023, vol. 6, no. 2 suwarni, et.al. weight is a major risk factor for stunting (marume et al., 2023). socioeconomic factors, such as low income and low maternal education, are also associated with stunting, as they can limit access to nutritious food and healthcare (marume et al., 2023). inadequate breastfeeding practices, including early cessation of breastfeeding and lack of exclusive breastfeeding, can contribute to stunting (marume et al., 2023). poor dietary quality, including insufficient intake of essential nutrients, can also contribute to stunting (marume et al., 2023). stunting has been found to be predicted by a number of child-related characteristics, such as the child's age, length at birth, weight at birth, weight-for-age outcome, breastfeeding status, number of meals, dietary quality, hunger, and presence of worm and diarrheal diseases (marume et al., 2023). maternal factors such as age, education, occupation, and hiv status also play a role in stunting (marume et al., 2023). household and socio-cultural factors, such as income status, access to safe water and toilets, health clubs, and maternal support in infant feeding, are also significant predictors of childhood stunting (marume et al., 2023). additional risk factors for stunting have been found by other research, such as poor levels of education among fathers, maternal heights under 150 cm, high-risk maternal age, low birth weight, and a history of infectious diseases (fikadu et al., 2014; manggala et al., 2018). the consumption of animal-sourced foods, child underweight status, and income type have also been associated with stunting (umwali et al., 2022). it is important to note that stunting has long-term consequences for children's health, well-being, and productivity (correa, 2022). stunted children are more susceptible to infections and are at a higher risk of cognitive, motor, and language impairments (park et al., 2019). stunting also has economic implications, as it can lead to decreased productivity and increased risk of chronic diseases in adulthood (mcgovern et al., 2017; nasser et al., 2022). it is crucial to remember that stunting is a complicated problem affected by a variety of variables, some of which may interact with one another. for instance, fetal growth and development can be impacted by maternal nutrition and infection, which can subsequently have an effect on child nutrition and infection (danaei et al., 2016). additionally, socioeconomic factors can influence access to nutritious food and healthcare, which can in turn affect child nutrition and infection (marume et al., 2023). efforts to reduce stunting should focus on improving maternal nutrition and infection control, promoting optimal child nutrition and reducing the burden of childhood illnesses, and addressing environmental factors such as access to safe water and sanitation (danaei et al., 2016). additionally, interventions targeting household and socio-cultural factors, such as improving income status and maternal support in infant feeding, can also contribute to reducing stunting (marume et al., 2023). in conclusion, stunting among children under five years old in indonesia and asian countries is a complex issue influenced by various factors. this current study revealed the factors such as birth interval and low birth weight are the main risk factors of severe stunted in pontianak city. maternal nutrition and infection, adolescent pregnancy and short intervals between pregnancies, fetal growth restriction, preterm birth, child nutrition and infection, environmental factors, low birth weight, socioeconomic status, breastfeeding practices, and nutritional quality are additional contributors. efforts to address stunting should focus on improving maternal nutrition and healthcare, promoting exclusive breastfeeding, improving access to nutritious food, implementing effective water, sanitation, and hygiene practices, and addressing socioeconomic factors. by addressing these factors comprehensively, it is possible to reduce the prevalence of stunting and improve the health and wellbeing of children in indonesia and asian countries. in conclusion, stunting among children under five years old is a significant public health issue in indonesia and asian countries. numerous elements, such as those pertaining to children, mothers, households, and societies, have an impact on it. efforts to reduce stunting should focus on addressing these factors through interventions that improve maternal and child nutrition, reduce the burden of childhood illnesses, and improve access to safe water and suwarni, et.al. ghmj (global health management journal) 2023, vol. 6, no. 2 88 sanitation. these interventions have the potential to improve the health, well-being, and productivity of children in these countries. 5. conclusion stunting is a major public health issue in developing countries, including indonesia. in high-risk areas of stunting in pontianak city, indonesia it was found 75.98% of children with a high risk of stunting were severe stunted, and 24.20% were stunted. according to children’s factors and maternal factors, the variables of low birth weight and birth interval were found to correlate with being severely stunted. however, other variables observed in this study did not significantly correlated with being severe stunted including premature when born, birth height, history of chronic lack of energy, exclusive breastfeeding, age when pregnant, mother’s height, mother’s history of anemia, and completion of all immunizations. these findings may lead to policy recommendations to encourage women to have at least two years of birth interval and increase intake of nutritious food during pregnancy to prevent low birth weight. all other stakeholders also need to promote and educate women and family members about the prevention of stunting starting from the pregnancy period. conflict of interest the authors declare no conflicts of interest for the results. the authors received financial support from the national research and innovation agency (brin) in collaboration with the education fund management agency (lpdp), to conduct the research. references akombi, b. j., agho, k. e., hall, j. j., merom, d., astell-burt, t., & renzaho, a. m. n. (2017). stunting and severe stunting among children under-5 years in nigeria: a multilevel analysis. bmc pediatrics, 17(1), 15. https://doi.org/10.1186/s12887-016-0770-z chowdhury, m. r. k., khan, h. t. a., mondal, md. n. i., & kabir, r. (2021). socio-demographic risk factors for severe malnutrition in children aged under five among various birth cohorts in bangladesh. journal of biosocial science, 53(4), 590–605. https://doi.org/doi:10.1017/s0021932020000425 correa, p. r. (2022). factors associated with stunting among children 0 to 59 months of age in angola: a crosssectional study using the 2015–2016 demographic and health survey. plos global public health, 2(12), e0000983. danaei, g., andrews, k. g., sudfeld, c. r., fink, g., mccoy, d. c., peet, e., sania, a., smith fawzi, m. c., ezzati, m., & fawzi, w. w. (2016). risk factors for childhood stunting in 137 developing countries: a comparative risk assessment analysis at global, regional, and country levels. plos medicine, 13(11), e1002164. https://doi.org/10.1371/journal.pmed.1002164 de onis, m., & branca, f. (2016). childhood stunting: a global perspective. maternal & child nutrition, 12, 12–26. https://doi.org/10.1111/mcn.12231 fikadu, t., assegid, s., & dube, l. (2014). factors associated with stunting among children of age 24 to 59 months in meskan district, gurage zone, south ethiopia: a case-control study. bmc public health, 14(1), 1–7. https://doi.org/10.1186/1471-2458-14-800 hailu, b. a., bogale, g. g., & beyene, j. (2020). spatial heterogeneity and factors influencing stunting and severe stunting among under-5 children in ethiopia: spatial and multilevel analysis. scientific reports, 10(1), 16427. https://doi.org/10.1038/s41598-020-73572-5 kairiza, t., kembo, g., pallegedara, a., & macheka, l. (2020). the impact of food fortification on stunting in zimbabwe: does gender of the household head matter? nutrition journal, 19(1), 22. https://doi.org/10.1186/s12937-020-00541-z kalinda, c., phri, m., qambayot, m. a., ishimwe, m. c. s., gebremariam, a., bekele, a., & wong, r. (2023). sociodemographic and environmental determinants of under-5 stunting in rwanda: evidence from a multisectoral study. frontiers in public health, 11, 1107300. https://doi.org/10.1186/s12887-016-0770-z https://doi.org/doi:10.1017/s0021932020000425 https://doi.org/10.1371/journal.pmed.1002164 https://doi.org/10.1111/mcn.12231 https://doi.org/10.1186/1471-2458-14-800 https://doi.org/10.1038/s41598-020-73572-5 https://doi.org/10.1186/s12937-020-00541-z 89 ghmj (global health management journal) 2023, vol. 6, no. 2 suwarni, et.al. lartey, a. (2015). what would it take to prevent stunted growth in children in sub-saharan africa? proceedings of the nutrition society, 74(4), 449–453. https://doi.org/doi: 10.1017/s0029665115001688 manggala, a., kenwa, k. w., kenwa, m., sakti, a. a. g. d. p., & sawitri, a. a. (2018). risk factors of stunting in children aged 24-59 months. paediatrica indonesiana, 58(5). https://doi.org/10.14238/pi58.5.2018.205-12 marume, a., archary, m., & mahomed, s. (2023). predictors of stunting among children aged 6–59 months, zimbabwe. public health nutrition, 26(4), 820–833. https://doi.org/doi:10.1017/s1368980023000046 mcgovern, m. e., krishna, a., aguayo, v. m., & subramanian, s. v. (2017). a review of the evidence linking child stunting to economic outcomes. international journal of epidemiology, 46(4), 1171–1191. https://doi.org/10.1093/ije/dyx017 mengesha, a., hailu, s., birhane, m., & belay, m. m. (2021). the prevalence of stunting and associated factors among children under five years of age in southern ethiopia: community based cross-sectional study. annals of global health. https://doi.org/10.5334/aogh.3432 mzumara, b., bwembya, p., halwiindi, h., mugode, r., & banda, j. (2018). factors associated with stunting among children below five years of age in zambia: evidence from the 2014 zambia demographic and health survey. bmc nutrition, 4(1), 51. https://doi.org/10.1186/s40795-018-0260-9 nasser, m. s., akhlaq, a., ali, h., & nasser, d. (2022). evidence linking stunting to economic outcomes in the saarc region: a systematic review. pakistan journal of public health, 12(2), 88–101. nshimyiryo, a., hedt-gauthier, b., mutaganzwa, c., kirk, c. m., beck, k., ndayisaba, a., mubiligi, j., kateera, f., & elkhatib, z. (2019). risk factors for stunting among children under five years: a cross-sectional population-based study in rwanda using the 2015 demographic and health survey. bmc public health, 19(1). https://doi.org/10.1186/s12889-019-6504-z park, j. j. h., harari, o., siden, e., dron, l., zannat, n.-e., singer, j., lester, r. t., thorlund, k., & mills, e. j. (2019). interventions to improve linear growth during complementary feeding period for children aged 6-24 months living in low-and middle-income countries: a systematic review and network meta-analysis. gates open research, 3. https://doi.org/10.12688/gatesopenres.13083.1 pemprof kalbar. (2023). kalbar provinsi pertama tekan stunting melalui pendekatan pelayanan posyandu. shofifah, a., sulistyorini, l., & praveena, s. m. (2022). environmental sanitation at home and history of infection diseases as risk factors for stunting in toddlers in drokilo village, kedungadem district, bojonegoro regency. journal of environmental health, 14(4). https://doi.org/10.20473/jkl.v14i4.2022.289-295 suratri, m. a. l., putro, g., rachmat, b., nurhayati, ristrini, pracoyo, n. e., yulianto, a., suryatma, a., samsudin, m., & raharni. (2023). risk factors for stunting among children under five years in the province of east nusa tenggara (ntt), indonesia. international journal of environmental research and public health, 20(2), 1640. https://doi.org/10.3390/ijerph20021640 susyani, s., febry, f., margarhety, i., sadiq, a., sartono, s., sari, i. p., & ni’mah, t. (2022). maternal risk factor on incidence of stunting in south sumatera. open access macedonian journal of medical sciences, 10(e), 1599– 1604. https://doi.org/10.3889/oamjms.2022.10761 tiwari, r., ausman, l. m., & agho, k. e. (2014). determinants of stunting and severe stunting among under-fives: evidence from the 2011 nepal demographic and health survey. bmc pediatrics, 14(1), 239. https://doi.org/10.1186/1471-2431-14-239 umar, e., & darajat, a. (2022). factors affecting the management of stunting in banten province. kne life sciences, 380–393. umwali, n., kunyanga, c. n., & kaindi, d. w. m. (2022). determinants of stunting in children aged between 6–23 months in musanze region, rwanda. frontiers in nutrition, 9. https://www.frontiersin.org/articles/10.3389/fnut.2022.1044350 unicef indonesia. (2023). tackling the “double burden” of malnutrition in indonesia. wemakor, a., garti, h., azongo, t., garti, h., & atosona, a. (2018). young maternal age is a risk factor for child undernutrition in tamale metropolis, ghana. bmc research notes, 11(1), 877. https://doi.org/10.1186/s13104-018-3980-7 world bank. (2023). stworld bank approves support to expand indonesia’s efforts to reduce childhood stunting. cite this article as: suwarni, l., selviana, s., vidyastuti, v., abdullah a., adi, p. (2023). risk factors for severe stunted among children aged 2-5 years with stunting in pontianak city, indonesia. ghmj (global health management journal), 6(2). 81–89. https://doi.org/10.35898/ghmj-62965 https://doi.org/10.14238/pi58.5.2018.205-12 https://doi.org/doi:10.1017/s1368980023000046 https://doi.org/10.1093/ije/dyx017 https://doi.org/10.5334/aogh.3432 https://doi.org/10.1186/s40795-018-0260-9 https://doi.org/10.1186/s12889-019-6504-z https://doi.org/10.12688/gatesopenres.13083.1 https://doi.org/10.20473/jkl.v14i4.2022.289-295 https://doi.org/10.3390/ijerph20021640 https://doi.org/10.3889/oamjms.2022.10761 https://doi.org/10.1186/1471-2431-14-239 https://www.frontiersin.org/articles/10.3389/fnut.2022.1044350 https://doi.org/10.1186/s13104-018-3980-7 https://doi.org/10.35898/ghmj-62965 https://doi.org/10.35898/ghmj-62965 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. (2013). hubungan riwayat hipertensi pada keluarga dengan aktivitas saraf otonom (relationship between family history of hypertention and autonomic nervous system activity). sains medika, 5(1):8–10. atun, l., siswati, t., and kurdanti, w. (2014). asupan sumber natrium, rasio kalium natrium, aktivitas fisik, dan tekanan darah pasien hipertensi. media gizi mikro indonesia, 6(1). bell, k., twiggs, j., olin, b. r., and date, i. r. (2015). hypertension: the silent killer: updated jnc-8 guideline recommendations. alabama pharmacy association, 334:4222. blaustein, m. p., leenen, f. h., chen, l., golovina, v. a., hamlyn, j. m., pallone, t. l., van huysse, j. w., zhang, j., and wier, w. g. (2011). how nacl raises blood pressure: a new paradigm for the pathogenesis of saltdependent hypertension. american journal of physiology-heart and circulatory physiology, 302(5):h1031– h1049. dinas kesehatan (2016). profil kesehatan kota cirebon (cirebon city health profile in 2016). 144 hamzah a et al. ghmj (global health management journal) 2019, vol. 3, no. 3 green, m. s., jucha, e., and luz, y. (1986). blood pressure in smokers and nonsmokers: epidemiologic findings. american heart journal, 111(5):932–940. gunawan, l. (2007). hipertensi, penyakit tekanan darah tinggi. kanisius. jangid, p., tilwani, k., maheshwari, m., nagal, m., and soni, n. (2015). co-relation of family history of hypertension with hypertension in the young male adults in western rajasthan. indian journal of clinical anatomy and physiology, 2(4):223–225. jiang, s.-z., lu, w., zong, x.-f., ruan, h.-y., and liu, y. (2016). obesity and hypertension. experimental and therapeutic medicine, 12(4):2395–2399. kemenkes ri (2014). hipertensi (hypertension). http://www.depkes.go.id/download.php?file=download/ pusdatin/infodatin/infodatin-hipertensi.pdf. kemenkes ri (2018). hasil utama riset kesehatan dasar tahun 2018 (baseline health research main results 2018). http://www.depkes.go.id/resources/download/info-terkini/materi_rakorpop_2018/ hasil%20riskesdas%202018.pdf. lee, d.-h., ha, m.-h., kim, j.-r., and jacobs jr, d. r. (2001). effects of smoking cessation on changes in blood pressure and incidence of hypertension: a 4-year follow-up study. hypertension, 37(2):194–198. maharani, d. (2014). waspadai hipertensi saat hamil dan menopause (watch out for hypertension during pregnancy and menopaus). https://sains.kompas.com/read/2016/05/18/211900923/waspadai. hipertensi.saat.hamil.dan.menopause. narkiewicz, k., kjeldsen, s. e., and hedner, t. (2005). is smoking a causative factor of hypertension? novitaningtyas, t. (2014). hubungan karakteristik (umur, jenis kelamin, tingkat pendidikan) dan aktivitas fisik dengan tekanan darah pada lansia di kelurahan makamhaji kecamatan kartasura kabupaten sukoharjo. phd thesis, universitas muhammadiyah surakarta. oncken, c. a., white, w. b., cooney, j. l., van kirk, j. r., ahluwalia, j. s., and giacco, s. (2001). impact of smoking cessation on ambulatory blood pressure and heart rate in postmenopausal women. american journal of hypertension, 14(9):942–949. ratulangi, a. j., bodhi, w., manampiring, a., et al. (2016). hubungan tekanan darah dengan obesitas pada remaja obes dan non-obes di kabupaten bolaang mongondouw utara (relationship between obesity and blood pressure in obese and non-obese adolescents in bolaang mongondouw utara district). jurnal kedokteran klinik, 1(1):55–63. semet, g. r., kembuan, m. a., and karema, w. (2016). gambaran pengetahuan stroke pada penderita dan keluarga di rsup prof. dr. rd kandou manado. e-clinic, 4(2). setyanda, y. o. g., sulastri, d., and lestari, y. (2015). hubungan merokok dengan kejadian hipertensi pada laki-laki usia 35-65 tahun di kota padang (the relationship between habits of smoking and the incidence of hypertension in men aged 35-65 years in the city of padang). jurnal kesehatan andalas, 4(2). sofyan, a. m., sihombing, i. y., and hamra, y. (2015). hubungan umur, jenis kelamin, dan hipertensi dengan kejadian stroke. medula, 1(1). sugiharto, a. (2007). faktor-faktor risiko hipertensi grade ii pada masyarakat (studi kasus di kabupaten karanganyar) ((risk factors for grade ii hypertension in the community (study in kabupaten karanganyar)). phd thesis, program pascasarjana universitas diponegoro. sulastri, d., elmatris, e., and ramadhani, r. (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 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 sourcemay 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. (2013). the aluminium content of infant formulas remains too high. bmc pediatrics, 13(1):162, doi: 10.1186/1471-2431-13-162. esch, h. l., kleider, c., scheffler, a., and lehmann, l. (2016). isoflavones: toxicological aspects and efficacy. in nutraceuticals, pages 465–487. elsevier, doi: 10.1016/b978-0-12-802147-7.00034-6. 157 https://dx.doi.org/10.1016/j.anireprosci.2019.02.007 https://dx.doi.org/10.1007/s10545-010-9157-8 https://dx.doi.org/10.1186/1471-2431-10-63 https://dx.doi.org/10.1146/annurev.nutr.24.101603.064950 https://dx.doi.org/10.1186/1471-2431-13-162 https://dx.doi.org/10.1016/b978-0-12-802147-7.00034-6 ghmj (global health management journal) 2019, vol. 3, no. 3 sera ac fsanz (2019a). australia new zealand food standards code – standard 2.9.1 – infant formula products. https: //www.legislation.gov.au/details/f2017c00332. fsanz (2019b). the safe food system. retrieved from food standards australia and new zealand. http://www. foodstandards.gov.au/about/safefoodsystem/pages/default.aspx. gomez, b. g., perez-corona, m. t., and madrid, y. (2016). availability of zinc from infant formula by in vitro methods (solubility and dialyzability) and size-exclusion chromatography coupled to inductively coupled plasma-mass spectrometry. journal of dairy science, 99(12):9405–9414, doi: 10.3168/jds.2016-11405. lucht, j. m. (2015). public acceptance of plant biotechnology and gm crops. viruses, 7(8):4254–4281, doi: 10.3390/v7082819. mccarver, g., bhatia, j., chambers, c., clarke, r., etzel, r., foster, w., hoyer, p., leeder, j. s., peters, j. m., rissman, e., et al. (2011). ntp-cerhr expert panel report on the developmental toxicity of soy infant formula. birth defects research part b: developmental and reproductive toxicology, 92(5):421–468, doi: 10.1002/bdrb.20314. redgrove, j., rodriguez, i., mahadevan-bava, s., and exley, c. (2019). prescription infant formulas are contaminated with aluminium. international journal of environmental research and public health, 16(5):899, doi: 10.3390/ijerph16050899. stallings, v. a., adgent, m. a., umbach, d. a., zemel, b. s., kelly, a., schall, j. i., ford, e. g., james, k., darge, k., botelho, j. c., et al. (2017). soy-based infant formula feeding and impact on estrogen-responsive tissue. the faseb journal, 31(1_supplement):958–2, doi: 10.1096/fasebj.31.1_supplement.958.2. upson, k., harmon, q. e., laughlin-tommaso, s. k., umbach, d. m., and baird, d. d. (2016). soy-based infant formula feeding and heavy menstrual bleeding among young african american women. epidemiology (cambridge, mass.), 27(5):716, doi: 10.1097/ede.0000000000000508. vandenplas, y., castrellon, p. g., rivas, r., gutiérrez, c. j., garcia, l. d., jimenez, j. e., anzo, a., hegar, b., and alarcon, p. (2014). safety of soya-based infant formulas in children. british journal of nutrition, 111(8):1340– 1360, doi: 10.1017/s0007114513003942. westmark, c. j. (2017). soy-based therapeutic baby formulas: testable hypotheses regarding the pros and cons. frontiers in nutrition, 3:59, doi: 10.3389/fnut.2016.00059. yu, j., bi, x., yu, b., and chen, d. (2016). isoflavones: anti-inflammatory benefit and possible caveats. nutrients, 8(6):361, doi: 10.3390/nu8060361. zhu, y., xu, h., li, m., gao, z., huang, j., liu, l., huang, x., and li, y. (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 ghmj (global health management journal) 2023, vol. 6, no. 1 indonesian scholars’ alliance open access research article standard operating procedures of antenatal care and its relation with pregnant women’s satisfaction during pregnancy examination: results of a survey at gamping i public health center, yogyakarta, indonesia hilma triana1,2*, sulistyaningsih2, jumpanata1 and yogi yamani1 1 depati bahrin regional general hospital, bangka regency, indonesia 2 universitas 'aisyiyah yogyakarta, yogyakarta, indonesia *corresponding author’s e-mail: trianahilma@gmail.com doi: 10.35898/ghmj-61927 abstract background: the achievement parameter for maternal health services program is the access of pregnant health services, as indicated by measuring the coverage of antenatal care services. in indonesia, examination of pregnant women according to antenatal standards is regulated by ministry of health indonesia number 21 of 2021, where pregnancy checks must fulfill the standard 10 t criteria. aims: this study aimed to identify the standard operating procedures of antenatal care in gamping i public health center, yogyakarta, indonesia, and determine its relation with pregnant women’s satisfaction during pregnancy examination. methods: of 70 tm iii pregnant women, who routinely visit for antenatal care service at the public health center gamping i, a total of 40 pregnant women were selected using consecutive sampling with 10% margin of error. a set of questionnaires was distributed to the respondents to asses: (1) the implementation of the antenatal care service standard (20 questions, and weighted using a dichotomy scale) and (2) the pregnant women satisfaction (22 questions, and weighted using the likert scale. the data obtained from respondents were then tabulated and processed using microsoft office excel 2010 and then analyzed using the spss statistics 16.0 program (pearson product moment formula with an error rate of 5%). results: there are 10 pregnancy tests (10t) received by the pregnant women at the health center including the measurement of height, weight, blood pressure, upper arm circumference, uterine fundus height, presentation & fetal heart rate, provision of 90 fe tablets, laboratory examinations, case handling, tt immunization screening, and counseling & mental health assessment. according to the findings of the research conducted by the researchers, antenatal examinations were not carried out in a comprehensive and thorough manner in instances. this article provides the women satisfaction to the antennal care on different dimensions of satisfaction including physical proof, reliability, responsiveness, guarantee, and empathy. even though the analysis shows that the respondents was satisfied with the antennal care services; however, the relation is not statistically significant (p-value of 0.652). conclusion : one's satisfaction is very difficult to measure and someone's satisfaction is different from the satisfaction of someone else. according to the findings of the study, every time a midwife performed an antenatal checkup, she had never provided complete 10t-based antenatal care. in addition, this research has been carried out through direct observation of prenatal care, where pregnant women and midwives' perceptions of antenatal care examinations do not differ. keywords: standard operating procedures, antenatal care, satisfaction, pregnancy test received: 24 october 2022; revised: 25 november 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) mailto:trianahilma@gmail.com https://doi.org/10.35898/ghmj-61927 19 ghmj (global health management journal) 2023, vol. 6, no. 1 triana, et. al. 1. introduction pregnancy is one of the targets of reproductive health services, to those requires special attention and gets top priority, because at any time disease can arise that can threaten the life of the mother and the fetus it contains. one effort that can be done is to conduct regular antenatal care checks (ermaya and nugroho, 2015). indicators to illustrate the success of maternal health care programs are the access of pregnant women to health services as measured by the coverage of antenatal services (k1 and k4) (damopolii, kundre and bataha, 2015). according to the world health organization, antenatal care was successfully implemented in every country in the world for 70% of the time. however, in some countries such as those on the african continent, the implementation of antenatal care examinations was still limited 30 percent of the time due to factors such as a lack of facilities, knowledge, and infrastructure(world health organization, 2016). according to the indonesian health profile in 2016, there was a decrease in the k4 coverage in 2016 which was 85.35% compared to 2013 which was 86.85%. despite a decline in 2016, coverage of k4 pregnant women health services in 2016 has met the ministry of health's strategic plan target of 74%. however, there are 9 provinces that have not achieved the target namely north maluku, papua, east nusa tenggara, west papua, jambi, maluku, west sulawesi, southeast sulawesi, and special region of yogyakarta (kementerian kesehatan republik indonesia, 2016). according to the health profile of the special region of yogyakarta in 2016, the coverage of pregnancy checks in the entire yogyakarta area had not reached 100%. according to the sleman district health office, the target of visits to pregnant women at the sleman district health centers should be at least 90%. of the 25 health centers in the district, the gamping i health center has only reached 88% (dinas kesehatan daerah istimewa yogyakarta, 2016). according to regulation of the ministry of health indonesia number 21 of 2021 regarding implementation of health services pre pregnancy, pregnancy, delivery, and postpartum, contraception services, and sexual health services aim to reduce morbidity and mortality rates for mothers and newborns. pregnancy health services are performed at least six times during pregnancy, once in the first trimester, twice in the second trimester, and three times in the third trimester. a doctor or specialist in obstetrics and gynecology performs ultrasound examinations twice once at the beginning of pregnancy and once at the end of pregnancy (kementerian kesehatan republik indonesia, 2021). the pregnancy assessment gave by the service of wellbeing guidelines are equivalent to those in the maternal youngster wellbeing (mch) handbook, where antenatal consideration principles are administrations performed to pregnant ladies by meeting the 10 t models, in particular: 1) take measurements of weight and height; 2) take measurements of blood pressure; 3) take measurements of nutritional status (measuring upper arm circumference); 4) take measurements of the height of the top of the uterus; 5) take measurements of the fetal presentation and the fetal heart rate (fhr); 6) screen for tetanus immunization status and, if necessary, administer tetanus toxoid (tt) immunization; 7) pregnancy-related administration of blood tablets in addition to a minimum of 90 tablets, (8) laboratory tests: tests for pregnancy, blood hemoglobin (hb), blood type (if not already done), and protein levels in the urine (if necessary); the provision of services based on the pregnancy's trimester, management and case management in accordance with authority, and mental health evaluation and counseling (kementerian kesehatan republik indonesia, 2021). the experience of pregnant women in carrying out antenatal care will affect the behavior of mothers in carrying out antenatal care now. impacts of pregnant women who do not carry out antenatal care include the detection of pregnancy abnormalities in the mother, physical abnormalities that occur during delivery are not detected early and can increase mortality and morbidity in pregnant women (hardiani and purwanti, 2015). based on a preliminary study at public health center gamping i on october 24, 2017 with interviews it was found that around 5 pregnant women (50%) said that counseling about pregnancy was too short and 5 pregnant women (50%) said they did not understand good counseling time. out of 10 triana, et. al. ghmj (global health management journal) 2023, vol. 6, no. 1 20 pregnant women (100%) said their examinations did not yet cover minimum antenatal care service standards (10t). it is hoped that in antenatal care examinations, pregnant women can be given comprehensive and maximum service. the purpose of this study was to determine the relationship between the implementation of antenatal care service standards with the satisfaction of pregnant women in antenatal care. 2. methods this research is an analytic survey research, using cross sectional method, following the previous study (sulistyaningsih, 2011). this study has obtained ethical clearance from the ethics commission of aisyiyah university in yogyakarta with letter number: 137 / kep-unisa / iii / 2018 on march 14, 2018. of 70 tm iii pregnant women, who routinely visit for antenatal care service at the public health center gamping i, a total of 40 pregnant women were selected using consecutive sampling (a. hidayat, 2014), and willingly participate to the survey. the study used slovin formula with 10% margin of error to count the required number of respondents. consecutive sampling is the selection of samples met the inclusive criteria defined in the study within a certain period of time (nursalam, 2016). the inclusion criteria were tm iii pregnant women domiciled in the working area of public health center gamping i, tm iii pregnant women who had had pregnancy checks at public health center gamping i, and tm iii pregnant women who could read and write. the exclusion criteria were tm iii pregnant women did not come for a pregnancy check up at the public health center gamping i and tm iii pregnant mothers who were sick, such as dizziness, who could not be respondents of the study. to determine the standard operating procedures of antenatal care and its relation with pregnant women’s satisfaction during pregnancy examination at the gamping i public health center, a set of questionnaires was distributed to the respondents to asses: (1) the implementation of the antenatal care service standard (20 questions, and weighted using a dichotomy scale) and (2) the pregnant women satisfaction (22 questions, and weighted using the likert scale with very satisfied, satisfied, quite satisfied, dissatisfied, and very dissatisfied). the independent and dependent variable was an interval scale. the questionnaire was tested for validity and reliability. the results of the standard antenatal care questionnaire using the formula using split half obtained the reliability coefficient category of 0.905 which means reliable. the analysis used in this study is univariate and bivariate analysis. the data was then analyzed using the pearson product moment formula because the data analyzed came from different sources, with an error rate of 5% (sugiyono, 2014). the analysis technique used is the pearson product moment correlation statistical test, which is a parametric statistical technique that uses interval or ratio data with the condition that the interval or ratio data, the data are normally distributed, and the number of sample data is greater than 30, so this study uses the pearson correlation analysis technique. besides that pearson's product moment analysis technique is the most common analysis technique stable with the smallest error rate (hidayat, 2012). questionnaire data obtained from respondents were then tabulated and processed using the help of microsoft office excel 2010 and the spss statistics 16.0 program. 3. results respondent characteristics univariate analysis in this study explains the frequency distribution of the pregnant women at gamping i public health center includes their age, age of pregnancy, education, profession and number of children. table 1 shows that characteristics of respondents at the highest age is 25-35 years. age is one of the factors that can describe a person's maturity both physically, psychologically and socially, so that at the age of 25-35 years there are many pregnant women because of their reproductive age and are more able to accept their pregnancies than women under the age of 20 or above 35 years , there by 21 ghmj (global health management journal) 2023, vol. 6, no. 1 triana, et. al. increasing women's awareness in maintaining pregnancy (pernanda, 2014). because third trimester pregnant women have at least one pregnancy checkup, third trimester pregnant women have also received 10 t-based antenatal care services correctly, and measuring third trimester pregnant women satisfaction is more valid, the results were compared by measuring the satisfaction of pregnant women in first trimester and second trimester (winarni, 2014). measuring the satisfaction of pregnant women in the implementation of antenatal care must be done with tm iii pregnant women (winarni, 2014). table 1. the general characteristics of the respondents it is known that in rural and urban areas, there is no single wife does not want children. the distribution of families in rural and urban areas based on the number of children desired by families in rural and urban areas is significantly different. the number of children wanted by families living in rural areas is greater than the number of children wanted by families living in urban areas, so that the gamping region is still rural areas so that the highest number of children is 3-4 people with 28 people (oktriyanto, herien puspitawati, 2015). based on the level of education, the level of junior high school education is 5 people. according to research swardhana (2015) secondary education level down affects the ability to understand the information provided by officers, unable to listen to even understand the communication that occurs between officers and patients. as many as 8 people have a bachelor/diploma education so that many pregnant women are very good at understanding and absorbing information provided by health workers (swardhana, 2015). the majority of pregnant women were housewife (65%) whilst the other 30% working in private sectors, and the other 5% working for the government. because one's work will describe the activity and level of economic prosperity that will be obtained, jobs affect one's level of satisfaction. mothers who are employed are more knowledgeable than those who are not. because information has an impact on satisfaction, working mothers will have more opportunities to interact with others and obtain information (lumempouw, kundre and bataha, 2016). standard operating procedures of antenatal care table 2 provides the number of pregnant women participated to each antennal cares for their pregnancy examination namely: weight measurement, blood pressure measurement, uterine fundal height variables (n = 40) n (%) age a. 15-25 years 11 27.5 b. 25-35 years 25 62.5 c. > 35 years 4 10.0 age of pregnancy a. 24-36 week 40 100 number of children a. 0 people 10 25.0 b. 1-2 people 2 50.0 c. 3-4 people 28 70.0 education a. middle school graduate 5 12. 5 b. high school graduate 27 67.5 c. diploma/bachelor 8 20.0 profession a. housewife 26 65.0 b. private employee 12 30.0 c. goverment employee 2 5.00 triana, et. al. ghmj (global health management journal) 2023, vol. 6, no. 1 22 measurement, fetal heart rate & presentation, case management, counseling & mental health assessment, while as many as < 75% tt immunization screening, administration of 90 fe tablets, and laboratory examinations, and as many as 26% or 11 pregnant women underwent upper arm circumference. table 2. implementation of antenatal care service standards in pregnancy test according to the findings of the research conducted by the researchers, antenatal examinations were not carried out in a comprehensive and thorough manner in instances where the previous study (aisyah et al., 2017) found that midwives performed standard 10t examinations on 69.7% of pregnant women in integrated antenatal services in accordance with the other study which found that 43 pregnant women (78.2%) met the 10t anc service standards completely (rakhmah, rosyidah and wulandari, 2021). satisfaction in pregnancy woman the results in table 3 showed that the pregnant women were satisfied with the examination of pregnancy in the physical evidence dimension (tangibles) of 27 (score: 67.5). as many as 31 pregnant women (score: 79.37) were very satisfied with the reliability dimension. a total of 26 pregnant women were satisfied with the midwife's responsiveness for antenatal care services based on 10 t (score: 66.25). additionally, 26 pregnant women were satisfied (score: 66.25), with the assurance dimensions, and 25 pregnant women were satisfied (score: 62) with the empathy aspects that midwives provided when conducting antenatal care service checks. table 3. pregnancy satisfaction in pregnancy tests based on satisfaction dimensions the results showed that the pregnant women were satisfied with the examination of pregnancy in the physical evidence dimension (tangibles) of 27 (67.5%). pregnant women feel satisfied with the statements 1, 2, 3 and 4 only in the statement of the unavailability of a smoke-free room as many as 16 people (40%) said they were not satisfied with the comfort of the waiting room at the maternal and child health poly. no. 10 t frequency (n=40) percentage % 1. height measurement 34 85.0 weight measurement 40 100.0 2. blood pressure measurement 40 100.0 3. upper arm circumference measurement 11 27.5 4. uterin fundus height measurement 40 100.0 5. presentation & fetal heart rate 40 100.0 6. tt immunization screening 8 20.0 7. provision of 90 fe tablets 36 90.0 8. laboratory examinations 38 95.0 9. case handling 40 100.0 10. counseling & mental health assessment 40 100.0 no. dimensions of satisfaction satisfaction scores category 1 physical proof 67.5 satisfied 2 reliability 79.37 very satisfied 3 responsiveness 66.25 satisfied 4 guarantee 67.5 satisfied 5 empathy 62.5 satisfied 23 ghmj (global health management journal) 2023, vol. 6, no. 1 triana, et. al. physical evidence such as uncomfortable waiting rooms and inappropriate services makes them dissatisfied with the services provided, so that it will affect the satisfaction of pregnant women during pregnancy checks (aini and andari, 2016). the description of the reliability aspect which was divided into 4 items statement, that 31 people (79.37%) expressed very satisfied with all statements in the aspect of reliability, where the midwife's skills in providing antenatal care services were very good according to research with the tittle analysis of factors influencing the implementation of 10 t given by midwives to pregnant women in medan marelan district, that the midwife's work experience factor in providing midwifery practice services over 3 years can perform her midwifery practice well in the 10 t examination of pregnant women (panjaitan, 2014). in the aspect of responsiveness which is divided into 4 statements as many as 26 people (66.25%) expressed satisfaction with the midwife's responsiveness to antenatal care services based on 10 t according to the theory health promotion for midwifery, if midwives have a role and provide services that are both in antenatal care can make pregnant women feel that midwives have competence in carrying out antenatal care (mubarak, 2011). assurance aspects midwives must provide comfort in pregnancy examinations because if a midwife provides comfort during antenatal care, it will improve the quality of antenatal care services and the more quality antenatal care services, the more pregnant women will check their pregnancies in health services (rahayu, lina dwi puji, dyah fajarsari, 2015). the aspect of empathy must also be possessed by midwives, in conducting antenatal care service checks, because if midwives have good empathy in providing antenatal care services, more and more pregnant women who are exposed to tuberculosis will have their pregnancy checked at local health services. the dimensions of empathy greatly affect a pregnant woman in checking her pregnancy, the better the empathy of a midwife provides, the more satisfied a pregnant woman is in receiving antenatal care services (oktavia, 2017). from the research on the satisfaction of pregnant women with antenatal care services at women and children hospital in south okkalapa, myanmar, the satisfaction of pregnant women on several service group indicators consisting of general facilities, general services, registration services and providers' services, it was found that as many as 69 pregnant women (48%) out of 125 pregnant women had a high satisfaction score, while pregnant women were satisfied with general service consisting of ultrasound service examination, laboratory service, drug supply, process of antenatal care procedure and low satisfaction score is 70 (56.0%). satisfaction of pregnant women with general facilities, namely 27.2% and low satisfaction pregnant women score 72.8% and mother satisfaction with the registration service, only 36 pregnant women were very satisfied with the service and as many as 89 (71.2%) pregnant women were dissatisfied with the service (hsai et al., 2020). sop of antenatal care and pregnant women’s satisfactory in pregnancy examination from the statistical analysis we conducted, it is noted that the hypothesis is rejected because the pearson product moment correlation test yielded statistical results with a p-value of 0.652, which is greater than the level of error (p> 0.05). as a result, it is possible to draw the conclusion that pregnant women's satisfaction with antenatal care is unrelated to the application of antenatal care standards. this is in line with previous studies defining the relationship between midwifery services and patient satisfaction in the public health center in soreang, bandung, which indicates that there is no relationship between pregnancy services and patient satisfaction (p-value of 0.796). age and the training that midwives receive have the greatest impact on pregnancy services. additionally, there is a negative correlation between waiting times for laboratory and physical examinations, with patients receiving fewer physical examination services from midwives the longer the waiting period. there is no connection between pregnancy services and patient satisfaction (faozi, wijaya and sukanda, 2022). triana, et. al. ghmj (global health management journal) 2023, vol. 6, no. 1 24 figure 1. scatter plot of antenatal care sop and pregnant women’s satisfactory (kepuasan) in pregnancy tests this study also does not align with the other study which found a relationship between the quality of antenatal care services and the level of satisfaction of pregnant women due to antenatal care services (rahayu, lina dwi puji, dyah fajarsari, 2015). according to do et al., examination basic of 10 t based research has been carried out exceptionally well, with 93% applied at public health center gamping i there is no correlation between the level of satisfaction experienced by pregnant women at public health center gamping i during pregnancy checks and the implementation of standards for antenatal care services. this is due to the fact that satisfaction is subjective and difficult to quantify. 4. discussion measurements of height, weight, blood pressure, upper arm circumference, uterine fundus height, presentation and fetal heart rate, tt immunization screening, administration of 90 fe tablets, laboratory examination, case handling, and mental health counseling and assessment are included in the standard of antenatal care in indonesia, according to regulation of the minister of health of the republic of indonesia number 21 of 2021(kementerian kesehatan republik indonesia, 2021). in africa the standard of antenatal care according to the department of health republic of south africa are more complicated which not only measuring the weight, height, heart rate, colour of mucous membranes, and blood pressure; but also, to check for edema, and palpation for lymph nodes. some systemic examinations are also included such as teeth and gums, breasts, thyroid, and heart and lung examination. pregnancy examination also includes inspecting the palpation of the pregnant uterus, with measurement of the symphysis-fundal height (sfh) in centimeter, palpation, and ultrasound and the measurement of mid-upper arm circumference (departement health republic of south africa, 2016). at each antenatal visit, pregnant women receive essential screening tests, including hiv serology, tb screening for both hiv positive and hiv negative women, syphilis serology, rhesus (d) blood group and haemoglobin (hb) level, and protein and glucose dipstick testing in their urine. pregnancy-related medications and vaccines include ferrous sulfate (200 mg) tablets for anemia prevention and calcium (1000 mg) tablets for preeclampsia complications, such as calcium carbonate (168 mg), taken orally twice 25 ghmj (global health management journal) 2023, vol. 6, no. 1 triana, et. al. daily with food. this should be taken four hours before or after iron supplements, folic acid tablets containing five milligrams per day, and tetanus toxoid (tt) vaccination (departement health republic of south africa, 2016). meanwhile in the australian government department of health in clinical practice guidelines pregnancy care 2020 get clinical assessment is discuss conception and date of last menstrual period and offer ultrasound scan for gestational age assessment (carried out between 8 and 14 weeks of pregnancy), measure height and weight and calculate body mass index and provide advice on appropriate weight gain, measure blood pressure, test for proteinuria, delay auscultation of fetal heart until after 12 weeks gestation if using a doppler and 28 weeks gestation if using doppler or a pinard stethoscope, assess risk of preterm birth and provide advice on risk and protective factors, administer the epds at this visit or as early as practical in pregnancy and ask questions about psychosocial factors that affect mental health (australian government department of health, 2020). meanwhile, the clinical practice guidelines for pregnancy care 2020 published by the australian government department of health clinical evaluation includes talking about conception and the timing of your last period. it also includes offering an ultrasound scan for gestational age assessment (done between 8 and 14 weeks of pregnancy), taking your height and weight, calculating your bmi, giving you advice on how much weight to gain, taking your blood pressure, checking for proteinuria, and delaying the auscultation of the fetal heart until after 12 weeks if using a doppler and until 28 weeks if using a pinard stethoscope. maternal health testing gets check blood group and antibodies, full blood count and haemoglobin concentration and consider testing ferritin, testing for hiv, hepatitis b, hepatitis c, rubella non-immunity, syphilis, and asymptomatic bacteriuria, offer testing for gonorrhoea and chlamydia, trichomoniasis, cytomegalovirus testing, thyroid, testing for vitamin d deficiency if there is a specific indication, testing for chromosomal anomalies and get advise women about measures to avoid toxoplasmosis or cytomegalovirus infection, also pregnant women in australia get specific vaccinations including influenza and pertussis (australian government department of health, 2020). when testing for maternal health, blood groups, antibodies, a complete blood count, hemoglobin concentration, ferritin, hiv, hepatitis b, hepatitis c, rubella non-immunity, syphilis, and asymptomatic bacteriuria are checked. offer testing for gonorrhoea, chlamydia, trichomoniasis, cytomegalovirus, thyroid, testing for chromosomal abnormalities, vitamin d deficiency if there is a specific indication, and advice on how to prevent toxoplasmosis and cytomegalovirus infection. pregnant women in australia also receive specific vaccinations, such as those for influenza and pertussis (australian government department of health, 2020). each country has regulations in antenatal examination. the standard of antenatal care in indonesia is almost the same as the regulation in south africa. in prenatal check-ups in indonesia, africa and australia, everything is the same in prenatal check-ups, all of which are carried out such as checks to measure height, weight, check the upper arm circumference, measure blood pressure, check the height of the uterine fundus, ultrasonography. differences in prenatal care in australia, pregnant women get a complete examination compared to indonesia and south africa. in australia, pregnant women receive complete laboratory tests and receive influenza and pertussis vaccines, while in indonesia and south africa only get tetanus toxoid immunization for pregnant women. in the research results of researchers there is no relationship antenatal care sop and pregnant women’s satisfactory in pregnancy examination, this is in line with research (faozi, wijaya and sukanda, 2022) with the titte relationship between midwifery services and patient satisfaction in the public health center in soreang, bandung, p-value of 0.796 indicates that there is no relationship between pregnancy services and patient satisfaction. according to the findings of these researchers, there is no correlation between antenatal care sop and pregnant women's satisfactory in pregnancy examination. with the titte relationship between triana, et. al. ghmj (global health management journal) 2023, vol. 6, no. 1 26 midwifery services and patient satisfaction in the public health center in soreang, bandung, a p-value of 0.796 indicates that there is no relationship between pregnancy services and patient satisfaction (faozi, wijaya and sukanda, 2022). this is additionally in accordance with research with the title on nature of antenatal consideration and client satisfaction in kenya and namibia that the nature of antenatal consideration administrations gave in kenya and namibia is now great yet the fulfillment of pregnant ladies in kenya and namibia is exceptionally poor because of need wellbeing data, low schooling and view of pregnant ladies fulfillment of pregnant ladies relies upon every individual itself. where it is very difficult to measure one's happiness and where one person's happiness differs from another person's happiness (do et al., 2017). a measure of service quality is how well the level of service is tailored to the patient's preferences. if the health care they receive meets or exceeds their expectations, patients will be satisfied, and vice versa. if the quality of the health services they receive falls short of their expectations, they will experience feelings of dissatisfaction or disappointment. from the results of the research, where every antenatal care examination, midwives have never carried out a comprehensive 10t-based antenatal care that has been stipulated in health ministry regulation no. 21 of 2021. 5. conclusion because one's level of contentment differs from that of others and is difficult to quantify, there is no correlation between the two. because it is subjective and difficult to measure, a person's satisfaction is subjective because everyone always has desires that they want to fulfill. however, once a person is satisfied, other desires will appear, and each person has unique feelings of satisfaction and characteristics that indicate that he is satisfied. according to the findings of the study, every time a midwife performed an antenatal checkup, she had never provided complete 10t-based antenatal care. in addition, this research has been carried out through direct observation of prenatal care, where pregnant women and midwives' perceptions of antenatal care examinations do not differ. conflict of interest there is no conflict of interest. nothing to disclosure. references aini, y. and andari, e. (2016) 'analisis kualitas pelayanan terhadap kepuasan pasien berobat di puskesmas pembantu desa pasir utama', 5(1), pp. 81-88. https://doi.org/10.30736/jpim.v1i1.2 australian government department of health (2020) clinical practice guidelines: pregnancy care. australia. damopolii, t.a.j., kundre, r. and bataha, y. (2015) 'hubungan standar pelayanan antenatal care dan kebijakan program pelayanan antenatal care dengan pengetahuan antenatal care terintegrasi di wilayah kerja puskesmas gogaman kota', e-journal keperawatan (ekp), 3. departement health republic of south africa (2016) guidelines for maternity care in south africa. south africa. dinas kesehatan daerah istimewa yogyakarta (2016) profil kesehatan daerah istimewa yogyakarta tahun 2016. do, m. et al. (2017) 'quality of antenatal care and client satisfaction in kenya and namibia', international journal for quality in health care, 29(2), pp. 183-193. available at: https://doi.org/10.1093/intqhc/mzx001 ermaya, n. and nugroho, d. (2015) 'pengaruh motivasi dan persepsi pelayanan terhadp keteraturan antenatal care pada ibu hamil di puskesmas ngemplak simongan kota semarang pada tri wulan i tahun 2015', 3(april). faozi, b.f., wijaya, m. and sukanda, h. (2022) 'relationship characteristic of midwife in pregnancy services and patient satisfaction in public health center, soreang, bandung', jurnal ners dan kebidanan indonesia, 10(1), pp. 48-54. https://doi.org/10.21927/jnki.2022.10(1).48-54 https://doi.org/10.30736/jpim.v1i1.2 https://doi.org/10.1093/intqhc/mzx001 https://doi.org/10.21927/jnki.2022.10(1).48-54 27 ghmj (global health management journal) 2023, vol. 6, no. 1 triana, et. al. hardiani, r.s. and purwanti, a. (2015) 'motivasi dan kepatuhan kunjungan anc pada ibu hamil trimester iii', keperawatan, 3, pp. 183-188. hidayat, a. (2012) uji pearson product moment dan asumsi klasik". jakarta: statistikan. hidayat, a.a.a. (2014) metode penelitian kebidanan dan teknik analisis data. jakarta: salemba medika. hsai, n.m. et al. (2020) 'satisfaction of pregnant women with antenatal care services at women and children hospital in south okkalapa, myanmar: a facility-based cross-sectional study triangulated with qualitative study', national library of medicine, 14, pp. 2489-2499. https://doi.org/10.2147/ppa.s266916 kementerian kesehatan republik indonesia (2016) profil kesehatan indonesia. kementerian kesehatan republik indonesia (2021) peraturan kementerian kesehatan no 21 tahun 2021 tentang penyelenggaraan pelayanan kesehatan masa sebelum hamil, masa hamil, persalinan, dan masa sesudah melahirkan, pelayanan kontrasepsi, dan pelayanan kesehatan seksual. jakarta. lumempouw, v.j.., kundre, r.m. and bataha, y. (2016) 'hubungan faktor sosial ekonomi ibu hamil dengan keteraturan pemeriksaan antenatal care (anc) di puskesmas ranotana weru kecamatan wanea kota manado', e-journal keperawatan (e-kp), 4(november), pp. 1-7. mubarak, w. (2011) promosi kesehatan untuk kebidanan. jakarta: salemba medika. nursalam (2016) metodologi penelitian ilmu keperawatan pendekatan praktis. edisi 4. jakarta: salemba medika. oktavia, e. (2017) 'peran bidan dalam antenatal care meningkatkan tindakan pencegahan tuberkulosis pada ibu hamil', public health perspective journal, 1(1), pp. 1-11. oktriyanto, herien puspitawati, i.m. (2015) 'nilai anak dan jumlah anak yang diinginkan pasangan usia subur di wilayah perdesaan dan perkotaan', jur. ilm. kel. & kons, 8(1), pp. 1-9. https://doi.org/10.24156/jikk.2015.8.1.1 panjaitan, m. (2014) 'analisis faktor-faktor yang mempengaruhi pelaksanaa 10 t yang diberikan bidan pada ibu hamil di kecamatan medan marelan'. pernanda, y.& d.r. (2014) 'hubungan persepsi pasien tentang mutu pelayanan antenatal dengan status k4 pada ibu hamil trimester iii di puskesmas wirobrajan', jikmu, 5(1), pp. 1-15. rahayu, lina dwi puji, dyah fajarsari, & s.m. (2015) 'hubungan kualitas pelayanan antenatal care (anc) dengan tingkat kepuasan ibu hamil di puskesmas karanganyar kabupaten purbalingga', jurnal ilmiah kebidanan, 6(2), pp. 106-115. rakhmah, k., rosyidah, h. and wulandari, r.c.l. (2021) 'hubungan standar pelayanan antenatal care (anc) 10 t dengan kepuasan ibu hamil di wilayah kerja puskesmas tlogosari kulon kota semarang', jurnal link, 17(1), pp. 43-22. available at: http://ejournal.poltekkes-smg.ac.id/ojs/index.php/link. https://doi.org/10.31983/link.v17i1.6683 sugiyono, p.d. (2014) metode penelitian kuantitatif kualitatif dan r & d. bandung: penerbit alfabeta. sulistyaningsih (2011) metodologi penelitian kebidanan (kuantitatif-kualitatif). edisi pert. yogyakarta: graha ilmu. swardhana (2015) pengaruh kinerja perawat terhadap kepuasan pasien pengguna kartu jamkesmas dalam pelayanan keperawatan di rsud cengkareng, jakarta barat. universitas esa unggul. winarni (2014) 'kepuasan ibu hamil terhadap pelayanan antenatal care (anc) oleh bidan di wilayah kerja puskesmas ngoresan', gaster, vol 11, no(2). world health organization (2016) 'who recommendation on antenatal care for positive pregnancy experience', world health organization. cite this article as: triana, h., sulistyaningsih, s., jumpanata, j., & yamani, y. (2023). standard operating procedures of antenatal care and its relation with pregnant women’s satisfaction during pregnancy examination: results of a survey at gamping i public health center, yogyakarta, indonesia. ghmj (global health management journal), 6(1), 18–27. https://doi.org/10.35898/ghmj-61927 https://doi.org/10.2147/ppa.s266916 https://doi.org/10.24156/jikk.2015.8.1.1 http://ejournal.poltekkes-smg.ac.id/ojs/index.php/link https://doi.org/10.31983/link.v17i1.6683 https://doi.org/10.35898/ghmj-61927 ghmj (global health management journal) 2024, vol. 7, no. 2 indonesian scholars’ alliance open access research article mothers’ parenting patterns on stunting cases in toddlers: a case from cirebon health center, west java, indonesia eni suhaeni*, salman nur azmii, siti maria ulfah, tiar masykuroh pratamawati faculty of medicine, universitas swadaya gunung jati, cirebon, indonesia. *corresponding author’s email: eni.suhaeni@ugj.ac.id doi: 10.35898/ghmj-72968 abstract background: a recent survey conducted in 2021 noted a high stunting incident was found in cirebon, west java of indonesia, reached to 30.6%, even higher compare to the provincial rate (24.5%). it has been known that parenting patterns and nutritional status are greatly influenced by the mother's understanding of managing health and nutrition for their baby in order to lower the stunting case. aims: this study is to analyze the association between mother's parenting patterns and stunting in toddlers age 24-48 month in cirebon municipality. methods: a total of 68 mothers have been selected using the consecutive sampling from a health facility in cirebon city, indonesia. this research uses survey and descriptive methods with a quantitative approach to examine the impact of mother's parenting patterns on stunting incidence in toddlers aged 24-48 months. this research also uses secondary data in the form of kia (mother and child health) records to identify the stunting cases among the respondents. statistical analysis was employed to find how significant the variables affecting to the others. results: from the questionnaire, it was found that the majority of participants were mothers aged 26-35 years old, and only graduated from high school or lower, and most of them were not working mothers. the stunting incidence found in this health center reached to 58.8 %. while only 36.8% of mothers exhibits well parenting pattern, the majority may show sufficient level (52.9%). even only 10.3% of respondents correspond with low parenting pattern, however all of them found with stunting incidence. from statistical analysis, it is noted that mothers’ parenting pattern significantly affecting stunting cases in toddlers (p value = 0.001). conclusion: this recent study concludes that parenting pattern significantly contributes to the number of stunting cases in toddler aged 24-48 months. the statistical analysis found mothers with well parenting pattern lower chance of having a stunted child. the data highlights the importance of knowledge and attitude will benefit in reducing the total number of stunted children in cirebon city, indonesia. keywords: parenting pattern; stunting; mothers; toddlers; indonesia. received: 09 november 2023, reviewed: 19 november 2023, revised: 06 january 2024, accepted: 03 june 2024. © 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:eni.suhaeni@ugj.ac.id https://doi.org/10.35898/ghmj-72968 https://orcid.org/0000-0002-2844-9307 49 ghmj (global health management journal) 2024, vol. 7, no. 2 suhaeni, et.al. 1. introduction based on world health organization (who)’s definition, stunting is characterized by a child's impaired growth and development due to several factors including nutritional intake, infections, or insufficient stimulation. the ministry of health of indonesia defines stunting as when a child under five has height-for-age, weight-for-age, and heightfor-body-weight z-score values of less than -2 sd (stunted) and less than -3 sd (severely stunted). fitriani & darmawi (2022) describe that children under two years old (baduta) with stunting may have a suboptimal level of intelligence. the short-term impacts of stunting may include effects on intelligence, physical growth, and metabolic health. in the long term, stunting can lead to decreased cognitive abilities, lower learning achievement, and compromised immunity leading to increased susceptibility to illnesses, and a higher risk of cardiovascular diseases, cancer, stroke, and disabilities in old age (pratiwi, masrul, & yerizel, 2016). according to who estimates on the prevalence of stunted toddlers, up to 22%, or over 149.2 million toddlers worldwide, were stunted in 2020. a survey conducted by the indonesian nutrition status study (ssgi), the stunting rate in indonesia in 2022 reached 21.6%. looking to the national data, it is important to look deep to the situation in the study area, where it is found in 2021 the stunting rate in cirebon city reached to 30.6%, even higher compare to the stunting rate in west java (24.5%). in 2022, the cirebon official website estimated the stunting rate in kesambi district reached the third highest in the cirebon municipality, reaching 429 cases of stunting (ministry of health, 2018). parenting pattern is one of the dominant factors that cause stunting indirectly. parenting patterns and nutritional status are greatly influenced by the mother's understanding of managing health and nutrition in her family. education is needed to change behavior that can lead to improved healthy nutrition for mothers and children (rosuliana, 2022). the parenting pattern given by the mother to the child is related to the state of health (both physical and mental), nutritional status, education, knowledge and skills of roles in the family, and the mother's customs. health status is one aspect of parenting that can influence children's nutritional status to improve (bella et al., 2020). the causes of stunting include toddlers with a history of low birth weight, history of infectious diseases, parenting patterns regarding nutrition, exclusive provision of breast milk, availability of food and clothing, parental education, culture, and economics. behavior related to inadequate or bad parenting can also cause stunting specifically the mother's lack of knowledge about fulfilling her nutrition during pregnancy, and even the nutritional preparations that must be fulfilled when preparing for pregnancy and after giving birth to increase good breast milk production (noorhasanah, 2021). the first thousand days of birth are the golden period, namely the critical period in growth and development. lack of attention from parents, especially mothers, during this critical period resulted in failure of optimal growth and development which will carry over into adulthood permanently. if the breastfeeding pattern is not correct or complementary breast milk food (mp-asi) does not meet the body's nutritional needs, the baby will experience growth problems. as age increases, nutritional intake is lower than requirements, and the high burden of infectious diseases in early life means that the majority of babies in indonesia continue to experience a decline in nutritional status with a peak decline at approximately 24-48 months of age (herianti & elwindra, 2017). it becomes very important to study and analyze the association between mother's parenting patterns and stunting in toddlers age 24-48 month in cirebon municipality. 2. methods study design this research uses survey and descriptive methods with a quantitative approach to examine the impact of mother's parenting patterns on stunting incidence in toddlers aged 24-48 months. drajat health center of cirebon city, west java, indonesia, was selected since it has been considered with high stunting rate compared with the provincial rate. this study has been ethically approved by the ethic committee of faculty of medicine, universitas swadaya gunung jati, following the seven who standards, with number no.14/ec/fkugj/v/2023, on may 15th, 2023. suhaeni, et.al. , et.al. ghmj (global health management journal) 2024, vol. 7, no. 2 50 population and samples this research was conducted in april-june 2023 in the drajat community health center area, cirebon municipality. respondents in the research sample were mothers with toddlers aged 24-48 months, had a kia (mother and child health) record, residence of the drajat cirebon community health center area, and selected using consecutive sampling technique. measurement the data was carried out by researchers using a set of questionnaire distributed to the mother that met the criteria. the children with stunting were measured the height based on the age. respondents’ characteristics have been documented. this study observes the parenting pattern among the respondents, and measured the relationship with the stunting cases in the sampling location. data collection the respondents’ characteristics and parenting pattern among the participated parents were collected using questionnaire. the data was then analyzed statistically using univariate and bivariate analysis with spearman test. this research also uses secondary data in the form of kia (mother and child health) records to identify the stunting cases among the respondents. research data collection was carried out after obtaining a letter of ethical approval from the research ethics commission of the faculty of medicine swadaya gunung jati university. analysis data the research results are presented in the form of a textual table. statistical analysis used univariate and bivariate analysis with spearman test. validity and reliability testing using spss is declared valid with result >0.63. the theories presented led to reflective indicators being used in this study. 3. results the number of respondents taken was 68 respondents using the consecutive sampling method who met the inclusion and exclusion criteria. the characteristics of the respondents in this study were described based on age, highest level of education, and occupation. the data used in this research is primary data obtained directly by researchers through questionnaires. the questions in the questionnaire have been tested for validity and reliability. with valid results for all question items and reliable reliability results (alpha coefficient value 0.877). table 1. frequency distribution of respondent characteristics variables n % age 17-25 years old 6 8.8 26-35 years old 46 67.6 36-45 years old 15 22.1 46-55 years old 1 1.5 mother’s education sd (elementary school) 7 10.3 smp (junior high) 9 13.2 sma/smk (senior high) 51 75.0 s1(bachelor’s degree) 1 1.5 mother’s occupation housewife 50 73.5 entrepreneur 9 13.2 employee 9 13.2 total 68 100.0 index: n = number, % = percentage based on table 1, it states that the most respondents were in the 26-35 year age group, namely 46 respondents (67.6%), while the fewest were in the 46-55 year age group, namely 1 respondent (1.5%) there was 1 respondent (1.5%) aged 46-55 years. based on the mother's education, it was found that the majority of mothers' last education was sma/smk, 51 respondents (75.0%), and there were 7 respondents (10.3%) whose last education was elementary school. based on maternal occupation, it was found that the majority of mothers' occupation was as a housewife, 50 respondents (75.3%). 51 ghmj (global health management journal) 2024, vol. 7, no. 2 suhaeni, et.al. table 2. parenting pattern frequency distribution parenting pattern f % well 25 36.8 sufficient 36 52.9 low 7 10.3 total 68 100.0 index: f = frequency, % = percentage based on table 2, it shows that the frequency distribution of respondents with good maternal parenting patterns was 25 respondents (36.8%). there were 7 respondents (10.3%) who had poor parenting patterns, while the majority of parents have sufficient parenting patterns (52.9%). table 3. stunting frequency distribution stunting f % stunting 40 58.8 normal 28 41.2 total 68 100 index: f = frequency, % = percentage based on table 3, it shows the frequency distribution of stunting incidents in children under five in the drajat community health center area, with the stunting category there were 40 respondents (58.8%). there were 28 respondents in the normal category (41.2%). table 4. cross-tabulation between parenting pattern and stunting stunting total pvalue stunting normal parenting pattern well n 9 16 25 0.001 % 36.0 64.0 100 sufficient n 24 12 36 % 66.7 33.3 100 low n 7 0 7 % 100 0.0 100 total n 40 28 68 % 58.8 41.2 100 table 4 shows that, of the 25 respondents with good parenting patterns there are 9 cases of stunting (36%) with stunting nutritional status. among the 36 respondents with sufficient parenting patterns, there were 24 stunting incidents (66.7%). this study notes that all parents with deficient parenting pattern, it was found with stunting incidents (100%). the results of the spearman test shows a significance value (p-value) of 0.001, which shows that statistically there is a relationship between parenting patterns and the incidence of stunting in toddlers aged 24-48 months in the drajat community health center area. 4. discussion the results of this research analysis show that there were 25 respondents (36.8%) who had good parenting patterns whilst there are 7 poor parenting patterns (10.3%). this shows that there are still poor parenting patterns given by mothers to their toddlers in the cirebon’s local community. from this study, it is noted that half of respondents in the drajat community health center area recorded with sufficient parenting pattern (52.9%). parenting pattern is the care given by parents or other caregivers in the form of attitudes and behavior in terms of closeness to the child, feeding, caring for, maintaining cleanliness, giving affection, and so on. this parenting interaction is good communication and all actions that support the creation of closeness between mother and child. with sufficient or even full time given by the mother to her toddler, it will provide a sense of suhaeni, et.al. , et.al. ghmj (global health management journal) 2024, vol. 7, no. 2 52 comfort and good attention from the mother, thereby supporting efforts to maintain the toddler's health and nutritional status. a close, intimate, and harmonious relationship between parents and children (toddlers) is an absolute requirement to ensure harmonious growth and development, physical, mental, and psychosocial. mothers who provide good psychosocial stimulation to children have a positive effect on the child's nutritional status. parenting patterns are one of the indirect factors that support the achievement of good status for children under five (rusdi & mariyona, 2019). this is in line with research conducted by bella et al (2020) which concluded that there is a significant relationship between feeding habits and stunting incidents. providing food in a good and healthy way by controlling the portion of food consumed will improve the nutritional status of children. good food for children must meet the requirements for adequate energy and nutrients according to age, a balanced menu pattern with available food ingredients, the child's eating habits and tastes, food forms and portions adapted to the child's condition and paying attention to personal and environmental hygiene (bella et al., 2020). additionally, it is noted that that mothers’ knowledge on causes and preventions of diarrhea will significantly reduce the diarrhea incidence rate to their under-five children (lwin & putra, 2018) a cross sectional study with 100 mothers in the a local health center in cirebon city found that education, working status and knowledge were significantly related with nutritional status of infants aged 6 to 24 months (alfiana, pratiwi, & sanif, 2019). the majority of mothers in the cirebon local community were housewife only graduated from high school or lower. a qualitative study conducted by bakara and fikawati (2018) among mothers with 0-6 months infants in a district health center found that early age mother may not receive a complete early breast feeding (efb) knowledge and significantly having lack of knowledge on exclusive breastfeeding and low perception of insufficient breast milk. it becomes important since a significant relationship was found between exclusive breastfeeding and the incidence of stunting (pratama & irwandi, 2021). it is noted that families that implement bad parenting habits (poor parenting patterns) have a 9 times chance of having bad nutritional status. parenting patterns are important in the child's growth and development process. one of the factors that influence a child's growth and development is the presence of psychosocial factors which include important things in a child's life, namely the importance of stimulation in parenting. a good parenting pattern is an illustration of the child's positive interaction with the main caregiver (mother) which plays a role in the child's emotional and psychological development, thereby creating normal child development. the role of parents as early as possible is to establish a sense of security in their children. this is realized through physical and psychological contact from the time the child is born until the process of growth and development. lack of parental love in the first years has a negative impact on children's growth and development physically, mentally and emotionally (bella et al., 2020). the results of this study based on measurements of nutritional status, namely weight, height, and bmi of toddlers, showed that the incidence of stunting was 40 cases (58.8%). this shows that the prevalence of stunting in the drajat community health center, cirebon city, remains a public health problem. this is in accordance with the indonesian ministry of health's report which states that indonesia placed the third highest country in the world and the highest country in southeast asia for the prevalence of stunting. the average prevalence of stunted toddlers in indonesia in 2005-2017 was 36.4%. the prevalence of stunting under five in indonesia in 2016 was 27.5% and increased by 29.6% in 2017. according to the indonesian nutrition status study (ssgi) in 2022, the stunting rate in indonesia in 2022 reached 21.6 % (ministry of health, 2018). stunting is a serious health problem because it is associated with the risk of morbidity and death and suboptimal brain development in children. stunting threatens the development of the nation's next generation, thereby reducing a nation's productive capacity in the future (bappenas, 2017). if not handled properly, stunting will become a risk factor for increased mortality rates, cognitive abilities, low motor development, and even imbalance in body functions. apart from that, stunting is also associated with an increased risk of decreased intellectual abilities, and productivity and an increased risk of degenerative diseases in the future. children with stunting will tend to be more susceptible to infectious diseases, thereby increasing the risk of experiencing a decline in the quality of learning. the results of this research are in line with research by rosuliana et al (2022), which showed that there was a significant relationship between maternal parenting in terms of feeding and cases of stunting in children aged 12-59 months at one of the bima regency health centers. another research conducted by bella et al (2020) showed that the proportion of stunting under-five children in poor families in palembang city was 29%. there is a significant relationship between feeding habits, parenting habits, hygiene habits, and habits of getting health services and the incidence of toddler stunting. another study conducted by noorhasanah et al (2021), showed results that as many as 55.7% of respondents with poor parenting patterns had short and very short children and there was a relationship between maternal parenting patterns and the incidence of stunting in children aged 1259 months (bella et al., 2020; noorhasanah, 2021; rosuliana, 2022). 53 ghmj (global health management journal) 2024, vol. 7, no. 2 suhaeni, et.al. the results of this research analysis also show that there are 7 toddlers experiencing poor parenting patterns and 7 (100.0%) of these toddlers have stunting. the parenting pattern applied by the mother will affect the growth and development of toddlers because malnutrition during the toddler years will be irreversible (cannot be returned), so during the toddler year’s quality food intake is needed to prevent stunting. the better the parenting pattern, the better the nutritional status of the child (bella et al., 2020; pratiwi, masrul, & yerizel, 2016). parenting pattern plays important role in toddlers’ nutritional status, including family's ability to provide time, attention and support to meet the physical, mental and social needs of children growing in the family. parenting patterns for children are applied in several ways, for example providing breast milk and quality complementary foods, psychosocial stimulation, environmental hygiene and sanitation practices, caring for children when they are sick, in this case health practices at home and patterns of seeking health services. this study found that bad parenting pattern significantly affecting the stunting incidence in cirebon where high number of stunting cases was measured. if we try to draw how exclusive breastfeeding has been implemented in indonesia, it is still far from expectations. nationally, the coverage of babies receiving exclusive breastfeeding in 2017 was 61.33%. however, this figure has not reached the exclusive breastfeeding coverage target set by the government, namely 80%. this is due to the lack of public knowledge regarding the importance of exclusive breastfeeding, babies who are given additional food before the age of 6 months and lack of nutrition from breastfeeding mothers so that breast milk production decreases. in this study, we found that the lack of exclusive breastfeeding strongly correlated with the variable maternal parenting patterns, and moderately related with the incidence of stunting. mothers who apply a democratic parenting pattern will give their children the opportunity to choose the food they like, but still supervise them. democratic parenting is considered the most ideal parenting pattern, especially for toddlers who are experiencing a period of growth and development. having discussions among parents regarding eating will play an effective role in controlling children's nutritional intake because parents pay attention to nutritional needs and balance, this causes children's growth to be ideal and the risk of stunting or other nutritional problems can be reduced (unicef, 2019). it should be noted also that information sharing by the family and the support to the mothers are very essential to the mothers in providing adequate nutrition for their babies (tiasna & astuti, 2017). future research can examine other determinants affecting stunting incidents, including external and internal factors. not only low birth weight, future studies need to cover the birth interval since this factor also significantly related with severe stunting incidence (suwarni et. al., 2023). 5. conclusion this recent study concludes that parenting pattern significantly contributes to the number of stunting cases in toddler aged 24-48 months. the statistical analysis found mothers with well parenting pattern lower chance of having a stunted child. the data highlights the importance of knowledge and attitude will benefit in reducing the total number of stunted children in cirebon city. conflict of interest the authors declare no conflicts of interest for the results. references alfiana, d., pratiwi, w., & sanif, m. e. (2019). the correlation between education, work, and maternal knowledge on complementary feeding with 6-24 months' nutritional status. in proceedings of the international conference on applied science and health (no. 4, pp. 157-162). https://publications.inschool.id/index.php/icash/article/view/629 bakara, s. m., & fikawati, s. (2018). perceived insufficient milk (pim) among mothers of 0-6 months infants in cipayung health centre, depok indonesia: a qualitative study. in proceedings of the international conference on applied science and health (no. 3, pp. 143-148). https://publications.inschool.id/index.php/icash/article/view/767 bappenas. (2017). laporan baseline sdg tentang anak-anak di indonesia. kementerian perencanaan pembangunan nasional (bappenas) dan united nations children’s fund, 1–105. https://www.unicef.org/indonesia/id/sdg_baseline_report.pdf bella, f. d., fajar, n. a., & misnaniarti, m. (2020). hubungan pola asuh dengan kejadian stunting balita dari keluarga miskin di kota palembang. jurnal gizi indonesia, 8(1), 31. https://doi.org/10.14710/jgi.8.1.31-39 fitriani, f., & darmawi, d. (2022). hubungan pengetahuan dan sikap ibu dengan kejadian stunting pada balita di desa arongan kecamatan kuala pesisir kabupaten nagan raya. jurnal biology education, 10(1), 23–32. https://doi.org/10.32672/jbe.v10i1.4114 herianti, f., & elwindra. (2017). analisis faktor risiko kejadian stunting pada anak balita di wilayah puskesmas kelurahan cipinang melayu jakarta timur. persada husada indonesia, 4(14), 74–83. http://jurnal.stikesphi.ac.id/index.php/kesehatan/article/view/132 https://publications.inschool.id/index.php/icash/article/view/629 https://publications.inschool.id/index.php/icash/article/view/767 https://www.unicef.org/indonesia/id/sdg_baseline_report.pdf https://doi.org/10.14710/jgi.8.1.31-39 https://doi.org/10.32672/jbe.v10i1.4114 http://jurnal.stikesphi.ac.id/index.php/kesehatan/article/view/132 suhaeni, et.al. , et.al. ghmj (global health management journal) 2024, vol. 7, no. 2 54 lwin, k. z., & putra, i. g. n. e. (2018). mothers' knowledge of the causes and prevention associated with diarrhea among under-five children in hlaing thar yar township, yangon, myanmar. ghmj (global health management journal), 2(3), 7683. https://doi.org/10.35898/ghmj-23559. ministry of health, i. (2018). basic health research 2018. ministry of health, indonesia, 53(9), 1689–1699. noorhasanah, e. (2021). hubungan pola asuh ibu dengan kejadian stunting anak usia 12-59 bulan. jurnal ilmu keperawatan anak, 4(1), 37–42. https://doi.org/10.32584/jika.v4i1.959 pratama, m. r., & irwandi, s. (2021). hubungan pemberian asi eksklusif dengan stunting di puskesmas hinai kiri, kecamatan secanggang, kabupaten langkat. jurnal kedokteran stm (sains dan teknologi medik), 4(1), 17–25. https://doi.org/10.30743/stm.v4i1.65 pratiwi, d.t., masrul, m., & yerizel, e. (2016). hubungan pola asuh ibu dengan status gizi balita di wilayah kerja puskesmas belimbing kota padang. jurnal kesehatan andalas, 5(3), 661–665. https://doi.org/10.25077/jka.v5i3.595 rosuliana, n. e. (2022). hubungan pola asuh ibu dengan kasus stunting pada anak usia 12-59 bulan. jurnal ilmu kesehatan masyarakat, 10(8.5.2017), 2003–2005. rusdi, p. h. n., & mariyona, k. (2019). hubungan pola asuh terhadap kejadian stunting pada balita. jurnal kesehatan, 12(2), 693– 698. suwarni, l., selviana, s., vidyastuti, v., abdullah, a., & adi, p. (2023). risk factors for severe stunted among children aged 2-5 years with stunting in pontianak city, indonesia. ghmj (global health management journal), 6(2), 81-89. https://doi.org/10.35898/ghmj-62965 tiasna, a., & astuti, d. a. (2017). the relationship between family supports towards the early complementary feeding for 0-6 months babies in public health center, sewon i bantul, indonesia. in proceedings of the international conference on applied science and health (no. 1, pp. 310-316). https://publications.inschool.id/index.php/icash/article/view/851 unicef. (2019). regional report on nutrition security in asean. in regional report on nutrition security in asean (vol. 2). cite this article as: suhaeni, e., azmii, s.n., ulfah, s.m., & pratamawati, t.m. (2024). mothers’ parenting patterns on stunting cases in toddlers: a case from cirebon health center, west java, indonesia. ghmj (global health management journal), 7(2). 48–54. https://doi.org/10.35898/ghmj-72968 https://doi.org/10.35898/ghmj-23559 https://doi.org/10.32584/jika.v4i1.959 https://doi.org/10.30743/stm.v4i1.65 https://doi.org/10.25077/jka.v5i3.595 https://doi.org/10.35898/ghmj-62965 https://publications.inschool.id/index.php/icash/article/view/851 https://doi.org/10.35898/ghmj-72968 knowledge, attitudes, and hiv/aids risk behaviors of myanmar migrant workers in thailand ghmj (global health management journal) 2023, vol. 6, no. 2 indonesian scholars’ alliance open access review perceived of survivors, families, and health professionals on the recovery process of schizophrenia in indonesia: a scoping review efri widianti 1,* , nur oktavia hidayati 1 , imas rafiyah 1 , indra kusumah 2 1 department of mental health nursing, faculty of nursing, universitas padjadjaran, bandung, indonesia. 2 faculty of psychology, universitas mercu buana, jakarta, indonesia. *corresponding author’s email: efri.widianti@unpad.ac.id doi: 10.35898/ghmj-62975 abstract background: the recovery process of people with schizophrenia in indonesia is still not optimal. the lack of success in the recovery process is indicated by the relapse rate in people with schizophrenia, which is still high. aims: this literature review aims to describe the views of ods, families, and health workers in the ods recovery process in indonesia. methods: a literature search was carried out using google scholar and also the databases pubmed and cinahl with the keywords schizophrenia or psychosis and family or caregiver or relatives or care or spouse or sibling or parents and psychiatrist and mental health nurse and mental health professionals and perspective or perceived and recovery and indonesia with free-full text criteria in english and indonesian, and publication time has no limitations. results: based on a literature review of 13 articles, different views were obtained between survivors, families, and mental health professionals. conclusion: the results of these findings recommend that mental health policymakers consider the views of survivors, families, and health workers regarding recovery in survivors to produce appropriate strategies to help survivors achieve a state of recovery. keywords: perceptions; recovery process; schizophrenia; survivors; indonesia. received: 21 november 2023, revised: 21 december 2023, accepted: 25 december 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 mental disorders are syndromes of individual behavioral patterns related to distress or impairment in one or more critical human functions, including psychological, behavioral, and biological functions, and these disorders have an impact on social life (yusuf et al., 2015). symptoms that appear in mental disorders can include hallucinations, illusions, delusions, disturbances in thought processes thinking abilities, and abnormal behavior such as aggressiveness or catatonia. mental disorders can become https://orcid.org/0000-0002-3525-9157 https://orcid.org/0000-0003-2325-2385 https://orcid.org/0000-0002-2699-4926 https://orcid.org/0000-0002-3525-9157 https://orcid.org/0000-0003-2325-2385 https://orcid.org/0000-0002-2699-4926 https://orcid.org/0000-0002-3525-9157 https://orcid.org/0000-0003-2325-2385 https://orcid.org/0000-0002-2699-4926 https://orcid.org/0000-0002-3525-9157 https://orcid.org/0000-0003-2325-2385 https://orcid.org/0000-0002-2699-4926 https://orcid.org/0000-0002-3525-9157 https://orcid.org/0000-0003-2325-2385 https://orcid.org/0000-0002-2699-4926 mailto:efri.widianti@unpad.ac.id https://doi.org/10.35898/ghmj-62975 https://orcid.org/0000-0002-3525-9157 https://orcid.org/0000-0003-2325-2385 https://orcid.org/0000-0002-2699-4926 https://orcid.org/0000-0002-3525-9157 https://orcid.org/0000-0003-2325-2385 https://orcid.org/0000-0002-2699-4926 https://orcid.org/0000-0002-3525-9157 https://orcid.org/0000-0003-2325-2385 https://orcid.org/0000-0002-2699-4926 https://orcid.org/0000-0002-3525-9157 https://orcid.org/0000-0003-2325-2385 https://orcid.org/0000-0002-2699-4926 91 ghmj (global health management journal) 2023, vol. 6, no. 2 widianti, et.al. severe, known as schizophrenia (horan & green, 2019). schizophrenia is a psychotic disorder characterized by significant thoughts, emotions, and behavior disturbances. schizophrenia is a major psychiatric disorder characterized by changes in a person's perceptions, thoughts, affects, and behavior (sari & subandi, 2021; astuti et al., 2020). based on the world mental health report (2016), the number of people with schizophrenia worldwide has reached 24 million people or around 1 in 200 adults (aged 20 years and over). meanwhile, in indonesia, cases of schizophrenia increase every year. based on riskesdas 2018, the prevalence of households with art for the mental disorder schizophrenia or psychosis is 6.7 per mile, which means there are 6-7 households with art for the mental disorder schizophrenia or psychosis per 1000 households. this figure has increased more than three times compared to the 2013 riskesdas results, which were 1.7 per 1,000 households (kementrian kesehatan ri, 2019). schizophrenia impacts behavior and conditions that disturb the patient, other people, and the environment (kurniawan et al., 2021). schizophrenia is a complex mental health condition that can be effectively treated with somatic therapy. somatic therapy includes antipsychotic medication, psychosocial therapy, and hospitalization when necessary. with the right treatment, individuals living with schizophrenia can experience significant improvements in their symptoms and quality of life (asher et al., 2017). other research states that the family can carry out medical and non-medical treatment (suryani, hidayah, et al., 2019). obtain an explanation of the causes of the illness and also ways to overcome it (bachtiar et al., 2020). the recovery process for schizophrenia survivors requires a collaborative role between various parties, including family and mental health professionals (hidayah et al., 2022). the debate about the recovery process for schizophrenia survivors is still developing. the recovery process is defined as how individuals with mental health challenges regain and develop significant relationships with their family, friends, community, and themselves to overcome the harmful effects of stigma (apostolopoulou et al., 2020). however, riskesdas's (2013) data shows that as many as 1,655 households with schizophrenia still use shackling methods, which means that the stigma is still strong in society. other research shows that shackling of schizophrenic patients is carried out due to ignorance on the part of the family, shame on the part of the family, mental disorders that do not heal, there is no cost for treatment, and the purpose of shackling is to protect odgj so that acts of violence do not occur (puspitosari et al., 2019). based on the background above, researchers are interested in conducting a scoping review regarding the picture of recovery in people with schizophrenia in indonesia based on the views of the survivors, their families, and mental health professionals. 2. methods this review uses a scoping review approach design. a scoping review aims to identify and map existing research literature (munn et al., 2018). the author has searched for relevant articles regarding the recovery of schizophrenia patients in indonesia. during the process, the author used several keywords, namely schizophrenia or psychosis and family or caregiver or relatives or carer or spouse or sibling or parents and psychiatrist and mental health nurse and mental health professionals and perspective or perceived and recovery and indonesia. the search used two electronic databases, pubmed and cinahl, and one search engine, google scholar. inclusion criteria for this study include free-text articles in english and indonesian, excluding articles in the form of literature reviews, people diagnosed with schizophrenia, publication time has no restrictions, and articles discussing how schizophrenia patients recover in indonesia. widianti, et.al. ghmj (global health management journal) 2023, vol. 6, no. 2 92 figure 1. prisma flow chart the selection process uses prisma flow diagram 2020 according to the guidelines. the search results are in a diagram in figure 1, which depicts the article selection process based on keywords, titles, content, and inclusion criteria for research articles. apart from that, the selection was based on whether there was duplication or not in the literature found, resulting in 13 articles that met the requirements. data was manually extracted from selected papers and organized in a table with columns for author and publication year following its number of sample, research methods, and results. 3. results thirteen articles were found based on the selection criteria to explore the perceptions of schizophrenia survivors, their families, and health professionals in indonesia about the recovery process. out of the 13 articles, six discussed the experiences of schizophrenia survivors regarding their recovery process, seven explained the views of their families about the recovery process, and three discussed the opinions of mental health professionals on it. the details of the literature search for schizophrenia recovery can be seen in the table below: records identified from*: pubmed (n = 8 ) cinahl (n = 3 ) google scholar (n = 6840) total (n= 6851) records removed before screening: duplicate records removed (n = 1 ) records marked as ineligible by automation tools (n = 6521) records screened (n = 330) records excluded** (n = 315 ) reports sought for retrieval (n = 15 ) reports not retrieved (n = 2) reports assessed for eligibility (n = 13 ) studies included in review (n = 13 ) identification of studies via databases and registers id e n ti fi ca ti o n s cr e e n in g in cl u d e d 93 ghmj (global health management journal) 2023, vol. 6, no. 2 widianti, et.al. table 1. results of scoping review to the perceptions of schizophrenia survivors, their families, and health professionals in indonesia about the recovery process health provider: psychiatric nurse, mental health nurse, and healthcare professionals halimah wenny yulina astuti, murti agustin, sri padma sari, diyan yyuli wijayanti, widodo sarjana, rozzana c. locsin (2020) this study aims to investigate the impact of mindfulness on hope and recovery in individuals diagnosed with schizophrenia. quasiexperimental 54 patients diagnosed with schizophrenia at an indonesian mental hospital there is a significant difference in expectations and recovery rates between the two groups, with a p-value of less than 0.001. this study indicates that mindfulness is an effective strategy. fandro armando tasigawa, suryani,titin sutini, dan sinthia rosanti maelissa (2021) mental health nurses' perspectives on recovery from schizophrenia will be explored. phenomenology study eight mental health nurse after conducting the research, we identified five main themes that emerged, which include:  treating patients with a personal touch, as if they were family members.  ambiguity surrounding the term "recovery," with multiple interpretations.  treatment being viewed as the primary solution, but also as the primary issue.  recovery being associated with mental hospitals.  ineffective mental health programs. mamnuah, intansari nurjannah, yayi suryo prabandari and carla raymondalexas marchira (2019) to describe health professionals' perceptions of recovery in schizophrenia survivors qualitative the study involved 12 healthcare professionals including 2 psychiatrists, 2 psychologists, 2 nurses, 2 doctors from the community health center, 2 social workers, and 2 officials from the yogyakarta province health service. the research results identified four themes, namely: definition of recovery, types of recovery, characteristics of recovery, and differences in perceptions about recovery. recovery is defined as returning to a previous condition, which includes physical, psychological, social, economic, and spiritual aspects. survivor sri padma sari, murti agustin, diyan yuli wijayanti, widodo sarjana, umi afrikhah, kwisoon choe (2021) this study investigates the mediating role of hope and the moderating effect of depression on recovery in individuals with schizophrenia. crosssectional design this refers to a group of 115 individuals who have been diagnosed with schizophrenia and are from central java province, indonesia. depression moderated the relationship between hope and recovery, and hope mediated the relationship between depression and recovery. tegu pribadi, esther c-l lin, posee chen, shih-kai lee, reziki fitryasari, chih hsuan chen (2020) to assess the levels of internalized stigma and related factors among individuals with a diagnosis of schizophrenia in indonesia. survey cross sectional study 300 patients between the ages of 18 and 60 diagnosed with schizophrenia at an indonesian mental hospital in a study, it was found that almost one-third of the participants experienced moderate-tosevere levels of internalized stigma, with discrimination being the most significant type. further analysis using multivariable ordinal logistic regression revealed that younger age, unemployment, and psychotic symptoms were risk factors for internalized stigma. widianti, et.al. ghmj (global health management journal) 2023, vol. 6, no. 2 94 survivor (cont.) i dewa gede candra dharma; ahsan; retno lestari (2022) to explore and understand the meaning of life for schizophrenia survivors. qualitative, phenomenology study there are five individuals who have survived schizophrenia and they are currently residing at rumah berdaya denpasar. the study identified eight main themes, which were: feeling cared for by others, being accepted by society, having a positive selfidentity, the role of ngayah in the recovery process, the importance of exploring one's abilities, recovering oneself, enjoying active socializing, and situations that affect one's abilities. the results indicate that these themes play a crucial role in mental health and wellbeing. suryani suryani, nurul hidayah, titin sutini, lilibeth al-kofahy (2022) the purpose of this study is to describe the important aspects of the recovery process of indonesian people living with schizophrenia. an exploratory study seven survivors who participated in the fgd were selected using purposive sampling technique. five themes arose from this study including becoming an agent of recovery, accepting yourself as you are, keeping a smile in all situations, seeking god’s help as a way to get well, and ignoring by the government. family retno lestari, ah yusuf, rachmat hargono, febri endra budi setyawan, ridhoyanti hidayah, ahsan ahsan (2021) to explore the experiences of rural residents in adapting to pws in indonesia qualitative research design dan interpretive phenomenologic al approach ten family members most of the participants believed that pws induced alertness rather than fear. furthermore, they mentioned that they were wary of similar situations and stressed the importance of preserving traditional beliefs and practices. participants also highlighted the effectiveness of displaying indifference and combining traditional and modern health practices as suggested by spiritual leaders. watari budiono, kevin kantono, franciscus cahyo kristianto, christina avanti, fauna herawati (2021) to compare the standard mental health care for schizophrenia in indonesia with psychoeducationenriched care for family members and investigate the family and patient parameters. rct 64 family members compared to the control group, the intervention group showed significant improvements in their perception of illness as well as a decrease in expressed emotion among family members. patients in the intervention group also demonstrated a significant improvement in medication adherence (p < 0.001), but only if their family members were part of the intervention group. analysis using partial least-squares path modeling revealed that patients with family members who had low expressed emotion had higher medication adherence (β = −0.718; p < 0.001). herlin ferliana, nyoman anita, damayanti, diana nurfarida aisyah, nuh huda, dwi ernawati (2020) this study aims to investigate the relationship between knowledge, perceptions, attitudes, support, and family independence in caring for patients with hebephrenic schizophrenia. correlational analytic design with cross sectional approach 57 family members this research highlights the significance of family support in enhancing the self-esteem of patients diagnosed with schizophrenia. consequently, it is anticipated that the hospital can enhance its patient recovery program that is centered around families. 95 ghmj (global health management journal) 2023, vol. 6, no. 2 widianti, et.al. family (cont.) marthoenis, marion c aichberger, meryam sch ouler ocak (2016) to identify treatment seeking patterns and factors causing delays in psychiatric care access for early psychosis patients. qualitative 16 relatives of patients with schizophrenia and psychological distress are accompanying them in mental hospitals. in many villages, mental disorders are believed to be related to a sickness or disease, commonly known as "village sickness". therefore, families tend to take their loved ones to traditional healers before seeking help from mental health professionals. this can delay access to psychiatric treatment. several factors contribute to this delay, such as misinformation or incorrect beliefs about the causes of mental illness, stigmatization, the role of extended family, financial problems, and long distances to psychiatric hospitals. many families believe that it is essential for educated individuals to live closer to health facilities, to have prior experience with successful psychotic therapy, and for mental health awareness campaigns to be conducted in their communities. service user and families herni susanti, karen james, bagus utomo, budi anna keliat et al (2019) to gather feedback on the use and potential of patient and public involvement (ppi) in mental health services in indonesia, we aim to survey service users, families/ guardians. qualitative involved 22 service users and 21 families who had previous experience with utilizing psychosis services, or were primary caregivers of individuals receiving such services. the respondents believe that ppi could be valuable in mental health services in indonesia, but only if individual contexts are taken into consideration. they expressed a desire to be more involved in holistic care, but they felt that community organizations were better suited for this because ppi is more in line with the ethos of third-sector organizations. survivor and their families subandi m.a. (2015) to find out the recovery process for the first episode of psychosis in a javanese cultural atmosphere qualitative seven psychosis patients and their families in the javanese culture, recovery is a process that can be divided into three phases. first, the "rise" phase, which involves increasing one's insight. second, the "effort" phase, which involves striving to achieve recovery. and third, the "rukun" phase, which involves harmonious integration with family and society. participants in this process described their recovery in terms of physical movement, progressing from being confined to their homes to larger spaces with family and community. this enabled patients to achieve social recovery. 4. discussion the schizophrenia survivors’ perceptions people with schizophrenia often experience delusions and hallucinations, as well as symptoms of depression. the study by sari et al., (2021) highlights the importance of hope in the recovery of patients with schizophrenia. patients who maintain a hopeful attitude towards recovery are more likely to experience a speedy and successful recovery, as well as a reduction in depression, due to their desire to return to their normal activities. meanwhile, a study by pribadi et al., (2020) found that one-third of 300 patients diagnosed with schizophrenia experienced moderate to severe levels of internalized stigma, which increases the likelihood of discrimination against them. risk factors for discrimination widianti, et.al. ghmj (global health management journal) 2023, vol. 6, no. 2 96 include younger age, unemployment, and psychotic symptoms (pribadi et al., 2020). therefore, nurses need intervention regarding stigma management and psychoeducation for people diagnosed with schizophrenia and their caregivers, such as family or the surrounding community. research by dharma et al., (2022) demonstrates that individuals with schizophrenia can achieve recovery, improving self-awareness, emotional control, and socialization. healing is closely related to eliminating stigma in society. so, the patient needs to be accepted back by society, namely social recovery. according to singla et al., (2020), people with schizophrenia may view recovery as a goal to reintegrate into society. this recent sco perception: (1) to maintain a hopeful attitude towards recovery, (2) the acceptance to society, namely social recovery, and (3) need stigma management and psychoeducation. family views on schizophrenia recovery schizophrenia patients rely heavily on the support of their family members. involving the family in the recovery process is crucial as the patient will interact with them. this is supported by research conducted by ferliana et al., (2020), which highlights the importance of family support in boosting the self-esteem of patients with schizophrenia. to facilitate the recovery of schizophrenic patients, family members should be included in the program, equipping them with the knowledge and skills necessary to provide care and support for their loved ones, while also promoting their independence. according to research conducted by lestari et al., (2021) families still tend to resort to shackling patients with schizophrenia. in most cases, a local shaman or balian is responsible for the treatment of the patient. however, it has been found that a combination of modern and traditional therapies is more effective for the recovery of schizophrenia patients. on the other hand, another study indicates that psychoeducation provided by mental health professionals is critical for the families of such patients (budiono et al., 2021). psychoeducation involves watching videos for two weeks on topics such as introduction to schizophrenia, stigma surrounding it, therapy options, expressing emotions, challenges faced by families, and understanding the patient's mood status. health professionals' views on the recovery of individuals with schizophrenia survivors according to a research study by tasijawa et al., (2021), schizophrenic patients face difficulties in recovery. the study also found that mental nurses show sincerity, willingness and make sacrifices in caring for the patients. they treat the patients wholeheartedly and consider them like their own brothers. however, the findings suggest that the patients view recovery as an unrealistic hope. several studies have shown that nurses can impede the recovery process of patients due to their lack of understanding and negative attitudes towards recovery. suryani et al., (2019) supports this finding, while shean, (2009) suggests that healthcare professionals should adopt an optimistic approach towards their patients' recovery and help them lead productive and meaningful lives. van langen et al., (2016) also highlight the importance of nurses recognizing and preventing patient relapses, empowering patients and their families, and being a good friend for patients to share their experiences openly. a study conducted by mamnuah et al., (2019) in indonesia revealed differing perspectives among healthcare workers regarding the meaning of recovery, with most of them not considering the recurrence of mental illnesses as a part of recovery that requires appropriate treatment. the study recommends that mental health policymakers establish specific standards to align healthcare workers' perceptions of the recovery and create effective strategies to help patients achieve recovery. 97 ghmj (global health management journal) 2023, vol. 6, no. 2 widianti, et.al. psychiatric nurses offer an intervention to help schizophrenic patients recover through mindfulness therapy. according to astuti et al., (2020) research, this therapy is significantly effective in increasing hope and recovery rates in schizophrenia patients. the therapy is divided into several sessions, which include training in deep-breathing relaxation techniques to promote relaxation, self-awareness sessions to increase awareness of the environment around them (such as time, place, and people), selfcompassion sessions to reduce negative self-assessment, and acceptance sessions to acknowledge and believe in the possibility of recovery. 5. conclusion after reviewing 13 articles, this recent study highlights the perceptions of survivors, families, and health professionals regarding schizophrenia recovery. the findings suggest that mental health policymakers should establish clear standards to ensure that perceptions of schizophrenia recovery are balanced. this will aid in the development of effective strategies to help patients achieve recovery. this scoping review discusses the important aspect in fasten the process of recovery toward the patients. not only understanding and attitudes during the recovery, the health providers must show sincerity, willingness and make sacrifices in caring for the patients. being good friends with the survivors may lead the patients to share their experience and feelings openly. conflict of interest the authors declare no conflicts of interest for the results. references apostolopoulou, a., stylianidis, s., issari, p., chondros, p., alexiadou, a., belekou, p., giannou, c., karali, e. k., foi, chime concepts: a qualitative inquiry. frontiers in psychiatry, 11(february), 1 12. https://doi.org/10.3389/fpsyt.2020.00024 asher, l., patel, v., & de silva, m. j. (2017). community-based psychosocial interventions for people with schizophrenia in low and middle-income countries: systematic review and meta-analysis. bmc psychiatry, 17(1), 1 15. https://doi.org/10.1186/s12888-017-1516-7 bachtiar, a., windarwati, h. d., keliat, b. a., ismail, r. i., ati, n. a. l., sulaksono, a. d., & ilmy, s. k. (2020). the fight against stigma: multilevel stigma interventions in schizophrenipatients. journal of public health research, 9(4), 417 422. https://doi.org/10.4081/jphr.2020.1883 budiono, w., kantono, k., kristianto, f. c., avanti, c., & herawati, f. (2021). psychoeducation improved illness perception and expressed emotion of family caregivers of patients with schizophrenia. international journal of environmental research and public health, 18(14). https://doi.org/10.3390/ijerph18147522 dharma, i. d. g. c., ahsan, a., & lestari, r. (2022). lived experiences of the recovery process of people with schizophrenia during a pandemic. jurnal aisyah  : jurnal ilmu kesehatan, 7(1), 117 124. https://doi.org/10.30604/jika.v7i1.820 ferliana, h., damayanti, n. a., aisyah, d. n., huda, n., & ernawati, d. (2020). determinants of family independence in caring for hebephrenic schizophrenia patients. journal of public health research, 9(2), 21 24. https://doi.org/10.4081/jphr.2020.1828 hidayah, n., rahmawati, n., & nisma, n. (2022). the role of a supportive environment in recovery from schizophrenia: a literature review. kne medicine, 2022, 277 288. https://doi.org/10.18502/kme.v2i2.11091 horan, w. p., & green, m. f. (2019). treatment of social cognition in schizophrenia: current status and future directions. schizophrenia research, 203, 3 11. https://doi.org/10.1016/j.schres.2017.07.013 widianti, et.al. ghmj (global health management journal) 2023, vol. 6, no. 2 98 kurniawan, r. a., suryani, s., hernawaty, t., & al-kofahy, l. (2021). the structure, process, and outcome of mentorship on survivor with schizophrenia: a case study. jurnal keperawatan padjadjaran, 9(1), 71 83. https://doi.org/10.24198/jkp.v9i1.1645 lestari, r., yusuf, a., hargono, r., setyawan, f. e. b., hidayah, r., & ahsan, a. (2021). adapting to people with schizophrenia: a phenomenological study on a rural society in indonesia. indian journal of psychological medicine, 43(1), 31 37. https://doi.org/10.1177/0253717620926847 ns toward recovery of patients with schizophrenia in community. the open public health journal, 12(1), 26 32. https://doi.org/10.2174/1874944501912010026 marthoenis, m., aichberger, m. c., & schouler-ocak, m. (2016). patterns and determinants of treatment seeking among previously untreated psychotic patients in aceh province, indonesia: a qualitative study. scientifica, 7. https://doi.org/10.1155/2016/9136079 munn, z., peters, m. d. j., stern, c., tufanaru, c., mcarthur, a., & aromataris, a. (2018). systematic review or scoping review? guidance for authors when choosing between a systematic or scoping review approach. bmc medical research methology, 18(1). https://doi.org/10.1186/s12874-018-0611-x pribadi, t., lin, e. c. l., chen, p. s., lee, s. k., fitryasari, r., & chen, c. h. (2020). factors associated with internalized stigma for indonesian individuals diagnosed with schizophrenia in a community setting. journal of psychiatric and mental health nursing, 27(5), 584 594. https://doi.org/10.1111/jpm.12611 puspitosari, w. a., wardaningsih, s., & nanwani, s. (2019). improving the quality of life of people with schizophrenia through community based rehabilitation in yogyakarta province, indonesia: a quasi experimental study. asian journal of psychiatry, 42(february 2018), 67 73. https://doi.org/10.1016/j.ajp.2019.03.022 kementrian kesehatan. ri (2019). situasi kesehatan jiwa di indonesia. sari, o. k., & subandi, s. (2021). psychological intervention in community-based treatment of schizophrenia: a systematic narrative review. journal of educational, health and community psychology, 10(3), 432. https://doi.org/10.12928/jehcp.v10i3.20525 sari, s. p., agustin, m., wijayanti, d. y., sarjana, w., afrikhah, u., & choe, k. (2021). mediating effect of hope on the relationship between depression and recovery in persons with schizophrenia. frontiers in psychiatry, 12(february), 1 6. https://doi.org/10.3389/fpsyt.2021.627588 shean, g. d. (2009). evidence-based psychosocial practices and recovery from schizophrenia. psychiatry, 72(4), 307 320. https://doi.org/10.1521/psyc.2009.72.4.307 singla, n., avasthi, a., & grover, s. (2020). recovery and its correlates in patients with schizophrenia. asian journal of psychiatry, 52, 102162. https://doi.org/10.1016/j.ajp.2020.102162 subandi, m. a. (2015). bangkit: the processes of recovery from first episode psychosis in java. culture, medicine and psychiatry, 39(4), 597 613. https://doi.org/10.1007/s11013-015-9427-x suryani, hidayah, n., & sutini, t. (2019). withdrawn: the aspects of recovery from schizophrenia: from the international journal of africa nursing sciences, 342, 100179. https://doi.org/10.1016/j.ijans.2019.100179 suryani, hidayah, n., & sutini, t. (2019). the aspects of recovery from schizophrenia: from the indonesian international journal of africa nursing sciences, 100179. https://doi.org/10.1016/j.ijans.2019.100179 susanti, h., james, k., utomo, b., keliat, b. a., lovell, k., irmansyah, i., rose, d., colucci, e., & brooks, h. (2020). exploring the potential use of patient and public involvement to strengthen indonesian mental health care for people with psychosis: a qualitative exploration of the views of service users and carers. health expectations, 23(2), 377 387. https://doi.org/10.1111/hex.13007 health nurses in the eastern island of indonesia. belitung nursing journal, 7(4), 336 345. https://doi.org/10.33546/bnj.1621 99 ghmj (global health management journal) 2023, vol. 6, no. 2 widianti, et.al. van langen, w. j. m., beentjes, t. a. a., van gaal, b. g. i., nijhuis-van der sanden, m. w. g., & goossens, p. j. j. (2016). how the illness management and recovery program enhanced recovery of persons with schizophrenia and other psychotic disorders: a qualitative study. archives of psychiatric nursing, 30(5), 552 557. https://doi.org/10.1016/j.apnu.2016.04.005 who. (2016). world mental health day 2016. yulina astuti, h. w., agustin, m., sari, s. p., wijayanti, d. y., sarjana, w., & locsin, r. c. (2020). effects of mindfulness on stimulating hope and recovery among people with schizophrenia. nurse media journal of nursing, 10(2), 119 129. https://doi.org/10.14710/nmjn.v10i2.28775 yusuf, a. ., p.k, r. f., & nihaya, h. e. (2015). buku ajar keperawatan kesehatan jiwa. salemba medika. cite this article as: widianti, e., hidayati n.o., rafiyah i., kusumah i. (2023). perceived of survivors, families, and health professionals on the recovery process of schizophrenia in indonesia: a scoping review. ghmj (global health management journal), 6(2). 90 99. https://doi.org/10.35898/ghmj-62975 https://doi.org/10.35898/ghmj-62964 knowledge, attitudes, and hiv/aids risk behaviors of myanmar migrant workers in thailand ghmj (global health management journal) 2023, vol. 6, no. 2 indonesian scholars’ alliance open access review prevalence, pathophysiology, and treatment of urticaria post-covid-19 vaccination: a systematic review ardhina nugrahaeni 1 , rani tiyas budiyanti 2 1 center for health policy and management, faculty of medicine, public health, and nursing, gadjah mada university, yogyakarta, indonesia. 2 faculty of public health, universitas diponegoro, semarang, indonesia. *corresponding author’s email: ardhinanugrahaeni@gmail.com doi: 10.35898/ghmj-62960 abstract background: vaccination for covid-19 has been intensively developed since the end of 2020. its use must also obtain an emergency use authorization (eua) permit. some of the vaccines have been used including sinovac, astra zeneca, moderna, pfizer, johnson & johnson, and sinopharm. in fact, there are many effects that have developed after the covid-19 vaccination administration like local reactions, systemic reactions, and other reactions. in addition, one of them is urticaria. however, the existing literature has focused poorly on urticaria caused by covid-19 vaccines. aims: this research explores the prevalence, pathophysiology, and treatment of urticaria post-covid19 vaccination. methods: this study conducted a systematic review based on the guideline which is preferred reporting items for systematic reviews and meta-analyses (prisma). we searched scopus, proquest, ebsco, and google scholar databases from 2020 until 2022 for identifying the data regarding urticaria post-covid-19 vaccination. in a nutshell, 9 studies were included in the systematic review. results: only 28% of urticarial rashes incident among all cutaneous adverse reactions after postcovid-19, it was higher among females and people aged 45-49 years old, and people with allergy histories. the most frequent reaction is urticarial following the covid-19 vaccine administration. this concerns hypersensitivity reaction related to immunoglobulin e (ige) mediated, immunoglobulin g (igg), and sensitizing excipients in covid-19 vaccines. conclusion: this systematic review raises the concern of hypersensitivity reaction that related to igemediated, igg, and sensitizing excipients in covid-19 vaccines. urticaria is the most frequent reaction after the covid-19 vaccine administration. attention to medical history and immunology/allergy consultation might be advantageous to assess the risk of allergy and the guidance of the vaccine. keywords: urticaria, post-covid-19 vaccination, mrna vaccines, whole inactivated virus, hypersensitivity reactions. received: 9 may 2023; revised: 8 june 2023; accepted: 18 july 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 the coronavirus (covid-19) outbreak spread rapidly throughout the entire world and became a new challenge for controlling the pandemic and reducing its impact. it has affected more than 600 million people worldwide since declaring in march 2020 by the world health organization. vaccination is presently a safe and effective way to control covid-19. covid-19 vaccination development started at mailto:ardhinanugrahaeni@gmail.com https://doi.org/10.35898/ghmj-62960 nugrahaeni & budiyanti ghmj (global health management journal) 2023, vol. 6, no. 2 58 the end of 2020. it holds emergency use authorization (eua) permit. according to the world health organization (who), numerous covid-19 vaccines administered such as viral vectors (johnson & johnson's janssen and astrazeneca), mrna (pfizer and moderna), and inactivated virus (sinovac and sinopharm). adverse events following immunization (aefi) are medical events after immunization. some people might have side effects following covid-19 vaccination. common side effects consist of pain or redness at the injection site, fever, headache, muscle aches, and fatigue. dermatologic reactions after administering covid-19 vaccinations became reality. urticaria is a main skin condition that is mast cell-driven disease. it shows angioedema, wheels (hives), or both. the active skin mast cells discharge histamine and other mediators like cytokines and platelet-activating factor (paf). the signals of mast cell activating in urticaria are various. these include autoantibodies and t-cell-driven cytokines (zuberbier, et al., 2022). however, this research aims to explore the prevalence, cause, prevention, and treatment of urticaria post-covid-19 vaccination. 2. methods the research was a systematic review using the prisma model. the scope of this research includes the prevalence, pathophysiology, and treatment of urticaria after post-covid-19 vaccination. the keywords that were used are “urticaria” “and” cause” “and” “prevalence” “and” treatment” “and” “covid-19 vaccination”. we used the preferred reporting items for systematic reviews and meta-analyses (prisma) flowchart and form the basis for the inclusion or exclusion criteria of the articles. the inclusion criteria were articles related to urticaria post-covid-19 vaccination that has been published in scopus, proquest, ebsco, and google scholar databases from 2020 until 2022 and open access. the articles should be related to the prevalence, pathophysiology, and treatment of urticaria post-covid-19. the exclusion criteria were data that had unclear characteristics, review articles, and not full paper articles. the authors initially collected the identified records from four databases source including scopus, proquest, ebsco, and google scholar. we checked for duplicates using stata and screened the resulting studies based on titles and abstracts afterward. we screened independently the studies based on their full texts and excluded the ineligible studies. the authors independently extracted the data from the eligible studies. these data include the author, title, year, method, and resume. the eligibility criteria of studies included 102 articles out of 430 articles. after reviewing the full-text articles, 93 articles were excluded and only 9 articles were included. figure 1. search results from various databases records identified through database searching (n = 430) full text articles assessed for eligibility (n = 102) articles were eliminated (n = 328) articles were involved (n = 9) articles excluded after full text review (n = 93) 59 ghmj (global health management journal) 2023, vol. 6, no. 2 nugrahaeni & budiyanti table 1. information of the included articles author title year method resume burlando m, herzum a, micalizzi c, cozzani e, parodi a. cutaneous reactions to covid-19 vaccine at the dermatology primary care 2021 the data among patients with skin reactions after covid-19 administration were collected retrospectively from march 2021 to june 2021 in dermatology primary only 15% of patients developed cutaneous reactions following covid-19 administration. most of them were either mild or moderate. ten of twenty-one patients developed urticarial reactions following covid19 administration. four of them appeared within 24 hours and the rest after 24 hours grieco t, ambrosio l, trovato f, vitiello m, demofonte i, fanto m, et al effects of vaccination against covid19 in chronic spontaneous and inducible urticaria (csu/ciu) patients: a monocentric study. 2022 from 1 november 2021 until 10 december 2021, only 160 chronic spontaneous and inducible urticaria patients in antihistamine therapy were administered two doses of the moderna vaccine. twenty of them got booster vaccines. a web-based questionnaire was collected by phone interview. the questionnaire consists of demographics, adverse event following immunization, medical history, urticaria activity score-7 and cutaneous adverse reactions outcome only 17.86% patients developed worsening pre-existing urticaria with average urticaria activity score-7, 3.12. covid-19 vaccination is secure among chronic spontaneous and inducible urticaria patients. the cases of worsening disease are able to manage by using antihistamines therapies català a, muñoz-santos c, galváncasas cr, riesco mr, nebreda d, solá-truyols a, et al. cutaneous reactions after sars-cov-2 vaccination: a cross-sectional spanish nationwide study of 405 cases 2021 this study, a cross-sectional study, was conducted from 16 february until 15 may 2021. the sample of this study is patients who developed cutaneous reactions within 21 days following covid-19 vaccine administration. an electronic case report form and questionnaire were collected. an online professional survey reported reactions of cutaneous after having a visit with a dermatologist. clinical images were sent by email. the examiner identified for consensus on clinical patterns and classification only 405 patients were with a mean of age of (50.7) (17.6) and 80.2% of them were female. there were 40.2% of the pfizer administration, 36.3% of the moderna administration, and 23.5% of the astrazeneca administration. cutaneous reactions represented covid arm (32.1%), urticaria (14.6%), morbiliform (8.9%), papulovesicular (6.4%), pityriasis rosea-like (4.9%) and purpuric (4%) reactions. varicella zoster and herpes simplex virus reactivations accounted for 13.8% of reactions. urticaria and/ angioedema reactions after pfizer administration was higher than moderna and astrazeneca. pfizer was 24 patients (40.7%). astrazeneca was 20 patients (33.9%). moderna was 15 patients (25.9%). only 46 patients (78%) of 59 patients with urticaria and/ angioedema reactions were female. mostly its reaction developed after the first dose of covid-19 vaccines. cutaneous reactions following the covid-19 vaccine administration are diverse. nugrahaeni & budiyanti ghmj (global health management journal) 2023, vol. 6, no. 2 60 author title year method resume pourani mr, shahidi dadras m, salari m, diab r, namazi n, abdollahimajd f. cutaneous adverse events related to covid-19 vaccines: a cross-sectional questionnairebased study of 867 patients 2022 this study was a descriptive cross-sectional questionnaire study. the online questionnaire was shared from the first of june 2021 to 1 july 2021. the questionnaire was related to covid-19 vaccine reactions. the questionnaire consists of cutaneous reactions, the onset time, and the persistence duration. there are 30% of iran people who developed cutaneous reactions after covid-19 vaccine administration. the most frequent effects against covid-19 vaccine were urticaria, focal injection site reaction, and exanthematous rash. there were 25 urticaria cases. bruusgaardmouritsen m, jensen bm, poulsen lk, johansen jd, garvey lh. optimizing investigation of suspected allergy to polyethylene glycols 2022 the results of the histamine test and the result of the skin prick test were collected from diagnosis time and early allergy assessment the positive skin prick test patients and the positive polyethylene glycols 3000/6000 patients reported positive on polyethylene glycols 20000. three patients had systematic urticaria during the skin prick test. only 8 patients developed cross-sensitization to poloxamer 407 and 3 to polysorbate 80. all controls tested negative. the skin prick test with rising polyethylene glycols 20000 concentration is able to be diagnostic when the molecular weight of polyethylene glycols is negative. the skin prick test is mandatory magro c, nuovo g, mulvey j, laurence j, harp j, crowson an. the skin as a critical window in unveiling the pathophysiologic principles of covid-19 2021 the dataset of cutaneous caused by covid-19 vaccine and covid-19. the data provided by regional medical laboratory and weill cornell medicine and in tulsa, oklahoma from march 2020 to june 2021 was reviewed. these included the clinical histories, light microscopic findings, additional immunohistochemical studies, and molecular studies after vaccine of covid-19 administration, the localization of spike glycoprotein was found among cutaneous cases. it binds endothelium in the absence of an intact virus. almuhizi f, ton-leclerc s, fein m, tsoukas c, garvey lh, lee d, et al. successful desensitization to mrna covid-19 vaccine in a case series of patients with a history of anaphylaxis to the first vaccine dose 2022 participants chosen from cohort of study related to ongoing reaction of allergic to covid-19 vaccine. the clinical evaluation after the first dose of either the pfizer or the moderna was hold at the mcgill university health center (muhc). the participants undertook skin prick testing. a desensitization protocol applied for the second dose six of 142 patients were chosen with allergic history. all participants were female. most of them developed urticaria within 30 minutes after the first dose of covid-19 vaccine. a desensitization protocol applies for the immediate reaction following the first dose of mrna covid-19 vaccine. 61 ghmj (global health management journal) 2023, vol. 6, no. 2 nugrahaeni & budiyanti author title year method resume pitlick mm, joshi ay, gonzalezestrada a, chiarella se delayed systematic urticarial reactions following mrna covid19 vaccination 2022 the study was a retrospective case series from 19 january 2021 until 30 april 2021. there were twelve patients referring to mayo clinics in jacksonville, florida, and rochester, minnesota following mrna covid-19 administration in order to evaluate delayed systemic urticarial reactions. each patient reported a history of medical and allergic, demographics, a side effect of the covid-19 vaccine, and the results of vaccine excipient skin testing. eleven patients who developed delayed urticaria after getting the first dose of covid-19 vaccines. antihistamines are able to treat delayed systemic urticarial reactions after mrna covid-19 vaccine administration. macy e, pandya s, sheikh j, brunette a, m.shi j, chung j, et al population based incidence, severity, and risk factors associated with treated acuteonset covid19 mrna vaccinationassociated hypersensitivity reactions 2022 this study collected unique individuals with active kaiser permanente southern california (kpsc) health plan coverage. they were administered the covid-19 mrna vaccine at the kpsc facility from 16 december 2020 until 11 march 2021. they were also identified, characterized, and along with all treated acute-onset vaccinationassociated hypersensitivity events. the younger females with typical risk factors have more likely treated with acute-onset hypersensitivity events following covid-19 vaccine. only 15200 people developed chronic urticaria. 16.3% of patients with treated hypersensitivity reactions had chronic urticarial after first dose reactions and 12.5% of them had it after the second dose reactions. 3. results a. prevalence of urticaria post-covid-19 vaccination numerous adverse reactions to the covid-19 vaccination have been reported (burlando et al., 2021). based on burlando et al (2022), only 21 of 200 patients developed cutaneous reactions following covid-19 vaccine administration. fifteen (71%) patients were females with a mean age of 48 years. ten of twenty-one patients developed urticarial reactions following covid-19 administration. four of them appeared it within 24 hours and the rest after 24 hours. astrazeneca, moderna, and pfizer cause acute urticaria, an adverse reaction after getting vaccinated (brooks et al., 2022). messenger rna (mrna) which encapsulates lipid nanoparticles in the pfizer vaccine and the moderna vaccine, encrypt the sars cov 2 viral spike protein inducing both cell-mediated responses and antibodies. a viral vector needs to synthesize sars-cov-2 protein s is the astrazeneca vaccine (bianchi et al., 2021). after getting messenger rna or mrna vaccination from moderna and pfizer, the local reactions were the most frequent cutaneous findings. the immune response shows as rash against spike protein which is similar to morbilliform eruptions that are negative. like patients with primary covid-19 infection, their negatives are in viral particles (burlando et al., 2021). only 28% of urticarial rashes incident found among all cutaneous adverse reactions. the most common of it in patients are rash and itching after receiving mrna covid-19 vaccines (grieco et al., 2022). the risk of urticaria after administration of the pfizer mrna covid-19 vaccine among healthcare workers was higher among females and people aged 45-49 years old. it rose in people with had previous covid-19 infections and people with an allergy history (cugno et al., 2021). nugrahaeni & budiyanti ghmj (global health management journal) 2023, vol. 6, no. 2 62 in spanish, only 21.1% of patients had urticaria after getting astrazeneca, the covid-19 vaccine. it was the most frequent reaction after administration (català et al., 2021). the higher urticarial and. angioedema reactions were 40.7% (n= 24) of patients after pfizer administration. astrazeneca was 20 patients (33.9%). moderna was 15 patients (25.9%). only 46 patients (78%) of 59 patients with urticaria and/ angioedema reactions were female. mostly its reaction developed after the first dose of covid-19 vaccines. based on brooks et al (2022), chronic spontaneous urticaria triggered by astrazeneca was reported. the patient with an asthma history and environmental allergies had the first dose of astrazeneca, the covid-19 vaccination. in five days, the 60 years old man developed erythema on his palms and cheeks followed by a pruritic rash on his scalp, face, neck, shoulder, and armpit. a caucasian female who was 48 years old had acute urticaria within 3 hours after the second dose of astrazeneca (burlando et al., 2021). a 39 years old man without a history of atopic disorders developed widespread urticaria and swelling of his hands. he got a jab of the second of astra zeneca and urticaria showed up in 2 weeks (suan and lee, 2022). in iran, it is reported that 25 cases of urticaria after getting astra zeneca, sinopharm, sputnik v, and bharat vaccines. however, most of them were vaccinated using astra zeneca (pourani et al., 2022). in thailand, the most common skin allergy reactions from 35,229 injections of vaccination were urticaria after getting astrazeneca and sinovac (rerknimitr et al., 2022). the previous study reported that urticaria prevalence after the coronavac vaccine administration among healthcare workers in turkey was about 0.8% (triwatcharikorn et al., 2022). urticaria was the most frequent reaction among healthcare workers in turkey after administering with sinovac/ coronavac (durmaz et al., 2022). the study reported a-28 years old patient who was under regular histamine treatment had chronic urticaria after getting the first dose of coronavac. another study recorded a female patient who an allergy history had developed urticaria within 10 minutes of getting coronavac (kaya and kaya, 2022). other studies reported that four patients developed symptoms of urticaria after coronavac administration. three of them had it after the first dose of coronavac. another one presented symptoms of urticaria after the second dose of coronavac (akdaş et al., 2022). b. pathophysiology of urticaria post-covid-19 vaccination the mrna vaccines use polyethylene glycols (pegs) as excipients. it contains varied polymers' molecular weight (bruusgaard-mouritsen et al., 2022). the peg2000 or polyethylene glycols have 2000 molecular weight present as a stabilizer, a solubilizer, and an adjuvant. being a stabilizer avoids premature degradation of the nanoparticles by the mononuclear phagocytosis system. during the transition of the particles into the intracellular cytosol, the peg2000 is a solubilizer. being an adjuvant is for immunogenic potential. ethylene oxide makes pegs by polymerization (worm et al., 2021). formaldehyde, neomycin, propylene glycol, and thimerosal are exogenous antigens in vaccine constituents that cause allergic contact dermatitis. polyethylene glycol moieties and polysorbate-80 have the potential to cause immediate hypersensitivity reactions, as well as delayed hypersensitivity reactions (magro et al., 2021). polyethylene glycol (peg) and structurally-related polysorbate-80 stimulate both non-ige-mediated reactions and ige reactions among people with type i allergic reactions after covid-19 vaccine administration (grieco et al., 2022). polyethylene glycol enhances water solubility as an excipient. alike peg, polysorbate 80 is an excipient in johnson & johnson and the astrazeneca vaccines against covid-19. the two mrna vaccines contain peg-triggering hypersensitivity reactions. it is caused by previous sensitization to polysorbate 80 and cross-reactivity between polysorbate 80 and peg (almuhizi et al., 2022). the whole inactivated viruses are the primary element in coronavac which is cultured with aluminum hydroxide adjuvant and some mineral salts in vero cell. urticaria related to coronavac is less likely to be ige-mediated hypersensitivity. the immune response plays a role in the pathogenesis of coronavac. the result of a cross-reactive immune response to the sars-cov-2-spike protein present 63 ghmj (global health management journal) 2023, vol. 6, no. 2 nugrahaeni & budiyanti in previous coronavirus infections causes urticaria for sensitive people (triwatcharikorn et al., 2022). morbilliform eruptions and urticaria are the main reason for hypersensitivity reactions primarily (namazi et al., 2022). three of four patients developed recurrent delayed urticaria after the second dose of the covid-19 vaccine. these patients thrive a memory t-cell response to the mrna covid-19 vaccine. another reason is the delayed t-cell responses (pitlick et al., 2022). either ige mediated or igg is the reaction from hypersensitivity after vaccine administration. it is caused by complementmediated anaphylactic and delayed t-cell-mediated reactions ige (namazi et al., 2022) c. urticaria treatment post-covid-19 vaccination second-generation h1 antihistamine is the first-line treatment that resulted in half of reduction in the urticaria treatment. treatment of omalizumab is required to prevent urticaria flares during the vaccination period (grieco et al., 2022). a recombinant humanized monoclonal anti-ige antibody, omalizumab, is effective to inhibit hypersensitivity reactions (smola et al., 2021). omalizumab is an anti-ige antibody for the treatment of chronic spontaneous urticaria as well (bernstein et al., 2020). dosing does not depend on total serum ige (zuberbier et al., 2022). high-dose nonsedating antihistamines like up to 40 mg cetirizine daily are needed to treat urticaria associated with covid mrna vaccination. systemic corticosteroids did not work for acute urticaria or any cause. it causes unsharpened development of effective t-cell–mediated immunity (macy et al., 2022). patients with chronic spontaneous urticaria require regular antihistamines for 2 days prior to and after receiving the vaccine. patients on long-term antihistamines may be advised to increase their usual dose for this period (under clinical supervision) (bermingham et al., 2021). 4. discussion astrazeneca contains sensitizing excipients namely polysorbate 80. an immediate hypersensitivity type i reaction, urticarial rash, is developed after getting vaccinated of astrazeneca (burlando et al., 2021). pfizer involves polyethylene glycol 2000 which is excipient with sensitizing. moderna consists of polyethylene glycol 2000 and tromethamine (bianchi et al., 2021). polyethylene glycol‐2000 (peg‐ 2000) in some drugs produces hypersensitivity reactions 1 right away and plays a role the urticarial manifestations (farinazzo et al., 2021). the main elements in coronavac are whole inactivated viruses. these are cultured with aluminum hydroxide adjuvant and some mineral salts in vero cells. coronavac-associated urticaria is less likely to be ige-mediated hypersensitivity to the vaccine. an immune response to the sars-cov-2-spike protein, rather than the vaccine excipients, may play a role in the pathogenesis of coronavac-associated urticaria. the result of a cross-reactive immune response to sars-cov-2-spike protein present in previous coronavirus infections causes urticaria for sensitive people (triwatcharikorn et al., 2022). urticaria which is immediate hypersensitivity based on centers for disease control and prevention (cdc) happen within 4 hours after administrating vaccines (gronbeck and grant-kels, 2021). either ige mediated or igg is the reaction from hypersensitivity after vaccine administration. it is caused by complement-mediated anaphylactic and delayed t-cell-mediated reactions ige (namazi et al., 2022). people who developed urticaria less than 30 minutes after the first dose of vaccination had an increased risk of urticaria after the second vaccination (rerknimitr et al., 2022). a minor subset of cases demonstrated urticarial vasculitis, a morphologic subset of leukocytoclastic vasculitis characteristically triggered by immune complex deposition but other proinflammatory pathways can be implicated. antibodies bound to an undefined foreign protein introduced by the vaccine could be deposited in microvessels as an immune complex and trigger the classic complement pathway to result in a neutrophil-rich inflammatory reaction (magro et al., 2021). nugrahaeni & budiyanti ghmj (global health management journal) 2023, vol. 6, no. 2 64 5. conclusion urticaria is the most frequent reaction after the covid-19 vaccine administration. this concerns hypersensitivity reaction which is related to ige-mediated, igg, and sensitizing excipients in covid-19 vaccines. the awareness of healthcare professionals is essential in order to recognize and treat eventual severe reactions from covid-19 vaccinations. besides, medical history is required to discover possible risk factors and keep down adverse reaction incidence. furthermore, immunology/allergy consultation might be advantageous to assess the risk of allergy and the guidance of the vaccine. conflict of interest the authors declare no conflicts of interest, and no financial support. references akdaş, e., öğüt, b., erdem, ö., öztaş, m. o., & i̇lter, n. (2021). cutaneous reactions following coronavac covid-19 vaccination: a case series of six healthcare workers from a single centre. journal of the european academy of dermatology and venereology: jeadv, 35(12), e861–e864. https://doi.org/10.1111/jdv.17592 almuhizi, f., ton-leclerc, s., fein, m., tsoukas, c., garvey, l.h., lee, d.,et al. (2022). successful desensitization to mrna covid-19 vaccine in a case series of patients with a history of anaphylaxis to the first vaccine dose. front. allergy, 02 february 2022. https://doi.org/10.3389/falgy.2022.825164 bermingham, w.h., ardern-jones, m.r., huissoon, a.p., krishna, m.t. (2021). forewarned is forearmed: chronic spontaneous urticaria as a potential risk to effective sars-cov-2 vaccine uptake and global public health. british journal of dermatology (2021)185, pp838–839. https://doi.org/10.1111/bjd.20495 bernstein, j.a., singh, u., rao, m.b., berendts, k., zhang, x., mutasim, d. (2020). benralizumab for chronic spontaneous urticaria. n engl j med 2020; 383:1389-1391. doi: 10.1056/nejmc2016395 bianchi, l., biondi, f., hansel, k., murgia, n., tramontana, m., stingeni, l. (2021). skin tests in urticaria/angioedema and flushing to pfizer‐biontech sars‐cov‐2 vaccine: limits of intradermal testing. wiley allergy. 2021 apr 22 : 10.1111/all.14839. doi: 10.1111/all.14839 brooks, s.g., de jong, a.m., abbaslou, m., sussman, g. (2022). chronic spontaneous urticaria triggered by the astrazeneca/oxford covid-19 vaccine with achieved remission: a case report. sage allergy & rhinology volume 13: 1–2. https://doi.org/10.1177/21526567211068458 bruusgaard-mouritsen, m., jensen, b.m., poulsen, l.k., johansen, j.d., garvey, l.h. (2022). optimizing investigation of suspected allergy to polyethylene glycols. journal of allergy and clinical immunology volume 149, issue 1, january 2022, pages 168-175.e4. https://doi.org/10.1016/j.jaci.2021.05.020 burlando, m., herzum, a., cozzani, e., parodi, a. (2021). acute urticarial rash after covid-19 vaccination containing polysorbate 80. korean vaccine society clinical experimental vaccine research 2021 sep; 10(3): 298–300. https://doi.org/10.7774/cevr.2021.10.3.298 burlando, m., herzum, a., micalizzi, c., cozzani, e., parodi, a. (2021). cutaneous reactions to covid-19 vaccine at the dermatology primary care. wileyimmunity, inflammation and diseasevolume 10, issue 2 p. 265-271. https://doi.org/10.1002/iid3.568 català a, muñoz-santos c, galván-casas cr, riesco mr, nebreda d, solá-truyolsa, et al. (2022). cutaneous reactions after sars-cov-2 vaccination: a cross sectional spanish nationwide study of 405 cases. dermatologists british journal of dermatology (2022)186, pp142–152.. https://doi.org/10.1111/bjd.20639 cugno, m., consonni, d., lombardi, a., bono, p., oggioni, m., renteria, s.u., et al. (2021). increased risk of urticaria/angioedema after bnt162b2mrna covid-19 vaccine in health care workers taking ace inhibitors. vaccines 2021, 9(9), 1011; https://doi.org/10.3390/vaccines9091011 durmaz, k., aykut temiz, s., metin, z., dursun, r., & abdelmaksoud, a. (2022). allergic and cutaneous reactions following inactivated sars-cov-2 vaccine (coronavac®) in healthcare workers. clinical and experimental dermatology, 47(1), 171–173. https://doi.org/10.1111/ced.14896 farinazzo, e., ponis, g., zelin, e., errichetti, e., stinco, g., pinzani, c., et al. (2021). cutaneous adverse reactions after m-rna covid-19 vaccine: early reports from northeast italy. journal of the european academy of dermatology and venereology : jeadv, 35(9), e548–e551. https://doi.org/10.1111/jdv.17343 grieco, t., ambrosio, l., trovato, f., vitiello, m., demofonte, i., fanto, m., et al. (2022). effects of vaccination against covid-19 in chronic spontaneous and inducible urticaria (csu/ciu) patients: a monocentric study. journal of clinical medicine. 2022; 11(7):1822. https://doi.org/10.3390/jcm11071822 https://doi.org/10.1111/jdv.17592 https://doi.org/10.3389/falgy.2022.825164 https://doi.org/10.1111/bjd.20495 https://www.ncbi.nlm.nih.gov/pmc/articles/pmc8251329/ https://dx.doi.org/10.1111%2fall.14839 https://doi.org/10.1177%2f21526567211068458 https://www.sciencedirect.com/journal/journal-of-allergy-and-clinical-immunology https://www.sciencedirect.com/journal/journal-of-allergy-and-clinical-immunology/vol/149/issue/1 https://doi.org/10.1016/j.jaci.2021.05.020 https://doi.org/10.7774/cevr.2021.10.3.298 https://onlinelibrary.wiley.com/journal/20504527 https://onlinelibrary.wiley.com/journal/20504527 https://onlinelibrary.wiley.com/toc/20504527/2022/10/2 https://doi.org/10.1002/iid3.568 https://doi.org/10.1111/bjd.20639 https://doi.org/10.3390/vaccines9091011 https://doi.org/10.1111/ced.14896 https://doi.org/10.1111/jdv.17343 https://doi.org/10.3390/jcm11071822 65 ghmj (global health management journal) 2023, vol. 6, no. 2 nugrahaeni & budiyanti gronbeck, c. and grant-kels, j. m. (2021). attention all anti-vaccinators: the cutaneous adverse events from the mrna covid-19 vaccines are not an excuse to avoid them. clinics in dermatology volume 39, issue 4, july–august 2021, pages 674-687. https://doi.org/10.1016/j.clindermatol.2021.05.027 kaya, l., and kaya, z. (2022). a case report of a nurse who received the covid-19 vaccine. international journal of pharmata 2022; 2(2): 9-14. macy, e., pandya, s., sheikh, j., brunette, a., m.shi, j., chung, j.,et al. (2022). population based incidence, severity, and risk factors associated with treated acute-onset covid-19 mrna vaccinationassociated hypersensitivity reactions. the journal of allergy and clinical immunology: in practice volume 10, issue 3, march 2022, pages 827-836. https://doi.org/10.1016/j.jaip.2021.12.021 magro, c., crowson, n., franks, l., schaffer, p.r., whelan, p. nuovo, g. (2021). the histologic and moleculer correlates of covid-19 vaccine-induced in the skin. clinics in dermatology volume 39, issue 6, november–december 2021, pages 966-984. https://doi.org/10.1016/j.clindermatol.2021.07.011 magro, c., nuovo, g., mulvey, j., laurence, j., harp, j., crowson, a.n. (2021). the skin as a critical window in unveiling the pathophysiologic principles of covid-19. elsevierclinics in dermatology volume 39, issue 6, november–december 2021, pages 934-965. https://doi.org/10.1016/j.clindermatol.2021.07.001 namazi, n., diab, r., mardani, g., jamali, e., kaddah, a. (2022). figurate purpuric eruption post-covid-19 vaccination. dermatologic therapy.2022;35:e15360. https://doi.org/10.1111/dth.15360 pitlick, m.m., joshi, a.y., gonzalez-estrada, a., chiarella, s.e. (2022). delayed systematic urticarial reactions following mrna covid-19 vaccination. allergy and asthma proceedings, volume 43, number 1, 1 january 2022, pp. 40-43(4). https://doi.org/10.2500/aap.2022.43.210101 pourani, mr, shahidi dadras, m, salari, m, diab, r, namazi, n, abdollahimajd, f. (2022). cutaneous adverse events related to covid-19 vaccines: a cross-sectional questionnaire-based study of 867 patients. dermatologic therapy. 2022; 35( 2):e15223. doi:10.1111/dth.15223 rerknimitr, p., puaratanaarunkon, t., wongtada, c., wittayabusarakam, n., krithin, s., paitoonpong, l., et al. (2022), cutaneous adverse reactions from 35,229 doses of sinovac and astrazeneca covid-19 vaccination: a prospective cohort study in healthcare workers. j eur acad dermatol venereol, 36: e158e161. https://doi.org/10.1111/jdv.17761 smola, a., samadzadeh, s., müller, l., adams, o., homey, b., albrecht, p.,et al. (2021). omalizumab prevents anaphylactoid reactions to mrna covid-19 vaccine. journal of the european academy of dermatology and venereology : jeadv, 35(11), e743–e745. https://doi.org/10.1111/jdv.17549 suan, d., and lee, a.y.s. (2022). chronic spontaneous urticaria following chadox1-scovid-19 vaccination. springer allergo j int. (2022). https://doi.org/10.1007/s40629-022-00204-x triwatcharikorn, j., puaratana-arunkon, t., punyaratabandhu, p., mongkolpathumrat, p., palapinyo, s., buranapraditkul, s., et al. (2022), acute urticaria alone after coronavac covid-19 vaccination should not be a contraindication for revaccination. clin exp dermatol, 47: 735-738. https://doi.org/10.1111/ced.14962 worm, m., bauer, a., wedi, b., treudler, r., pfuetzner, w., brockow, k., et al. (2021). practical recommendations for the allergological risk assessment of the covid-19 vaccination a harmonized statement of allergy centers in germany. allergologie select, 5, 72–76. https://doi.org/10.5414/alx02225e zuberbier, t., hamzah, a. l., abuzakouk, m. aquailina, s., asero, r., et al. (2022). the international eaaci/ga²len/euroguiderm/apaaaci guideline for the definition, classification, diagnosis, and management of urticaria. wileyallergy 2022;77:734–766. https://doi.org/10.1111/all.15090 cite this article as: nugrahaeni, a. & budiyanti, r.t. (2023). prevalence, pathophysiology, and treatment of urticaria postcovid-19 vaccination: a systematic review. ghmj (global health management journal), 6(2). 57–65 https://doi.org/10.35898/ghmj-62960 https://www.sciencedirect.com/journal/clinics-in-dermatology https://www.sciencedirect.com/journal/clinics-in-dermatology/vol/39/issue/4 https://doi.org/10.1016/j.clindermatol.2021.05.027 https://doi.org/10.1016/j.jaip.2021.12.021 https://www.sciencedirect.com/journal/clinics-in-dermatology https://www.sciencedirect.com/journal/clinics-in-dermatology/vol/39/issue/6 https://doi.org/10.1016/j.clindermatol.2021.07.011 https://www.sciencedirect.com/journal/clinics-in-dermatology https://doi.org/10.1016/j.clindermatol.2021.07.001 https://doi.org/10.1111/dth.15360 https://doi.org/10.2500/aap.2022.43.210101 https://doi.org/10.1111/dth.15223 https://doi.org/10.1111/jdv.17761 https://doi.org/10.1111/jdv.17549 https://doi.org/10.1007/s40629-022-00204-x https://doi.org/10.1111/ced.14962 https://doi.org/10.5414/alx02225e https://doi.org/10.1111/all.15090 https://doi.org/10.35898/ghmj-62960 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 nursing practice guidance: a practical strategy for skills’ development in nursing clinics gad datak*, ester inung sylvia department of nursing, poltekkes kemenkes palangka raya, indonesia *corresponding author’s email: gaddatak@gmail.com doi: 10.35898/ghmj-51604 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) learning laboratory is one of learning methods in nursing colleges which contributes to a learning experience to enhance nursing skills thus learning objectives can be achieved. practical learning experience in a laboratory emphasizes mastery of skill aspects which are a crucial stage of learning processes in providing supplies and preparing students before carrying out practices in actual situations in hospitals or in communities (musiana & husein, 2015). according to benner (apriani et al., 2020), learning laboratory plays an important role in preparing nursing students before commencing clinical practices by practicing clinical skills in communication, physical examination, and nursing technical and manipulative skills. figure 1 learning proccess in a nursing laboratory of health polytechnic of palangka raya, ministry of health (moh) mailto:gaddatak@gmail.com https://dx.doi.org/10.35898/ghmj-51604 datak & sylvia ghmj (global health management journal) 2022, vol. 5, no. 1 76 the learning laboratory in the department of nursing at health polytechnic of palangkaraya (poltekkes), in particular, for a medical surgical nursing course, is mostly carried out in a nursing laboratory using phantoms and without a simulated patient. in comparison, nursing higher education in general uses the simulated patient for helping nursing students build integrated skills for better clinical practice in a transition period before commencing a clinical practice. in addition, the simulated patient is useful for enhancing clinical and conversation skills for a real patient. therefore, nursing students can understand better in relation to the real patient management. although practicing using the simulated patient has a significant number of benefits, a previous study conducted by ramadhany & khoiriyah (2011) reported that the role of simulated patients was not effective and had limitations, for instance, presentation of complaints and symptoms as well as it could not master a given scenario. one of innovative learning methods developed by medical surgical nursing lecturers is to provide actual learning experiences to nursing students by modifying learning laboratory with a nursing practice guidance, equipped with real patients in a community. the nursing practice guidance comprises a real and evidencebased learning experience and provides opportunities for students to implement their acquired skills in the laboratory under structured guidance. students were divided into several small groups consisting of eight (8) to ten (10) students, based on the most frequently encountered cases of management in palangka raya city. one of which was a case of endocrine system disorders, for example, diabetes mellitus with or without complications of foot ulcers. after going through the debriefing and briefing processes, all groups implemented the guidance on a scheduled basis, subsequently, they were assessed periodically. the implementation of the guidance in the community was applied to all students by applying a nursing care process, consisting of assessment process, formulating nursing diagnoses, compiling nursing plans, and implementing nursing evaluations. when a new case was given, a lecturer acted as a facilitator, demonstrating a direct care to a real patient. the guidance process was continued to a case discussion method which was carried out in a comfortable room (i.e. on campus or off campus). the discussion ended with future planned activities. next, one of the students practiced care management skills with guidance from the lecturer, followed by case discussions and evaluation on responses and development data which were gathered during their practices. following this, other students in the group continued nursing care on a scheduled basis until all group members demonstrated nursing care to treat patients. some examples of caring activities in a community can be seen in the following figures: figure 2 guidance in group 1 with a case study: lateral dorsum pedis left ulcer due to spines 77 ghmj (global health management journal) 2022, vol. 5, no. 1 datak & sylvia figure 3 guidance in group 2 with a case study: right digital pedis ulcer in a mother who lived alone without a family. figure 4 guidance in group 3 with a case study: injury caused by falling from a motorcycle datak & sylvia ghmj (global health management journal) 2022, vol. 5, no. 1 78 figure 5 guidance in group 4 with a case study: plantar pedis wound which did not heal for 2 years figure 6 group 5 guidance with a case study of right leg ulcers for 6 months with the risk of amputation due to refusing to be hospitalized 79 ghmj (global health management journal) 2022, vol. 5, no. 1 datak & sylvia figure 7 guidance of group 6 with a case study of a diabetic patient whose callus extended to the right plantar pedis area nursing students of the health polytechnic of palangka raya performed nursing practice, learning both in the laboratory and in the community, implementing nursing practice guidance. a subsequent learning process was carried out in health care facilities, in particular, in hospitals and primary health care centers (puskesmas) where students had wider opportunities to improve their skills under a guidance from a field expertise (figure 8). having gone through a series of learning in the laboratory, implementing the nursing pratice guidance, they had sufficient knowledge to implement direct nursing care to real patients who were treated in health care facilities to achieve learning objectives (figure 9). figure 8 learning experiences of nursing students in a hospital, following the learning process of clinical practices datak & sylvia ghmj (global health management journal) 2022, vol. 5, no. 1 80 figure 9 students demonstrated nursing care in a health care facility in conclusion, nursing practice guidance allows students, gaining experiences and increases selfconfidence when caring patients in health care facilities. references apriani, e. s., somantri, i., & pahria, t. (2020). pengalaman belajar mahasiswa keperawatan dalam mengikuti proses pembelajaran praktikum di laboratorium. journal of nursing care, 3(2), 60–70. http://journal.unpad.ac.id/jnc/article/view/20583/13409. datak, g., & febriani, i. (2020). hubungan komunikasi interpersonal perawat terhadap kepatuhan minum obat pasien diabetes melitus tipe 2. jurnal kesehatan poltekkes kemenkes ri pangkalpinang, 8(1), 56–62. musiana, & husein, h. d. (2015). persepsi mahasiswa terhadap pembelajaran praktik laboratorium di jurusan keperawatan tanjungkarang. jurnal kesehatan, vi(1), 49–55. ramadhany, n. f., & khoiriyah, u. (2011). persepsi mahasiswa terhadap peran pasien simulasi dalam ujian osce di fakultas kedokteran universitas islam indonesia. jurnal kedokteran dan kesehatan indonesia, 3(8). https://journal.uii.ac.id/index.php/jkki/article/view/6709 syahreni, e., & waluyanti, f. t. (2007). pengalaman mahasiswa s1 keperawatan program reguler dalam pembelajaran klinik. jurnal keperawatan indonesia, 11(2), 47–53. sylvia, i. e., azizah, i., manuntung, a., & datak, g. (2019). peningkatan pengetahuan pasien diabetes melitus melalui edukasi tentang katarak dengan media booklet. jurnal ilmiah permas, 9(4), 353–358. cite this article as: datak g, sylvia ei. nursing practice guidance: a practical strategy for skills’ development in nursing clinics. ghmj (global health management journal). 2022; 5(1):75-80. doi:10.35898/ghmj-51604 https://dx.doi.org/10.35898/ghmj-51604 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 risk factors of stunting in toddlers aged 24-59 months living in floating houses on the kahayan river of palangka raya city: a case-control study mars khendra kusfriyadi*, sugiyanto sugiyanto department of nutrition, poltekkes kemenkes palangka raya, indonesia *corresponding author’s email: marskhend@gmail.com doi: 10.35898/ghmj-51605 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) central kalimantan, one of the provinces in indonesia, has many tributaries that flow into kahayan river. the river has a length of 450 m 2 and a width of 100 m 2 . around the river, we can see portraits of the people and their daily activities. residential housing on kahayan river is divided into two models, namely rumah lanting or floating house (raft house), and rumah tiang or pillar houses (hamidah at al., 2014). figure 1 kahayan bridge passing over kahayan river and a row of floating houses mailto:marskhend@gmail.com https://dx.doi.org/10.35898/ghmj-51605 kusfriyadi & sugiyanto ghmj (global health management journal) 2022, vol. 5, no. 1 82 there were 342 floating houses on the river. the people use the river’s water for cooking, washing, drinking, bathing, and defecation. these activities may devastate the environmental quality around the river. poor quality environmental quality will also impact the public health , especially children. the prevalence of stunting in toddlers in central kalimantan exceeded the national average of 39.0% and in palangka raya city, it reached 29.7% (dinas kesehatan, 2018). this background suggest it already exceeded the standards of who as well (20%). thus, it must be addressed promptly with proper actions. to solve public health problems, especially stunting, cooperation across sectors and research for spatially analyzing stunting risk factors are required. community residential condition also warrants attention from the local authorities. to look further into the stunting issue, we studied stunting risk factors that may harm the community on the river. figure 2 activities around kahayan river this observational study used a case control design to find out risk factors of stunting in toddlers living in floating houses on kahayan river in palangka raya. eighty stunting toddlers aged between 24-59 months were studied. forty toddlers who lived in floating houses were treated as a case group, and 40 toddlers who lived in kahayan watersheds became a control group. figure 3 visiting floating house residence approximately for 20-30 minutes from the port 83 ghmj (global health management journal) 2022, vol. 5, no. 1 kusfriyadi & sugiyanto approximately 98% of the people lived permanently on the houses, and only 12 % lived less than a year. figure 5 floating houses as homes for fish farmers figure 6 landscape of floating houses from the boat figure 4 researcher and the floating houses kusfriyadi & sugiyanto ghmj (global health management journal) 2022, vol. 5, no. 1 84 stunting risk factors examined in this study include child, maternal, and environmental factors. the multivariate regression analysis showed the behavioral factor i.e., garbage disposal to the river was the most influential for causing stunting (or = 0.210), followed by infectious disease factor such as acute respiratory tract infections which most frequently occurred (or = 0.190), food intake (or = 0.163), fruit consumption (or = 0.029), mother’s knowledge of nutrition (or = 0.026) and education level of father (or = 0.009). figure 8 a stunting child with his mother who had lived for 20 years in the floating house figure 7 floating toilet on the river 85 ghmj (global health management journal) 2022, vol. 5, no. 1 kusfriyadi & sugiyanto figure 9 measuring toddler’s height on floating houses figure 10 researchers also measured the height of toddler parents toddlers living in floating houses were more likely to be at risk of stunting those living in the watersheds. we calculated the possibility of stunting occurrence (p) with the following formula: gd = garbage disposal into the river, id = infectious disease factor, fi = food intake, fc = fruit consumption, mk = mother’s knowledge about nutrition, fe = level education of father this model that shows stunting risk factors aligns with the models created by unicef and un and specifically portrays stunting prevalence on kahayan river. kusfriyadi & sugiyanto ghmj (global health management journal) 2022, vol. 5, no. 1 86 figure 11 research data collection by enumerators figure 12 habit of dumping garbage into rivers local government, especially the palangkaraya district health office is able to use results of this study for better policy and intervention planning to improve the nutritional status of the community around kahayan river. besides, our research gives implications for tourist area development around the river. consent participants of the research have given their consent for use of their photographs as needed in this study. all of the photographs belong to the researchers under this study. conflict of interest none. acknowledgments this study was funded by the health polytechnic of palangka raya in 2018. references bunga ch rosha, hardinsyah dan yayuk farida baliwati. 2012. analisis determinan stunting anak 0-23 bulan pada daerah miskin di jawa tengah dan jawa timur penel gizi makan. the journal nutrition and food research, 35(1):34-41. retrieved from: https://ejournal.litbang.kemkes.go.id/index.php/pgm/article/view/3081 https://ejournal.litbang.kemkes.go.id/index.php/pgm/article/view/3081 87 ghmj (global health management journal) 2022, vol. 5, no. 1 kusfriyadi & sugiyanto departemen kesehatan. 2005. rencana aksi nasional pencegahan dan penanggulangan gizi buruk 2005-2009. jakarta : depkes ri, direktorat jenderal pelayanan kesehatan. dinas kesehatan provinsi kalimantan tengah. 2018. laporan pemantauan status gizi provinsi tahun 2017.dian hani ulfani, drajat martianto, dan yayuk farida baliwati. 2011. faktor-faktor sosial ekonomi dan kesehatan masyarakat kaitannya dengan masalah gizi underweight, stunted, dan wasted di indonesia: pendekatan ekologi gizi. journal of nutrition and food, 6(1): 59–65. doi: https://doi.org/10.25182/jgp.2011.6.1.59-65 erna kusumawati, setiyowati rahardjo, hesti permata sari. 2015. model pengendalian faktor risiko stunting pada anak usia di bawah tiga tahun. jurnal kesehatan masyarakat nasional , 9(3). retrieved from. http://dx.doi.org/10.21109/kesmas.v9i3.572 firmanu cahyono, stefanus pieter manongga, intje picauly. 2016. faktor penentu stunting anak balita pada berbagai zona ekosistem di kabupaten kupang jurnal gizi pangan, 11(1): 9-18. doi: https://doi.org/10.25182/jgp.2016.11.1.%25p noor hamidah, r. rijanta bakti setiawan muh. aris marfai. 2014. kajian transportasi sungai untuk menghidupkan kawasan tepian sungai kahayan kota palangkaraya. jurnal tata loka, 16(1),1-17. retrieved from: https://www.academia.edu/48513047/ novrianti. 2016. pengaruh aktivitas masyarakat di pinggir sungai (rumah terapung) terhadap pencemaran lingkungan sungai kahayan kota palangka raya kalimantan tengah. media ilmiah teknik lingkungan, 1(2), 35-39. retrieved from: https://www.neliti.com/publications/258536/ supraptini dan dwi hapsari. 2011. status gizi balita berdasarkan kondisi lingkungan dan status ekonomi (data riskesdas 2007). jurnal ekologi kesehatan, 10 (2), 103-113. retrieved from: https://docobook.com/ cite this article as: kusfriyafi mk, sugiyanto s. risk factors of stunting in toddlers aged 24-59 months living in floating houses on the kahayan river of palangka raya city : a case-control study. ghmj (global health management journal). 2022; 5(1):81-87. doi:10.35898/ghmj-51605 https://doi.org/10.25182/jgp.2011.6.1.59-65 http://dx.doi.org/10.21109/kesmas.v9i3.572 https://doi.org/10.25182/jgp.2016.11.1.%25p https://www.academia.edu/48513047/ https://www.neliti.com/publications/258536/ https://docobook.com/ https://dx.doi.org/10.35898/ghmj-51605 template ghmj 2024 ghmj (global health management journal) 2025, vol. 8, no. 2s indonesian scholars’ alliance https://doi.org/10.35898/ghmj-82s1278 314 open access reviewer acknowledgements and editorial highlights: bridging clinical insights and public health solutions ghmj (global health management journal), volume 8, number 2s, 2025 editorial highlights this special edition of the ghmj (global health management journal) presents six diverse studies that reflect the breadth of health challenges across indonesia, addressed at the 1st cirebon international health symposium (vol.8, no.2s, 2025). from the clinical field, a study on head injury patients highlights the link between ct-scan midline shift and glasgow coma scale outcomes, offering valuable insight for emergency care (permana, royyani, & ladala, 2025). complementing this, genetic research identifies ace2 g8790a polymorphism as a potential risk factor for essential hypertension, emphasizing the importance of biomedical perspectives in understanding chronic disease (husna, nauphar, & pratamawati, 2025). at the community level, investigations reveal key determinants of leprosy treatment success (sari, risman, & affandi, 2025), highlight pediatric tuberculosis risk factors (pratama, nisaa, & ruhyana, 2025), and expose contamination in refilled drinking water (shonia, fitriani, & indrakusuma, 2025), each pointing to urgent public health and environmental concerns. meanwhile, attention to medical education is seen in a study exploring how motivation shapes professional identity among medical students, reminding us that building strong health systems begins with cultivating future professionals (mustopa, permatasari, & sulistiyana, 2025). together, these contributions showcase the journal’s commitment to advancing integrated knowledge in clinical practice, public health, and education. link to download: https://publications.inschool.id/index.php/ghmj/issue/view/cihes02s we extend our heartfelt appreciation to the reviewers who have played a crucial role in refining and enhancing these works. editor-in-chief prof. andrew john macnab managing editors doni marisi sinaga, m.sc. kukuh madyaningrana, m.biotech. ph.d. journal managers suyitno, m.phm maretalinia, m.a, ph.d. reviewers  dr. witri pratiwi, m.kes. (universitas swadaya gunung jati, indonesia)  putu erma pradnyani, s.km., m.kes. (universitas pembangunan nasional veteran, indonesia)  piti anontapant, ph.d (cand.) (ramkhamhaeng university, thailand)  dr. drg. theresia puspitawati, m kes. (universitas respati yogyakarta, indonesia)  dr. vivi meidianawaty, m.meded (universitas swadaya gunung jati, indonesia)  supim wongtongtair, ph.d. (srinakharinwirot university, thailand) eligible reviewers may be considered for future roles on our editorial board, and receive exclusive publishing opportunity and the chance to publish guest editorial papers at no cost. simply register on our website and select the "reviewer" option during sign-up. https://doi.org/10.35898/ghmj-82s1278 https://publications.inschool.id/index.php/ghmj/index https://publications.inschool.id/index.php/ghmj/announcement/view/32 https://publications.inschool.id/index.php/ghmj/announcement/view/32 https://publications.inschool.id/index.php/ghmj/issue/view/cihes02s https://publications.inschool.id/index.php/ghmj/article/view/1241 https://publications.inschool.id/index.php/ghmj/article/view/1231 https://publications.inschool.id/index.php/ghmj/article/view/1238 https://publications.inschool.id/index.php/ghmj/article/view/1238 https://publications.inschool.id/index.php/ghmj/article/view/1228 https://publications.inschool.id/index.php/ghmj/article/view/1224 https://publications.inschool.id/index.php/ghmj/article/view/1237 https://publications.inschool.id/index.php/ghmj/article/view/1237 https://publications.inschool.id/index.php/ghmj/issue/view/cihes02s https://www.researchgate.net/profile/andrew_macnab https://publications.inschool.id/index.php/ghmj/section/view/guest-editorial https://www.inschool.id/publications/index.php/ghmj/user/register https://orcid.org/0000-0002-4904-881x https://orcid.org/0000-0003-1634-6949 https://orcid.org/0000-0002-6817-7852 https://orcid.org/0000-0003-0250-7721 https://orcid.org/0000-0001-8714-9198 https://orcid.org/0000-0001-6827-2764 https://orcid.org/0000-0002-9698-8572 https://orcid.org/0000-0002-7816-6081 ghmj (global health management journal) 2025, vol. 8, no. 2s indonesian scholars’ alliance 315 acceptance rate : 33 % days to first editorial decision : 18 days days to accept : 55 days published: 21 august 2025 references husna, n., nauphar, d., & pratamawati, t. m. (2025). angiotensin converting enzyme 2 (ace2) g8790a gene polymorphism as a risk factor for essential hypertension. ghmj (global health management journal), 8(2s), 285–292. https://doi.org/10.35898/ghmj-82s1231 mustopa, m. s. m., permatasari, t. o., & sulistiyana, c. s. (2025). correlation between motivation and professional identity of medical students of universitas swadaya gunung jati, cirebon, indonesia. ghmj (global health management journal), 8(2s), 304–313. https://doi.org/10.35898/ghmj-82s1237 permana, a., royyani, n., & ladala, e. w. (2025). correlation between head midline shift ct-scan with glasgow coma scale in head injury patient at waled general hospital, cirebon, indonesia. ghmj (global health management journal), 8(2s), 259–266. https://doi.org/10.35898/ghmj-82s1241 pratama, a. s., nisaa, d. r., & ruhyana, n. (2025). relationship analysis of risk factors concerning the incidence of pulmonary tuberculosis in children at panti abdi dharma hospital, cirebon, indonesia. ghmj (global health management journal), 8(2s), 293–303. https://doi.org/10.35898/ghmj-82s1228 sari, a. n., risman, m., & affandi, t. t. (2025). the influence of internal factors on the success of leprosy treatment at cibuaya health center, indonesia. ghmj (global health management journal), 8(2s), 267– 274. https://doi.org/10.35898/ghmj-82s1238 shonia, a. n., fitriani, h., & indrakusuma, m. e. (2025). examination of coliform and escherichia coli contamination in refilled drinking water in cirebon regency, indonesia. ghmj (global health management journal), 8(2s), 275– 284. https://doi.org/10.35898/ghmj-82s1224 cite this article as: ghmj (global health management journal). (2025). reviewer acknowledgements and editorial highlights: bridging clinical insights and public health solutions ghmj (global health management journal), volume 8, number 2s, 2025. ghmj (global health management journal), 8(2s), 314–315. https://doi.org/10.35898/ghmj-82s1278 https://doi.org/10.35898/ghmj-82s1231 https://doi.org/10.35898/ghmj-82s1237 https://doi.org/10.35898/ghmj-82s1241 https://doi.org/10.35898/ghmj-82s1228 https://doi.org/10.35898/ghmj-82s1238 https://doi.org/10.35898/ghmj-82s1224 https://doi.org/10.35898/ghmj-82s1278 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 peatland coffee: potential export commodity from dayak’s land agnescia clarissa sera*, prisilia oktaviyani department of nutrition, poltekkes kemenkes palangka raya, indonesia *corresponding author’s email: agnesciasera@gmail.com; agnesciasera@poltekkes-palangkaraya.co.id doi: 10.35898/ghmj-51590 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) coffee is one of indonesia's leading export commodities which made indonesia the fourth largest coffee exporting country in the world (lisdayanti & anwar, 2018; sunarharum, fibrianto, yuwono & nur, 2019). this is inseparable from the historical story of dutch colonialism in the 17 th century where coffee seeds brought from malabar (india) were planted on java island. they were of very good quality compared to those cultivated in europe. therefore, to meet the increasing demand for coffee from europe, the colonial dutch expanded the coffee plantation areas to sumatra, sulawesi, and bali islands (tim karya mandiri, 2018). in kalimantan (aka borneo island), the coffee crop was introduced in the 1980s by javanese transmigrants. figure 1 peatland coffee cultivated in gandang barat village, pulang pisau regency, central kalimantan. mailto:agnesciasera@gmail.com mailto:agnesciasera@poltekkes-palangkaraya.co.id https://dx.doi.org/10.35898/ghmj-51590 https://www.google.co.id/search?tbo=p&tbm=bks&q=inauthor:%22wenny+bekti+sunarharum%22 https://www.google.co.id/search?tbo=p&tbm=bks&q=inauthor:%22kiki+fibrianto%22 https://www.google.co.id/search?tbo=p&tbm=bks&q=inauthor:%22mokhamad+nur%22 sera & oktaviyani ghmj (global health management journal) 2022, vol. 5, no. 1 2 in central kalimantan province, gandang barat village is one of the most famous peat coffee-producing villages. this village is located in pulang pisau regency. though its vegetation is dominated by peatlands, coffee can still grow and have a unique taste. there are two types of coffee cultivated in central kalimantan, namely robusta and liberica. as the name implies, robusta coffee (coffea canephora) is known as robust coffee against pests and hostile environments (tim karya mandiri, 2018). the size of robusta coffee beans is smaller, therefore the local farmers call it “kopi kecil” (small coffee beans). however, it has a strong bitter taste than arabica coffee (coffea arabica) because it contains more caffeine (chindapan, soydok & devahastin, 2019). on the other hand, liberica coffee (coffea liberica) beans are larger, therefore they are known as „kopi besar‟ (bigger coffee beans). due to its predominant sour taste, coffee lovers identified its taste to be vegetablelike taste (duaja, simatupang & kartika, 2019). central kalimantan is one of the three producing regions of liberica coffee in indonesia. both robusta and liberica coffees can grow on peatlands due to their characteristics that are easy to grow in lowlands (no higher than 200 m) with high humidity levels (martini, riyandoko & roshetko, 2017). according to the indonesian ministry of agriculture, 2,828 hectares of the central kalimantan area have been planted with coffee (kementerian pertanian, 2020). unfortunately, until now there has been no calculation of the annual coffee production capacity in gandang barat village (badan restorasi gambut, 2018). in gandang barat village, coffee production can be managed individually or in groups. one of the coffee businesses groups that have received government support is "kelompok usaha kopi bersama bisa", founded in 2018. this group consists of 7 women and is assisted by a farmer group facilitator from badan restorasi gambut (peat restoration agency). figure 2 robusta coffee, also known as 'kopi kecil' 3 ghmj (global health management journal) 2022, vol. 5, no. 1 sera & oktaviyani this coffee business group accommodates around 30 coffee farmers with an average production of around 500 kg of green coffee beans annually. because this coffee business group is well managed and offers a more reasonable price, most of the coffee farmers in gandang village have no longer sell their coffee to middlemen. the main products of this business group are roasted coffee and ground coffee with the sahep gadabar brand name. sahep means peatland in the local language, while gadabar stands for gandang barat, their village. figure 3 liberica coffee, also known as "kopi besar" figure 4 from left to right: ms. kurnia (the facilitator), mrs. agnescia (the author), mrs. pur (the treasurer), mrs. iin (the leader of coffee business group) sera & oktaviyani ghmj (global health management journal) 2022, vol. 5, no. 1 4 figure 5 sahep gadabar roasted bean and ground coffee over the past two years, this group has been supplying coffee beans to several cafes and small enterprises in the central and south kalimantan regions. besides, loyal customers from java, sumatra, and sulawesi also love the unique taste of peatland coffee. one of the small business owners who use this peat coffee raw material is mrs. heni. mrs. heni mixes peat coffee with native dayak herbs, including bawang dayak (eleutherine bulbosa), sintuk madu (cinnamomum sintoc), and pasak bumi / longjack (eurycoma longifolia). these native herbs are believed to provide health benefits for their consumers (yuanita, sunarti, wahyuni & suthama, 2019; hendrawan, herdiningsih, maharani & hawa, 2019; khanijo & jiraungkoorskul, 2016). those types of coffee produced by mrs. heni were branded as copasme. figure 6 mrs. heni described her product (mixture of ground peatland coffee and longjack) to mrs. prisilia (the second author) apart from adding to the selling value, peat coffee which is innovated with local herbs is certainly a special attraction for consumers. this is actually a huge potential that can be explored more deeply and has the opportunity to become an export product. however, of course, further research is needed especially to provide health claims that may be offered from these local products. on top of that, the important thing in developing the potential of peatland coffee to become an export commodity is by building a sustainable certification system (ibnu, offermans & glasbergen, 2018). therefore, synergistic cooperation between the government, business owners, coffee farmers, investors, and related sectors is strongly needed. 5 ghmj (global health management journal) 2022, vol. 5, no. 1 sera & oktaviyani 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. acknowledgments the authors wish to thank mrs. heni (ibu arya), mrs. iin and mrs. pur (the sahep farmer group), ms. kurnia (farmer group facilitator from badan restorasi gambut / peat restoration agency) and mbah sutrismi (one of the coffee farmers) for their hospitality and generosity in sharing their knowledge and experience when the authors visited the project site at desa gandang barat, pangkoh v, pulang pisau regency, central kalimantan. references badan restorasi gambut. (2018). profil desa peduli gambut, desa gandang barat, kecamatan maliku, kabupaten pulang pisau, provinsi kalimantan tengah. http://brg.go.id/wp-content/uploads/2019/03/fix-gandang-baratmaliku-pulang-pisau.pdf. chindapan, n., soydok, s. & devahastin, s. (2019). roasting kinetics and chemical composition changes of robusta coffee beans during hot air and superheated steam roasting. journal of food science, 84(1), 292-302, doi:10.1111/1750-3841.14422. duaja, m.d., simatupang, j. & kartika, e. (2019). strengthening group: entrepreneurship reorientation toward the development of liberica coffee. iop conference series: earth and environmental science, 391(1), doi: 10.1088/1755-1315/391/1/012060. hendrawan, y., herdiningsih, e.h., maharani, d. m. & hawa, l.c. (2019). effect of ultrasonic-assisted extraction on dayak onion powder extraction (eleutherine palmifolia). iop conference series: earth and environmental science, 475(1), doi: 10.1088/1755-1315/475/1/012015. ibnu, m., offermans, a. & glasbergen, p. (2018). certification and farmer organization: indonesian smallholder perceptions of benefits, bulletin of indonesian economic studies, 54(3), 387415, doi: 10.1080/00074918.2018.1506093. kementerian pertanian. (2020). luas areal kopi menurut provinsi di indonesia, 2016-2020. https://www.pertanian.go.id/home/index.php?show=repo&filenum=227. khanijo, t., & jiraungkoorskul, w. (2016). review the ergogenic effect of long jack (eurycoma longifolia). pharmacognosy reviews, 10(20), 139–142. retrieved from https://doi.org/10.4103/09737847.194041. lisdayanti, a. & anwar, t.a. (2018). increasing public awareness of consuming indonesian coffee through electronic marketing. iop conference series: earth and environmental science, 164(1), doi:10.1088/17551315/164/1/012019. martini, e., riyandoko, roshetko, j.m. (2017). guidelines for establishing coffee-agroforestry systems, world agroforestry center, retrieved from https://library.sweetmarias.com/wp-content/uploads/2020/08/guidelinesfor-establishing-coffee-agroforestry-systems.pdf sunarharum, w.b., fibrianto, k., yuwono, s.s., & nur, m. (2019). sains kopi indonesia. malang: universitas brawijaya press. tim karya mandiri. (2018). rahasia sukses budidaya kopi: membudidayakan kopi berstandar internasional. bandung: nuansa aulia. yuanita, i., sunarti, d., wahyuni, h. i. & suthama, n. (2019). feeding dayak onion (eleutherine palmifolia) extract and lactobacillus acidophilus mixture on blood biochemicals, meat quality characteristics, and growth performance in broiler chickens. livestock research for rural development, 31(144). retrieved from http://www.lrrd.org/lrrd31/9/yuanit31144.html cite this article as: sera ac, oktaviyani p. peatland coffee: potential export commodity from dayak‟s land. ghmj (global health management journal). 2022; 5(1):01-05. doi:10.35898/ghmj-51590 http://brg.go.id/wp-content/uploads/2019/03/fix-gandang-barat-maliku-pulang-pisau.pdf http://brg.go.id/wp-content/uploads/2019/03/fix-gandang-barat-maliku-pulang-pisau.pdf https://doi.org/10.1111/1750-3841.14422 https://iopscience.iop.org/journal/1755-1315 https://iopscience.iop.org/journal/1755-1315 https://iopscience.iop.org/journal/1755-1315 https://doi.org/10.1080/00074918.2018.1506093 https://www.pertanian.go.id/home/index.php?show=repo&filenum=227 https://doi.org/10.4103/0973-7847.194041 https://doi.org/10.4103/0973-7847.194041 https://iopscience.iop.org/journal/1755-1315 https://library.sweetmarias.com/wp-content/uploads/2020/08/guidelines-for-establishing-coffee-agroforestry-systems.pdf https://library.sweetmarias.com/wp-content/uploads/2020/08/guidelines-for-establishing-coffee-agroforestry-systems.pdf https://www.google.co.id/search?tbo=p&tbm=bks&q=inauthor:%22wenny+bekti+sunarharum%22 https://www.google.co.id/search?tbo=p&tbm=bks&q=inauthor:%22kiki+fibrianto%22 https://www.google.co.id/search?tbo=p&tbm=bks&q=inauthor:%22mokhamad+nur%22 http://www.lrrd.org/lrrd31/9/yuanit31144.html https://dx.doi.org/10.35898/ghmj-51590 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 (re)visiting the recommendations of joint committee on reducing maternal and neonatal mortality performance in rural areas in central kalimantan, indonesia oktaviani oktaviani*, riny natalina department of midwifery, poltekkes kemenkes palangka raya, indonesia *corresponding author’s email: oktaviani@poltekkes-palangkaraya.co.id doi: 10.35898/ghmj-51600 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) maternal mortality rate (mmr) and infant mortality rate (imr) are the success indicators of health sector development. based on indonesia's health profile in 2019, aki during the 1991-2015 period has decreased from 390 to 305 per 100,000 live births (kemenkes ri, 2019). despite the downward trend in mmr, it has not yet reached the millennium development goals target in 2015 of 102 per 100,000 live births (standar profesi bidan, 2020b). the decline of mmr and imr is carried out with various efforts including improving access and quality of services through increasing the capacity of health workers, health insurance, and improving the outreach of services mainly for the remote. recent statistics show that the population of large midwives continues to grow since 1989 when the indonesian government launched a midwifery education rapid training program to improve access to basic midwifery services in the villages. figure 1 poltekkes kemenkes palangka raya infrastructure development to sustain a healthcare education and training (courtesy: poltekkes kemenkes palangka raya) mailto:oktaviani@poltekkes-palangkaraya.co.id https://dx.doi.org/10.35898/ghmj-51600 oktaviani & natalina ghmj (global health management journal) 2022, vol. 5, no. 1 52 in general, programs are developed to provide adequate support for maternity care at the level needed to save maternal and newborn lives in indonesia, particularly in rural communities in central kalimantan. subsequently, another setback emerged as the sars-cov2 stroke in early 2020, a global pandemic. as we move along, the joint committee on reducing maternal and neonatal mortality in indonesia of the u.s. national academy of sciences and the indonesian academy of sciences in 2013, has suggested eight recommendations designed to guide future efforts to reduce maternal and neonatal mortality in indonesia (joint committee on reducing maternal and neonatal mortality, 2013). (a) (b) figure 2 a snapshot comparison between pregnancy in rural (a) and municipal (b) in terms of tools and equipment; yet the standardize health protocol are in place carolins (a); amalia septiani (b) we would like to address six out of eight recommendations since we could not provide recommendation #5 (financing) and #6 (data), yet to provide a critical portrait of what are many dedicated midwives faces these days yet provide a critical portrait of what many dedicated midwives face these days. recommendation 1—facilities we emphasized that basic emergency care for obstetrics and newborns is in place. one can witness elsewhere, the so-called puskesmas, gradually managing their performance as well as their accreditation. recommendation 2—strategies and plans indonesia’s districts vary widely in population density, personal wealth, and numbers of doctors and other health workers, as well as in unalterable features such as isolation, island geography, and transport difficulties. as for rural areas in central kalimantan, some puskesmas are also equipped with ambulance, in case of admittance to municipal hospital. recommendation 3—system of care the organization of this system of care will be adequately followed by standardization of the training and licensing of providers. there are numerous programs have developed to guarantee the health worker’s capacities, such as competency tests as well as professional ethics (standar profesi bidan, 2020a). the government is suggested to acknowledge stakeholders and public demand employing equally distributed competent doctors, nurses, and midwives throughout regions (yuningsih, 2014). 53 ghmj (global health management journal) 2022, vol. 5, no. 1 oktaviani & natalina figure 3 a woman is admitted to regency hospital due to complications in pregnancy recommendation 4—training as previously described those recent statistics have shown midwives population continues to grow, major turnover was also incorporated into education both infrastructure and curriculum (standard profesi bidan, 2020a). as per the development program, more specifically, puskesmas, there are numerous criteria to meet and fulfill their role in the community, including community involvement and empowerment. (a) (b) figure 4 training on midwifery update (a) and pregnant women (b) addressing rural bonding midwife’s performance in central kalimantan (courtesy: authors) recommendation 7—community involvement and recommendation 8—education and empowerment oktaviani & natalina ghmj (global health management journal) 2022, vol. 5, no. 1 54 (a) (b) figure 5 health takers along with the mother practicing 20 seconds rules of handwashing to children (a) a midwife on duty has been explaining reproduction and public health to teenagers; notice that her mother has accompanied her (b) (courtesy: tiana kaleluni) moreover, the adequacy of antenatal care was also a prominent factor, including the number and timing of visits, as well as the content of services. nevertheless, we also notice that willingness of pregnant woman having to interact with healthcare in rural areas are determined by numerous factors, such as traditional birth attendance, taboo (agus et al., 2012; christiana et al., 2010; withers et al., 2018). we witness a young pregnant woman having washed their clothes. these are conditions that contradict the physical activities (pa) that should be avoided during pregnancy (pearce et al., 2013). some research findings suggest beneficial of pa, but somehow, the activity should measure and regularly evaluated by physicians (harrison et al., 2011; pearce et al., 2013). also, as pictured, her appearance was indicating anemia symptoms such as inactive mobility as well as daydreaming (lebso et al., 2017; scott & pritchard, 1974; soundarya, 2016). all these factors could lead to a complication during delivery. a regular home visit shall be conducted to prevent such complications. a capacity to draw early detection can save both mother and her fetus. figure 6 physical workout for elder woman (courtesy: eka mentari) figure 7 a pregnant woman with her mother having checked during the home visit (courtesy: vety marsela) 55 ghmj (global health management journal) 2022, vol. 5, no. 1 oktaviani & natalina (a) (b) figure 8 pregnant women, (a) washed her family clothes; notice its capacity next to her (courtesy: sonetawati) and (b) washed kitchenware after meals (courtesy: erfina) a taboo on diets, the nutrition supply of pregnant women was also an adequate factor to address (putri & yunita, 2020; martin-gronert & ozanne, 2006). we also would like to draw attention to reproductive health and teenage pregnancy (indarti et al., 2020; shrestha, 2012). overall, we can conclude that there are currently both positive and negative aspects associated with the performance of the recommendations. some major developments are already taking place, but there is also a counter-productive behavior of many pregnant women in rural areas. we hope that the pandemic, as we said earlier, a setback, will also represent a major leap in indonesia's health performance shortly. figure 9 a midwife in a regular home visit (courtesy: yohana verawati) oktaviani & natalina ghmj (global health management journal) 2022, vol. 5, no. 1 56 figure 10 sectio caesarian team address their salutation to communities, stay strong and motivated during sars-cov2 pandemic (courtesy: siti chodarsiah) consent all photographs, pregnant women, communities are subjected to informed consent. all information related is identifiable and well-documented. acknowledgments the authors would like to thank public relations division of politeknik kesehatan kemenkes palangkaraya, to share its building photograph. to all bonding-midwives in rural areas, erfina (desa kayu bulan); carolins floria hartsi (hulu tampang); amalia septiani (palangka raya), eka mentari (buntok baru), sonetawati (kudangan), yohana verawati, and tiana kaleluni (juju baru, lahei) who contributes not only photograph but also conducting a prior consent with this work. also, birth attendance who are willing to share their strong commitment during pandemic covid-19, siti chodarsiah (palangka raya) with her sc team. references agus, y., horiuchi, s., porter, s.e. (2012). rural indonesia women’s traditional beliefs about antenatal care. bmc res notes, 5. evenson, k.r., barakat, r., brown, w.j., dargent-molina, p., haruna, m., mikkelsen, e.m., et al. nih public access. american journal of lifestyle medicine, 8(2), 102–21. harrison, c.l., thompson, r.g., teede, h.j., lombard, c.b. (2011) measuring physical activity during pregnancy. international journal of behavioral nutrition and physical activity,8, 1–8. indarti, j., al fattah, a.n., dewi, z., hasani, r.d.k, mahdi, f.a.n., surya, r. (2020). teenage pregnancy: obstetric and perinatal outcome in a tertiary centre in indonesia. obstetrics and gynecology international, 2020. https://doi.org/10.1155/2020/2787602 joint commitee on reducing maternal and neonatal mortality. (2013). reducing maternal and neonatal mortality in indonesia: saving lives, saving the future. reducing maternal and neonatal mortality in indonesia: saving lives, saving the future. washington dc: the national academic press. available from: http://www.nap.edu kemenkes ri. (2020). standar profesi bidan. jakarta: kemenkes ri. retrieved from https://www.ibi.or.id/id/article_view/d20200724001/kepmenkes-320-tahun-2020-tentang-standar-profesibidan.html. lebso, m., anato, a., loha, e. (2017). prevalence of anemia and associated factors among pregnant women in southern ethiopia: a community based cross-sectional study. plos one, 12(12):1–11. martin-gronert, m.s., ozanne, s.e. (2006). maternal nutrition during pregnancy and health of the offspring. https://doi.org/10.1155/2020/2787602 57 ghmj (global health management journal) 2022, vol. 5, no. 1 oktaviani & natalina biochemical society transactions, 34(5):779–82. pearce, e.e., evenson, k.r., downs, d.s,, steckler, a. (2013). strategies to promote physical activity during pregnancy. american journal of lifestyle medicine. 7(1), 38–50. putri, s.i, yunita, a. (2020). food taboos with socioeconomic status during pregnancy in west kalimantan, indonesia. al-sihah: the public health science journal, 12(2), 219–31. scott, d.e., pritchard, j.a. (1974). anemia in pregnancy. clinics in perinatology, 1(2), 491–506. shrestha, a. (2012). teenage pregnancy in nepal: consequences, causes and policy recommendations. kit (royal tropical institute)/vrije universiteit amsterdam, 2012. soundarya, n.s.p. (2016). a review on anaemia –types, causes, symptoms and their treatments. the international journal of science and engineering investigations, 1(1), 10–7. retrieved from: https://www.researchgate.net/publication/324247750_a_review_on_anaemia__types_causes_symptoms_and_their_treatments titaley, c.r., hunter, c. l., dibley, m.j., peter, h. (2010). why do some women still prefer traditional birth attendants and home delivery?: a qualitative study on delivery care services in west java province, indonesia. bmc pregnancy childbirth,10(43). retrieved from: http://ovidsp.ovid.com/ovidweb.cgi?t=js&page=reference&d=medl&news=n&an=20701762 withers, m., kharazmi, n., lim, e. (2018). traditional beliefs and practices in pregnancy, childbirth and postpartum: a review of the evidence from asian countries. midwifery, 56, 158–70. retrieved from: https://doi.org/10.1016/j.midw.2017.10.019. yuningsih, r. (2014). undang-undang tenaga kesehatan health policy triangle analysis in the forming of health workforce act rahmi yuningsih. 2014;5:93–106. cite this article as: oktaviani o, natalina r. (re)visiting the recommendations of joint committee on reducing maternal and neonatal mortality performance in rural areas in central kalimantan, indonesia. ghmj (global health management journal). 2022; 5(1):51-57. doi:10.35898/ghmj-51600 https://dx.doi.org/10.35898/ghmj-51600 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 effect of professional nursing practice model training (mpkp) with the implementation of pillar iv nursing care delivery system (pillar iv ncds) at a hospital in kotamobagu, indonesia tri ismu pujiyanto, helkim sarino laode manika*, rita dewi department of community health nursing, universitas karya husada, semarang, indonesia *corresponding author’s email: helkimmanika123@gmail.com doi: 10.35898/ghmj-61934 abstract background: professional nursing practice model training (model praktik keperawatan profesional; mpkp) is one of the efforts to improve the quality of service in hospitals in nursing services to minimize errors or omissions that can occur. the training carried out is expected to be able to improve the implementation of pillar iv ncds in hospitals. aims: this study aimed to determine the effect of mpkp training with the application of pillar iv ncds at the general hospital of the evangelical masehi church bolaang mongondow monompia kotamobagu. methods: this research is a quantitative research type with a pre-experimental research design one group pre-test post-test design. this research was conducted in august 2022 as many as 52 nurse respondents working at the monompia gmibm hospital kotamobagu. results: from the survey, it shows that the intervention will increase the number of nurses implementing the pillar iv nursing care delivery system (pillar iv ncds) including the assessment element (from 76.9% to 90.4%), nursing diagnosis (from 36.5% to 75.0%), planning (from 51.9% to 88.5%), action or measurement (from 84.6% and 92.3%), evaluation (from 46.2% to 90.4%), and nursing care notes (78.8% and 98.1%). there are differences in the implementation of pillar iv ncds before and after being given mpkp training (p-value: <0.001). it is known that education level and the work experience of the nurses will significantly determine the success of the training, respectively with p value of <0.001 and 0.004. conclusion: from the survey, we may note how the professional nursing practice model training (mpkp) affecting the number of nursing implementing the pillar iv ncds. data from the results can be used as recommendation to the hospitals’ human resources department in designing their program in order to increase the nurses’ competences. keywords: professional nursing practice model training, nursing care delivery system, hospital management received: 10 november 2022; revised: 15 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 the hospital is an integral part of a social and health organization with the function of providing complete services (comprehensive), disease healing (curative), and disease prevention (preventive) in the community (scovell, 2010). concerning hospital is a health service institution that provides https://doi.org/10.35898/ghmj-61934 29 ghmj (global health management journal) 2023, vol. 6, no. 1 pujiyanto, manika, & dewi comprehensive and complete health services for individuals by providing inpatient, outpatient, and emergency services (mogopa et al., 2017). professional services as an integral part of health services based on nursing knowledge and tips aimed at individuals, families, groups, or communities both healthy and sick with the support of successful implementation policies governing procedures and related treatment room management (mpkp) (erickson & ditomassi, 2011). improving the quality of nursing care requires restructuring, reengineering, and redesigning through mpkp so that the success of services and the application of nursing care to patients will be professional (pramono et al., 2022). the only well-executed mpkp stages were team formation and handovers (amir et al., 2020). meanwhile, pre-conference, post-conference, and nursing rounds were not carried out properly which could affect the application of professional values to patients and families (meade et al., 2006). regarding the influence of mpkp on the performance of team leader service management in inpatients, showing a significant difference in the performance of mpkp service management in planning, directing, and supervising while organizing there is no significant difference before and after receiving mpkp training (arisanti et al., 2018). the application of mpkp is developed based on nursing activities which consist of five main pillars, namely management approach, compensatory reward, professional relationship, professional value, patient care delivery system (amir & ningsih, 2022). using the nursing theory of peplau's interpersonal relationship model, the concept of the nursing paradigm has four pillars, namely human, environment, nursing, and health, which are integrated through four relationship phases, orientation phase, identification phase, exploitation phase, and resolution phase (alligood, 2017). the nurses had the ability according to their roles to be successful in providing professional services, providing comfort, and nurses being more caring and more experienced in their fields according to the management of the after-got care room management training (mpkp) (wasaya et al., 2021). the preliminary study was conducted in april may 2022 by observing and interviewing the head of the room. it is known from the results of the initial study that each inpatient room has installed a vision, mission, and philosophy of the nursing field and organizational structure. however, the management approach and patient care delivery at the monompia gmibm hospital kotamobagu have not been structured and have not been effective. short-term policies and plans have not been achieved. the implementation of the team method in nursing is still functional. in addition, personnel mapping related to the degree of client dependence is not appropriate in every inpatient room. the management of the treatment room has not been structured in every room so that nurses have not carried out nursing actions by standard operating procedures (sops). based on interviews and observations of implementing nurses related to the motivational climate as much as 40%, giving praise as much as 56%, giving motivation as much as 40%, the delegation has not been in accordance with procedures, supervision has not run effectively and the function of controlling quality indicators has been running as much as 55%, audit documentation has carried out every month but there are no extension program unit (sap) / nursing care guidelines (pak) in each inpatient room. the results of the documentation format that are filled in are 90% completeness of the assessment, 70% nursing diagnoses, 70% nursing plans, 70% implementation, and 70% evaluation with a target of 90% documentation completeness, the satisfaction survey of the tools used already exist but the results of the achievements have not been socialized in each room, a survey of health and nursing problems has not been carried out by the person in charge of the room. the results of interviews conducted with clinical case managers regarding the implementation of mpkp at the monompia gmibm hospital kotamobagu, it is known that the nursing sector has policies and sops in accordance with hospital accreditation provisions. these policies and sops have not been socialized so every nurse in their implementation has different perceptions. most nurses have not attended mpkp training and education. the mission is to develop holistic health services based on love, to provide optimal health services in accordance with hospital standards, to improve the competence and professionalism of hospital pujiyanto, manika, & dewi ghmj (global health management journal) 2023, vol. 6, no. 1 30 human resources, and to realize fast and quality services. the above phenomenon encourages researchers to find out the effect of mpkp training on pillar iv of the nursing care delivery system (ncds) at the monompia gmibm hospital kotamobagu". 2. methods this research is a type of quantitative research with a pre-experimental one-group pre-test post-test design to look for the possibility of a change in perception in the form of training on mpkp against pillar iv ncds. the flow of research implementation can be seen in the following scheme (figure 1) : note: r : group of respondent o1: pillar iv of ncds before training on mpkp o2: pillar iv of ncds after training on mpkp. x: mpkp training. figure 1. research scheme: one group pre-test post-test research design the population in this study was nurses at monompia hospital gmibm kotamobagu who served in inpatient installations. the total number of nurses is 110 people. the sample in this study was 52 nurses. this sampling technique is purposive sampling. the samples in this study were the head of the room, the team leader, and implementing nurses in the inpatient room at the monompia hospital gmibm kotamobagu. the research has been carried out from may to july 2022 after obtaining a research permit from karya husada university, semarang. this research tool uses a questionnaire consisting of 3 parts, namely demographic data, mpkp implementation training, and pillar iv ncds. pillar iv ncds is methods of providing nursing care, such as case, functional, team, and primary nursing methods, and case management. so the practice of professional nursing is the most possible method of providing professional nursing care. mpkp training is a learning process through the training given to implementing nurses about mpkp in hospitals. the results of this study will be analyzed using univariate and bivariate methods using the spss version 15 application. 3. results respondent characteristics from table 1, it is shown that most of the participants were nurses at the age of 26-35 years as much as 86.5%. the majority nurses were female (90.4%) and it is noted that at the monompia hospital gmibm kotamobag, only one of tenth are male nurses. the education level is relatively not varied, with 90.4% of the nurses graduated only from diploma (diii kep/keb). from the survey, it is known that more than half of nurses are in charge for 3-5 years (pk 2), and only 26.9% can be considered in senior level (length of work more than 5 years). pre-test first experiment intervention of the training post-test last experiment experiment group (o1) (x) (o2) r 31 ghmj (global health management journal) 2023, vol. 6, no. 1 pujiyanto, manika, & dewi table 1. the general characteristics of the respondents implementation of pillar iv ncds before and after the training from the survey, we may note how the professional nursing practice model training (mpkp) affecting the number of nursing implementing the pillar iv ncds. table 2 shows that the intervention will increase the number of nurses implementing the assessment element (from 76.9% to 90.4%), nursing diagnosis (from 36.5% to 75.0%), planning (from 51.9% to 88.5%), action or measurement (from 84.6% and 92.3%), evaluation (from 46.2% to 90.4%), and nursing care notes (78.8% and 98.1%). the record shows that the training highly increases the number of nurses to do nursing diagnoses in order to implementing the pillar iv nursing care delivery system (pillar iv ncds). table 2. distribution of implementation of pillar iv ncds for before and after training variables frequency percentage (%) age (years) 17-25 3 5.8 26-35 45 86.5 36-45 4 7.7 >45 0 0.0 sex male 5 9.6 female 47 90.4 education diploma 47 90.4 bachelor/profession 5 9.6 length of work (years) 1 < 3 7 13.5 3-5 31 59.6 >5 14 26.9 doing pillar iv ncds pre-test post-test frequency % frequency % assessment no 12 23.1 5 9.6 yes 40 76.9 47 90.4 nursing diagnoses no 33 63.5 13 25.0 yes 19 36.5 39 75.0 planning no 25 48.1 6 11.5 yes 27 51.9 46 88.5 action no 8 15.4 4 7.7 yes 44 84.6 48 92.3 evaluation no 28 53.8 5 9.6 yes 24 46.2 47 90.4 nursing care notes no 11 21.2 1 1.9 yes 41 78.8 51 98.1 pujiyanto, manika, & dewi ghmj (global health management journal) 2023, vol. 6, no. 1 32 how respondents’ characteristics affecting to the implementation of the pillar iv ncds from the set of questionnaires distributed to the participants, we may learn how significant the respondents’ characteristics (age, sex, education, and length of work) were affecting the implementation of the pillar iv ncds in the respondents, as shown in table 3. from a statistical analysis chi-square test, it is noted age and years are not the significant factors (p>0.05) in determining the success of implementing the standard to the nurses. however, it is known that education level and the work experience of the nurses will significantly determine the success of the training, respectively with p value of <0.001 and 0.004. table 3. the relationship of characteristics to the implementation of pillar iv ncds variables pillar iv ncds p-value no yes freq. % freq. % age (years) 0.131 17-25 2 66.7 1 33.3 26-35 8 17.8 37 82.2 36-45 1 25.0 3 75.0 sex 0.057 male 3 60 2 40 female 8 17 39 83.1 education <0.001 diploma 10 76.9 3 23.1 bachelor/profession 1 2.6 38 97.4 length of work (years) 0.004 1 < 3 4 57.1 3 42.9 3-5 2 6.5 29 93.5 >5 5 35.7 9 64.3 based on table 4 below, it can be seen that the difference in the implementation of pillar iv ncds before and after being given mpkp training at the monompia gmibm hospital kotamobagu, namely the mean value: sd before (74.5±20.1) and the mean: sd value after (88.9±15.9). min-max before (0.00-100.0) and min-max after (25.0-100.0). the p-value is 0.000 (p-value <0.05) which indicates that there is a difference in the implementation of pillar iv of the nursing care delivery system before and after being given mpkp training. table 4. differences in the implementation of pillar iv ncds before and after training 4. discussion the relationship between job satisfaction and turnover intention the results showed that the characteristics of nurses at the monompia hospital gmibm kotamobagu were 86.5% aged 26-35 years. age is related to a person's maturity as a person gets older, his technical and psychological skills also increase and show mental maturity (hogan & roberts, 2004). the young adult age group has the characteristics of identifying social and work roles, experiencing stress related to changing roles and trying to cope with these stressors, experiencing conflict related to role demands, and having an interest in finding their identity and personality (croes & bartels, 2021). age < 35 years in nurses is the stage where a nurse wants to compete and complete to form a good performance in the workplace (quek et al., 2021). variable mean±sd min -max se p-value pillar iv ncds before 74.5±20.1 0.00 -100.0 2.78 <0.001 after 88.9±15.9 25.0 – 100.0 2.21 33 ghmj (global health management journal) 2023, vol. 6, no. 1 pujiyanto, manika, & dewi the results showed that the majority of women were 90.4%. gender is an interesting thing because the nature of the nursing profession is predominantly female (gray, 2010). generally, the gender is dominated by women because the nursing profession is synonymous with motherhood, but recently there have been many men who work as nurses (mcintosh et al., 2015). men who work as nurses do not feel interested in work and feel there are limitations when doing nursing work that requires physical contact with female patients (younas et al., 2022). the study also states that women are better at providing nursing services to patients, especially for services that are not medical actions, such as handling patients who are anxious, embarrassed, or feeling helpless. women who choose to nurse for their careers have higher levels of satisfaction (clayton-hathway et al., 2020). however, there was no difference in problemsolving ability, analytical ability, sociability, learning ability, and desire to compete. the result of the research shows that diploma education is 90.4%. education is something that is expected to be able to change a person's mindset which influences knowledge and decision making. knowledge is very closely related to education, with increasing levels of education, individuals will have more extensive knowledge (notoatmodjo, 2014). the level of education affects the performance of nurses (aswad & ferrial, 2016). however, the lower level of education of new nurses can have the same quality of care as new nurses who have a higher level of education by holding an orientation program and structured training program so as to increase self-confidence, knowledge, critical thinking skills, and interpersonal skills. the relationship between education and the implementation of pillar iv ncds is still lacking because there is still diploma nursing education and there is no opportunity for these nurses to take education to a higher level. low or unsustainable education can have an impact on low awareness and responsibility in carrying out tasks (duffield et al., 2008). nurse career development motivation through increased formal education must be utilized properly because it is a potential resource to be able to improve performance in the quality of nursing services (manongi & marchant, 2006). the results showed that the length of work of nurses with the length of work (3-5 years) was 59.6%. length of work is a process of forming knowledge and skills regarding work methods with employee involvement in carrying out their duties so that by working hard you can improve methods or techniques so as to reduce stress levels on employees (nuryani et al., 2021). tenure and satisfaction show a positive relationship the longer the work, the more skills and knowledge will increase (judge, 1994). the length of work begins when the nurse is officially appointed as an employee (penn et al., 2008). the longer a person works is expected to be able to carry out nursing care in the hospital well. the length of work is associated with the skills and abilities of nurses in performing nursing care (longhini et al., 2021). based on table 4 above, shows that there is an increase in the application of assessment elements before and after training (76.9% and 90.4%) of nursing diagnosis (63.5% and 75.0%). planning (51.9% and 88.5%). measures (84.6% and 92.3%). evaluation (53.8% and 90.4%). nursing care records (78.8% and 98.1%). this result is supported by previous research which states that there is an increase in the implementation of pillar iv ncds before and after training by 69.8%. not only that, but another study also stated that the implementation of pillar iv ncds increased significantly before and after being given training. it was concluded that mpkp training could increase nurses' knowledge so that they were able to perform pillar iv ncds well. mpkp training as an organized method ensures that a person has the knowledge and skills for the specific purpose that they get the knowledge needed to perform work tasks (marquis & huston, 2010). the benefits of training are part of an organization that can increase organizational work productivity which can create a harmonious relationship between superiors and subordinates when the decision-making process is faster, increases the morale of all workers, can encourage an attitude of management openness, facilitates the mpkp training process in hospitals. the peplau nursing theory concept model has four stages including the first stage, where the researcher and the client enter into an initial contract to build trust by fostering a trusting relationship and the data collection process occurs, the second stage, the identification phase of the nurse's role whether she has done or acted as a facilitator who facilitates the expression of the client's feelings and carrying out nursing care, third, the exploration phase where the nurse has helped the client in providing an overview of the client's condition by providing motivation and helping the client to mobilize early postoperatively and fourth, the nurse's resolution phase gradually motivates the client so as not to depend on the workforce health (comley, 1994). a leadership that is able to motivate the role of nurses in the implementation of nursing care from the results of this study shows that starting with growing high trust from leaders to nurses to start early mobilization to patients, and a significant influence from leadership on nurse performance, which raises the spirit of nurses (rokhyati & hasib, 2018). the difference in the increase in the implementation of the pillar iv ncds before and after the mpkp training proves that the training makes a positive contribution pujiyanto, manika, & dewi ghmj (global health management journal) 2023, vol. 6, no. 1 34 to increasing nurses' knowledge about the implementation of the pillar iv ncds. the more often the training is carried out, the more understanding and knowledge that a nurse is able to carry out pillar iv ncds in hospital services. 5. conclusion there are differences in the implementation of pillar iv ncds before and after being given mpkp training (p-value: <0.001). from the survey, we may note how the professional nursing practice model training (mpkp) affecting the number of nursing implementing the pillar iv ncds. after the statistical analysis, it is known that education level and the work experience of the nurses will significantly determine the success of the training, respectively with p value of <0.001 and 0.004. data from the results can be used as recommendation to the hospitals’ human resources department in designing their program in order to increasing the nurses’ competences. conflict of interest there is no conflict of interest. nothing to disclosure. references alligood, m. r. (2017). pakar teori keperawatan dan karya mereka. edisi indo). singapore. amir, h., chanafie, d., & hastono, s. p. (2020). pengaruh pelatihan model praktek keperawatan profesional (mpkp) terhadap penerapan pilar i pendekatan manajemen dan pilar iv sistem pemberian asuhan keperawatan perawat di rumah sakit x kotamobagu. media publikasi promosi kesehatan indonesia (mppki), 3(3), 168–177. https://doi.org/10.56338/mppki.v3i3.1134 amir, h., & ningsih, s. r. (2022). implementation of the professional nursing practice model at hospitals in kotamobagu. jurnal ilmiah keperawatan, 17(2), 94–102. arisanti, h., abidin, z., & andriani, r. (2018). implementation of professional nursing practice model (mpkp) and its effect on hospital patient satisfaction in baubau city hospital. international journal of academic research and reflection, 5(6), 51–58. aswad, h. n., & ferrial, e. (2016). pengaruh tingkat pendidikan, pelatihan dan kompensasi terhadap kinerja perawat di rumah sakit uit makassar. jurnal mirai management, 1(2), 413–425. clayton-hathway, k., humbert, a. l., schutz, s., mcilroy, r., & griffiths, h. (2020). gender and nursing as a profession: valuing nurses and paying them their worth. royal college of nursing london. comley, a. l. (1994). a comparative analysis of orem’s self‐care model and peplau’s interpersonal theory. journal of advanced nursing, 20(4), 755–760. https://doi.org/10.1046/j.1365-2648.1994.20040755.x croes, e., & bartels, j. (2021). young adults’ motivations for following social influencers and their relationship to identification and buying behavior. computers in human behavior, 124, 106910. https://doi.org/10.1016/j.chb.2021.106910 duffield, c., gardner, g., & catling‐paull, c. (2008). nursing work and the use of nursing time. journal of clinical nursing, 17(24), 3269–3274. https://doi.org/10.1111/j.1365-2702.2008.02637.x erickson, j. i., & ditomassi, m. (2011). professional practice model: strategies for translating models into practice. nursing clinics, 46(1), 35–44. https://doi.org/10.1016/j.cnur.2010.10.011 gray, b. (2010). emotional labour, gender and professional stereotypes of emotional and physical contact, and personal perspectives on the emotional labour of nursing. journal of gender studies, 19(4), 349–360. https://doi.org/10.1080/09589236.2010.514207 hogan, r., & roberts, b. w. (2004). a socioanalytic model of maturity. journal of career assessment, 12(2), 207–217. https://doi.org/10.1177/1069072703255882 judge, t. a. (1994). person–organization fit and the theory of work adjustment: implications for satisfaction, tenure, and career success. journal of vocational behavior, 44(1), 32–54. https://doi.org/10.1006/jvbe.1994.1003 longhini, j., papastavrou, e., efstathiou, g., andreou, p., stemmer, r., ströhm, c., schubert, m., de wolf‐ linder, s., & palese, a. (2021). strategies to prevent missed nursing care: an international qualitative study based upon a positive deviance approach. journal of nursing management, 29(3), 572–583. https://doi.org/10.1111/jonm.13176 https://doi.org/10.56338/mppki.v3i3.1134 https://doi.org/10.1046/j.1365-2648.1994.20040755.x https://doi.org/10.1016/j.chb.2021.106910 https://doi.org/10.1111/j.1365-2702.2008.02637.x https://doi.org/10.1016/j.cnur.2010.10.011 https://doi.org/10.1080/09589236.2010.514207 https://doi.org/10.1177/1069072703255882 https://doi.org/10.1006/jvbe.1994.1003 https://doi.org/10.1111/jonm.13176 35 ghmj (global health management journal) 2023, vol. 6, no. 1 pujiyanto, manika, & dewi manongi, r. n., & marchant, t. c. (2006). improving motivation among primary health care workers in tanzania: a health worker perspective. human resources for health, 4(1), 1–7. https://doi.org/10.1186/1478-4491-4-6 marquis, b. l., & huston, c. j. (2010). kepemimpinan dan manajemen keperawatan. mcintosh, b., mcquaid, r., & munro, a. (2015). the impact of gender perceptions and professional values on women’s careers in nursing. gender in management: an international journal. https://doi.org/10.1108/gm-12-2013-0135 meade, c. m., bursell, a. l., & ketelsen, l. (2006). effects of nursing rounds: on patients’ call light use, satisfaction, and safety. ajn the american journal of nursing, 106(9), 58–70. https://doi.org/10.1097/00000446-200609000-00029 mogopa, c. p., pondaag, l., & hamel, r. (2017). hubungan penerapan metode tim dengan kinerja perawat pelaksana di irina c rsup prof. dr. rd kandou manado. jurnal keperawatan, 5(1). notoatmodjo, s. (2014). pendidikan dan perilaku kesehatan. pt rineka cipta. nuryani, e., dwiantoro, l., & nurmalia, d. (2021). faktor-faktor yang meningkatkan kepatuhan perawat dalam penerapan prinsip enam benar pemberian obat. jurnal kepemimpinan dan manajemen keperawatan, 4(1), 50–57. https://doi.org/10.32584/jkmk.v4i1.572 penn, b. k., wilson, l. d., & rosseter, r. (2008). transitioning from nursing practice to a teaching role. online journal of issues in nursing, 13(3). https://doi.org/10.3912/ojin.vol13no03man03 pramono, h., sudiharja, s., & suryana, u. (2022). pelatihan mpkp untuk meningkatkan pengetahuan perawat tentang mpkp di rsj grhasia yogyakarta. jurnal ilmiah kesehatan, 15(2), 114–122. https://doi.org/10.48144/jiks.v15i2.1142 quek, s. j., thomson, l., houghton, r., bramley, l., davis, s., & cooper, j. (2021). distributed leadership as a predictor of employee engagement, job satisfaction and turnover intention in uk nursing staff. journal of nursing management, 29(6), 1544–1553. https://doi.org/10.1111/jonm.13321 rokhyati, r., & hasib, h. (2018). transformasional leadership meningkatkan motivasi perawat pada early mobilization pasien retensi urine pasca pembedahan dengan anasthesi spinal: literature review. prosiding seminar nasional mahasiswa unimus, 1. scovell, s. (2010). role of the nurse-to-nurse handover in patient care. nursing standard, 24(20). https://doi.org/10.7748/ns.24.20.35.s47 wasaya, f., shah, q., shaheen, a., & carroll, k. (2021). peplau’s theory of interpersonal relations: a case study. nursing science quarterly, 34(4), 368–371. https://doi.org/10.1177/08943184211031573 younas, a., ali, n., sundus, a., & sommer, j. (2022). approaches of male nurses for degendering nursing and becoming visible: a metasynthesis. journal of clinical nursing, 31(5–6), 467–482. https://doi.org/10.1111/jocn.15958 cite this article as: pujiyanto, t.i., manika, h.s.l., & dewi, r. (2023). the effect of professional nursing practice model training (mpkp) with the implementation of pillar iv nursing care delivery system (pillar iv ncds) at a hospital in kotamobagu, indonesia. ghmj (global health management journal), 6(1), 28–35. https://doi.org/10.35898/ghmj-61934 https://doi.org/10.1186/1478-4491-4-6 https://doi.org/10.1108/gm-12-2013-0135 https://doi.org/10.1097/00000446-200609000-00029 https://doi.org/10.32584/jkmk.v4i1.572 https://doi.org/10.3912/ojin.vol13no03man03 https://doi.org/10.48144/jiks.v15i2.1142 https://doi.org/10.1111/jonm.13321 https://doi.org/10.7748/ns.24.20.35.s47 https://doi.org/10.1177/08943184211031573 https://doi.org/10.1111/jocn.15958 https://doi.org/10.35898/ghmj-61934 indonesian scholars’ alliance ghmj (global health management journal) 2024, vol. 7, no. 4 open access research article the 1st cirebon international health symposium: faculty of medicine, universitas swadaya gunung jati update on non-communicable diseases: global perspective on health challenges and innovation demographics and histopathological characteristics of lung cancer patients in cirebon district, indonesia (2021-2023) syakira puteri sulaeman1* , alya amila fitrie2 , sedayu3 1 faculty of medicine, universitas swadaya gunung jati, indonesia, 2 department of anatomical pathology, universitas swadaya gunung jati, indonesia, 3 department of internal medicine, universitas swadaya gunung jati, indonesia. *corresponding author’s e-mail: puterisulaeman2002@gmail.com doi: 10.35898/ghmj-741070 abstract background: based on the global burden of cancer study (globocan) in 2020, in the world, lung cancer is the first cause of death. in indonesia, lung cancer is the third highest. lung cancer is classified into two cell types: small cell lung cancer and non-small cell lung cancer. there are two types of non-small cell lung cancer: squamous cell carcinoma, adenocarcinoma, and large cell carcinoma. aims: to determine the demographics and histopathological characteristics of lung cancer patients in cirebon district (2021-2023). methods: this research employed a descriptive observational method. the data were collected from general hospitals’ medical records of lung cancer patients at rsud waled cirebon and rsud arjawinangun in 2021-2023 using the total sampling technique. there were 69 respondents met the inclusion criteria for this recent study. results: in this study, there were 68.1% of patients aged from 46 to 70 years, and the majority were male (66.7%). the most common cancer cell type was adenocarcinoma (69.6%). most patients did not have information regarding occupational data (68.1%), smoking history (98.6%), family history (98.6%), and staging (89.9%) included in their medical records. conclusion: the analysis showed that most lung cancer patients are aged 46-70 years and male incidences in lung cancer patients were higher. the most common type of histopathological is adenocarcinoma. related to occupational data, smoking history, family history, and staging could not be concluded because they were not included in the medical record. keywords: lung cancer; demographic; histopathology; staging. received: 25 september 2024 reviewed: 19 october 2024 revised: 30 november 2024 accepted: 12 december 2024 © 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:puterisulaeman2002@gmail.com https://doi.org/10.35898/ghmj-741070 https://orcid.org/0009-0000-0717-6197 https://orcid.org/0009-0001-4059-3731 https://orcid.org/0009-0007-0259-8973 sulaeman, et. al. ghmj (global health management journal) 2024, vol. 7, no. 4 294 1. introduction the world health organization, or who, defined cancer as a condition in which abnormal cells proliferate uncontrollably and spread to other organs. the most common cause of mortality from cancer is metastases to other organs. cancer is a huge public-health issue around the world. lung cancer is one of the most common malignancies in the world that comes from the lung parenchyma or bronchi (nicholson et al. 2022). according to global burden of cancer study (globocan) in 2020, in the world, lung cancer is the first cause of deaths with 1.8 million deaths and the second highest of new cases after breast cancer. in asia, the incidences of lung cancer were higher with an estimated number of 1.3 million new cases. in indonesia, lung cancer is the third highest (8.8%) after breast cancer (16.6%) and cervical cancer (9.2%). in 2019, there were five provinces with the highest number of lung cancer patients, namely east java, jakarta, central java, west java and south sumatra (ferlay, et. al., 2024). based on gender, lung cancer is mostly found in male with 25,943 (14.1%) new cases, while female has a lower incidence than male with 8,840 (4.1%) cases in 2020 (ferlay, et. al., 2024). smoking is a primary risk factor for lung cancer. the highest risk was found in male smokers. passive smokers are 20-30% more susceptible to lung cancer. riskesda in 2018 reported that around 34% of the indonesian population is a smoker and the country with the most smokers in the entire globe (kementrian kesehatan republik indonesia, 2019). another risk factor is exposure to asbestos and radon. exposure to asbestos, especially in the workplace could increase the risk of lung cancer depending on how frequent the exposure is (buana and agustian harahap, 2022). the probability of lung cancer developed with age, as the disease progressed before symptoms manifested. in general, 83% of cases are diagnosed at age 70 or older. nsclc occurs most frequently in male between the ages of 80-84 years, and in female between the ages of 75-79 years. sclc occurs most commonly in male and female between the ages of 75-79 years. there are two categories of lung cancer: 14% are sclc and 81% are nsclc.(american cancer society 2023) there are various kinds of nsclc, including adenocarcinoma, squamous cell carcinoma (scc), and large cell carcinoma (lcc). adenocarcinoma is a malignant tumor that has glandular differentiation. a malignant epithelial tumor that has keratinization from the bronchial epithelium is called squamous cell carcinoma. undifferentiated carcinomas are large cell carcinomas (travis, brambilla, and mullerhermelink, 2005). this research aimed to determine the demographics and histopathological characteristics of lung cancer in cirebon district from 2021 to 2023. 2. methods study design this research employed a descriptive observational method. this research is a cross-sectional study conducted at rsud waled cirebon and rsud arjawinangun. this research has been approved by the health research and development ethics committee of rsud arjawinangun (ethical approval 427.9/kkepk.24/vi/rsud awn/2024). research license has also been obtained by rsud waled cirebon (number: 800.2.2.1/1297-diklit/2024) and rsud arjawinangun (number: 447.26/7506/rsudawn). population and sample the population in this study were all patients who diagnosed with lung cancer by cytology and/or histopathology in 2021 to 2023. data were acquired from medical records of lung cancer patients at rsud waled cirebon and rsud arjawinangun in 2021-2023 using the total sampling technique. inclusion criteria; patients diagnosed with lung cancer by cytology and/or histopathology when admitted to rsud waled cirebon and rsud arjawinangun in 2021-2023 and patient’s medical records contained main data regarding age, gender and histopathological features as well as additional data such as smoking history, family history, occupational data and staging. exclusion criteria, related to the main data including age, gender, and histopathological features are not sulaeman, et. al. ghmj (global health management journal) 2024, vol. 7, no. 4 295 contained in the patient's medical record. this study had a total population of 121 patients, with 69 of them meeting the inclusion criteria. this research was conducted in may 2024 at rsud waled cirebon and rsud arjawinangun. measurements the research variables include lung cancer patients demographics, such as age, gender, occupation, smoking history and family history as well as histopathological characteristics, such small cell lung cancer, adenocarcinoma, squamous cell carcinoma (scc), large cell carcinoma (lcc), and staging. tnm staging was used to identify the stage of lung cancer. data were acquired from medical records of lung cancer patients at rsud waled cirebon and rsud arjawinangun in 2021-2023. data analysis the collected data were analyzed using univariate analysis. univariate analysis describes the characteristics of the demographics and histopathological using frequency distribution and percentage. data were processed using spss 27 software. 3. results the data were acquired from medical records of lung cancer patients at rsud waled cirebon and rsud arjawinangun in 2021-2023 using the total sampling technique, 69 patients who met the inclusion criteria and exclusion criteria were included in this study. age, sex, occupation, smoking history, and family history were used to describe demographic characteristics. histopathological findings and staging were used to describe the histopathological characteristics of lung cancer. as shown in table 1, the majority of patients were aged 46-70 years (68.1%). there were more male patients than female patients, with 46 male patients (66.7%) and 23 female patients (33.3%). adenocarcinoma was the most common histopathological finding (69.6%). related to occupational data (69.6%), smoking history (98.6%), family history (98.6%), and staging (89.9%) the majority had no information on their medical reports table 2 shows the variation in the distribution of histopathological characteristics by age in lung cancer patients in cirebon districts in 2021 to 2023. of the 69 lung cancer patients, 68.1% or 47 patients were aged 4670 years with sclc type and squamous cell carcinoma totalling 7 patients (10.1%), nsclc totalling 1 patients (1.4%), and adenocarcinoma totalling 32 patients (46.3%). there were 2 (2.9%) patients <46 years old with squamous cell carcinoma and 7 (10.1%) with adenocarcinoma. there were 4 patients (5.8%) with squamous cell carcinoma and 9 patients (3%) with adenocarcinoma aged >70 years old. as shown in table 3, the histopathological characteristics of lung cancer patients in cirebon district in 2021 to 2023 by gender. in male, 6 patients (8.7%) had sclc, 11 patients (15.9%) had squamous cell carcinoma, and 29 patients (42%) had adenocarcinoma, while in female, 1 patient each (1.4%) had sclc and nsclc, 2 patients (2.9%) had squamous cell carcinoma, and 19 patients (27.5%) had adenocarcinoma. the ratio of adenocarcinoma to squamous cell carcinoma in males was 29:11 and 19:2 in females. in this study, adenocarcinoma was the most common type of cancer cell found in both males and females. the ratio of adenocarcinoma patients in males and females was 29:19. this means that in this study, adenocarcinoma was found more in male than female. sulaeman, et. al. ghmj (global health management journal) 2024, vol. 7, no. 4 296 table 1. patient’s characteristics variables frequency (n) percentage (%) age <46 years 9 13 46-70 years 47 68.1 >70 years 13 18.8 gender male 46 66.7 female 23 33.3 occupation labor 2 2.9 housewife 6 8.7 farmer 1 1.4 entrepreneur 6 8.7 not working 7 10.1 no information 47 68.1 smoking history smoking 0 0 no smoking 1 1.4 no information 68 98.6 family history yes 0 0 no 1 1.4 no information 68 98.6 histopathology sclc 7 10.1 nsclc 1 1.4 squamous cell carcinoma (scc) 13 18.8 adenocarcinoma 48 69.6 large cell carcinoma (lcc) 0 0 lung cancer staging ia 0 0 ib 0 0 iia 0 0 iib 0 0 iiia 0 0 iiib 1 1.4 iiic 0 0 iv 4 5.8 iva 1 1.4 ivb 1 1.4 no information 62 89.9 table 2. histopathological characteristics by age histopathology age total <46 years 46-70 years >70 years sclc 0 (0%) 7 (10.1%) 0 (0%) 7 (10.1%) nsclc 0 (0%) 1 (1.4%) 0 (0%) 1 (1.4%) squamous cell carcinoma 2 (2.9%) 7 (10.1%) 4 (5.8%) 13 (18.8%) adenocarcinoma 7 (10.1%) 32 (46.3%) 9 (3%) 48 (69.5%) large cell carcinoma 0 (0%) 0 (0%) 0 (0%) 0 (0%) total 9 (13%) 47 (68.1%) 13 (18.8%) 69 (100%) sulaeman, et. al. ghmj (global health management journal) 2024, vol. 7, no. 4 297 table 3. histopathological characteristics by gender histopathology gender total male female sclc 6 (8.7%) 1 (1.4%) 7 (10.1%) nsclc 0 (0%) 1 (1.4%) 1 (1.4%) squamous cell carcinoma 11 (15.9%) 2 (2.9%) 13 (18.8%) adenocarcinoma 29 (42%) 19 (27.5%) 48 (69.5%) large cell carcinoma 0 (0%) 0 (0%) 0 (0%) total 46 (66.7%) 23 (33.3%) 69 (100%) 4. discussion the findings in this study show that lung cancer patients in cirebon district in 2021 to 2023 are mostly aged 46-70 years (68.1%) and based on the type of cancer cells, adenocarcinoma is the most common (46.3%). the findings of this study is in line with those of study by aini et al. (2019) where 78.3% of patients were aged 46-70 years and the most common type of cancer cell found was adenocarcinoma (75%). this happened because the risk of lung cancer tends to increase at the age of over 40 years and over 50 years. according to balzer et al. (2018), adenocarcinoma typically develops between the ages of 26 and 40, whereas squamous cell carcinoma develops after the age of 50. this is in line with this study, which showed adenocarcinoma among patients under the age of 46 (10.1%) and squamous cell carcinoma was more common among patients aged 46-70 (10.1%) (aini, wulandari, and andajani 2019; balzer et al. 2018). as we age, we are more exposed to hormones, degenerative disease, a reduce ability of cells to repair themselves, and decreasing lung function. the slowing of cilia movement is one of the explanations for a decrease in lung function. cilia cleanse the lungs from particles and bacteria. if the movement of cilia decreases, the lungs become susceptible to infection. the buildup of unrepaired damage caused by carcinogen exposure, such as nicotine, the age related deterioration in the immune system, and increased risk of lung cancer as people age. the phrase “lung age” (calculated from age, body height, and the first second of forced expiration) has demonstrated to be a predictor of pulmonary obstructive impairment and substantially linked with post-operative breathing issues and survival in patients with lung cancer (ma et al. 2023; pritami et al. 2022). the outcomes of this study showed that lung cancer patients in the cirebon district are more likely to be male (66.7%) than female (33.3%). adenocarcinoma is more common in male (42%), based on the type of cancer cells. this is because estrogen regulates the secretion of inflammatory cytokines by macrophages and neutrophils, lowering the risk of cancer in female. according to who, squamous cell carcinoma is more common in male because it is associated with smoking behaviors, which are more often practiced by male than female, while adenocarcinoma is more common in female. this is in line with this study where squamous cell carcinoma was found more in male (15.9%) than female (2.9%), and in female patients with adenocarcinoma were more numerous than other types of cancer cells (27.5%). these findings are align with those of the research conducted by putri et al. (2023) which was conducted at dr soedarso hospital pontianak, with 82.7 % of patients were male and 17.3% were female (putri, pratiwi, and musawaris 2023; travis et al. 2005; vavalà et al. 2021). female patients are more likely than male patients to be diagnosed with adenocarcinoma at a younger age, inherit cancer from their families, and have had less exposure to tobacco. smoking has been identified as one of the causes of lung cancer in both male and female. polypeptide 1, family 1, polymorphisms of cytochrome p450, subfamily a that can impair dna repair, x-linked gastrin-releasing peptide receptor overexpression, and p53 mutations are among the genetic variants associated with lung cancer in the non-smoking population. most of the potential carcinogens present in cigarette smoke are polycyclic hydrocarbons, amino aromatics and heavy metals such as nickel. cigarette smoking causes cilia to disappear and progression to carcinoma in situ. a study accomplished by salsabila et al. (2023) found that patients who smoked (74%) were more than patients who did not smoke (9.4%). however, this study discovered that 98.6% of patients did not have information about their smoking history (kementrian kesehatan republik indonesia 2018; kusumawardani et al. 2022; salsabila, intan, and fitrina 2023). sulaeman, et. al. ghmj (global health management journal) 2024, vol. 7, no. 4 298 according to data from the central statistics agency of west java province in 2023, the percentage of the population aged 15 and up who smoke in cirebon district in 15.34% in the age group, 24.80% in the age 25-34 age group, 17.76% in the 45-54% age group, 12.37% in the 55-64 age group, and 6.67% in those over 65 age group. the large number of smokers in cirebon district may be a risk factor for lung cancer diagnoses, although the majority of the diagnosed patients in this study did not provide smoking history information. risk factors are not restricted to active smokers. other risk factors, such as second-hand smoke, radon exposure, environmental exposure to industrial carcinogens and air pollution. the most well-known occupational lung carcinogen is asbestos, which is frequently found in building materials and vehicles. smoking after asbestos exposure raises the risk of lung cancer. air pollution is defined as air that has been contaminated with chemical, physical, or biological elements that, when placed in the lungs, might initiate the carcinogenesis process (balzer et al. 2018; buana and agustian harahap 2022). adenocarcinoma was the most often diagnosed cancer in this study (69.6%), followed by squamous cell carcinoma (18.8%). these findings align with the study accomplished by salsabila et al. (2023), who found that 60.4% of patients had adenocarcinoma and 34.9% had squamous cell carcinoma. adenocarcinoma spreads mainly through lymphatic and hematogenous pathways. adenocarcinoma is a type of cancer cell that is common in female and often occurs in patients who are non-smokers. whereas, squamous cell carcinoma occurs in 90% of patients who are smokers. squamous cell carcinoma patients typically have poor prognosis because the cancer is most common in smokers with concurrent diseases such cerebral infraction, chronic obstructive pulmonary disease, and cardiovascular atherosclerosis. based on lung cancer staging, most lung cancer patients did not have information related to staging (89.9%). however, according to the study’s findings, there are 4 patients with stage 4 lung cancer. the therapy of choice in patients with staging 4 is chemotherapy palliative, radiotherapy palliative, targeted therapy, immunotherapy, interdisciplinary team, and comprehensive palliative care (asmara et al. 2023; kawase et al. 2012; salsabila et al. 2023; travis et al. 2005). this research has several limitations such as limitations in research time and many of the data needed by researchers are incomplete in medical records, such as occupation, smoking history, family history, and staging. further research is expected to fill inadequacies in smoking and family history data, as well as research specific lung cancer risk factors and analyze lung cancer progression and outcomes based on histopathological types and stages. 5. conclusion in conclusion, most lung cancer patients were age 46-70 years. the analysis showed that male incidence in lung cancer patients were higher. based on histopathological, adenocarcinoma was the most prevalent cancer cell type. related to occupational data, smoking history, family history, and staging could not be concluded because they were not included in the medical record. further research is expected to fill inadequacies in smoking and family history data, as well as research specific lung cancer risk factors and analyze lung cancer progression and outcomes based on histopathological types and stages. conflict of interest there is no potential conflict of interest. references aini, sita ro'yul, laksmi wulandari, and susilowati andajani. 2019. "lung cancer patients' profile in dr soetomo general hospital surabaya 2016 2017: newest report." juxta: jurnal ilmiah mahasiswa kedokteran universitas airlangga 10(1):44. https://doi.org/10.20473/juxta.v10i12019.44-47 american cancer society. 2023. cancer facts & figures 2023: special section on lung cancer. american cancer society. https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annualcancer-facts-and-figures/2023/2023-cff-special-section-lung-cancer.pdf. https://doi.org/10.20473/juxta.v10i12019.44-47 https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-and-figures/2023/2023-cff-special-section-lung-cancer.pdf https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-and-figures/2023/2023-cff-special-section-lung-cancer.pdf sulaeman, et. al. ghmj (global health management journal) 2024, vol. 7, no. 4 299 asmara, oke dimas, eric daniel tenda, gurmeet singh, ceva wicaksono pitoyo, cleopas martin rumende, wulyo rajabto, nur rahmi ananda, ika trisnawati, eko budiyono, harik firman thahadian, e. christiaan boerma, achmad faisal, david hutagaol, wuryantoro soeharto, fahmi radityamurti, erika marfiani, pradana zaky romadhon, fathur nur kholis, hendarsyah suryadinata, arto yuwono soeroto, soehartati a. gondhowiardjo, and wouter h. van geffen. 2023. "lung cancer in indonesia." journal of thoracic oncology 18(9):1134-45. https://doi.org/10.1016/j.jtho.2023.06.010 balzer, ben w. r., christine loo, craig r. lewis, toby n. trahair, and antoinette c. anazodo. 2018. "adenocarcinoma of the lung in childhood and adolescence: a systematic review." journal of thoracic oncology 13(12):183241. https://doi.org/10.1016/j.jtho.2018.08.2020 buana, indra, and dwi agustian harahap. 2022. asbestos, radon dan polusi udara sebagai faktor resiko kanker paru pada perempuan bukan perokok. vol. 8. https://doi.org/10.29103/averrous.v8i1.7088 ferlay j, ervik m, lam f, laversanne m, colombet m, mery l, piñeros m, znaor a, soerjomataram i, bray f (2024). global cancer observatory: cancer today. lyon, france: international agency for research on cancer. available from: https://gco.iarc.who.int/today. kawase, akikazu, junji yoshida, genichiro ishii, masayuki nakao, keiju aokage, tomoyuki hishida, mitsuyo nishimura, and kanji nagai. 2012. "differences between squamous cell carcinoma and adenocarcinoma of the lung: are adenocarcinoma and squamous cell carcinoma prognostically equal?" japanese journal of clinical oncology 42(3):189-95. https://doi.org/10.1093/jjco/hyr188 kementrian kesehatan republik indonesia. 2018. pedoman pengendalian faktor risiko kanker paru. jakarta. kementrian kesehatan republik indonesia. 2019. laporan nasional riskesdas 2018. jakarta: lembagapenerbitbadanpenelitiandanpengembangankesehatan. kusumawardani, ida ayu jasminarti dwi, luh komang ayu widhiaty karang, ni wayan candrawati, herman saputra, ni putu sriwidyani, and nornazirah binti azizan. 2022. "risk factors and challenging management of lung adenocarcinoma in young adult women: case series." jurnal respirasi 8(2):94-98. https://doi.org/10.20473/jr.v8-i.2.2022.94-98 ma, zhimin, chen zhu, hui wang, mengmeng ji, yanqian huang, xiaoxia wei, jing zhang, yuzhuo wang, rong yin, juncheng dai, lin xu, hongxia ma, zhibin hu, guangfu jin, meng zhu, and hongbing shen. 2023. "association between biological aging and lung cancer risk: cohort study and mendelian randomization analysis." iscience 26(3). https://doi.org/10.1016/j.isci.2023.106018 nicholson, andrew g., ming s. tsao, mary beth beasley, alain c. borczuk, elisabeth brambilla, wendy a. cooper, sanja dacic, deepali jain, keith m. kerr, sylvie lantuejoul, masayuki noguchi, mauro papotti, natasha rekhtman, giorgio scagliotti, paul van schil, lynette sholl, yasushi yatabe, akihiko yoshida, and william d. travis. 2022. "the 2021 who classification of lung tumors: impact of advances since 2015." journal of thoracic oncology 17(3):362-87. https://doi.org/10.1016/j.jtho.2021.11.003 pritami, aldiesa ade, retno ariza, soeprihatini soemarwoto, risal wintoko|, faktor risiko, kanker paru, and risal wintoko. 2022. faktor risiko kanker paru: tinjauan pustaka. lampung. putri, agusriani, sari eka pratiwi, and risa febriana musawaris. 2023. "characteristics of lung cancer patients at dr. soedarso hospital pontianak from 2017 to 2019." indonesian journal of cancer 17(2):101. https://doi.org/10.33371/ijoc.v17i2.950 salsabila, syifa, shinta ayu intan, and dewi wahyu fitrina. 2023. "gambaran tipe sel kanker paru berdasarkan usia, jenis kelamin, dan paparan rokok di rsup dr. m. djamil padang tahun 2018-2020." jurnal ilmu kesehatan indonesia 4(4):281-88. https://doi.org/10.25077/jikesi.v4i4.1118 travis, william d. .., elizabeth. brambilla, and h. konrad. muller-hermelink. 2005. world health organization classification of tumours : pathology and genetics of tumours of the lung, pleura, thymus and heart. iarc publications. vavalà, tiziana, annamaria catino, pamela pizzutilo, vito longo, and domenico galetta. 2021. "gender differences and immunotherapy outcome in advanced lung cancer." international journal of molecular sciences 22(21). https://doi.org/10.3390/ijms222111942 cite this article as: sulaeman, s. p., fitrie, a. a., & sedayu, s. (2024). demographics and histopathological characteristics of lung cancer patients in cirebon district, indonesia (2021-2023). ghmj (global health management journal), 7(4), 293– 299. https://doi.org/10.35898/ghmj-741070 https://doi.org/10.1016/j.jtho.2023.06.010 https://doi.org/10.1016/j.jtho.2018.08.2020 https://doi.org/10.29103/averrous.v8i1.7088 https://gco.iarc.who.int/today https://doi.org/10.1093/jjco/hyr188 https://doi.org/10.20473/jr.v8-i.2.2022.94-98 https://doi.org/10.1016/j.isci.2023.106018 https://doi.org/10.1016/j.jtho.2021.11.003 https://doi.org/10.33371/ijoc.v17i2.950 https://doi.org/10.25077/jikesi.v4i4.1118 https://doi.org/10.3390/ijms222111942 https://doi.org/10.35898/ghmj-741070 ghmj (global health management journal) 2024, vol. 7, no. 4 indonesian scholars’ alliance open access research article the 1st cirebon international health symposium: faculty of medicine, universitas swadaya gunung jati update on non-communicable diseases: global perspective on health challenges and innovation the influence of body image and energy intake on nutritional status in adolescents at sman 1 cirebon city, indonesia farah gustin kurniasih1,* , muhammad duddy satrianugraha wahidin2 , duddy fachrudin3 1 faculty of medicine, universitas swadaya gunung jati, indonesia, 2 department of basic medical sciences, faculty of medicine, universitas swadaya gunung jati, indonesia, 3 department of medical education, faculty of medicine, universitas swadaya gunung jati, indonesia. *corresponding author’s e-mail: gustinfarah@gmail.com doi: 10.35898/ghmj-741090 abstract background: adolescents are among the groups vulnerable to nutritional problems. these issues can arise due to restrictive diets, self-assessment (body image), lifestyle choices, energy intake, physical activity, and knowledge of balanced nutrition. according to the who (2018), the prevalence of overnutrition among adolescents aged 15–19 years has risen significantly from 4% to over 18%. the increase was observed in 18% of females and 19% of males. aims: this research aims to examine the correlation between body image, energy intake, and nutritional status among adolescents at sman 1 in cirebon city. methods: a quantitative approach with a descriptive research design was employed in this study. the sampling technique used was purposive sampling. primary data were collected through questionnaires, 24hour food recall interviews, and measurements of body weight and height. statistical analyses included univariate and multivariate analysis. results: the findings indicate that most adolescents had a negative body image (60.1%), good energy intake (44.0%), and normal nutritional status (70.2%). data analysis using the ordinal logistic regression test revealed that body image significantly affects nutritional status (p < 0.001), and energy intake also significantly affects nutritional status (p < 0.001). conclusion: this study concluded that body image and energy intake significantly influence the nutritional status of adolescents. statistical analysis demonstrated that adolescents with a positive body image and good energy intake are more likely to have normal nutritional status. keywords: adolescents, body image, energy intake, nutritional status. received: 25 september 2024 reviewed: 16 october 2024 revised: 30 november 2024 accepted: 12 december 2024. © 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:gustinfarah@gmail.com https://doi.org/10.35898/ghmj-741090 https://orcid.org/0009-0007-6107-0714 https://orcid.org/0000-0003-4495-9048 https://orcid.org/0000-0001-7435-941x ghmj (global health management journal) 2024, vol. 7, no. 4 kurniasih, et. al. 272 1. introduction nutritional status is a measure of a person's body shape, as seen from the food consumed and the use of nutrients in the body. determination of nutritional status in a person can be done directly in the form of anthropometric, clinical, biochemical, and biophysical or indirectly in the form of food consumption surveys, vital statistics, and ecological factors (winerungan et al. 2018). one of the indicators used to assess health status in adolescents is nutritional status. nutritional status in adolescents occurs due to incorrect nutritional behavior, wich is an imbalance between nutrient consumption and nutrient adequacy. adolescents are one of the groups that are vulnerable to nutritional problems, and nutritional problems that occur in adolescents are malnutrition and overnutrition (insani 2022). data from the world health organization in 2018 states that the prevalence of nutritional problems in adolescents aged 15-19 years has increased significantly from 4% to more than 18%, an increase that occurred in the female group as much as 18% and men 19% (who, 2018). in indonesia, the prevalence of nutritional status in adolescents aged 16-18 years according to the 2018 basic health research based on imt / u is 1.4% in the very thin category, 6.7% are in the thin category, 78.3% have normal nutritional status, 9.5% are in the fat category, and 4.0% are in the obese category. the prevalence of adolescent nutritional status in west java province ranks 22nd, which is relatively good normal nutritional status, especially in cirebon city which has an excellent normal adolescent nutritional status category (riskesdas, 2018). adolescence is a period of very unique and continuous physical changes. these physical changes will make adolescents begin to occupy themselves and pay more attention to their body shape, which physical changes in adolescents are the most prominent problems that become one of the primary sources of problems in adolescents (nurleli 2019). nutritional problems in adolescents can be caused by restrictive diets, selfassessment (body image), lifestyle, energy intake, physical activity and knowledge of balanced nutrition (ovita, ade nur, dkk, 2019). the formation of self-concept in the form of body image is one of the changes in adolescents that can cause them to lack energy intake due to the wrong diet. this change is formed due to the body image the teenager has believed in, a perspective called negative body image, which happens because of comments and responses from people around the teenager. in the end, the teenager will withdraw and feel more comfortable being alone than hanging out with people around him. the changes that occur will disturb the teenager's psychological aspects and make their behavior change, where a person will try to lose weight due to dissatisfaction with his body. the problem will grow and can affect the lives of many adolescents. the problem will continue into adulthood if not appropriately addressed during adolescence (nurleli 2019). this problem will encourage adolescents to diet under the recommendations and will later have eating disorders. the strict diet carried out by adolescents will cause them to lose energy because the metabolism of nutrients is not correctly formed. this energy intake can affect development and growth in adolescents, if the energy intake needs are not met, they will impact the body's functional system. meanwhile, if the energy intake is excessive, it will result in weight gain or even obesity if it is not balanced with physical activity as a step for energy expenditure. it means that these two things must be balanced in order to have no problems regarding nutritional status (makhrajani 2018). the problem of an adolescent's body image and energy intake can cause various kinds of health problems, especially changes in behavior regarding nutritional fulfillment. this behavioral change usually occurs in middle adolescents aged 15-18 who are still in high school. there are differences between the research to be conducted by researchers and other studies such as place, year of research, analytical tests used, and samples used. not many studies have raised the effect of body image and energy intake on nutritional status. so, this research is very important and useful for adolescents, because with this, adolescents can solve body image and energy intake problems that occur in their teenage years. based on this, this research will conduct a study entitled the effect of body image and energy intake on nutritional status in adolescents at sman 1 cirebon city. kurniasih, et. al. ghmj (global health management journal) 2024, vol. 7, no. 4 273 2. methods study design/ research procedures this study was conducted at sman 1 cirebon city from december 2023 july 2024. this type of research is quantitative research with a descriptive research design. this study was conducted to determine the effect of body image and energy supply on nutritional status in adolescents at sman 1 cirebon city. the population in the study was 11th-grade students. based on calculations using the slovin formula, 168 respondents were obtained. the sampling method used a purposive sampling technique, which had previously been selected following the predetermined inclusion criteria, specifically those who were willing to become respondents and be present at the time of the study. measurements researchers collect data using questionnaires about body image, 24-hour food recall interviews, and anthropometric measurements. in the first step, the researcher gathers prospective respondents in one place and then explains the research. then, after the prospective respondent understands, the prospective respondent is asked for permission with informed consent. if the prospective respondent agrees, informed consent and research brochures are left to ask for approval from the respondent's parents on the next day. after approval of the informed consent, the prospective respondent gets approval from the parents, and then the research data is collected directly. statistical techniques the characteristics of respondents in this study were filling out questionnaires about body image, 24-hour food recall interviews, and anthropometric measurements according to predetermined criteria. data were then analyzed using spss software using univariate analysis to determine frequency distribution and multivariate analysis for ordinal scale data with logistic regression test. the ordinal logistic regression test is used to see the dominant variable by analyzing the correlation between the response variable and the predictor variable, where the variable is ordinal scale, so this test is appropriate for this study because all variables are ordinal scale. validity and reliability tests were not carried out, because the questionnaire used in this study has been tested, namely using the body shape questionnaire (bsq) 34. resulted in the reflective indicators used in this study. ethical clearance the research was conducted in accordance with the research flow and was carried out after obtaining a research permit obtained after passing the thesis proposal examination.this study has been ethically approved by the ethic committee of faculty of medicine, universitas swadaya gunung jati, following the seven who standards, with number 86/ec/fkugj/vi/2024, on june 6th, 2024. 3. results this study was conducted at sman 1 cirebon city with the number of respondents taken was 168 students using purposive sampling methods and respondents who participated in this study have met the inclusion and exclusion criteria that have been determined previously. the characteristics of respondents in this study are described based on age, gender, weight, height, and energy intake. the data used in this study were primary data obtained directly by researchers through questionnaires, 24-hour food recall interviews, and measurements of body weight and height. respondent characteristics based on table 1, the gender distribution obtained in this study showed that out of 168 respondents, 71 were male (42.3%) and 97 were female (57.7%). the ages of respondents ranged from 14-17 years; among the 168 respondents, 1 person (0.6%) was 14 years old, 21 people (12.5%) were 15 years old, 127 people (75.6%) were 16 ghmj (global health management journal) 2024, vol. 7, no. 4 kurniasih, et. al. 274 years old, and 19 people (11.3%) were 17 years old. body image measurements using the body shape questionnaire (bsq) indicated that, among the 168 respondents, 67 (39.9%) had a positive body image, and 101 (60.1%) had a negative body image. based on energy intake measurements through 24-hour food recall interviews, it was found that of the 168 respondents, 51 (30.4%) had energy intake categorized as low, 74 (44.0%) as sufficient, and 43 (24.6%) as high. measurements of body weight and height according to anthropometric standards based on bmi-for-age (bmi/u) revealed nutritional statuses as follows: very thin for 7 people (4.2%), thin for 12 people (7.1%), normal for 118 people (70.2%), overweight for 26 people (15.5%), and obese for 5 people (3.0%). table 1. respondents characteristics category n % gender male 71 42.3 female 97 57.7 age 14 1 0.6 15 21 12.5 16 127 75.6 17 19 11.3 body image positive (score <110) 67 30.4 negative (score ≥110) 101 60.1 energy intake less (score ≤80%) 51 30.4 good (score 81-110%) 74 44.0 more (score ≥110%) 43 24.6 nutritional status very thin (<-3 sd) 7 4.2 thin (-3 sd to <-2 sd) 12 7.1 normal (-2 sd to +1 sd) 118 70.2 fat (>+1 sd to 2 sd) 26 15.5 obese (>2 sd) 5 3.0 total per category 168 100.0 multivariate analysis based on table 2, multivariate analysis between body image and energy intake on nutritional status, it can be seen that after the ordinal logistic regression test, the body image variable has a significance value of (p <0.001) which can be concluded that body image affects nutritional status. the energy intake variable has a significance value of (p<0.001), and it can be concluded that energy intake affects nutritional status. table 2. multivariate analysis of body image and energy intake on nutritional status variable coefficient s.e. wald df p value or ik 95% min max body image 0.366 0.161 3.767 1 0.000 0.25 0.14 1.01 energy intake 0.453 0.097 7.099 1 0.000 0.47 0.23 2.48 constant 1.589 0.064 9.859 1 0.000 5.16 4. discussion based on the results of this study, the frequency distribution on gender and age found that the most significant gender was female and the frequency was between the ages 14 and 17 years. in this gender and age range, respondents are included in the middle adolescent phase. where appearance becomes the most essential factor for adolescents, they try to increase attention to their body shape by doing something to improve their physical appearance. this finding is supported by the results of research conducted by nurleli, which states that kurniasih, et. al. ghmj (global health management journal) 2024, vol. 7, no. 4 275 dissatisfaction with body shape is more common in adolescents, especially females. the result is that mass media more easily influence adolescents (nurleli 2019). indonesia’s rich and diverse culture had a significant influence on students' body image and eating habits. beauty norms in indonesia were often shaped by local culture, which emphasized certain body types. for example, in some cultures, a fuller body was considered more attractive and healthy, while in others, a slim body might have been more valued. the family, as the first social unit, played a role in teaching these values to children. parents often instilled expectations of physical appearance that aligned with beauty standards prevalent in their society. in javanese families, for instance, there was an emphasis on modesty and proper appearance as part of cultural identity. this influenced how students viewed their bodies and how they tried to meet those expectations.(rochayanti, pujiastuti, and warsiki 2012) body image of adolescents of grade 11 sman 1 cirebon city based on the study results, it can be seen that most respondents have a negative body image, namely 101 people (60.1%), while respondents with a positive body image are 67 people (39.9%). this means that almost all adolescents feel dissatisfied with their appearance, especially regarding their body image. these teenagers think that they are fatter/thinner than they really are. a teenager wants an ideal body shape and looks attractive when looking, but in reality they feel dissatisfied with the shape and size of their body. this finding aligns with the results of research conducted by ni nyoman ayu and wigutomo in 2021, which showed that adolescents were dissatisfied with the shape and size of their bodies (astini and gozali 2021). body image is a person's image of their body shape and size. knowledge about adolescent body image perceptions is still inaccurate, which causes changes in behavior in adolescents. they consider having a body shape that looks fatter/thinner but has an ideal body shape. this aligns with the results of research conducted by nurleli in 2019, which found that many adolescents have the wrong perception of body image (nurleli 2019). everyone has an assessment of the shape and size of their respective bodies, the desire to have an ideal body is a very desirable matter. teenagers are susceptible to their appearance, and it is not uncommon for them to constantly reflect on their body shapes and sizes, their faces, and whether other people like them, especially when someone compares their body condition. this is one of the main reasons teenagers lose confidence (astini and gozali 2021). adolescents with a positive body image apparently would act positively without being affected by their body shape. positive body image can encourage a person to behave healthily by exercising habits, having positive personal experiences, and having stable mental and emotional conditions, which will give a better perception. a negative body image will encourage a person to do things that can harm themselves by dieting strictly. in addition, body image dissatisfaction can encourage a person to consume drugs that are not balanced with exercise and consumption of unhealthy foods that can cause damage to the liver and kidneys (siregar 2023). energy intake of adolescents of grade 11 sman 1 cirebon city based on the study's results, it can be seen that most respondents have good energy intake, namely 74 people (44.0%). however, some have less energy intake as many as 51 people (30.4%) and more energy intake as many as 43 people (24.6%). this finding aligns with research conducted by richard winerungan, et al. in 2019, which showed that most respondents had good energy intake. energy can be obtained from metabolizing nutrients such as carbohydrates, fats, and proteins. energy can be obtained from foods that contain macronutrients, which are then processed in the body. nutrients in food will fulfill energy needs in the body (winerungan et al. 2018). parents should pay attention to their children's food intake, not only to nutritional value, but also the difficulty for body to digest. the total amount of nutrients needed also depends on the quality of the food, the ability to absorb, and the use of nutrients by the body, which is influenced by the composition and condition of the food as a whole (winerungan et al. 2018). adolescents' requirements for energy and other nutrients vary widely, even when factors such as weight, height, gender, age and other factors are considered. this energy intake can affect development and growth in adolescents. lack of energy will make the body experience a negative balance. as a result, the body weight will be reduced from the weight that should be. meanwhile, excess energy will be converted into body fat, resulting in excess weight. the imbalance of nutrient intake in adolescents is the basis for the emergence of nutritional status problems (siregar 2021). ghmj (global health management journal) 2024, vol. 7, no. 4 kurniasih, et. al. 276 nutritional status of adolescents of grade 11 sman 1 cirebon city based on the study's results, it can be seen that most respondents have normal nutritional status as many as 118 people (70.2%). in addition, some respondents had a fragile nutritional status of 7 people (4.2%), thin as many as 12 people (7.1%), fat as many as 26 people (15.5%), and obese as many as 5 people (3.0%). this is in line with research conducted by wulan nur insani in 2022, which showed that most respondents had normal nutritional status (insani 2022). nutritional status results from a balance between food intake and nutrient absorption. inaccurate intake of nutrients will affect a person's nutritional status. the nutritional intake needs of each individual are different, depending on age, gender, weight, height, physical activity, and others (siregar 2021). a good nutritional status will contribute to health, while nutritional problems can cause several negative impacts that a person's eating behavior can influence. nutritional problems that occur in adolescents are malnutrition and overnutrition. malnutrition occurs due to insufficient consumption of nutrients and energy that cannot meet the body's needs. meanwhile, overnutrition is caused by food intake exceeding the body's daily needs (ovita, ade nur, dkk, 2019). effect of body image on adolescent nutritional status the study results show that most respondents have normal nutritional status, 118 respondents (70.2%), and negative body image, namely 101 respondents (60.1%). the results of the analysis test using the ordinal logistic regression test obtained a significance value of p <0.001, so it can be concluded that body image affects the nutritional status of adolescents. this is in line with research conducted by nurleli in 2019 (nurleli 2019) and salsabila siregar in 2023 (siregar, 2023), which states that there is an influence between body image assessment and nutritional status. this study states that adolescents have a normal nutritional status and a negative body image. this means that many adolescents still have a wrong perception of body image. they may feel they have a fat/thin body shape and a normal nutritional status. this is in line with research conducted by wulan nur insani in 2022, which shows that these adolescents have an ideal body shape but tend to judge their body shape as larger than their actual body shape. the age factor that adolescents have is also easily influenced by today's mass media, which causes adolescents to constantly feel dissatisfied with their body shape and size (insani 2022). the formation of self-concept in the form of body image in adolescents causes most adolescents to lack food intake due to the wrong diet and causes adolescents to be disrupted in their eating patterns, low self-esteem, depression, anxiety, and various other emotional disorders (siregar 2023). effect of energy intake on adolescent nutritional status the results showed that most respondents had normal nutritional status, 118 respondents (70.2%) and good energy intake, 74 respondents (44.0%). the results of the analysis test using the ordinal logistic regression test obtained a significance value of p <0.001, so it can be concluded that energy intake affects the nutritional status of adolescents. this is in line with research conducted by richard winerungan, et al. in 2018 (winerungan et al. 2018) and lia amirta siregar in 2021 (siregar, 2021), which states that there is an influence between energy intake assessment on nutritional status. everyone is advised to consume sufficient foods in energy content so that they can carry out activities. a well-chosen daily diet will provide all the nutrients the body needs to function normally. nutrients provide energy, help the growth process, and maintain body condition (winerungan et al. 2018). the imbalance of nutrient intake in adolescents is the basic problem of nutritional status in adolescents. if adolescents consume foods with sufficient energy for their needs, there is no energy storage in the body. in contrast, if adolescents consume more energy than their body needs, it will be stored as energy reserves, and if adolescents lack energy, it can cause a negative energy balance. the energy consumption category is consuming food during the last 24 hours, then converted into energy or nutritional adequacy per day for each individual (siregar 2021). physical activity levels significantly impacted energy intake among adolescents. the higher the level of physical activity performed, the greater the energy needs. intensive or heavy physical activity increased calorie expenditure, thus requiring a higher energy intake to support such activities. adolescents with low energy intake tended to be unable to meet their daily caloric needs, especially if they were physically active. this could lead the kurniasih, et. al. ghmj (global health management journal) 2024, vol. 7, no. 4 277 body to break down fat reserves to meet energy demands, potentially resulting in weight loss. adolescents with low physical activity levels often experienced nutritional issues, including obesity, due to an imbalance between calorie intake and energy expenditure. physically inactive adolescents had a higher risk of becoming obese. research showed that obese adolescents spent more time engaging in light activities and less in moderate or intense activities. when energy intake was high but not balanced by adequate physical activity, it could lead to excess weight gain (islami, yanti, and hariati 2023). limitations of the research in the process of collecting data and working on it, researchers faced several obstacles which became one of the limitations that still needed to be improved in further research. limitations in this study are caused by several factors including many factors that can affect nutritional status, but were not studied such as physical activity, infectious diseases, nutritional knowledge, mass media, sleep quality, economic factors, and stress conditions and this study was conducted for 1 day to collect data, due to the limited time given by the school. the results of this study were expected to serve as baseline data that could be further developed into better research. other researchers could choose schools located in intermediate areas, as the food consumed there is more diverse, and to achieve more comprehensive results. additionally, they could explore the causeand-effect relationships of each variable, making the focus clearer and providing a deeper understanding of the factors that could influence nutritional status in adolescents. 5. conclusion this study concludes that there is an influence between body image and energy intake on adolescent nutritional status. the results of this study can be applied in every school and health service, such as health centers, as a preventive and promotive development effort. this research can also be used as a reference for further research and can be developed into further research by completing the cause-and-effect relationship of each variable so that it is more focused and can find out more factors that can affect nutritional status in adolescents. conflict of interest the authors declare no conflicts of interest for the results. references winerungan, r. et al. (2018) hubungan antara asupan energi dengan status gizi pada pelajar smp di wilayah malalayang i kota manado. hasil riset kesehatan dasar tahun 2013 tentang status gizi remaja usia 16-18, 7(5). insani, w.n. (2022) ‘hubungan body image dengan status gizi remaja putri kelas xi di sman 2 majalaya kecamatan majalaya kabupaten bandung’, jurnal ilmiah hospitality, 11(2), pp. 1567–1572. world health organization. (2018) ‘global database on the implementation of nutrition action’, (june). kemenkes ri (2018) ‘hasil riset kesehatan dasar tahun 2018’, kementrian kesehatan ri, 53(9), pp. 1689–1699. nurleli (2019) ‘hubungan body image dengan status gizi remaja di kota makassar’, infokes : info kesehatan, 9(2), pp. 128–133. available at: https://jurnal.ikbis.ac.id/infokes/article/view/116/47. ovita, ade nur, hatmanti, nety mawarda, amin, n. (2019) ‘hubungan body image dan aktivitas fisik dengan status gizi remaja putri kelas viii smpn 20 surabaya’, sport and nutrition journal, 11(56), pp. 26–27. available at: https://doi.org/10.1016/j.sasoi.2013.12.010. makhrajani, m. (2018) ‘perbedaan tingkat pengetahauan, body image, asupan energi, dan status gizi pada mahasiswa gizi dan non gizi fakultas ilmu kesehatan universitas muhammadiyah parepare ;1(1), pp. 24–33. astini, n.n.a.d. and gozali, w. (2021) ‘body image sebagai faktor penentu dalam meningkatkan status gizi remaja putri’, international journal of natural science and engineering, 5(1), pp. 1–7. available at: https://doi.org/10.23887/ijnse.v5i1.31382. siregar, s. (2023) ‘hubungan antara body image, aktivitas fisik, pengetahuan gizi dengan status gizi remaja putri sman 1 rambah’, universitas islam negeri sultan syarif kasim riau pekanbaru, pp. 1–77. https://jurnal.ikbis.ac.id/infokes/article/view/116/47 https://doi.org/10.1016/j.sasoi.2013.12.010 https://doi.org/10.23887/ijnse.v5i1.31382 ghmj (global health management journal) 2024, vol. 7, no. 4 kurniasih, et. al. 278 siregar, l. a. (2021). hubungan asupan energi dengan status gizi remaja sma negeri 1 ulu barumun (doctoral dissertation, universitas islam negeri sumatera utara). islami, septi nur, rusmini yanti, and niken widyastuti hariati. 2023. “screen time dan aktivitas fisik dengan asupan energi pada remaja obesitas.” jurnal keperawatan profesional (kepo) 4(2):88–95. https://doi.org/10.36590/kepo.v4i2.685. rochayanti, christina, eny endah pujiastuti, and ayn warsiki. 2012. “sosialisasi budaya lokal dalam keluarga jawa.” jurnal ilmu komunikasi 10(3):308–20. cite this article as: kurniasih, f. g., wahidin, m. d. s., & fachrudin, d. (2024). the influence of body image and energy intake on nutritional status in adolescents at sman 1 cirebon city, indonesia. ghmj (global health management journal), 7(4), 271–278. https://doi.org/10.35898/ghmj-741090 https://doi.org/10.36590/kepo.v4i2.685 https://doi.org/10.35898/ghmj-741090 template ghmj 2024 ghmj (global health management journal) 2025, vol. 8, no. 2 indonesian scholars’ alliance https://doi.org/10.35898/ghmj-821269 257 open access reviewer acknowledgements: bridging science, care, and community – ghmj (global health management journal), volume 8, number 2, 2025 as the ghmj (global health management journal) continues to advance integrated solutions for global health challenges, this edition highlights cutting-edge research and innovations spanning from molecular science to health systems strengthening. this issue of the global health management journal (vol. 8, no. 2, 2025) presents an interconnected range of studies that reflect the dynamic challenges and innovations in global health. beginning with clinical and pharmacological research, the issue highlights a study on radiographic patterns in tuberculosis patients with and without diabetes (fatihah et al., 2025)—a dual burden increasingly relevant in both endemic and developing contexts. this clinical insight is followed by two experimental studies on plant-based therapies: one evaluating the hypoglycemic effect of bay leaf and celery extract in diabetic rats (laorenz et al., 2025), and another investigating the antiviral potential of cassava leaf-derived nicotiflorin against dengue virus serotype 1 (yulianti et al., 2025), reflecting a growing interest in local bioresources as alternatives to conventional treatment. the issue then transitions into broader public health and educational themes. a study from ghana examines the risks of adolescent pregnancy complicated by diabetes (ameyaw et al., 2025), while orthopedic data from indonesia compares healing outcomes in different types of tibial fractures post-orif (sakinah et al., 2025), offering evidence to improve trauma recovery. a thoughtful paper from south africa challenges the way we conduct educational research with students with disabilities (muzite & gasa, 2025), advocating for more inclusive and participatory approaches. from thailand, we see how self-efficacy–based programs can significantly reduce fall risk among older adults (sukaree et al., 2025), offering a preventive approach to managing geriatric health. meanwhile, a retrospective study from türkiye (boğa, 2025) shifts the focus to acute care, identifying critical predictors of icu admission among emergency patients—highlighting the importance of timely response systems within hospital settings. these health system perspectives are further reinforced by a report from zimbabwe that emphasizes the foundational role of laboratory capacity in supporting diagnosis, surveillance, and treatment for hiv/aids and other diseases (mayavo, 2025). the issue concludes with a photo essay that captures the human side of scholarship— tracing how digital connections sparked a decade-long journey of academic friendship and collaboration (yeyentimalla et al., 2025). link to download: https://publications.inschool.id/index.php/ghmj/issue/view/ghmj.08.02 editor-in-chief prof. andrew john macnab managing editors doni marisi sinaga, m.sc. kukuh madyaningrana, m.biotech. ph.d. journal managers suyitno, m.phm maretalinia, m.a external reviewers  dr. witri pratiwi, m.kes. (universitas swadaya gunung jati, indonesia)  dr. tiar masykuroh pratamawati, m.m., m.biomed. (universitas swadaya gunung jati, indonesia)  tiisetso chuene, m.ph (university of limpopo, south africa)  crossman mayavo, ph.d (midlands state university, zimbabwe)  assoc. prof. dr. atthawit singsalasang (nakhon ratchasima rajabhat university, thailand)  asst. prof. dr. benchaporn sukprasert (suranaree university of technology, thailand)  dr. elmiawati latifah (universitas muhammadiyah magelang, indonesia)  dr. türker karaboğa (esenyurt necmi kadıoğlu state hospital, türkiye)  lasata shrestha, m.ph. (university of washington, united states)  dr. emmanuel ameyaw (kwame nkrumah university of science and technology, ghana) https://doi.org/10.35898/ghmj-821269 https://publications.inschool.id/index.php/ghmj/index https://publications.inschool.id/index.php/ghmj/article/view/1161 https://publications.inschool.id/index.php/ghmj/article/view/1174 https://publications.inschool.id/index.php/ghmj/article/view/1192 https://publications.inschool.id/index.php/ghmj/article/view/1192 https://publications.inschool.id/index.php/ghmj/article/view/1213 https://publications.inschool.id/index.php/ghmj/article/view/1200 https://publications.inschool.id/index.php/ghmj/article/view/1212 https://publications.inschool.id/index.php/ghmj/article/view/1215 https://publications.inschool.id/index.php/ghmj/article/view/1218 https://publications.inschool.id/index.php/ghmj/article/view/992 https://publications.inschool.id/index.php/ghmj/article/view/1256 https://publications.inschool.id/index.php/ghmj/issue/view/ghmj.08.02 https://www.researchgate.net/profile/andrew_macnab https://orcid.org/0000-0002-4904-881x https://orcid.org/0000-0003-1634-6949 https://orcid.org/0000-0002-6817-7852 https://orcid.org/0000-0003-0250-7721 https://orcid.org/0000-0001-8714-9198 https://orcid.org/0000-0002-2844-9307 https://orcid.org/0000-0003-1976-146x https://orcid.org/0000-0002-1066-9432 https://orcid.org/0000-0003-4123-210x https://orcid.org/0000-0002-3316-0014 https://orcid.org/0000-0002-3328-3700 https://orcid.org/0000-0001-8518-837x https://orcid.org/0000-0002-9760-7348 https://orcid.org/0000-0001-5548-9905 ghmj (global health management journal) 2025, vol. 8, no. 2 indonesian scholars’ alliance 258 we express our sincere gratitude to the reviewers who have generously contributed their time and expertise to this edition of the global health management journal. their commitment to scholarly excellence and constructive peer feedback has helped ensure the integrity and impact of every article published. eligible reviewers may be considered for future roles on our editorial board, and receive exclusive publishing opportunity and the chance to publish guest editorial papers at no cost. simply register on our website and select the "reviewer" option during sign-up. acceptance rate : 17 % days to first editorial decision : 18 days days to accept : 75 days published: 28 july 2025. references ameyaw, e., asafo-agyei, s. b., hammond, c. k., nguah, s. b., damalie, f. j. k., senaya, c. m., & adutwum, l. m. (2025). pregnancy outcomes among adolescents and young adults with diabetes in kumasi, ghana. ghmj (global health management journal), 8(2), 200–208. https://doi.org/10.35898/ghmj-821213 boğa, e. (2025). predictors of intensive care unit admission in red code patients in the emergency department: a single-center retrospective observational study. ghmj (global health management journal), 8(2), 228– 235. https://doi.org/10.35898/ghmj-821218 fatihah, h. b., latief, m. a., & herdwiyanti, m. (2025). comparing chest radiograph lesion areas in pulmonary tuberculosis patients with and without diabetes mellitus: a 2023 study at waled hospital, cirebon, indonesia. ghmj (global health management journal), 8(2), 166–171. https://doi.org/10.35898/ghmj-821161 laorenz, d. e., naldi, y., & oktavrisa, f. (2025). the effectiveness of the combination of bay leaf extract (syzygium polyanthum) and celery leaf extract (apium graveolans l.) on lowering blood sugar level in wistar rats (rattus norvegicus). ghmj (global health management journal), 8(2), 172–180. https://doi.org/10.35898/ghmj-821174 mayavo, c. (2025). strengthening laboratory capabilities in improving hiv/aids and other diseases support in zimbabwe. ghmj (global health management journal), 8(2), 245–256. https://doi.org/10.35898/ghmj-82992 muzite, p., & gasa, v. (2025). rethinking educational research involving students with disabilities. ghmj (global health management journal), 8(2), 190–199. https://doi.org/10.35898/ghmj-821212 sakinah, d. n., putro, w. a., & debyanti, m. (2025). comparison of healing time in closed fractures of the tibial diaphysis and tibial-fibula after orif plate and screw at waled regional public hospital, indonesia. ghmj (global health management journal), 8(2), 209–216. https://doi.org/10.35898/ghmj-821200 sukaree, w., sukhumal, p., & limpiteeprakan, p. (2025). the effects of self-efficacy-based fall prevention program among elderly in phibunmangsahan town municipality, ubon ratchathani province, thailand. ghmj (global health management journal), 8(2), 217–227. https://doi.org/10.35898/ghmj-821215 yeyentimalla, y., christyanni, y., & suryawati, s. (2025). a decade of growth: from social media to academic friendship. ghmj (global health management journal), 8(2), 236–244. https://doi.org/10.35898/ghmj-821256 yulianti, s., apriyanto, d. r., brajawikalpa, r. s., & dewi, b. e. (2025). inhibition test of cassava leaves (manihot esculenta crantz) flavonoid nicotiflorin on replication of dengue virus serotype 1 in vitro. ghmj (global health management journal), 8(2), 181–189. https://doi.org/10.35898/ghmj-821192 cite this article as: ghmj (global health management journal). (2025). reviewer acknowledgements: bridging science, care, and community – ghmj (global health management journal), volume 8, number 2, 2025. ghmj (global health management journal), 8(2), 257–258. https://doi.org/10.35898/ghmj-821269 https://publications.inschool.id/index.php/ghmj/section/view/guest-editorial https://www.inschool.id/publications/index.php/ghmj/user/register https://doi.org/10.35898/ghmj-821213 https://doi.org/10.35898/ghmj-821218 https://doi.org/10.35898/ghmj-821161 https://doi.org/10.35898/ghmj-821174 https://doi.org/10.35898/ghmj-82992 https://doi.org/10.35898/ghmj-821212 https://doi.org/10.35898/ghmj-821200 https://doi.org/10.35898/ghmj-821215 https://doi.org/10.35898/ghmj-821256 https://doi.org/10.35898/ghmj-821192 https://doi.org/10.35898/ghmj-821269 ghmj (global health management journal) 2024, vol. 7, no. 2 indonesian scholars’ alliance open access research article improving pulmonary tuberculosis treatment adherence: the role of patient knowledge in cirebon, west java, indonesia sri marfuati, hikmah fitriani, mustika weni, firanda putri riawan faculty of medicine, universitas swadaya gunung jati, cirebon, indonesia. *corresponding author’s e-mail: srimarfuati16@gmail.com doi: 10.35898/ghmj-72987 abstract background: with 10 million cases around the world, pulmonary tuberculosis (tb) has been classified as a highly contagious disease and mostly affecting low and middle countries. having the second highest incident cases in west java of indonesia, cirebon becomes a challenging city in order to reduce the number of tb cases in the country. aims: this study aims to identify the patients’ knowledge and treatment phases, and how the two factors encourage patients to comply with their medication. methods : this cross-sectional observational study was conducted among 91 new pulmonary tuberculosis patients at the cirebon city community lung health centre, selected using random sampling. not only respondent characteristics, but also data on the patients' knowledge levels, treatment phases, and medication adherence were collected using a questionnaire and medical records. to assess the relationship between these variables, the collected data was then analyzed using the spearman correlation test. ethical clearance was obtained from the health research ethics commission, and informed consent was gathered from all participants. results: this study reveals the most updated characteristics of the tuberculosis patients at the cirebon city community lung health center aged 15-64 years old with treatment duration ranged 1-6 months. the majority have insufficient knowledge about tuberculosis (45.1%), and 75.8% of patients adhered to their prescribed medication regimen, regardless of their knowledge level. the data indicates a significant positive correlation between knowledge level and medication adherence (p = 0.015), with 95% of patients with good knowledge adhering to treatment compared to only 34% with poor knowledge. furthermore, there is a significant relationship between adherence and treatment duration (p = 0.002), as 85% of patients who adhered to treatment did so for more than two months. conclusion: the study shows that patients with better knowledge of tuberculosis are more likely to stick to their medication, which also leads to longer treatment durations. given the high incidence of tb in the region, these findings suggest the need for targeted educational programs to enhance patients' understanding of tb, thereby improving adherence to treatment protocols. keywords: pulmonary tuberculosis, medication adherence, patient knowledge, treatment duration. received: 20 may 2024, reviewed: 09 june 2024, revised: 26 august 2024, accepted: 30 august 2024. © 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:srimarfuati16@gmail.com https://doi.org/10.35898/ghmj-72987 marfuati, et.al. ghmj (global health management journal) 2024, vol. 7, no. 2 104 1. introduction recorded with more than 10 million cases in global, pulmonary tuberculosis (tb) has been raised as major global issue which causes 1.5 million deaths per year (world health organization, 2023). caused by mycobacterium tuberculosis, tuberculosis is highly contagious, affecting the lungs, and impacting low and middle countries (global tuberculosis report, 2023). as per gtr report in 2023, recorded with approximately 808,000 drug-sensitive tuberculosis (tb) cases, world health organization (who) places indonesia as having the second highest number of tb cases in the world. while the country continues facing significant challenges, enhancing treatment adherence is crucial in order to reduce the risks associated with tb, such as health deterioration, complications, relapse, treatment failure, drug resistance, and ongoing community transmission. vandauli and bachtiar (2019) noted that not only stigma, but also lack of knowledge in tb patients relates to the medical compliance regarding to how vulnerable them to other high risk infection such as tb-hiv co-infection. this study will find out the relationship of knowledge level and phase of pulmonary tuberculosis treatment with medication compliance in tb patients at the cirebon city community lung health center, the only hospital in cirebon city that treats lung tuberculosis patients. ranking as the second highest incident in west java, cirebon city has been known with 94.01% of detection rate, and 84% of treatment success rate. comprehensive knowledge plays a critical role in the success of tuberculosis treatment by informing patients about transmission methods, treatment stages, goals, drug side effects, and disease complications, thereby shaping their behaviors, plans, and decisions; emphasizing the utmost priority on patient compliance due to its significant impact on treatment outcomes (dwiningrum et al., 2021; rizki et al., 2022). 2. methods study design this research includes observational analysis using cross sectional, to determine the relationship between level of knowledge and phase of treatment for pulmonary tuberculosis and adherence to taking medication, data collected at the same time. populations and samples the population of this study was all pulmonary tuberculosis patients in cirebon city and the sample for this study was taken from all new cases of tb sufferers who met the criteria at the cirebon city community lung health centre with a sample size of 91 people. data information was provided by several treatment centre officers who were selected based on a minimum work period of 3 years. this study employed a random sampling involving patients with age ranged 15-64 years, and currently being treated for tuberculosis (1-6 months). the patients will be excluded if more than 75% of the questions on the questionnaire were not answered. measurements the independent variable in this study is the level of knowledge and phase of treatment for pulmonary tuberculosis and the dependent variable is adherence to taking medication. the data was taken using a secondary data from a set of questionnaires and the patient's medical records at the hospital. data collection research data was collected directly by researchers at the hospital, by first providing information to respondents regarding an explanation of the research to be carried out, objectives, benefits, research procedures and guaranteeing the confidentiality of all information and personal data of respondents. ethical clearance has been obtained by the researcher, reviewed by the health research ethics commission (kepk) faculty of medicine, swadaya university, gunung jati with ethical number no.156/ec/fkugj/vi/2022. 105 ghmj (global health management journal) 2024, vol. 7, no. 2 marfuati, et.al. instruments and analysis the respondents who were willing to voluntarily take part in this research were asked for written consent by filling out an informed consent letter. the questionnaire was adopted from the mmas-8 score questionnaire. observations were carried out by researchers, lecturers at the faculty of medicine, ugj, the respondent's level of knowledge category refers to a good percentage if the overall score is >30, sufficient if the overall score is (16-30), and poor if the overall score is <16. the spearman correlation test was used to determine between knowledge and stages of treatment for pulmonary tb sufferers and compliance with the treatment program for pulmonary tb sufferers at the cirebon city community lung health center. 3. results respondents’ characteristics table 1 summarizes the respondent characteristics in this recent study including sex, age, and patients’ knowledge to the tb disease, and also the duration of treatment and their obedience to the given medication. the survey indicates that more male suffer tuberculosis at the subjected area. the data at the cirebon city community lung health center counts that there were 52 male patients with tb case (57.1%), compares to women with 39 cases (42.9%). the majority of patients were 15-29 years (43.9%), and only 8 patients (8.8%) with age more than 60 years old. looking to the data, more respondents involved in this study have bad knowledge even the majority are obeying the medication given to them during the observation. our survey noted that of 91 patients, only 20 patients are accompanied with good knowledge to tuberculosis. while 30 patients have adequate knowledge (33%), the majority of new cases of tuberculosis patients at the cirebon city community lung health center had a level of insufficient knowledge (45.1%). by the data, it can be said the patients’ knowledge does not affect their obedience and duration to follow the medication. the data shows that 61% of patients receive treatment for more than 2 months and still counting. table 1. respondents’ characteristics characteristics frequency percentage sex male 52 57.1 female 39 42.9 age 15 – 29 40 43.9 30 – 44 23 25.3 45 – 59 20 21.9 60 – over 8 8.8 knowledge bad 41 45.1 adequate 30 33.0 good 20 22.0 treatment duration ≤ 2months 30 33.0 > 2 months 61 67.0 obedience not obey 22 24.2 obey 69 75.8 table 2 shows the distributions of the patients based on their level knowledge to tuberculosis. the statistical analysis shows that the level of knowledge significantly contribute to the obedience level to comply the tb medication (p value = 0.015). if compared to the treatment phase, it can be said that the level knowledge deliver more positive correlation (r = 0.314). the data indicates that the highest the knowledge level, the more comply the patients with the tb treatment). among 20 patients with good knowledge, it is noted that 19 patients are following the medication, while out of 41 patients with bad level of knowledge, the percentage of patients obeying the medication are decreasing to only 14 patients. marfuati, et.al. ghmj (global health management journal) 2024, vol. 7, no. 2 106 table 2. relationship between level of knowledge and compliance with medication obedience total r p value not obey n obey n level knowledge bad 14 63.6% 27 39.1% 41 0.254 0.015 adequate 7 31.8% 23 33.3% 30 good 1 4.5% 19 27.5% 20 total 22 100% 69 100% 91 treatment phase ≤ 2 months 13 59.1% 17 24.6% 30 0.314 0.002 > 2 months 9 40.9% 52 75.4% 61 total 22 100% 69 100% 91 the results of this recent study not only show how knowledge is affecting the obedience level among the new tb cases patients at the cirebon city community lung health center, but also how long the patients willing the participate the treatments (counting as duration). the statistical analysis shows positive relationship where the more the patients obeying the medication, the more durations the tb patients complying the treatment (p value = 0.002). observed from table above, of 61 patients with more than 2 months treatment duration, 52 patients have been noted obeying the medication compliance. on the other hand, of 22 patients observed not obeying the medication from the total respondents, more than half patients (59.17%) have been surveyed with less than 2 months treatment phase. 4. discussion knowledge level the level of knowledge about tuberculosis of respondents in this study was 41 (45.1%) at a poor level of knowledge. while 30 patients (33%) were measured with a sufficient level of knowledge the other 20 (22%) had good level of knowledge. this is similar to previous research conducted by miranda & ridwan (2019) explaining that there is a relationship between the level of knowledge and efforts to prevent the spread of tb. the higher the level of knowledge, the greater the community's efforts are needed to prevent the transmission of tuberculosis. this means that knowledge is very important, because high knowledge can create good behavior. in the elderly group, the level of knowledge is lower than the age range in early and middle adulthood. women's knowledge level is higher (miranda & ridwan, 2019) than men, because women prefer to read or discuss with other people, so they have a better understanding of tuberculosis. women are more diligent and thorough when given a task or doing something. another factor that influences knowledge is education, the higher the level of education, the easier it is to obtain information. treatment phase it is noted that there were 30 respondents (33%) underwent treatment for ≤ 2 months and there were 61 respondents (67%) underwent treatment > 2 month. this research explains that if you do not undergo treatment for 6 months it will cause resistance to pulmonary tuberculosis drugs and will increase the source of transmission of pulmonary tuberculosis, therefore the majority of respondents adhere to taking medication regularly, the level of awareness and knowledge of respondents about pulmonary tuberculosis plays a role in the process. his recovery (seniantara et al., 2018). ita azizah's research shows that compliance with taking medication in this study was seen from information on compliance with taking medication and compliance with taking medication (azizah, 2020). adherence to taking medication in the intensive phase for two months at the start of treatment is done every 2 weeks, while in the advanced phase, patients take the medication every month. this is in line with research by masyudi et al (2019. compliance can be interpreted as patient behavior that complies with all advice and recommendations from medical personnel. compliance with taking medication is measured according to the guidelines that have been implemented, namely by complete treatment. 107 ghmj (global health management journal) 2024, vol. 7, no. 2 marfuati, et.al. medication adherence the number of respondents at the compliant level was 69 people (75.8%) while those included at the less compliant level were 22 people (24.2%). the results obtained in this study according to the level of compliance of smear positive pulmonary tuberculosis patients in carrying out the treatment program were quite good. the spearman test shows a correlation value of 0.254 with a p value of 0.015, which means there is a positive correlation with weak strength in the variables tested. this means that the higher the patient's level of knowledge, the higher the patient's level of compliance with taking medication. the results of this study are in accordance with research conducted by mellyana et. al. (2022) showing the results obtained using the spearman p-value test were 0.028 < α (0.05), means relationship between knowledge and the level of compliance of pulmonary tuberculosis patients. the positive correlation coefficient value of τ 0.389 shows a unidirectional relationship, which means that the higher the knowledge possessed by tuberculosis sufferers, the higher the patient's medication adherence and better compliance is determined by the patient's behavior in complying with instructions given by medical personnel. non-compliance with pulmonary tuberculosis sufferers is due to the patient not taking medication on time according to the predetermined schedule (rojali & noviatuzzahrah, 2018). atd must be taken regularly according to schedule, during the intensive and continuation phases to avoid treatment failure and relapse. patient noncompliance with tuberculosis treatment is common and an important cause of treatment failure. failure to comply with treatment can also lead to the emergence of tuberculosis treatment requiring longer treatment. correlation between knowledge level and compliance with medication this research shows relationship between knowledge level and treatment adherence. the level of knowledge has a significant relationship with compliance where the spearman test shows a correlation value of 0.254 with a p value of 0.015, which means there is a correlation in the variables tested has a positive direction with weak strength, the high level of patient knowledge causes , the higher the level of compliance with taking medication. as per research conducted by mellyana et. al. (2022), knowledge influences tb patients' adherence to medication and the more compliant the patient, the higher the cure rate and the impact on reducing resistance to anti-tuberculosis drugs. the patient's recovery rate is measured by regular treatment. compliance is also one of the factors that increases recovery from tuberculosis (mellyana et al., 2022). correlation between treatment phase and medication adherence the results of the research show that a correlation value of 0.314 with a p value of 0.002 is obtained, which means that there is a correlation in the variables tested in a positive direction with weak strength. this shows that if the respondent goes through a phase of more than 2 months of treatment, the patient will be more compliant in taking the medication. the or value was 4.418 (1.608-12.143), which means that respondents who underwent treatment for ≤ 2 months were 4.418 times more likely to be non-compliant with taking medication than those who underwent treatment for > 2 months. this finding is similar to previous research conducted by ita azizah showing that compliance with taking medication in this study was seen from information on compliance with taking medication and compliance with taking medication (azizah, 2020). adherence to taking medication in the intensive phase for two months at the start of treatment is done every 2 weeks, while in the advanced phase, patients take the medication every month. a research by masyudi et al. (2019) explains that compliance can be interpreted as patient behavior that complies with all advice and recommendations from medical personnel. compliance with taking medication is measured according to the guidelines that have been implemented, namely by complete treatment. this research explains that the results of data collection showed that those who were compliant in taking oat were those who received supervision from their families at home (azizah, 2020; masyudi et al., 2019). marfuati, et.al. ghmj (global health management journal) 2024, vol. 7, no. 2 108 5. conclusion this recent study shows that patients with better knowledge of tuberculosis are more likely to follow their medication regimen, which helps them stay on treatment longer. patients who go through the treatment phase for more than 2 months will be more compliant in taking medication. although the connection between knowledge, adherence, and treatment length is not very strong (r = 0.254 – 0.314), improving patient education can make a significant difference. policy implications include the needs for targeted educational programs and sustained community engagements to improve knowledge and adherence, ultimately reducing tuberculosis incidence and resistance in high-burden areas like cirebon of indonesia. conflict of interest the authors declare no conflict of interest for the results. references azizah, i. (2020). determinan lama waktu kesembuhan pada pengobatan pasien tuberkulosis kategori i. higeia (journal of public health research and development), 4(special 3), 574-583. dwiningrum, r., wulandari, r. y., & yunitasari, e. (2021). hubungan pengetahuan dan lama pengobatan tb paru dengan kepatuhan minum obat pada pasien tb paru di klinik harum melati. jurnal aisyah: jurnal ilmu kesehatan, 6, 209-214. https://doi.org/10.30604/jika.v6is1.788 global tuberculosis report 2023. (2023). retrieved from https://iris.who.int/. rizki, u., nyorong, m., theo, d., & anggraini, i. (2022). influence factors of effective communication of health officers on patient satisfaction. jurnal perilaku kesehatan terpadu, 1(1), 46-59. https://doi.org/10.61963/jpkt.v1i1.15 rojali, r., & noviatuzzahrah, n. (2018). faktor risiko kepatuhan pengobatan pada penderita tb paru bta positif. jurnal kesehatan, 9(1), 70-79. https://doi.org/10.26630/jk.v9i1.754 seniantara, i. k., ivana, t., & adang, y. g. (2018). pengaruh efek samping oat (obat anti tuberculosis) terhadap kepatuhan minum obat pada pasien tbc di puskesmas. jurnal keperawatan suaka insan (jksi), 3(2), 112. masyudi, m., syafriyana, r., yulidar, y., husna, h., & syam, b. (2019, december). analisis faktor yang mempengaruhi kesembuhan penderita tuberkulosis paru di rumah sakit tingkat ii iskandar muda banda aceh tahun 2018. in prosiding seminar nasional usm (vol. 2, no. 1, pp. 172-182). miranda, o. m., & ridwan, a. program studi ilmu keperawatan fakultas keperawatan universitas syiah kuala banda aceh, m., & keilmuan keperawatan komunitas fakultas keperawatan universitas syiah kuala banda aceh, b.(2019). the correlation between knowledge level and prevention efforts of tuberculosis (tb) infection, 4(2), 42-47. https://jim.usk.ac.id/fkep/article/download/12375/5369 mellyana, v., nurinda, e., fauzi, r., & indrayana, s. (2022). hubungan pengetahuan terhadap tingkat kepatuhan pasien tuberkulosis paru di puskesmas binangun cilacap. inpharnmed journal (indonesian pharmacy and natural medicine journal), 5(2), 1-7. https://doi.org/10.21927/inpharnmed.v5i2.1884 vandauli, m., & bachtiar, a. (2019, august). analysis of provider-initiated hiv testing and counseling in tuberculosis patient at a private hospital in jakarta. in proceedings of the international conference on applied science and health (no. 4, pp. 1145-1149). https://www.inschool.id/publications/index.php/icash/article/view/742 world health organization. (2023) "tuberculosis." accessed june 10, 2024. https://www.who.int/newsroom/fact-sheets/detail/tuberculosis cite this article as: marfuati, s., fitriani, h., weni, m., & riawan, f. p. (2024). improving pulmonary tuberculosis treatment adherence: the role of patient knowledge in cirebon, west java, indonesia. ghmj (global health management journal), 7(2), 103–108. https://doi.org/10.35898/ghmj-72987 https://doi.org/10.30604/jika.v6is1.788 https://iris.who.int/ https://doi.org/10.61963/jpkt.v1i1.15 https://doi.org/10.26630/jk.v9i1.754 https://jim.usk.ac.id/fkep/article/download/12375/5369 https://doi.org/10.21927/inpharnmed.v5i2.1884 https://www.inschool.id/publications/index.php/icash/article/view/742 https://www.who.int/news-room/fact-sheets/detail/tuberculosis https://www.who.int/news-room/fact-sheets/detail/tuberculosis https://doi.org/10.35898/ghmj-72987 ghmj (global health management journal) 2024, vol. 7, no. 3 indonesian scholars’ alliance open access research article students perception on soft skills in faculty of medicine, universitas swadaya gunung jati, cirebon, indonesia catur setiya sulistiyana1, , zamzam ahmad fauzan1, tissa octavira permatasari1, uswatun khasanah2,* 1 department of medical education, faculty of medicine, universitas swadaya gunung jati, indonesia. 2 department of public health, faculty of medicine, universitas swadaya gunung jati, indonesia. *corresponding author’s e-mail: uswatunhasanah7@gmail.com doi: 10.35898/ghmj-731000 abstract background: soft skills is important attributes of professionalism in the practice of medicine. soft skills to be known as person's ability beyond knowledge, intelligence, or competence. faculty of medicine in universitas swadaya gunung jati, cirebon, indonesia, has used various learning methods to support students' skills, allowing students to have different perspectives in understanding soft skills. aims: to identify the perception of medical students at faculty of medicine, swadaya gunung jati university, in the pre-clinical stage towards soft skills. methods: this was an observational descriptive study. respondents were selected using stratified random sampling techniques, sample size was 262 respondents were obtained from semester 2, 4, 6 and 8. this study used primary data with 42 statement items with univariate analysis. results: from 262 respondents, of 93.1% students (244) have a good perception of the definition of soft skills. as many as 50.4% (123) of 262 respondents have a good perception of time management. as many as 81.3% (213) of 262 respondents have a good perception of critical thinking. 73.7% (193) of 262 respondents have a good perception of teamwork. as many as 87.4% (229) of 262 respondents have a good perception of public speaking. conclusion: this study showed medical student perception of soft skills regarding definition, time management skills, critical thinking, teamwork, and public speaking had a good perception. in the future, faculty needs to provide space for students to develop these soft skills through training or interprofessional education and other programs. keywords: perception, soft skills, time management, critical thinking, medical students. received: 10 september 2024 reviewed: 16 october 2024 revised: 23 october 2024 accepted: 31 october 2024. © 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 medical practice designated only for qualified and competent professional personnel permitted by authorized institution. professional behavior is mandatory for medical doctor. within medical education, professionalism is a part of standard competency, whereas mandatory for medical doctor. to assess professionalism, arnold and stern visualize professionalism with clinical competence, communication skills, and understanding of law and ethics as the base of professionalism, and the pillars are excellence, humanism, accountability, and altruism. mailto:uswatunhasanah7@gmail.com https://doi.org/10.35898/ghmj-731000 https://orcid.org/0000-0002-7574-7745 https://orcid.org/0000-0002-3320-3993 sulistiyana, et.al. ghmj (global health management journal) 2024, vol. 7, no. 3 122 based on the definition, professionalism is a quality indicator for a medical doctor that described by a set of behaviors and skills or soft skills within their duties (purwanti, armyanti, and asroruddin 2020). according to the collins english dictionary as cited by achmadi, et al., soft skills are qualities required by a worker beyond knowledge, intelligence, or competency to perform a skill, such as the ability to interact and adapt with others. soft skills commonly divided into two types of personality aspects which is of intra-personal and inter-personal (achmadi, anggoro, and sari 2020.). based on the research done by achmadi, et al., about 10 soft skills mostly needed by 21st century students. among the ten most needed soft skills, it’s found that social responsibility is the top most needed with 59,5%, on the other hand, perspective taking are the least needed by only1,4% (achmadi et al. 2020.). there are several studies related to soft skills for doctors and dentists., one of them is the research conducted by khajeghyasi et al. at the university of isfahan, iran. the study explains that among the various soft skills components examined, there are relative weights for professional ethics as follows. work ethic has a relative weight of 0.212, responsibility (0.188), respecting patient privacy (0.187), righteous and honesty (0.160), and lastly teamwork with relatively lower weight of 0.052. on the other hand, in the management skills domain, time management holds a substantial relative weight (0.481). in the cognitive domain, reasoning and decisionmaking have a relative weight of 00.290, while critical evaluation and thinking have a lower weight (0.080). moving on to the communication skills domain, verbal and nonverbal communication as well as listening have a relative weight of 0.266 (khajeghyasi et al. 2021). another study conducted by ibrahim et al. at the university of bisha, saudi arabia, it is explained that students' perceptions of the benefits of problem-based learning (pbl) include a significant impact on developing interpersonal relationships at 92.5%, enhancing teamwork at 89.6%, and fostering critical thinking improvement at 82.1%.. furthermore, the study also found that students' responses to pbl related to the acquisition of soft skills overall had a mean score of 3.32 sd 0.45, that indicates a high level. these results comprise several aspects, two of which are students' perceptions regarding the development of communication skills, with a mean score of 3.48 sd 0.59, and promoting cooperation in small groups, with a mean score of 3.15 sd 0.74 (ibrahim et al. 2018). faculty of medicine, universitas swadaya gunung jati has been using several teaching methods to support the skills and abilities of students on its curriculum. learning methods such as problem-based learning (pbl), skills lab, discussion with experts are instruments to enhance students' soft skills through processes like selfdirected learning, critical thinking about problems, communication and public speaking skills, and time management. these findings accord to theories stated in amee guide no. 48, that small group learning can assist students in developing critical thinking, decision-making, teamwork, collaborative learning, and communication skills. this is achieved through processes of questioning, listening, speaking, explaining, and responding to the theories discussed during the learning process (edmunds and brown 2010). the following processes of learning experience at the faculty of medicine, universitas swadaya gunung jati, will allow students to gain different perspectives to understand soft skills. based on that description, it is interesting to conduct further research on the "students perception on soft skills in faculty of medicine, universitas swadaya gunung jati. 2. methods this research was conducted at the faculty of medicine, universitas swadaya gunung jati, in july 2023. the descriptive research design is conducted with observational approach research, with primary data collected through a questionnaire. the research targeted pre-clinical stage students on semester 2, 4, 6, and 8 at the faculty of medicine, universitas swadaya gunung jati. measurements the data was carried out by researchers using a set of validated questionnaire distributed to the students that met the criteria. respondents’ characteristics have been documented. this study observed the perception ghmj (global health management journal) 2024, vol. 7, no. 3 sulistiyana, et.al. 123 of respondents about soft skills. several indicators of soft skills questionnaire are soft skills regarding definition, time management skills, critical thinking, teamwork, and public speaking. analysis data the respondents’ characteristics and perceptions of soft skills among students were collected using questionnaire. the research results are presented in the form of table. statistical analysis used univariate analysis. the test results are displayed in a frequency and distribution table of data related to student soft skills as well as a description of soft skill indicators. ethical clearance this research has obtained approval from the ethics commission of the faculty of medicine, universitas swadaya gunung jati, with the number 44/ec/fkugj/v/2023. the data were analyzed using univariate analysis with computer software to describe the characteristics of variables along with frequency distribution tables. 3. results data obtained from 291 subjects, with 29 entries were excluded as they had already become respondents during the questionnaire's validity and reliability testing. in results, 262 subjects from students of faculty of medicine at ugj met the inclusion criteria for depicting their perceptions regarding soft skills. respondent characteristics table 1. frequency distribution on gender gender frequency (n) percentage (%) male 99 37,8 female 163 62,2 total 262 100,0 table 1 indicated that female had higher percentage than male, with 163 respondents (62.2%), while the remaining 99 respondents (37.8%), are males. table 2. medical faculty student perceptions on soft skills definition, time management, critical thinking, teamwork, and public speaking. categories measurements frequency (n) percentage (%) definition of soft skills good 244 93,1 fair 13 5,0 poor 5 1,9 total 262 100,0 time management good 132 50,4 fair 126 48,1 poor 4 1,5 total 262 100,0 critical thinking good 213 81,3 fair 47 17,9 poor 2 0,8 total 262 100,0 teamwork good 193 73,7 fair 67 25,6 poor 2 0,8 total 262 100,0 public speaking good 229 87,4 fair 33 12,6 poor 0 0,0 total 262 100,0 sulistiyana, et.al. ghmj (global health management journal) 2024, vol. 7, no. 3 124 the table above indicates that student perception on soft skills definition is good (93.1%), time management is good (50.4%), critical thinking is good (81,3%), teamwork is good (73.7%), public speaking is good (87.4%),the "definition of soft skills" variable shows the highest score with a percentage of 93.1%. conversely, the variable "time management" has the lowest percentage in the "good" category, which is 50.4%. table 3. medical faculty students’ perceptions on definition of soft skills semester measurements frequency (n) percentage (%) semester 2 good 66 93,0 fair 2 2,8 poor 3 4,2 total 71 100,0 semester 4 good 66 94,3 fair 3 4,3 poor 1 1,4 total 70 100,0 semester 6 good 54 93,1 fair 3 5,2 poor 1 1,7 total 58 100,0 semester 8 good 58 92,1 fair 5 7,9 poor 0 0,0 total 63 100,0 table 3 above illustrated the frequency distribution of the perceptions of students at the faculty of medicine, swadaya gunung jati university, regarding the definition of soft skills. based on the table, the semester with the highest percentage in the "good" category is "semester 4" with a percentage of 94.3%, while the semester with the lowest percentage in the "good" category is "semester 8" with a percentage of 92.1%. despite being slightly lower, this indicates that in this semester as well, the majority of students have a strong level of similarity in understanding the definition of soft skills, although there is a slight difference compared to other semesters. table 4. medical faculty students’ perceptions on time management semester measurements frequency (n) percentage (%) semester 2 good 37 52,1 fair 34 47,9 poor 0 0,0 total 71 100,0 semester 4 good 35 50,0 fair 34 48,6 poor 1 1,4 total 70 100,0 semester 6 good 33 56,9 fair 24 41,4 poor 1 1,7 total 58 100,0 semester 8 good 27 42,9 fair 34 54,0 poor 2 3,2 total 63 100,0 table 4 shows the frequency distribution of students' perceptions at the faculty of medicine, universitas swadaya gunung jati, regarding time management skills. in terms of assessing the "good" category related to time management across different semesters, "semester 6" shows the most positive result with a percentage of 56.9%. however, in "semester 8," the percentage in the "good" category reaches 42.9%, indicating that a significant portion of students in that semester feels less confident in managing their time effectively. ghmj (global health management journal) 2024, vol. 7, no. 3 sulistiyana, et.al. 125 table 5. medical faculty students’ perceptions on critical thinking semester measurements frequency (n) percentage (%) semester 2 good 56 78,9 fair 13 18,3 poor 2 2,8 total 71 100,0 semester 4 good 53 75,7 fair 17 24,3 poor 0 0,0 total 70 100,0 semester 6 good 52 89,7 fair 6 10,3 poor 0 0,0 total 58 100,0 semester 8 good 52 82,5 fair 11 17,5 poor 0 0,0 total 63 100,0 table 5 shows the frequency distribution of students' perceptions at the faculty of medicine, universitas swadaya gunung jati, regarding critical thinking skills. regarding the assessment category "good" related to critical thinking across different semesters, "semester 6" stands out as the semester with the highest result, with a percentage of 89.7%. meanwhile, in "semester 4," the percentage in the "good" category reaches 75.7%, which is the lowest percentage. this suggests that the majority of students in this semester also possess good critical thinking skills, although there is a slight difference compared to other semesters. regarding the perceptions of students at the faculty of medicine, universitas swadaya gunung jati, regarding teamwork skills at table 6, the semester with the highest percentage in the "good" category for teamwork is "semester 8" with a percentage of 87.3%. on the other hand, the semester with the lowest percentage in the "good" category for teamwork is "semester 6" with a percentage of 69.0%. table 7 presents the perceptions of students at the faculty of medicine, universitas swadaya gunung jati, regarding public speaking skills, the semester with the highest percentage in the "good" category for public speaking is "semester 6" with a percentage of 89.7%. conversely, the semester with the lowest percentage in the "good" category for public speaking is "semester 2" with a percentage of 85.9%. table 6. medical faculty students’ perceptions on teamwork semester measurements frequency (n) percentage (%) semester 2 good 57 80,3 fair 13 18,3 poor 1 1,4 total 71 100,0 semester 4 good 50 71,4 fair 19 27,1 poor 1 1,4 total 70 100,0 semester 6 good 40 69 fair 18 31 poor 0 0 total 58 100,0 semester 8 good 55 87,3 fair 8 12,7 poor 0 0 total 63 100,0 sulistiyana, et.al. ghmj (global health management journal) 2024, vol. 7, no. 3 126 table 7. medical faculty students’ perceptions on public speaking semester measurements frequency (n) percentage (%) semester 2 good 61 85,9 fair 10 14,1 poor 0 0,0 total 71 100,0 semester 4 good 61 87,1 fair 9 12,9 poor 0 0,0 total 70 100,0 semester 6 good 52 89,7 fair 6 10,3 poor 0 0,0 total 58 100,0 semester 8 good 55 87,3 fair 8 12,7 poor 0 0,0 total 63 100,0 4. discussion from the research results with a total of 262 respondents regarding the definition of soft skills, 93.1% (244) respondents perceive it as good, 5% (13) have fair perception, and 1.9% (5) have a poor perception. therefore, it can be concluded that in this study, more than half of the respondents have a positive perception of the definition of soft skills. the ugj medical students’ perception regarding the definition of soft skills is considered good because the respondents have similar understanding the statements in the questionnaire. they also agree on the definition of soft skills and the various aspects of tasks and the role of future doctors. the research results from a total of 262 respondents regarding time management show that 50.4% (123) of the respondents have a good perception, 48.1% (126) have a fair perception, and 1.5% (4) have a poor perception. therefore, it can be concluded that more than half of the respondents have a good perception of time management skills. this aligns with the study by roghayeh valipour khajeghyasi et al. in 2021, which found that time management skills accounted for 48% of the total management skills.(khajeghyasi et al. 2021) another study by hanafi et al. revealed that most students had moderate time management skills, with 79.5% in the moderate category, 19.1% in the high category, and 1.4% in the low category (hanafi and widjaja 2021). when analyzing the distribution by semester, semester 8 had the lowest percentage of good results, with 42.9%, compared to semesters 2, 4, and 6. this differs from other studies, such as one by macan et al. in 2021, which suggested that older age is associated with better time management skills (najafi et al. 2022). despite the older age of students in semester 8, their time management skills were not better than those in semesters 2, 4, and 6. this could be influenced by various factors, including stress, peer interaction, cultural differences, personality, procrastination habits, perceived control over time, age, gender, motivation, and anxiety. overall, the perception of fk ugj students regarding time management is considered good because respondents share a common understanding of the statements in the questionnaire about time management skills and agree on the importance of time management in their roles as future doctors. respondents believe that good time management skills come from effectively utilizing free time, planning clear weekly schedules, and avoiding deviations from the planned activities. the research results on critical thinking show that 81.3% (213) of the 262 respondents have a good perception, 17.9% (47) have a fair perception, and 0.8% of the students (2) have a poor perception. this suggests that more than half of the respondents have a positive perception of critical thinking abilities. another study by roghayeh valipour khajeghyasi et al. in 2021 found that critical evaluation and thinking skills accounted for 8% of the total cognitive skills (khajeghyasi et al. 2021). according to ali achmadi's study in 2020 on the analysis of 10 ghmj (global health management journal) 2024, vol. 7, no. 3 sulistiyana, et.al. 127 levels of soft skills needed by students in the 21st century, 73.9% believe that critical and logical thinking is highly needed (achmadi et al. 2020.). when analyzing results by semester, semesters 2 and 4 had lower percentages of good critical thinking skills, with 78.9% and 75.7%, respectively. this could be influenced by various factors, including differences in experiences, reflection, observation, and analysis. another study in iran revealed that 98.6% of medical students did not have a tendency for critical thinking (mehrpour et al. 2023). the variation in critical thinking skills among medical students may be influenced by the education system and various factors such as stress, peer interaction, cultural differences, personality, procrastination habits, perceived control over time, age, gender, motivation, and anxiety. the perception of fk ugj students regarding critical thinking is considered good because respondents share a common understanding of the statements in the questionnaire about critical thinking skills and agree on the importance of critical thinking in their roles as future doctors. the integrated curriculum and studentcentered learning (scl) at fk ugj are identified as factors contributing to the students' good critical thinking skills (masic and pandza 2018). the research results on teamwork show that 73.7% (193) of the 262 respondents have a good perception, 25.6% (67) have a fair perception, and 0.8% (2) have a poor perception. this indicates that more than half of the respondents have a positive perception of teamwork. this aligns with akbar rr's study on the perception of medical students towards interprofessional education, where 97.4% expressed the need for collaboration and 89.7% perceived that collaboration is essential (akbar 2021). another study by taofan ali achmadi in 2020 on the analysis of 10 levels of soft skills needed by students in the 21st century found that 80.3% believe collaboration and 62.7% teamwork are highly needed (achmadi et al. 2020) the perception of fk ugj students regarding teamwork is considered good because respondents share a common understanding of the statements in the questionnaire about teamwork skills and agree on the importance of teamwork in their roles as future doctors. problem based learning (pbl) and group learning methods are seen as effective in enhancing teamwork skills (vioren & hamidi, 2019). the research results on public speaking show that 87.4% (229) of the 262 respondents have a good perception, 12.6% (33) have a fair perception, and 0% (0) have a poor perception. this concludes that more than half of the respondents have a positive perception of public speaking skills. this is consistent with indah puspasari kiay demak's study in 2019, which reported a 75% proficiency in communication skills (demak, juraejo, and rupawan 2019). the perception of fk ugj students regarding public speaking is considered good because respondents share a common understanding of the statements in the questionnaire about public speaking skills and agree on the importance of public speaking in their roles as future doctors. activities such as problem based learning (pbl) and class presentations are believed to enhance public speaking skills (siqueira et al. 2022). in the context of effective communication, three basic components—verbal, non-verbal, and para-verbal— can be applied to public speaking. communication, especially in public speaking, is crucial in medical practice, as it relates to processes such as anamnesis, informed consent, information delivery, and delivering bad news. communication skills, including public speaking, are essential in medical practice, and developing these competencies is crucial in medical education (edmunds and brown 2010). the positive perception of soft skills among students at the faculty of medicine, ugj, is largely due to the effective learning methods applied in their education. methods like problem-based learning (pbl), skills lab, expert discussions, and other academic programs create a dynamic and hands-on learning environment. these approaches help students not only to grasp theoretical knowledge but also to develop essential skills such as critical thinking, communication, teamwork, and problem-solving. as a result, these learning methods play a key role in shaping well-rounded, competent future healthcare professionals 5. conclusion based on the results, the medical student perceptions of faculty of medicine, universitas swadaya gunung jati on soft skills are good. considering that soft skills are very important for students, it is hoped that this good perception will also be in line with students' soft skills. in the future, faculty needs to provide space for students to develop these soft skills through training or interprofessional education and other programs. sulistiyana, et.al. ghmj (global health management journal) 2024, vol. 7, no. 3 128 conflict of interest there is no conflict of interest. nothing to disclosure references achmadi, taofan ali, ayub budhi anggoro, and lia sari. 2020. ‘analisis 10 tingkat soft skills yang dibutuhkan mahasiswa di abad 21. doi: https://doi.org/10.15294/teknobuga.v8i2.29049 akbar, resti rahmadika. 2021. ‘persepsi mahasiswa tahap profesi kedokteran terhadap interprofessional education’. health and medical journal 3(2):20–25. doi: https://doi.org/10.33854/heme.v3i2.681. demak, indah puspasari kiay, farah andini j. juraejo, and i. kadek rupawan. 2019. ‘hubungan kepercayaan diri dalam kemampuan komunikasi pada metode pembelajaran problem based learning mahasiswa kedokteran universitas tadulako’. https://doi.org/10.22487/htj.v5i1.111 edmunds, sarah, and george brown. 2010. ‘effective small group learning: amee guide no. 48’. medical teacher 32(9):715–26. doi: https://doi.org/10.3109/0142159x.2010.505454. hanafi, carine nadia, and yoanita widjaja. 2021. ‘kemampuan manajemen waktu mahasiswa tahap profesi fakultas kedokteran universitas tarumanagara’. tarumanagara medical journal 3(1):18–28. doi: https://doi.org/10.24912/tmj.v3i2.11740. ibrahim, mutasim, abdullah alshahrani, mohamed abdalla, inshirah abubaker, and mohamed mohamed. 2018. ‘the effectiveness of problem-based learning in acquisition of knowledge, soft skills during basic and preclinical sciences: medical students’ points of view’. acta informatica medica 26(2):119. doi: https://doi.org/10.5455/aim.2018.26.119-124. khajeghyasi, r. v., liaghatdar, m. j., nili, m. r., & shirazi, m. (2021). ranking the soft skills of the dental profession based on the importance in job performance: a mixed method study in isfahan and mazandaran universities of medical sciences. dental research journal, 18, 24. marini, liza, fasti rola, and dian ulfasari. 2014. ‘gambaran soft skills mahasiswa di universitas sumatera utara’. 6. doi: https://doi.org/10.31289/analitika.v6i2.835 masic, izet, and haris pandza. 2018. ‘medical informatics education past, today and future’. european journal for biomedical informatics 14(2). doi: https://doi.org/10.24105/ejbi.2018.14.2.8. mehrpour, saeed reza, amin hoseini shavoun, azita kheiltash, rasoul masoomi, and roya nasle seraji. 2023. ‘evaluating and comparing critical thinking skills of residents of tehran university of medical sciences’. bmc medical education 23(1):133. doi: https://doi.org/10.1186/s12909-023-04094-7. najafi, minoo, maryam karbasi motlagh, maryam najafi, ahmad sabouri kashani, naser faal ostadzar, nazila zarghi, and mandana shirazi. 2022. ‘trend of tendency to critical thinking among medical students in tehran university of medical sciences, 2010–2015: a longitudinal study’. journal of education and health promotion 11(1):29. doi: https://doi.org/10.4103/jehp.jehp_1373_20. vioren, v., & hamidi, s. (2019). outcome dan tantangan penggunaan metode pembelajaran flipped classroom dalam pendidikan kedokteran. medula, medicalprofession journal of lampung university, 8(2), 47-54.. purwanti, melvy, ita armyanti, and muhammad asroruddin. 2020. ‘persepsi mahasiswa fakultas kedokteran universitas tanjungpura mengenai konsep profesionalisme dokter’. cermin dunia kedokteran 47(12):751. doi: https://doi.org/10.55175/cdk.v47i12.1242. siqueira, marina alves martins, matheus belloni torsani, gustavo rosa gameiro, lucas albuquerque chinelatto, bruna chacon mikahil, patricia zen tempski, and milton a. martins. 2022. ‘medical students’ participation in the volunteering program during the covid-19 pandemic: a qualitative study about motivation and the development of new competencies’. bmc medical education 22(1):111. doi: https://doi.org/10.1186/s12909-022-03147-7. cite this article as: sulistiyana, c. s., fauzan, z. a., permatasari, t. o., & khasanah, u. (2024). students perception on soft skills in faculty of medicine, universitas swadaya gunung jati, cirebon, indonesia. ghmj (global health management journal), 7(3), 121–128. https://doi.org/10.35898/ghmj-731000 https://doi.org/10.15294/teknobuga.v8i2.29049 https://doi.org/10.33854/heme.v3i2.681 https://doi.org/10.22487/htj.v5i1.111 https://doi.org/10.3109/0142159x.2010.505454 https://doi.org/10.24912/tmj.v3i2.11740 https://doi.org/10.5455/aim.2018.26.119-124 https://doi.org/10.31289/analitika.v6i2.835 https://doi.org/10.24105/ejbi.2018.14.2.8 https://doi.org/10.1186/s12909-023-04094-7 https://doi.org/10.4103/jehp.jehp_1373_20 https://doi.org/10.55175/cdk.v47i12.1242 https://doi.org/10.1186/s12909-022-03147-7 https://doi.org/10.35898/ghmj-731000 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 yeyentimalla1*, agnescia clarissa sera1, doni marisi sinaga2 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 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 missesa1,*, trissa viranti1, shasa dini martha ewa kaswana1, carolin firsta athena1, hendrowanto nibel2 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 ghmj (global health management journal) 2024, vol. 7, no. 4 indonesian scholars’ alliance open access research article the 1st cirebon international health symposium: faculty of medicine, universitas swadaya gunung jati update on non-communicable diseases: global perspective on health challenges and innovation the association between family knowledge and response with pre-hospital delay among stroke patients: a study from rural area of cirebon, indonesia muhammad nabil prawira ivanka1 , witri pratiwi2* , agus kusnandang1 1 department of neurology, physical medicine and rehabilitation, faculty of medicine, universitas swadaya gunung jati, indonesia; 2 department of community medicine and public health, faculty of medicine, universitas swadaya gunung jati, indonesia. *corresponding author’s e-mail: we3.borneo@gmail.com doi: 10.35898/ghmj-741111 abstract background: stroke is a non-communicable disease whose prevalence continues to increase in both young and old age groups. stroke patients require immediate treatment at the hospital to prevent disability and death. delayed treatment may result in a worse prognosis. aims: to analyze the relationship between family knowledge and response with pre-hospital delay in stroke patients in cirebon regency, indonesia. methods: this cross-sectional study was conducted at waled general hospital, cirebon regency, indonesia. the sampling technique used was consecutive sampling of patients hospitalized with stroke diagnosis from may 2024 to july 2024. patients with recurrent stroke were excluded. data were collected from medical records and questionnaires administered to the patient's families. the indonesian version of stroke recognition questionnaire (sqr) was used to explore family knowledge, while family responses were explored using the stroke action test (stat). results: there were 61 stroke patients recruited in this study. majority of the sample were delivered to hospital late (78.7%). most of the patients’ families had poor knowledge (47.5%) and inadequate attitudes (85.2%). in the bivariate analysis, there was a strong correlation between family knowledge of stroke symptoms and pre-hospital delay (p=<0.001; r=0.746). inadequate family response was associated with pre-hospital delay [p= 0.002; pr 2.596 (95%ci 1.024-6.581)]. conclusion: there is a positive correlation between family knowledge and response with pre-hospital delay in stroke patients in cirebon regency, indonesia. keywords: attitude, family knowledge, family response, pre-hospital delay, stroke. received: 26 september 2024 reviewed: 19 october 2024 revised: 24 november 2024 accepted: 30 november 2024 © 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:we3.borneo@gmail.com https://doi.org/10.35898/ghmj-741111 https://orcid.org/0009-0002-0717-6343 https://orcid.org/0000-0001-8714-9198 https://orcid.org/0009-0000-4481-3239 ivanka, et. al. ghmj (global health management journal) 2024, vol. 7, no. 4 158 1. introduction stroke is one of non-communicable diseases that causes high morbidity and mortality throughout the world. globally, stroke is the second leading cause of death and the third leading cause of disability. based on data from the world health organization (who), at least 15 billion people worldwide experience stroke each year. of these, 5 billion of them die and another 5 billion can be saved but live with disability (world health organization, 2024). an estimated 70% of stroke cases occur in lowand middle-income countries, including indonesia (world health organization, 2024). epidemiologic data in indonesia shows that stroke is the leading cause of death. based on riskesdas 2018, the prevalence of stroke in indonesia increased from 7 per 1,000 population in 2013 to 10.9 per 1,000 population in 2018. in west java province, the prevalence of stroke was 11.4% in the population aged ≥15 years. this number continues to increase due to the unhealthy lifestyle of indonesian people. stroke also causes a huge economic burden for the national health insurance (jkn), so it is called a catastrophic disease. data shows that jkn financing for stroke treatment is the third largest after heart disease and cancer. the cost reached idr 1.911 trillion in 2021 and increased to idr 3.23 trillion in 2022 (direktorat jenderal pelayanan kesehatan-kementerian kesehatan republik indonesia, 2023; kementerian kesehatan republik indonesia, 2018). one of the problems faced in the management of stroke patients is the delay in patients coming to the emergency room so that it is late to provide optimal treatment. pre-hospital delay is the prolonged time from the onset of symptoms until the patient arrives at the hospital (wang et al., 2021). if stroke patients are immediately given appropriate treatment, it can provide a better prognosis, namely preventing death and disability. prehospital delay includes delay in recognizing stroke symptoms and delay in responding to deliver patient to health service. in this case, the family plays a very important role (wanichanon et al., 2024). knowing the description of family knowledge about stroke symptoms, their responses, and its relationship with pre-hospital delay is very important. it can illustrate the burden in stroke management, especially from the patient's family factor. however, such data is still very limited, including in cirebon regency, indonesia. therefore, this study was conducted with the aim of finding out the description of stroke patient family knowledge regarding stroke symptoms and their responses. in addition, this study also aimed to determine the relationship between family knowledge and response with pre-hospital delay in stroke patients at waled general hospital, cirebon regency, indonesia. our study focuses on first-ever stroke patients, where rapid treatment greatly affects the outcome (prasanna & forshing, 2023; randhawa et al., 2022; wechsler et al., 2023). 2. methods study design and participants this is a cross-sectional study conducted at waled general hospital, as one of the largest referral hospitals in cirebon district. the sample was hospitalized patients with a stroke diagnosis from may 2024 to july 2024 and their families. the diagnosis of stroke was known through the diagnosis sheet in the medical record based on neurologist assessment. the sampling technique used was consecutive sampling. the calculation of the sample size used the proportion estimation formula and obtained 61 samples. the inclusion criteria in this study were patients with acute ischemic and hemorrhagic stroke. the inclusion criteria of the patient's family were >18 years old, living in the same house with the patient and knowing the patient's condition. we excluded patients with transient ischemic attack (tia), recurrent stroke and patients who were not accompanied by their families. data collection and definition of variables data for this study were collected through medical records and questionnaires completed by the patients’ families. stroke patient characteristics (gender, age and type of stroke) and arrival time to the hospital emergency department were collected from patients’ medical records. families accompanying the patients in the inpatient ward were asked about stroke onset, distance from home to hospital, transportation to hospital and family 159 ghmj (global health management journal) 2024, vol. 7, no. 4 ivanka, et. al. characteristics (gender, age, education level). families were also asked to complete a questionnaire exploring family knowledge and responses. family knowledge family knowledge is the level of knowledge of the patient's family regarding stroke symptoms. data on family knowledge was collected using validated indonesian version of the stroke recognition questionnaire (srq) (herliani, 2023). there were 17 questions with "yes" and "no" answer options. family knowledge of stroke symptoms was categorized as poor if they could answer <56% of the questions correctly, sufficient if 56-75% and good if >75-100%. family response family response was defined as actions taken by the family in several conditions related to the occurrence of stroke. it was measured using the stroke action test (stat) which consists of 21 questions. response options in this questionnaire include: [1]"immediately call an ambulance or go to the emergency room", [2] "immediately call or visit a doctor", [3] "wait 1 hour then decide to take the patient to the hospital" and [4] "wait 1 day to decide to take the patient to the hospital". family response was categorized as inadequate if ≤77% of the selected answers are [1] and [2]. adequate response if >77% of the selected answers were [3] and [4] (sumarsono, 2019). pre-hospital delay the operational definition of pre-hospital delay in this study iss the duration of time between the onset of stroke and the patient's arrival at the hospital emergency department. we asked the patient's family when the patient felt the stroke symptoms and recorded arrival time from medical record. if the time duration is ≥24 hours then the patient is categorized as pre-hospital delay. data analysis this data is presented in tables and graphs to describe the frequency and percentage values of the variables. numerical data for age variable is described through median, interquartile range and min-max values. bivariate analysis to determine the relationship between family knowledge and pre-hospital delay was carried out using the spearman rank test to obtain the p-value and correlation coefficient. the relationship between family response and pre-hospital delay was performed using fisher’s exact test. a p value of <0.05 was considered as statistically significant. analysis was performed using spss version 26 software. ethical approval respondents were given informed consent regarding the research procedures before data was collected. those who agreed were then asked to sign the consent form. this study has obtained ethical approval from the ethics committee of waled general hospital no: 000.9.2/060/kepk/v/2024. 3. results in this study, 61 stroke patients were recruited as samples during the study period. the characteristics of stroke patients during the study period are summarized in table 1. most of stroke patients were male (60.7%). based on age, stroke was dominated by the 50-59 years age group, with an age range of 25-85 years. this study also found that stroke occurred in younger age groups, namely 20-29 years (4.9%) and 30-49 (14.8%). a total of 85.2% of the samples experienced ischemic stroke. most stroke patients lived close to the hospital (80.3%), and there were 8.2% whose homes were quite far from the hospital (>20 km). as many as 24.6% of stroke patients were brought to the hospital by ambulance. figure 1 shows that as many as 78.7% of stroke patients arrived late at the hospital. pre-hospital delay occurred in 76.9% of ischemic stroke and 88.9% of hemorrhagic stroke (figure 2). ivanka, et. al. ghmj (global health management journal) 2024, vol. 7, no. 4 160 table 1. characteristics of stroke patients (n=61) figure 1. proportion of pre-hospital delay in stroke patients 78.7% 21.3% delay not delay characteristics frequency percentage gender male 37 60.7 female 24 39.3 age (years) 20-29 30-49 50-59 ≥60 median q1-q3 min-max 3 9 26 23 58 50-64 25-85 4.9 14.8 42.6 37.7 types of stroke ischemic stroke hemorrhagic stroke 52 9 85.2 14.9 distance from home to hospital <10 km 10-20 km >20 km 49 7 5 80.3 11.5 8.2 transportation to hospital ambulance others 15 46 24.6 75.4 161 ghmj (global health management journal) 2024, vol. 7, no. 4 ivanka, et. al. figure 2. pre-hospital delay based on type of stroke the characteristics of stroke patients’ families are summarized in table 2. in this study, 45.9% of the patients' families were male and 54.1% were female. the families were mostly aged 30-49 years (62.3%), with a median age of 40 years and an interquartile range 34-49.5 years. the majority of families were junior high school graduates (44.3%) and 21.3% were elementary school graduates. nearly half of the respondents were taken to hospital and accompanied by their wives or husbands. this study found that most of patient's families had poor knowledge of stroke symptoms (47.5%). in addition, most of them also had inadequate responses in taking action when stroke symptoms occurred (85.2%). 76.9% 88.9% 23.1% 11.1% 0.0% 20.0% 40.0% 60.0% 80.0% 100.0% ischemic stroke hemorrhagic stroke delay not delay table 2. characteristics of stroke patients’ families (n=61) characteristics frequency percentage gender male 28 45.9 female 33 54.1 age (years) 20-29 8 13.1 30-49 38 62.3 50-59 12 19.7 ≥60 3 4.9 median q1-q3 40 34-49.5 level of education elementary school 13 21.3 junior high school 27 44.3 senior high school 16 26.2 university 5 8.2 family relationship wife or husband parent child others 29 7 20 5 47.5 11.5 32.8 8.2 knowledge of stroke symptoms poor moderate good 29 20 12 47.5 32.8 19.7 family response inadequate adequate 52 9 85.2 14.8 ivanka, et. al. ghmj (global health management journal) 2024, vol. 7, no. 4 162 the families’ knowledge of stroke symptoms and their responses were shown in table 3. most male (50%) and female (45.5%) families had poor knowledge of stroke symptoms. poor knowledge was dominant in families aged ≥30 years, while in families aged 20-29 years more than half had moderate and good knowledge. the results showed that families with a low level of education had less knowledge. all families, whether wives, husbands, parents, children or others, mostly had poor knowledge. present study showed that both male and female families mostly had inadequate responses. inadequate responses were also seen predominantly in all age groups, education levels and family relationships. table 3. families’ knowledge of stroke symptoms and their response by characteristics; n(%) the results showed that there was a strong relationship between family knowledge of stroke symptoms and pre-hospital delay in stroke patients (p<0.001; r=0.746). the better family's knowledge about stroke symptoms, the less frequent the pre-hospital delay (table 4). the results of bivariate analysis also showed that there was a relationship between family response and pre-hospital delay (pr 2.596; 95%ci 1.024-6.581), as listed in table 5. table 4. the correlation between family knowledge with pre-hospital delay in stroke patients knowledge of stroke symptoms pre-hospital delay p-value r yes no poor moderate good 29 (100) 19 (95.0) 0 0 1 (5.0) 12 (100) <0.001 0.746 table 5. the correlation between family response with pre-hospital delay in stroke patients family response pre-hospital delay p-value pr; 95%ci (upper-lower) yes no inadequate adequate 45 (86.5) 3 (33.3) 7 (13.5) 6 (66.7) 0.002 2.596; 1.024-6.581 characteristics of family knowledge of stroke symptoms family response poor moderate good inadequate adequate gender male female 14 (50.0) 15 (45.5) 8 (28.6) 12 (36.4) 6 (21.4) 6 (18.2) 24 (85.7) 28 (84.8) 4 (14.3) 5 (15.2) age (years) 20-29 1 (12.5) 4 (50.0) 3 (37.5) 7 (87.5) 1 (12.5) 30-49 21 (55.3) 10 (26.3) 7 (18.4) 32 (84.2) 6 (15.8) 50-59 5 (41.7) 5 (41.7) 2 (16.7) 10 (83.3) 2 (16.7) ≥ 60 2 (66.7) 1 (33.3) 0 3 (100) 0 level of education elementary school 9 (69.2) 2 (15.4) 2 (15.4) 12 (92.3) 1 (7.7) junior high school 14 (51.9) 6 (22.2) 7 (25.9) 21 (77.8) 6 (22.2) senior high school 6 (37.5) 7 (43.8) 3 (18.8) 15 (93.8) 1 (6.3) university 0 5 (100) 0 4 (80.0) 1 (20.0) family relation wife or husband parent child others 14 (48.3) 3 (42.9) 11 (55.0) 1 (20.0) 8 (27.6) 2 (28.6) 8 (40.0) 2 (40.0) 7 (24.1) 2 (28.6) 1 (5.0) 2 (40.0) 25 (86.2) 6 (85.7) 18 (90.0) 3 (60.0) 4 (13.8) 1 (14.3) 2 (10.0) 2 (40.0) 163 ghmj (global health management journal) 2024, vol. 7, no. 4 ivanka, et. al. 4. discussion characteristics of stroke patients our results showed that stroke was more common in males than females. a multicenter study conducted in surabaya, indonesia also obtained similar results, with 57.94% males and 42.06% females (minalloh et al., 2022). likewise, data from the indonesian health survey in 2023 showed that the prevalence of stroke in males population aged ≥15 years was 8.8 ‰ (95%ci 8.3-9.3), higher than that of females (7.9‰; 95%ci 7.4-8.4) (kementerian kesehatan republik indonesia, 2023). however, a study at hasan sadikin hospital in bandung, indonesia found that more females (53.4%) experienced stroke than males (46.6%), although not significantly different (jamilatul badriyah et al., 2018). the incidence of stroke in males may be closely related to the higher prevalence of smoking in males compared to females, even at a young age. based on indonesian health survey data in 2023, 43.8% (95%ci 43.5-44.2) of males aged ≥18 years in indonesia smoked every day (compared to 0.7% of females) (kementerian kesehatan republik indonesia, 2023). based on meta-analysis, it was found that smoking was associated with an increased incidence of all types of stroke, with a pooled or of 1.61; 95%ci 1.34-1.93 (pan et al., 2019). cigarettes contain more than 7,000 harmful ingredients that cause inflammation, endothelial dysfunction, dyslipidemia and prothrombotic states. additionally, there is also impaired vasodilation and reduced nitric oxide bioavailability. atherosclerosis, an increased risk of thrombosis leads to impaired brain perfusion which then leads to ischemic stroke. smoking increases the risk of hemorrhagic stroke through disruption of vascular wall structure and rupture of aneurysm (luo et al., 2022). interestingly, present study examined that a higher proportion of stroke in young adults, namely 4.9% at ages 20-29 years and 14.8% at ages 30-49 years. research conducted at hasan sadikin hospital in bandung, indonesia found stroke at the age of 15-24 years was 0.6%, 25-34 years was 2.6% and 35-44 years was 9% (jamilatul badriyah et al., 2018). these results are also in line with national data from riskesdas 2018 which showed a shift in stroke patients to a younger age, even at the age of 18-24 years. (kementerian kesehatan republik indonesia, 2018; saraswati, 2021). stroke in young adults is defined as stroke experienced by an individual aged <50 years. the prevalence trend of stroke in young adults continues to increase worldwide and is closely related to morbidity. it is influenced by several risk factors, such as hypertension, dyslipidemia, heart disease, obesity, diabetes mellitus, smoking, sedentary lifestyle and unhealthy eating habits in young adults (andriyani et al., 2020; balgis et al., 2022; bukhari et al., 2023; effendi et al., 2022; faruq et al., 2021; harlianti et al., 2018; pratiwi & surgana, 2024; rachmawan et al., 2024). the increasing trend of stroke incidence in young adults occurs in many countries and needs serious attention. it has major consequences, especially in terms of psychosocial aspects of stroke sequelae in survivors, as well as being a huge burden for individuals, families and the government (bukhari et al., 2023). the current study found that ischemic stroke was more common than hemorrhagic stroke. previous research at hasan sadikin hospital bandung, indonesia also showed similar results that ischemic stroke occured in 66,4% of patients and hemorrhagic stroke in 33,6% (jamilatul badriyah et al., 2018). however, a study conducted at kandou hospital manado, indonesia obtained different results that hemorrhagic stroke (58%) was more common than ischemic stroke (42%) (barahama & tangkudung, 2019). pre-hospital delay the results examined that 78.7% of stroke patients arrived at the hospital late (>24 hours from the onset of symptoms). as many as 76.9% of pre-hospital delays occurred in ischemic stroke and 88.9% in hemorrhagic stroke. studies showed better outcomes in stroke patients who received treatment sooner than those who had missed the therapeutic window. the outcomes in stroke patients are time-dependent so treatment should be given as soon as possible, especially within 60 minutes of symptom onset (golden hour) (advani et al., 2017; anderson, 2016). moreover, references showed better outcomes in the first 30 minutes of symptom onset, which is called the platinum 30 minutes (randhawa et al., 2022). ivanka, et. al. ghmj (global health management journal) 2024, vol. 7, no. 4 164 the proportion of pre-hospital delays in this study was higher compared to several previous studies in indonesia. a study in manado, indonesia showed a lower proportion of pre-hospital delay than our study, which was 48.5% (barahama & tangkudung, 2019). previous study in banjarmasin, indonesia found that the proportion of pre-hospital delays was 34.7%. however, this study used a cut off of 3 hours to categorize delays (julianto et al., 2023). the high proportion of pre-hospital delays in this study may be closely related to the characteristics of the rural population in this study, which is dominated by residents with low levels of education. based on the type of stroke, pre-hospital delay was more common in hemorrhagic stroke compared to ischemic stroke, namely 88.9% and 76.9%. it is in line with a study in manado, indonesia that pre-hospital delay occurred 99.6% in hemorrhagic stroke and 0.4% in ischemic stroke, with a cut-off time of 4 hours (tangkudung et al., 2019). the relationship between family knowledge about stroke symptoms, family responses and pre-hospital delay in stroke patients our findings showed that most patients' families had poor knowledge of stroke symptoms, especially in those with low level of education. family knowledge of stroke symptoms was strongly related to pre-hospital delay in stroke patients. these results are similar with previous studies in gorontalo and lombok, indonesia (ishak et al., 2020; jusuf et al., 2023). good family knowledge about the symptoms of stroke leads to the perception that the patient's condition is an emergency. therefore, the patient's family will respond quickly by bringing the patient to health services. conversely, poor family knowledge leads to the perception that the symptoms experienced by the patient are normal, so the patient is brought to the hospital after the condition worsens (putri & santoso, 2020). results also found that the majority of families had inadequate responses. it was known that an adequate family response can reduce the risk of pre-hospital delay. pre-hospital delay mainly occurs when the decision to refer a patient requires the agreement of several family members. in this study, children as decision maker caused more pre-hospital delay compared to husbands or wives as decision makers. these results are in line with those obtained by previous study (rahmawan et al., 2020). the low level of knowledge and family response that led pre-hospital delays in this study was closely related to education level. previous study found that low education level increased the risk of pre-hospital delay with an aor of 2.29; 95%ci 1.12-5.1 (kazadi kabanda et al., 2024). public health campaigns on stroke prevention can increase public awareness of stroke, including knowledge, recognition of stroke symptoms and immediate access to health services (jiayi et al., 2021). through the results of this study, the government also needs to develop emergency medical services to reduce pre-hospital delays for stroke patients, for example by improving accessibility to ambulances and emergency calls for stroke patients. however, this study did not examine this further and may provide direction for future research (gude et al., 2023). the limitation of this study is the possibility that the families who filled out the questionnaire were not the ones who decided whether or not to refer the patient to hospital. the decision to refer the patient to hospital could have been the result of extended family discussion. in this case, selection bias may occur. 5. conclusion based on the results of this study, the proportion of pre-hospital delay in stroke patients at waled general hospital, cirebon regency, indonesia was 78.7%. most of the patients’ families had poor knowledge of stroke symptoms and inadequate responses. it also concluded that family knowledge and response were associated with pre-hospital delay in stroke patients in cirebon regency, indonesia. health education and promotion programs on early symptoms of stroke need to be encouraged to increase public knowledge about stroke symptoms. the public also needs to be educated about the importance of referring patients with stroke symptoms immediately to the emergency room so that patients get optimal treatment. in addition, further research is needed to analyze other factors besides the role of the family that influence pre-hospital delay in stroke patients. 165 ghmj (global health management journal) 2024, vol. 7, no. 4 ivanka, et. al. conflict of interest there is no conflict of interest to declare. references advani, r., naess, h., & kurz, m. w. (2017). the golden hour of acute ischemic stroke. scandinavian journal of trauma, resuscitation and emergency medicine, 25(1), 54. https://doi.org/10.1186/s13049-017-0398-5 anderson, j. a. (2016). acute ischemic stroke: the golden hour. nursing critical care, 11(3), 28–36. https://doi.org/10.1097/01.ccn.0000482731.69703.82 andriyani, f. d., biddle, s. j. h., arovah, n. i., & cocker, k. d. (2020). physical activity and sedentary behavior research in indonesian youth: a scoping review. international journal of environmental research and public health, 17(20), 7665. https://doi.org/10.3390/ijerph17207665 balgis, b., sumardiyono, s., & handayani, s. (2022). hubungan antara prevalensi hipertensi, prevalensi dm dengan prevalensi stroke di indonesia (analisis data riskesdas dan profil kesehatan 2018). jurnal kesehatan masyarakat (undip), 10(3), 379–384. https://doi.org/10.14710/jkm.v10i3.33243 barahama, d. v., & tangkudung, g. (2019). faktor-faktor yang berhubungan dengan keterlambatan kedatangan pasien stroke di rsup prof. dr. r. d. kandou manado. jurnal e-clinic, 7(1). bukhari, s., yaghi, s., & bashir, z. (2023). stroke in young adults. journal of clinical medicine, 12(15), 4999. https://doi.org/10.3390/jcm12154999 direktorat jenderal pelayanan kesehatan-kementerian kesehatan republik indonesia. (2023, october 29). world stroke day 2023, greater than stroke, kenali dan kendalikan stroke. https://yankes.kemkes.go.id/read/1443/world-stroke-day2023-greater-than-stroke-kenali-dan-kendalikan-stroke effendi, d. e., nugroho, a. p., handayani, s., novita, r., purwoko, s., & agustina, z. a. (2022). tobacco consumption among young population in rural indonesia: prevalence and associated factors. open access macedonian journal of medical sciences, 10(e), 1178–1183. https://doi.org/10.3889/oamjms.2022.10011 faruq, n. n., pratiwi, w., & satrianugraha, m. d. (2021). hubungan kebiasaan sarapan pagi dan frekuensi konsumsi makanan cepat saji terhadap berat badan berlebih pada siswa sman 1 kota cirebon. tunas medika jurnal kedkteran & kesehatan, 7(2). gude, m. f., valentin, j. b., christensen, h. c., mikkelsen, s., søvsø, m. b., andersen, g., kirkegaard, h., & johnsen, s. p. (2023). associations between emergency call stroke triage and pre-hospital delay, primary hospital admission, and acute reperfusion treatment among early comers with acute ischemic stroke. internal and emergency medicine, 18(8), 2355– 2365. https://doi.org/10.1007/s11739-023-03349-x harlianti, l., pratiwi, w., nauphar, d., & suhaeni, e. (2018, august). effect of physical activity and fast food consumption frequency on overweight level among high school adolescent. in proceedings of the international conference on applied science and health (no. 3, pp. 274-278). http://publications.inschool.id/index.php/icash/article/view/783/663 herliani, y. k. (2023). psychometric properties indonesian stroke recognition questionnaire (srq) untuk pasien dengan hipertensi, diabetes mellitus, dan penyakit jantung. jurnal keperawatan sriwijaya, 10(1), 1–9. ishak, s. j., yueniwati, y., & kapti, ns. r. e. (2020). factors related about family delay bring stroke patient to emergency departments of labuha hospital. international journal of science and society, 2(4), 657–672. https://doi.org/10.54783/ijsoc.v2i4.260 jamilatul badriyah, n., amalia, l., & suwarman, s. (2018). gambaran faktor risiko kejadian stroke di rshs bandung periode januari 2015– desember 2016. jurnal neuroanestesi indonesia, 7(3), 134–139. https://doi.org/10.24244/jni.vol7i3.18 jiayi, t., sheena, r., mclinres, sok, y. l., & wei, l. c. (2021). effectiveness of public education campaigns for stroke symptom recognation and response in non-elderly adults: a systematic review and meta-analysis. journal of stroke and cerebrovascular diseases, 31(2). https://doi.org/10.1016/j.jstrokecerebrovasdis.2021.106207 julianto, j., solikin, & firdaus, m. (2023). hubungan prehospital delay dengan tingkat keparahan pada pasien stroke di rumah sakit banjarmasin. journal of nursing invention, 3(2), 108–116. https://doi.org/10.33859/jni.v3i2.274 jusuf, m. i., pomalango, z. b., & suleman, i. (2023). factors associated with family delays in bringing stroke patients to aloei saboe hospital, gorontalo city. jambura nursing journal, 5(1), 26–38. https://doi.org/10.37311/jnj.v5i1.17429 kazadi kabanda, i., kiangebeni ngonzo, c., emeka bowamou, c.-k., divengi nzambi, j.-p., kiatoko ponte, n., tuyinama madoda, o., nkodila natuhoyila, a., m’buyamba-kabangu, j.-r., longo-mbenza, b., banzulu bomba, d., & kianu phanzu, b. (2024). stroke signs knowledge and factors associated with a delayed hospital arrival of patients with acute stroke in kinshasa. heliyon, 10(7), e28311. https://doi.org/10.1016/j.heliyon.2024.e28311 kementerian kesehatan republik indonesia. (2018). laporan nasional riskesdas. https://repository.badankebijakan.kemkes.go.id/id/eprint/3514/1/laporan%20riskesdas%202018%20nasional.pdf kementerian kesehatan republik indonesia. (2023). survei kesehatan indonesia (ski). https://drive.google.com/file/d/1rjndg_f8xg6-y9wmhjunxhj-vufevvjc/view luo, j., tang, x., li, f., wen, h., wang, l., ge, s., tang, c., xu, n., & lu, l. (2022). cigarette smoking and risk of different pathologic types of stroke: a systematic review and dose-response meta-analysis. frontiers in neurology, 12, 772373. https://doi.org/10.3389/fneur.2021.772373 minalloh, r. h., machin, a., mardiana, w., suansanae, t., chulavatnatol, s., & nathisuwan, s. (2022). pre-hospital and inhospital delay in acute ischemic stroke patients in indonesia: a multi-center study. indonesian journal of pharmacy. https://doi.org/10.22146/ijp.2036 https://doi.org/10.1186/s13049-017-0398-5 https://doi.org/10.1097/01.ccn.0000482731.69703.82 https://doi.org/10.3390/ijerph17207665 https://doi.org/10.3390/ijerph17207665 https://doi.org/10.14710/jkm.v10i3.33243 https://doi.org/10.3390/jcm12154999 https://yankes.kemkes.go.id/read/1443/world-stroke-day-2023-greater-than-stroke-kenali-dan-kendalikan-stroke https://yankes.kemkes.go.id/read/1443/world-stroke-day-2023-greater-than-stroke-kenali-dan-kendalikan-stroke https://doi.org/10.3889/oamjms.2022.10011 https://doi.org/10.1007/s11739-023-03349-x http://publications.inschool.id/index.php/icash/article/view/783/663 https://doi.org/10.54783/ijsoc.v2i4.260 https://doi.org/10.24244/jni.vol7i3.18 https://doi.org/10.1016/j.jstrokecerebrovasdis.2021.106207 https://doi.org/10.33859/jni.v3i2.274 https://doi.org/10.37311/jnj.v5i1.17429 https://doi.org/10.1016/j.heliyon.2024.e28311 https://repository.badankebijakan.kemkes.go.id/id/eprint/3514/1/laporan%20riskesdas%202018%20nasional.pdf https://drive.google.com/file/d/1rjndg_f8xg6-y9wmhjunxhj-vufevvjc/view https://doi.org/10.3389/fneur.2021.772373 https://doi.org/10.22146/ijp.2036 ivanka, et. al. ghmj (global health management journal) 2024, vol. 7, no. 4 166 pan, b., jin, x., jun, l., qiu, s., zheng, q., & pan, m. (2019). the relationship between smoking and stroke: a meta-analysis. medicine, 98(12), e14872. https://doi.org/10.1097/md.0000000000014872 prasanna, t., & forshing, l. (2023). acute stroke. statpearls publishing. https://www.ncbi.nlm.nih.gov/books/nbk535369/ pratiwi, w., & surgana, m. b. (2024). profile of diabetic nephropathy patients at waled general hospital, cirebon district, indonesia: high prevalence in productive age group, female and housewives. journal of law and sustainable development, 12(6), e3746. https://doi.org/10.55908/sdgs.v12i6.3746 putri, z. r., & santoso, b. r. (2020). family perception of diseases related to the reference time in stroke patient: literature review. journal of nursing practice, 4(1), 107–116. https://doi.org/10.30994/jnp.v4i1.113 rachmawan, y. p., pratiwi, w., & hanifah, a. n. (2024). prediabetes, dyslipidemia, and hypertension in acute coronary syndrome patients: a cross-sectional study at a tertiary hospital in cirebon district, indonesia. south east european journal of cardiology, 5, 26–29. https://doi.org/10.3889/seejca.2024.6071 rahmawan, f. a., yueniwati, y., & suharsono, t. (2020). perception of severity level and decision making of family correlation toward departing interval of ischemic stroke patient. 6(2). randhawa, a. s., pariona-vargas, f., starkman, s., sanossian, n., liebeskind, d. s., avila, g., stratton, s., gornbein, j., sharma, l., restrepo-jimenez, l., valdes-sueiras, m., kim-tenser, m., villablanca, p., conwit, r., hamilton, s., & saver, j. l. (2022). beyond the golden hour: treating acute stroke in the platinum 30 minutes. stroke, 53(8), 2426–2434. https://doi.org/10.1161/strokeaha.121.036993 saraswati, r. d. (2021). transisi epidemiologi stroke sebagai penyebab kematian pada semua kelompok usia di indonesia. sumarsono, e. (2019). analisis faktor determinan yang mempengaruhi keterlambatan kedatangan pasien stroke di rsud bangil [stikes widyagama husada]. https://repositori.widyagamahusada.ac.id/id/eprint/221/1/150714201398.pdf tangkudung, g., pertiwi, j. m., tongku, a., s., & ate, a. (2019). characteristics of factors associated with admission time of stroke patients in hospital. jurnal sinaps, 2(3), 5–8. wang, p.-y., tsao, l.-i., chen, y.-w., lo, y.-t., & sun, h.-l. (2021). “hesitating and puzzling”: the experiences and decision process of acute ischemic stroke patients with prehospital delay after the onset of symptoms. healthcare, 9(8), 1061. https://doi.org/10.3390/healthcare9081061 wanichanon, w., ananchaisarp, t., tantarattanapong, s., & chamroonkiadtikun, p. (2024). prevalence and factors influencing pre-hospital delays in patients with acute stroke. journal of public health and emergency, 8, 23–23. https://doi.org/10.21037/jphe-24-30 wechsler, l. r., adeoye, o., alemseged, f., bahr-hosseini, m., deljkich, e., favilla, c., fisher, m., grotta, j., hill, m. d., kamel, h., khatri, p., lyden, p., mirza, m., nguyen, t. n., samaniego, e., schwamm, l., selim, m., silva, g., yavagal, d. r., … yaghi, s. (2023). most promising approaches to improve stroke outcomes: the stroke treatment academic industry roundtable xii workshop. stroke, 54(12), 3202–3213. https://doi.org/10.1161/strokeaha.123.044279 world health organization. (2024). stroke, cardiovascular accident. https://www.emro.who.int/health-topics/strokecerebrovascular-accident/index.html cite this article as: ivanka, m. n. p., pratiwi, w., & kusnandang, a. (2024). the association between family knowledge and response with pre-hospital delay among stroke patients: a study from rural area of cirebon, indonesia. ghmj (global health management journal), 7(4), 157–166. https://doi.org/10.35898/ghmj-741111 https://doi.org/10.1097/md.0000000000014872 https://www.ncbi.nlm.nih.gov/books/nbk535369/ https://doi.org/10.55908/sdgs.v12i6.3746 https://doi.org/10.30994/jnp.v4i1.113 https://doi.org/10.3889/seejca.2024.6071 https://doi.org/10.1161/strokeaha.121.036993 https://doi.org/10.1161/strokeaha.121.036993 https://repositori.widyagamahusada.ac.id/id/eprint/221/1/150714201398.pdf https://doi.org/10.3390/healthcare9081061 https://doi.org/10.21037/jphe-24-30 https://doi.org/10.1161/strokeaha.123.044279 https://www.emro.who.int/health-topics/stroke-cerebrovascular-accident/index.html https://www.emro.who.int/health-topics/stroke-cerebrovascular-accident/index.html https://doi.org/10.35898/ghmj-741111 alliance indonesian scholars’ alliance ghmj (global health management journal) 2025, vol. 8, no. 2s open access research article the 1st cirebon international health symposium: faculty of medicine, universitas swadaya gunung jati update on non-communicable diseases: global perspective on health challenges and innovation the influence of internal factors on the success of leprosy treatment at cibuaya health center, indonesia anggi novita sari1 , muhammad risman2 , thysa thysmelia affandi3 1. faculty of medicine, universitas swadaya gunung jati, cirebon, indonesia (45132); 2. department of dermatovenereology, faculty of medicine, universitas swadaya gunung jati, cirebon, indonesia (45132); 3. department of public health, faculty of medicine, universitas swadaya gunung jati, cirebon, indonesia (45132); *corresponding author’s e-mail: novitanggi143@gmail.com doi: 10.35898/ghmj-82s1238 abstract background: indonesia still has a significant number of leprosy cases; there was an increase in cases to 12,441 compared to the previous year, which was 10,976 (who, 2023). at the national level, the target percentage of leprosy treatment has not been reached; 87% achievement was obtained, while the national indicator target is 90%. age, gender, marital status, education level, occupation, and leprosy type are among the internal characteristics that contribute to the effectiveness of leprosy therapy. the most leprosy cases in karawang regency are found in cibuaya health center, indonesia. aims: this study aims to determine the influence of internal factors (age, gender, marital status, education, occupation, and leprosy type) on the success of leprosy treatment at the cibuaya health center. methods: observational analysis with cross-sectional design was used in this study with a sample size of 110 respondents at the cibuaya health center. medical records from patients receiving leprosy treatment at the cibuaya health center served as the sample. total sampling, a non-probability sampling technique, has been used. the study was conducted in june 2024. results: leprosy treatment success was found to be influenced by age (p=0.09), gender (p=0.001), marital status (p=0.012), education level (p=0.001), and leprosy type (p=0.001) in the bivariate analysis using the chi-square test. however, the occupation factor did not show a significant effect on treatment success (p=0.275). based on multivariate logistic regression analysis, leprosy type was the most dominant factor influencing treatment success (exp(b) = 38.863). the limitation of this study is that it did not investigate internal factors in the success of leprosy treatment by using laboratory results (such as bta testing) after treatment. conclusion: the success of leprosy treatment at the cibuaya health center is influenced by age, gender, marital status, education level, and leprosy type. the most influential factor on the success of leprosy treatment is the type of leprosy. however, the occupation factor did not show a significant effect on treatment success. these findings can inform targeted strategies to improve treatment outcomes, especially among high-risk groups such as multibacillary (mb) patients and the elderly. keywords: internal factors; treatment success; leprosy. received: 22 june 2025 reviewed: 16 july 2025 revised: 25 july 2025 accepted: 15 august 2025. © 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:novitanggi143@gmail.com https://doi.org/10.35898/ghmj-82s1238 https://orcid.org/0009-0001-9311-5004 https://orcid.org/0009-0000-7312-8097 https://orcid.org/0009-0007-1873-2348 sari, et al ghmj (global health management journal) 2025, vol. 8, no. 2s 268 1. introduction leprosy is a chronic infectious disease caused by mycobacterium leprae. according to the world health organization (who), leprosy is one of the 17 neglected tropical diseases with a high incidence rate. leprosy cases in indonesia are still quite high. based on who data, in 2022 there was an increase in cases to 12,441 patients compared to the previous year, which was 10,976 patients (who, 2023). from 2021 to early 2022, karawang regency reported a total of 197 leprosy cases, including 196 cases of the multibacillary (mb) type and 1 case of the paucibacillary (pb) type. cibuaya health center is the health center with the highest incidence of leprosy compared to other health centers in karawang regency; namely, in 2022, a total of 16 cases were found at the cibuaya health center, with grade 0 disabilities in as many as 14 patients and grade 2 disabilities in 2 patients. this high number of cases indicates the need for special attention in the handling and treatment of leprosy in the region (dinkes kabupaten karawang, 2022). according to the who, leprosy is classified into two types: paucibacillary and multibacillary. this classification aims to determine the severity, therapy, and complications. leprosy treatment aims to cure the disease, break the chain of transmission, and prevent disability or complications. who recommends treating leprosy with multidrug therapy (mdt). leprosy treatment can last for 6-12 months, depending on the type of leprosy. the indicator of the percentage of leprosy patients who complete leprosy treatment on time is called rft (release from treatment). the calculation of this indicator is obtained after the patient is declared to have completed treatment for type pb for 6-9 months and type mb for 12-18 months. (siswanto, 2020) nationally, the percentage of leprosy treatment that meets the target has not been achieved; 87% achievement was obtained, while the national indicator target is 90%. this is influenced by several factors, one of which is internal. several studies have been conducted on the influence of internal factors on leprosy treatment success, including age, gender, education level, occupation, knowledge, and socioeconomic factors. however, internal factors, including leprosy types, have not yet been studied in relation to leprosy treatment success. leprosy treatment success is influenced by several factors, including age, gender, education, occupation, socioeconomic status, and knowledge (zahnia, 2017). in addition, research conducted by (oeleu et al. 2022) found that leprosy treatment regularity is influenced by several factors, such as the existence of community stigma regarding leprosy. therefore, this study aims to analyze the influence of internal factors (age, gender, marital status, education, occupation, and type of leprosy) on the success of leprosy treatment at the cibuaya health center. 2. methods study design this research includes observational analysis using cross-sectional data collected at the same time. the aim is to ascertain how internal factors impact the effectiveness of leprosy treatment at the cibuaya health center. the success of leprosy treatment is measured by the percentage of leprosy patients who complete their treatment on time, known as rft (release from treatment). this indicator is calculated following the completion of 6–9 months of treatment for type pb and 12–18 months of treatment for type mb. study design/research procedures the population in this study was all patients undergoing treatment at the cibuaya health center in the 2018– 2023 time span, and the sample of this study was taken from all medical record data of patients who were confirmed to have leprosy and were undergoing leprosy treatment, with a total sample size of 110 measurements the independent variables in this study are internal factors: age, gender, marital status, education level, occupation, and type of leprosy. the dependent variable in this study is the success of leprosy treatment. the research data was taken from the medical records of patients at cibuaya community health center. sari, et al ghmj (global health management journal) 2025, vol. 8, no. 2s 269 statistical techniques a univariate, bivariate, and multivariate analysis were used in this study. univariate analysis described the characteristics of each research variable. a bivariate analysis determined the relationship between the characteristics of age, gender, marital status, education level, occupation, and type of leprosy and the successful treatment of leprosy patients using the chi-square test. and multivariate analysis was used to analyze 6 internal factors to determine the most dominant relationship or influence on the success of leprosy treatment by using the logistic regression test. logistic regression analysis is used because there is one dependent variable, and the dependent variable data scale is categorical. the accuracy of the data was assessed by doing a completeness check, which began with examining the quantity and completeness of the necessary information, including age, gender, marital status, occupation, education level, and leprosy type. ethical clearance this research has been approved by the ethics commission, faculty of medicine, universitas swadaya gunung jati cirebon, number 43/ec/fkugj/v/2024. researchers did not collect patient name data or patient information; therefore, patient anonymity was preserved in the utilization of medical records in this study. to provide serial numbers from the medical record data, researchers only collected information on age, gender, marital status, occupation, education level, and type of leprosy. 3. results respondent characteristics table 1 summarizes the respondent characteristics in this recent study, including age, gender, marital status, education level, occupation, type of leprosy, and success of leprosy treatment. the most common age group was elderly, 46 (41.8%), compared to adults, 42 (38.2%), and children, 22 (20%). there were 65 (59.1%) male patients compared to 45 (40.9%) women. based on marital status, the most patients were unmarried, 64 (58.2%), compared to married, 46 (41.8%). based on the data, patients with low education levels were more dominant, 72 (65.5%), compared to patients with high education levels, 38 (34.5%). according to occupation, there were 57 (48.2%) employed patients and 53 (51.8%) unemployed. there were 47 (42.7%) and 63 (57.3%) mb leprosy patients. data shows that 66 people (60%) were successful in leprosy treatment and 44 people (40%) failed. table 1. respondents’ characteristics characteristics frequency percentage age children 22 20.0 adult 42 38.2 elderly 46 41.8 gender male 65 59.1 female 45 40.9 marital status married 46 41.8 unmarried 64 58.2 education level high education 38 34.5 low education 72 65.5 occupation employed 53 48.4 unemployed 57 51.8 type leprosy paucibacillary 47 42.7 multibacillary 57 51.8 success of leprosy success 66 60 failed 44 40 sari, et al ghmj (global health management journal) 2025, vol. 8, no. 2s 270 bivariate analysis table 2 shows the effect of internal factors on the success of leprosy treatment analyzed using the chi-square test. based on the research data, the internal factors of age (p=0.009), gender (p=0.001), marital status (p=0.012), education level (p=0.001), and leprosy type (p=0.001) were found to be significant to the success of leprosy treatment because the p-value < 0.05, which fulfills the criteria of the chi-square test. while the employment factor is not significant because it has a p-value > 0.05 (p = 0.275), it does not meet chi-square criteria. table 2. chi-square analysis multivariate analysis table 3 shows that the logistic regression analysis found the type of leprosy to be the most important factor, with an exp(b) value of 38.863. this means that paucibacillary (pb) patients are 38.8 times more likely to successfully complete their treatment compared to multibacillary (mb) patients. the next most important factors were gender with an exp(b) value of 13.326, marital status with an exp(b) value of 11.254, education level with an exp(b) value of 9.378, and age with an exp(b) value of 1.138. gender came next with an exp(b) value of 13.326, followed by marital status with an exp(b) value of 11.254, education level with an exp(b) value of 9.378 and age with an exp(b) value of 1.138. variable succes of therapy p value success (n = 66) failed (n = 44) total n % n % age children 17 77.3 5 22.7 22 0.009 adult 29 69 13 31 42 elderly 20 43.5 26 56.5 46 110 gender male 53 48 12 11 65 0.001 female 13 12 32 29 45 110 marital status married 34 31 12 11 46 0.012 unmarried 32 29 32 29 64 110 education level high education 43 39 6 6 38 0.001 low education 23 21 38 35 72 110 occupation employed 29 54.7 24 45.3 53 unemployed 37 64.9 20 35.1 57 0.275 110 type of leprosy paucibacillary 44 40 3 3 47 0.001 multibacillary 22 20 41 37 63 110 sari, et al ghmj (global health management journal) 2025, vol. 8, no. 2s 271 table 3. logistic regression analysis variable b s.e. wald df sig. exp(b) age 0.129 0.806 0.026 1 0.873 1.138 gender 2.590 0.732 12.505 1 0.000 13.326 marital status 2.421 0.842 8.272 1 0.004 11.254 education level 2.238 0.816 7.530 1 0.006 9.378 type of leprosy 3.660 0.944 15.047 1 0.000 38.863 constant -17.516 3.735 21.994 1 0.000 0.000 4. discussion this study aims to determine the influence of internal factors (age, gender, marital status, education, occupation, and leprosy type) on the success of leprosy treatment at the cibuaya health center. age age categories (kemenkes 2009) children: <15 years; adults: ≥ 15–45 years; elderly: >45 years. the most dominant age was in the “elderly” category, age > 45 years, with as many as 46 respondents (41.8%). in the chisquare analysis, it was found that the significance is 0.009. there is an effect of age on the success of leprosy treatment. in table 2, it was found that the elderly experienced the most treatment failures (56.5%) and the highest treatment success at the age of children, namely (77.3%). this conclusion is in line with (hutabarat, 2007) study, where it was found that children have a higher recovery rate than adults or the elderly because they are supervised by parents in taking medicine regularly. in elderly patients, medication compliance can be affected by memory loss, especially if they live alone. the relationship between age and immunity affects the potential exposure to disease risks and the body's physiological activities. in the context of leprosy, age plays an important role due to the long incubation period. thus, leprosy is rarely found in infants, as it takes longer to develop into a visible disease. gender based on the research data, there were 65 patients with male gender (59.1%) and 45 patients with female gender (40.9%), meaning that there were more leprosy patients with male gender than female. in the chi-square analysis, it was found that the significance was 0.001; there is an influence of gender on the success of leprosy treatment. based on table 2, the cure rate was higher in patients with a male gender (48%) than a female gender (12%). this finding aligns with the research of (tami, m., 2015), which indicates that the success rate of leprosy treatment in east java from 2015 to 2017 was higher for men than for women. in addition, this is in accordance with the research of (wang y et al., 2022), based on the distribution ratio of leprosy patients in this study, which shows a sex ratio of 3.82:1, with more men than women. this could be because men engage in a greater range of social activities, which increases their exposure to infection sources. additionally, some academics contend that women report illnesses later than men because they have less access to healthcare services. marital status based on the research data, patients with married marital status were 46 (41.8%), and those not married were 64 (58.2%). in the chi-square analysis, it was found that the significance was 0.012, which indicated the influence of marital status on the success of leprosy treatment. it was found that treatment success was higher in patients who had married marital status (31%) compared to patients with unmarried marital status (29%). this information is in line with research conducted by (andriani e et al., 2019). this family includes the patient's spouse, which is relevant to their marital status. emotional support is crucial for leprosy patients, as they need affection and encouragement to feel calmer while undergoing treatment. in addition, respondents who did not receive emotional support during treatment could be caused by a lack of affection and empathy from the family towards the patient. sari, et al ghmj (global health management journal) 2025, vol. 8, no. 2s 272 education level education level was assessed based on the last formal education taken by the patient at the time of leprosy treatment, low education level was categorized as elementary to junior high school, and high education level was categorized as high school to college. based on the research data, it was found that the majority of leprosy patients at the cibuaya health center had a low level of education, namely 72 people (65.5%), while patients with a high level of education were 38 people (34.5%). in the chi-square analysis, it was found that a significance of 0.001 indicates that there is an influence between education level and treatment success. in table 2, higher treatment success was obtained in patients who have a high level of education (39%) compared to patients with a low level of education (21%). according to research (muntasir et al. 2017), it was found that the dominant respondents had a low level of education (66.7%) compared to higher education levels. higher education (33.3%) can assist leprosy sufferers in making better health-related decisions. with greater knowledge about leprosy, patients tend to be more disciplined in taking medication and have a strong motivation to recover. low levels of education, on the other hand, may make it more difficult to seek treatment and receive a timely diagnosis, which could result in disability and a worsening of the patient's illness. occupation based on the research data, 53 leprosy patients (48.2%) were employed, and 57 people (51.8%) were unemployed. it can be seen in this study that respondents who do not have jobs have the largest number. based on the chi-square statistical test, the p-value was 0.275 or (p > 0.05), indicating that there was no influence between occupation and the success of leprosy treatment. in table 2, it was found that the success of leprosy treatment was greatest among respondents who did not work, namely 64.9%. this conclusion is in line with the research of siti zahnia et al. (2019), who found that there is no effect of work on the success of leprosy treatment. according to (tukiman et al. 2014), individuals who have jobs are usually more encouraged to undergo treatment for recovery. this motivation is caused by the desire to return to work, because work is the main source of income that is important to support their lives and their families. based on research conducted by (suki, 2018), which shows that people with leprosy who have a job tend to be more motivated to comply with their treatment compared to people who do not work. this is because work is considered a source of livelihood and a way for them to provide for their families. in contrast, unemployed patients have more time to focus on their health, including medication adherence. therefore, there was no significant difference in medication adherence between working and non-working leprosy patients. type of leprosy based on the research data, there were 47 patients with paucibacillary (pb) leprosy type (42.7%) and 63 respondents with multibacillary (mb) leprosy type (57.3%). based on the chi-square statistical test, the p-value is 0.001 (<0.05), indicating that there is an influence between the type of leprosy and the success of leprosy treatment. among the different types of leprosy, treatment success was highest for patients with pb leprosy type at 40%, compared to 20% for those with mb leprosy type. the highest treatment failure occurred in patients with mb leprosy, specifically involving 41 individuals (37%). this conclusion is in line with the research of (wang y et al., 2022), where it was found that the chance of recovery for pb patients was 2.06 (95% ci: 1.39-3.04) times higher than mb patients. significantly, mb leprosy patients have a lower chance of recovery than pb leprosy patients. mb leprosy patients tend to have more severe symptoms and a longer disease course. this conclusion is in line with the who report in 2018; global leprosy cases show that multibacillary (mb) cases are more dominant than paucibacillary (pb) cases. the number of patients with multibacillary leprosy was reported as 14,543. the most important factor in the success of leprosy treatment based on the results of research was conducted at the cibuaya health center. the type of leprosy has the strongest relationship, with an exp(b) value of 38.863, so the paucibacillary type has a better chance of successful treatment. this conclusion was followed by gender with an exp(b) value of 13.326, marital status with an exp(b) value of 11.254, education level with an exp(b) value of 9.378, and age with an exp(b) value of 1.138. sari, et al ghmj (global health management journal) 2025, vol. 8, no. 2s 273 the prevalence of patients with multibacillary type (mb) is higher than that of paucibacillary type (pb). this is due to the bacteria's virulence, heredity, low patient immunity, and community awareness. additionally, factors such as how quickly patients seek treatment, their distance from health facilities, socio-economic conditions, and the regularity of their medication intake also have an influence. the availability of access to medical care and the consistency with which patients undergo treatment play an important role in disease control. multibacillary (mb) leprosy is more common than paucibacillary (pb) leprosy because mb leprosy is more contagious. this effect is due to a weak cellular immune response to m. leprae, resulting in a greater number of bacteria in the lesions and becoming the main source of infection. type mb usually occurs in individuals with weakened immune systems, especially in older people (martomijoyo, 2014). this study is limited to respondent characteristics; however, prior research indicates that various external factors may affect treatment success, such as patient awareness of side effects, family support, and health education. the study by (nurhidayah et al., 2017) identified awareness of potential side effects as a critical factor in enhancing compliance. this indicates that educating and counselling patients about medication effects can improve adherence and, consequently, enhance the success of treatment interventions. family support and motivation significantly impact treatment success, as evidenced by a study conducted by (fauzi et al., 2017). emotional support from family members can significantly impact a patient's motivation to pursue and adhere to treatment. health education enhanced knowledge and significantly increased motivation to engage in preventive health measures (estiyani, a., et al., 2017). the limitations of the study should be highlighted, including its retrospective design, being conducted at a single center, and the absence of laboratory confirmation, such as post-treatment bta tests. future researchers are expected to add other variables that aim to determine factors associated with the success of leprosy treatment, such as external factors. in addition, further research is needed to determine the effect of external and internal factors on the success of leprosy treatment by using laboratory results (such as a bta examination) after treatment is carried out, as well as the criteria for drug completion (release from treatment). 5. conclusion this study found that several internal factors significantly influenced the success of leprosy treatment; the most important factor contributing to the success of leprosy treatment is the type of leprosy, with paucibacillary (pb) patients 38.8 times more likely to complete treatment successfully than multibacillary (mb) patients. this advantage is related to various factors such as high bacterial virulence, low immunity, and speed of drug seeking. this study also showed the relationship between the internal factors of age, gender, marital status, education level, and type of leprosy to the success of leprosy treatment. however, the occupation factor did not show a significant effect on treatment success. these findings can inform targeted strategies to improve treatment outcomes, especially among high-risk groups such as multibacillary (mb) patients and the elderly. conflict of interest the authors declare no conflict of interest for the results. references andriani e, et al. (2019). dukungan keluarga dalam kepatuhan pengobatan pada penderita kusta. vol. 7, community of publishing in nursing. https://risbang.unuja.ac.id/media/arsip/berkas_penelitian/230.pdf dinas kesehatan kabupaten karawang 2022. profil kesehatan kabupaten karawang tahun 2022. estiyani, a., w, s. a., syamrotul, i., & margiana, w. (2017). knowledge and motivation of woman in reproductive age given health education about early detection of cervical cancer. proceedings of the international conference on applied science and health, 1, 25–28. https://publications.inschool.id/index.php/icash/article/view/806 https://risbang.unuja.ac.id/media/arsip/berkas_penelitian/230.pdf https://publications.inschool.id/index.php/icash/article/view/806 sari, et al ghmj (global health management journal) 2025, vol. 8, no. 2s 274 fauzi, a. r., & yuniarti, s. (2017). the relationship of family support to motivation (intention) for medical treatment in patients with cervical cancer in ligar medika clinic, west java – indonesia. proceedings of the international conference on applied science and health, 1, 228–233. https://publications.inschool.id/index.php/icash/article/view/837 hutabarat. (2008). pengaruh faktor internal dan eksternal terhadap kepatuhan minum obat penderita kusta di kabupaten asahan tahun. http://repositori.usu.ac.id/handle/123456789/35989 martomijoyo. (2014). faktor-faktor yang mempengaruhi kejadian penyakit kusta pada penduduk di kecamatan tukdana kabupaten indramayu tahun 2012. issn 1693-7945. muntasir, et al. (2018). studi faktor-faktor yang berhubungan dengan kejadian penyakit kusta pada wilayah kerja puskesmas bakunase kota kupang tahun 2017. jurnal info kesehatan. 2018 dec 22;16(2). https://doi.org/10.31965/infokes nurhidayah, n., handayani, d., lestari, p. p., & yulastini, f. (2017, february 22). knowledge of side effects and its association to compliance in iron tablets consumption among third trimester pregnant women. https://publications.inschool.id/index.php/icash/article/view/850 oeleu, et al. (2022). faktor-faktor yang berhubungan dengan keberhasilan pengobatan pasien kusta di puskesmas maubesi. media kesehatan masyarakat vol 4, no 1, 2022: hal 1-17 https://doi.org/10.35508/mkm siswanto, et al. (2020). neglected tropical disease. kusta epidemiologi alikatif. mulawarman university press. samarinda. suki, et al. analisis faktor yang mempengaruhi kepatuhan minum obat pada penderita kusta di kota kupang tahun 2017. https://doi.org/10.35508/cmj.v6i3.660 tami m. (2019). hubungan antara kusta tipe pausi basiler dengan angka keberhasilan pengobata kusta di jawa timur. the relationship between paucibacillary type leprosy and the success of leprosy treatment in east java. 2019;7(1):17–24. http://journal.unair.ac.id/index.php/jbe/ tukiman. (2014). hubungan pengetahuan dan sikap keluarga dengan proses penyembuhan pada penderita kusta di kabupaten bengkalis riau. jurnal keluarga sehat 12(23), 50-57. https://doi.org/10.24114/jkss.v12i23.3572 wang y, et al. epidemiological characteristics and factors associated with cure of leprosy in chongqing, china, from 1949 to 2019. american journal of tropical medicine and hygiene. 2023 jan 1;108(1):165–73. https://doi.org/10.4269%2fajtmh.22-0474 world health organization (who). (2023). weekly epidemiological record. http://www.who.int/wer. zahnia, et al. (2020). internal yang berperan dalam keberhasilan terapi pasien terhadap penyakit morbus hansen di kota bandar lampung. https://doi.org/10.35457/josar.v8i1.2720 cite this article as: sari, a. n., risman, m., & affandi, t. t. (2025). the influence of internal factors on the success of leprosy treatment at cibuaya health center, indonesia. ghmj (global health management journal), 8(2s), 267–274. https://doi.org/10.35898/ghmj-82s1238 https://publications.inschool.id/index.php/icash/article/view/837 http://repositori.usu.ac.id/handle/123456789/35989 https://doi.org/10.31965/infokes https://publications.inschool.id/index.php/icash/article/view/850 https://doi.org/10.35508/mkm https://doi.org/10.35508/cmj.v6i3.660 http://journal.unair.ac.id/index.php/jbe/ https://doi.org/10.24114/jkss.v12i23.3572 https://doi.org/10.4269%2fajtmh.22-0474 http://www.who.int/wer https://doi.org/10.35457/josar.v8i1.2720 https://doi.org/10.35898/ghmj-82s1238 ghmj (global health management journal) 2023, vol. 6, no. 2 indonesian scholars’ alliance open access review the untapped skills of hospital pharmacists in south africa: how can pharmacists improve service delivery in preparation for national health insurance? tiisetso aubrey chuene1,*, , noko brilliant moloto2, 1 department of student affairs, university of limpopo, sovenga, 0727, south africa. 2 department of pharmacy, university of limpopo, sovenga, 0727, south africa. *corresponding author’s email: tiisetso.chuene@ul.ac.za, noko.moloto@ul.ac.za doi: 10.35898/ghmj-62964 abstract background: the tertiary education of a pharmacist in south africa covers a wide range of expertise; however, many of these skills remain untapped more especially at the public health facilities. to meet the national health insurance’s goals, the role of a pharmacist is anticipated to change as they will be required to embark on a more integrative role by shifting from product-centered focus to a patientcentered approach. aim: the aim of this review is to explore the untapped skills of public hospital pharmacists as a way of improving service delivery in preparation for national health insurance. methods: a secondary qualitative technique using desktop approach served as the foundation for this research. the study used thematic content analysis to identify and analyse the roles of hospital pharmacists. results: the findings of this article indicate that pharmacists can play different roles within the public hospital setting to improve service delivery. the identified roles are: provision of pharmacists initiated therapy, the integration of pharmacists into the wards, the involvement of pharmacists as part of the multidisciplinary healthcare team and the utilisation of specialities such as clinical pharmacists’ services. conclusion: to improve service delivery and promote the idea of holistic pharmaceutical care, it is crucial that the hospital pharmacist delegate responsibilities and functions related to product supply to pharmacist's assistants as this will give pharmacists more time for patient-focused roles. keywords: role; untapped skills; hospital pharmacists; multidisciplinary healthcare team; patients; service delivery; national health insurance. received: 20 september 2023; revised: 6 november 2023; accepted: 14 november 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 the tertiary education and the scope of practice of a pharmacist in south africa cover a wide range of expertise; however, many of these skills remain untapped in the country more especially at the institutional pharmacy in a public health facility (naidoo et al., 2021). according to sello and dambisya mailto:tiisetso.chuene@ul.ac.za mailto:noko.moloto@ul.ac.za https://doi.org/10.35898/ghmj-62964 https://orcid.org/0000-0003-1976-146x https://orcid.org/0000-0003-3426-0903 chuene & moloto ghmj (global health management journal) 2023, vol. 6, no. 2 72 (2014), dispensing of medicines and monitoring inventory are often the main tasks that pharmacists at public hospitals perform each day. katoue and al-taweel (2016) concur with sello and dambisya (2014) by noting that, most pharmacists are observed to be more active in managing pharmaceutical processes of compounding, dispensing, and keeping track of ward supply. gray et al. (2016) highlight that the additional routine tasks differ per facility and may involve tasks like ward rounds, extemporaneous preparations, cytotoxic and other sterile preparations, patient education, pharmaceutical safety monitoring and training for healthcare workers. since the national health insurance (nhi) is currently in phase 3, which focuses on improving the initiatives of the health system that are to be performed at the highest level and mobilizing additional resources (department of health, 2019), pharmacists are expected to be at the forefront in ensuring that the nhi's goals are met. to meet the nhi’s goals, the traditional role of a pharmacist is anticipated to change as they will be required to embark on a more integrative role by shifting their currently more product-centered focus to a patient-centered approach (naidoo et al., 2021). as the custodians of medicines, pharmacists will be crucial in ensuring the accessibility of essential medications. since therapeutic initiatives cannot be successful without medicines, the pharmacists will be essential to managing the pharmaceutical value chain properly and ensuring the success of nhi. patients must have access to a consistent supply of the appropriate medications at the appropriate time, in the appropriate quantity, and in the appropriate location. therefore, the cooperation of all parties concerned, notably the pharmacy profession, will be essential to nhi's success. to ensure successful coordination of services provided and that pharmaceuticals are available, it will be necessary to reimagine the supply networks for medicines across sectors. strong planning, information systems, and the right skill sets to use data to guide choices are essential for effective supply chain management. traditional roles for pharmacists have included primarily dispensing medications along with review of prescriptions for patients, and duties like medication counselling to ensure that medications are taken correctly and safely. during the nhi implementation, it is anticipated that pharmacists will be integrated into all situations where medications are used or given. this paper therefore seeks to identify the skills of public hospital pharmacists that are unutilised. identifying such skills will help improve service delivery during nhi implementation in south africa. 2. literature review a. theoretical framework the role theory serves as the theoretical foundation for this review. conway (1988) described role theory as a body of ideas and a range of speculative interpretations that forecast how individuals would behave in a particular role or under what conditions specific types of behaviours can be anticipated. according to schuler, aldag, and brief (1977), role theory can be utilized as a conceptual framework to connect the characteristics of an organization or a person. role theory is frequently utilized in gender, family and personality theory, organizational role theory, and communication framework analysis since it encompasses several concepts that form the foundation of the social science subject (yong et al., 2020). it is used conceptually to describe the many internal and external expectations put upon an individual filling the position (guirguis & chewning, 2005). role theory has previously been applied in the context of pharmacy-related research, or its application has been examined (lerkiatbundit, 2000; fleming et al., novak, 2014). this is supported by taylor et al. (2020), who assert that the role theory has been demonstrated to be useful in a variety of pharmaceutical situations. role theory can offer a useful framework for examining perspectives on roles by describing the behaviours, traits, social norms, and principles of an individual or position (brookes et al., 2007). according to schuler et al. (1977), the framework defines role components that are connected to a process of role sending, a reaction by the focal individual, and the implications of the response on 73 ghmj (global health management journal) 2023, vol. 6, no. 2 chuene & moloto the role senders. understanding the role theory that supports the expanded role for hospital pharmacists is vital as the pharmacist's scope of practice keeps evolving. role theory is therefore the ideal framework for exploring the potential responsibilities that hospital pharmacist can play within the public hospital settings to improve service delivery in preparation for national health insurance. b. the role and scope of practice of hospital pharmacist in south africa according to mosiane et al. (2022), pharmacists are among the most widely available healthcare professionals and the general public's primary option for health information. according to pharmacy act no. 53 of 1974 as amended, a pharmacist in south africa is a licensed healthcare practitioner with a focus on understanding pharmaceutical products (south africa, 1974). by acting in their capacities as medicine custodians, pharmacists are accountable for delivering pharmaceutical services. the duties, obligations, and actions that a pharmacist is qualified and allowed to conduct are listed in their scope of practice. therefore, pharmacists should only carry out those tasks that are within their purview of practice. the activities specifically related to a pharmacist's profession include those for which only pharmacists are completely qualified, and they serve as the cornerstone of the pharmacist's practice area. the pharmacist is responsible for the work done by pharmacy support personnel and different categories such as pharmacy students, pharmacist interns, and support staff may be given some of the duties for carrying out these activities (scope of practice, 2020). according to regulation 3 of the regulations relating to the practice of pharmacy gnr. 1158 of 2000, the following are the prescribed acts specifically related to the profession of a pharmacist: • delivering pharmaceutical services by being responsible for and taking charge of the patient's medication-related demands. • compounding, handling, preparing, or packaging any medication or controlled substance, or the oversight of such. • the production of any drug or controlled substance, or the control of such production. • the supervision of any activity involving the procurement, acquisition, importation, storage, retention, use, release, packing, supply, repackaging, or sale of any drug or controlled substance; and • submission an application to register a drug under the medicines act. there are several needs that a hospital pharmacy must meet, including those of the wards and clinics. all patients, including those in all the inpatient and outpatient wards, receive their medication and surgery supplies from the main pharmacy. this implies that assuming the burden of accountability and supply for all medications in the hospital by making sure they are always accessible. according to mayimele et al. (2015), pharmacists are in charge of managing medications to make sure that they are available at reasonable prices and are of high quality across the whole supply chain. the hospital pharmacist is in charge of directing the entire medication distribution cycle, commencing with the prescription in accordance with the diagnosis and continuing with the medication selection, dispensing, preparation, and administration of the medications (mayimele et al., 2015). as a result, the pharmacist can play a crucial part in assuring the safety of medicines within a hospital setting (schellack et al., 2009). c. barriers to the delivery of comprehensive pharmaceutical care services in south african public hospitals shortage of pharmacists when it comes to providing healthcare services, south africa has a human resource shortage (malakoane et al., 2020). it has been acknowledged that there is a shortage of pharmacists, particularly in the hospital setting (bronkhorst et al., 2020; south african pharmacy council, 2011; world health organization, 2016). according to foster and mcintyre (2012), staffing issues and workload demands affecting pharmaceutical services are comparable to those affecting other human resource for health services. even though the world health organization (who) standards call for a national average of 1 pharmacist for every 2300 people, several countries with low or middle incomes have numbers that are far higher. for instance, according to king and fomundam (2010), chuene & moloto ghmj (global health management journal) 2023, vol. 6, no. 2 74 south africa has one pharmacist for every 4332 people. as a result, hospital pharmacists are under more pressure to perform tasks that are product-focused, such as dispensing (bronkhorst et al., 2020). on the other hand, gray et al. (2016) emphasize that infrastructural and resource constraints are typically responsible for the sluggish adoption of clinical pharmacy services. no creation of posts for pharmacists according to the sapc annual report (2020), there are two registered subcategories of pharmacist specialists: clinical pharmacokinetics and radio-pharmacist. mosiane et al. (2022) highlight that although clinical pharmacokinetics is presently an area of expertise that can be registered with the south african pharmacy council, no actual positions at state facilities are available for this specialty. to fill the void left by the public sector's lack of appointment of clinical pharmacists to designated jobs, the private sector has established positions for the ward-based pharmacists or clinical practice pharmacists. the post/job descriptions for each hospital group or institution vary, as do the amounts of time that can be spent in the wards providing pharmacological treatment. this can be explained by the fact that there is now a dearth of human resources, and that technical support staff is either being used inefficiently or not at all, and makes it difficult to assign pharmacists to work in a clinical ward on a regular basis. lack of motivation by pharmacists according to research by bronkhorst et al. (2018), a lack of motivation is one of the reasons there are so few pharmacists working in the wards in south africa. professionals' motivation is crucial to their professional growth as well as to the general caliber of their work and performance (tjin a tsoi et al., 2018). like any other healthcare profession, a pharmacist's ability to work at a high level is based on their motivation and job satisfaction, which are generated by a combination of intrinsic and extrinsic motivators (smith et al., 2021). in situations when motivation is negatively impacted, emotional frustration is triggered, which lowers wellbeing, performance, and ultimately the standard of patient care (van der burgt et al., 2020). 3. methods the technique of content analysis (qualitative technique) serves as the foundation for this review. the authors adopted a desktop method to review secondary literature, which included published journal articles, books, and reports. as a result, the researchers employed a purposive sampling technique to gather secondary data from a variety of scholarly platforms, including google scholar, ebcohost, sabinet, and jstor which all were targeted towards the topic. a narrative addressing the untapped skills of hospital pharmacists to improve service delivery was produced as a result of the substantial literature review that was done. various search terms, including role of pharmacists; multidisciplinary healthcare team; service delivery; national health insurance etc., were used to find relevant content on the subject at hand. to arrive at a specific conclusion which addresses the goal of this review, the information was organized chronologically and thematically. this emphasizes the degree to which secondary data served as the conceptual and theoretical foundation for this study. this review adopted a descriptive design as outlined by nassaji (2015). atmowardoyo (2018) define descriptive research as a method used to as accurately as possible characterize the current investigation (the untapped skills of hospital pharmacists: how can pharmacists improve service delivery in preparation for national health insurance?). adopting descriptive research primarily aims to better characterize the roles that public hospital pharmacists can play to improve service delivery in preparation for nhi. the study is more significant because it uses thematic content analysis to identify the roles of hospital pharmacists. o'reilly and kiyimba (2015) claim that this method may be employed to find, examine, and evaluate trends in sets of data allowing descriptive data structuring that makes it easier to understand various research topic areas. according to braun and clarke (2014), the aforementioned technique concentrates on identifying and categorizing themes from qualitative information that has been gathered, which was done in accordance with the study's goals. 75 ghmj (global health management journal) 2023, vol. 6, no. 2 chuene & moloto 4. results and discussion the findings of this research demonstrates that there are untapped skills of hospital pharmacists which can be utilized to improve service delivery during the nhi implementation in south africa. a. implementation of pharmacist initiated therapy (pit) at hospitals to simplify patient management hospital pharmacists don’t use pharmacist-initiated therapy (pit). for mild ailments that may be quickly treated by pit initiatives, they direct such patients to doctors. community pharmacists who undergo similar tertiary training as hospital pharmacists can initiate therapy and this role is suppressed when coming to hospital pharmacists. in south africa, community pharmacists offer a wide selection of prescription and over-the-counter medications in addition to pharmacist-initiated therapy. pharmacists in both aforementioned categories have had considerable education in the fields of pathology, physiology and anatomy, pharmacology, pharmaceutics, and pharmaceutical chemistry. they also have a thorough understanding of the formulations of medications and how to utilize them. however, the pharmacist-initiated skills are suppressed at the hospital level. according to riordan et al. (2016), pharmacist-initiated interventions are approaches where the pharmacist performs a key role in decreasing and solving errors in prescriptions and drug-related problems, ultimately leading to a different approach to managing the patient’s condition. these strategies are supported by pharmaceutical care, which forms the basis of clinical pharmacy, and they involve the work of pharmacists who contribute to individual patient care to maximize the use of medications and enhance results (ertuna et al., 2019). pharmacy students complete practical training in both public and private facilities over the course of their four-year undergraduate education where they gain the skills necessary to determine patients’ medication needs and to work out a medication management strategy with both the patient and the rest of the healthcare team (moodley et al., 2021). medical doctors occasionally devote a large portion of their workday to treating mild illnesses. some individuals may find it quite appropriate to seek assistance from gps for the management of mild illnesses, but many would consider this to be inconvenient and ineffective due to the possibility of lengthier waiting times. this can divert medical personnel from duties that require their expertise. as a result, pharmacists should be able to treat mild illnesses using pit services. as such doctors will spend less time addressing minor illnesses, which will free up their time to concentrate on more challenging conditions and shorten the waiting time for patients. according to poh et al. (2018) systematic review, outcomes for glucose, blood pressure, anticoagulation, cholesterol, adherence to medicines and satisfaction were comparable to or even improved when pharmacists-initiated therapy in hospitals. therefore, if pharmacists are allowed to render pit services at institutional pharmacies, it will improve satisfaction and enhance patient care while decreasing waiting times. in some countries, a pharmacist can oversee a patient’s medication therapy after a doctor has made the initial diagnosis and prescribed the medication. as a result, while pharmacists working in south african hospitals may support antimicrobial stewardship initiatives (such as switching from iv to oral administration), offer pharmacokinetic guidance (therapeutic drug monitoring), or service anticoagulant clinics, they are unable to independently change dosages or request laboratory tests. b. utilization of primary care drug therapy pharmacists at hospital level to deal with minor ailments primary care drug therapy (pcdt) pharmacists receive thorough training on the standard treatment guidelines (stg) as part of their education and are qualified to make diagnoses and write prescriptions at primary health care (phc) for certain conditions as per approved list of phc conditions. most of these conditions are still seen by doctors at hospital level. this category of pharmacists can be used at the hospital level to treat mild illnesses since they have the clinical expertise and professional capacity to provide more extensive pharmacist-initiated therapy. therefore, the public health care system's functionality may be greatly enhanced by the shifting of chuene & moloto ghmj (global health management journal) 2023, vol. 6, no. 2 76 pcdt pharmacists' functions from the phc level to the hospital level. the stg is a guiding document used in the south african healthcare system with the goal of encouraging rational and safe medication usage by supporting practitioners to utilize pharmacological and non-pharmacological treatment for illnesses at all levels of care. c. unrecognised and underutilization of clinical pharmacists clinical pharmacy is not recognized as a speciality in the south african public health sector; hence no clinical pharmacists have been assigned to the designated positions (bronkhorst et al., 2018). to promote the specialty of clinical pharmacy, the south african pharmacy council should register pharmacists who have completed the necessary training. the national department of health should consider hiring clinical pharmacists for the benefit of the patients. creating clinical pharmacy positions within hospital settings is a good idea since it will enable clinical pharmacists to take part in individualized patient care and manage the patient's medication-related healthcare requirements. shulman et al. (2015) noted that one in six prescriptions necessitates a clinical pharmacist intervention, further highlighting the vital necessity of a clinical pharmacist. lin et al. (2020) contends that the application of pharmaceutical care using patient-centered clinical pharmacy services enhances the prudent use of pharmaceuticals, leading to better patient outcomes. despite the obvious advantages, crafford et al. (2021) indicate that many middleto low-income countries have had challenges in transitioning from patient-focused to product-focused pharmacy practice. studies shows that clinical pharmacists' participation in the delivery of services like reconciliation of medications, management of antibiotics, and anticoagulant monitoring emphasizes their position on the multidisciplinary healthcare team and demonstrates how clinical collaboration affects the delivery of pharmaceutical care (malan & gous, 2017; naicker et al., 2018; byrne et al., 2022). clinical pharmacists cannot perform their duties of delivering proper pharmaceutical care to the best of their ability if they are not fully integrated into the hospital environment (hazen et al., 2018). actions must be taken to restore clinical pharmacists' sense of autonomy and connectedness to support them. the best kind of professional motivation will be stimulated by an encouraging work setting where the fundamental psychological requirements are met (ryan & deci, 2000). additionally, it might bring about further advantageous effects, such as boosting their desire for lifelong learning. according to crafford et al. (2021), a setting that allows clinical pharmacists to plan their schedules autonomously, allows them to spend most of their time providing pharmaceutical care in the wards, and provides support from peers and management may help foster more autonomous motivation. d. the incorporation of pharmacists to deliver clinical services in the wards. according to mafarafara et al. (2019), pharmacists do not lead or take part in hospital ward rounds, which makes it difficult to monitor adverse drug events and improve patient care. furthermore, the absence of pharmacists in the wards could result in incorrect dosages, inappropriate prescriptions, and substandard pharmaceutical care. hospital pharmacists in south africa tend to concentrate on specific duties such as the procurement, distribution, and dispensing of medications, with ward visits being performed by a smaller proportion of them. schellack and gous (2011) assert that a pharmacist must be stationed in the wards where medications are prescribed and given in order to contribute effectively to the multidisciplinary healthcare team. although it is common practice in developed countries like the united kingdom and the united states of america to integrate pharmacists into the wards to offer clinical support, this practice is still lacking in south african public hospitals (bronkhorst et al., 2014; marra et al., 2017; gray et al., 2016) for pharmacists to be recognised as part of clinical support team in the wards, stakeholders ought to be educated on the duties of a hospital pharmacist within the multidisciplinary healthcare team. stakeholders ought to be educated on the duties of a pharmacist within the wards for them to be recognized as an essential component of the clinical support team in the wards. pharmacists will be motivated and given the ability to expand their services to the wards once their skills and worth are recognized. this is corroborated by a study conducted in 2014 by sello and dambisya, who concluded 77 ghmj (global health management journal) 2023, vol. 6, no. 2 chuene & moloto that it is important to recognize the support provided by pharmacists in the wards. however, pharmacists would have to lead this process of recognition by regular ward visits which will eventually give rise to the necessity for a pharmacist to be a member of a multidisciplinary healthcare team within the wards. e. the underutilization of pharmacists as part of multidisciplinary healthcare team in order to establish trust and facilitate interaction with the multidisciplinary healthcare team, pharmacists must leave the dispensary and visit the patient cubicles where medications are given and clinical rounds are conducted. hepler and strand (1999) first recognized the need for new practice standards and collaborative partnerships with other healthcare providers in 1990 with the development of "pharmaceutical care". the involvement of pharmacists as part of the multidisciplinary healthcare team will therefore lessens the workload and stress encountered by the multidisciplinary healthcare team members. according to mcneely (2017), adding a pharmacist to the multidisciplinary healthcare team can enhance patients' health and lessen complications linked to medications. considering this, pharmacists can supervise dosage modifications, assess patients' medications, and collaborate with prescribers during the prescribing process. a pharmacist performing these duties will guarantee that medications are used effectively, enhance patients' health outcomes, and lower the incidence of readmissions (shanika et al., 2018). pharmacists can help fill the gap between doctors and patients in facilities with scarce resources and a shortage of human resources through performing direct patient care (shrestha et al., 2019). poor pharmacist involvement in the wards in a clinical capacity has been caused by a combination of poor human resources for pharmacists, inefficient use of, or absence of, technical support workers, and the limitation of educated clinical pharmacists. according to bronkhorst et al. (2020), it is extremely challenging to assign pharmacists to work in the wards on a regular schedule given the shortage of human resources. 5. conclusion and recommendations task shifting to pharmacist assistants to improve service delivery and advance the idea of holistic pharmaceutical care, it is crucial that the hospital pharmacist, to the greatest extent possible, delegate responsibilities and functions related to product supply to pharmacist's assistants as this will give pharmacists more time for patient-focused activities. this task shifting optimisation is also supported by fogarty et al. (2020) who contend that task shifting of pharmacy staff needs to be re-evaluated in order to free-up the pharmacist for more patientcentered roles. multidisciplinary collaboration to execute and track outcomes for patients and use data for quality improvement, it is suggested that the process for including pharmacists as members of the multidisciplinary healthcare team be standardized to improve the engagement of pharmacists in the wards. this can be achieved through creation and application of pharmacy practice standards in the wards by including pharmacists in organizational structures. improved awareness of pharmacists' contributions to collaborative patient care within the hospital's multidisciplinary healthcare team is necessary. it is important to look into further ways that the pharmacist may assist patients with their pharmacotherapy. to maximize the role of each member of the healthcare team, there is still work to be done to develop this sense of multidisciplinary spirit within hospital settings. training of pharmacy personnel to improve service delivery in preparation for national health insurance, pharmacists need to be provided with the necessary clinical skills and such can be done through seminars and short courses. this is crucial for the ongoing professional development of pharmacists in general. pharmacists can better adapt to their changing roles with the support of ongoing professional development, which has a favourable impact on patient safety and the quality of healthcare. additionally, it is important to chuene & moloto ghmj (global health management journal) 2023, vol. 6, no. 2 78 provide pharmacist's assistants more training so they can become more self-assured and competent in carrying out administrative duties like managing the supply of medications. this will also lighten the workload and provide pharmacists more time to provide services on the wards. this suggestion is also supported by suleiman and onaneye (2011), who discovered that increasing staff and investing in education would enhance the delivery of pharmaceutical therapy. conflict of interest the authors declare no conflicts of interest, and no financial support. references atmowardoyo, h. (2018). research methods in tefl studies: descriptive research, case study, error analysis, and r & d. journal of language teaching and research, 9(1), 197-204. http://dx.doi.org/10.17507/jltr.0901.25 braun, v., & clarke, v. (2014). what can “thematic analysis” offer health and wellbeing researchers?. international journal of qualitative studies on health and well-being, 9(1), 26152. https://doi.org/10.3402%2fqhw.v9.26152 bronkhorst, e., schellack, n., gous, a. g. s., & pretorius, j. p. (2014). the need for pharmaceutical care in an intensive care unit at a teaching hospital in south africa. southern african journal of critical care, 30(2), 41-44. bronkhorst, e., gous, a. g., & schellack, n. (2020). practice guidelines for clinical pharmacists in middle to low income countries. frontiers in pharmacology, 11, 1-10. https://doi.org/10.3389%2ffphar.2020.00978 bronkhorst, e., schellack, n., & gous, a. g. s. (2018). the practice of clinical pharmacy in hospitals (private and public) in south africa. (doctor of philosophy thesis). sefako makgatho health sciences university, south africa. brookes, k., davidson, p. m., daly, j., & halcomb, e. j. (2007). role theory: a framework to investigate the community nurse role in contemporary health care systems. contemporary nurse, 25(1-2), 146-155. https://doi.org/10.5172/conu.2007.25.1-2.146 byrne, a., byrne, s., & dalton, k. (2022). a pharmacist's unique opportunity within a multidisciplinary team to reduce drug-related problems for older adults in an intermediate care setting. research in social and administrative pharmacy, 18(4), 2625-2633. https://doi.org/10.1016/j.sapharm.2021.05.003 conway, m. (1988). theoretical approaches to the study of roles, 2nd ed.; appleton and lange: california, ca, usa. crafford, l., wouters, a., bronkhorst, e., gous, a. g., & kusurkar, r. a. (2021). exploring factors associated with the motivation of clinical pharmacists: a focus on the south african context. frontiers in medicine, 8, 747348. https://doi.org/10.3389/fmed.2021.747348 department of health. (2019). milestones in the implementation of the national health insurance. pretoria. government printers. https://www.gov.za/sites/www.gov.za/files/gcis_documents/national-healthinsurance.pdf (accessed 05 september 2023) ertuna, e., arun, m. z., ay, s., koçak, f. ö. k., gökdemir, b., & i̇spirli, g. (2019). evaluation of pharmacist interventions and commonly used medications in the geriatric ward of a teaching hospital in turkey: a retrospective study. clinical interventions in aging, 587-600. https://doi.org/10.2147/cia.s201039 fleming, m. l., barner, j. c., brown, c. m., shepherd, m. d., strassels, s., & novak, s. (2014). using the theory of planned behavior to examine pharmacists' intention to utilize a prescription drug monitoring program database. research in social and administrative pharmacy, 10(2), 285-296. https://doi.org/10.1016/j.sapharm.2013.05.009 fogarty, t. l., bobbins, a. c., & burton, s. (2020). different models of pharmaceutical services and care in primary healthcare clinics in the eastern cape, south africa: challenges and opportunities for pharmacy practice. african journal of primary health care and family medicine, 12(1), 1-11. https://doi.org/10.4102/phcfm.v12i1.2323 foster, n., & mcintyre, d. (2012). economic evaluation of task-shifting approaches to the dispensing of antiretroviral therapy. human resources for health, 10(1), 1-10. https://doi.org/10.1186/1478-4491-10-32 gray, a., riddin, j., & jugathpal, j. (2016). health care and pharmacy practice in south africa. the canadian journal of hospital pharmacy, 69(1), 36-41. https://doi.org/10.4212%2fcjhp.v69i1.1521 guirguis, l. m., & chewning, b. a. (2005). role theory: literature review and implications for patient-pharmacist interactions. research in social and administrative pharmacy, 1(4), 483-507. https://doi.org/10.1016/j.sapharm.2005.09.006 hazen, a. c., de bont, a. a., boelman, l., zwart, d. l., de gier, j. j., de wit, n. j., & bouvy, m. l. (2018). the degree of integration of non-dispensing pharmacists in primary care practice and the impact on health outcomes: a systematic review. research in social and administrative pharmacy, 14(3), 228-240. https://doi.org/10.1016/j.sapharm.2017.04.014 http://dx.doi.org/10.17507/jltr.0901.25 https://doi.org/10.3402%2fqhw.v9.26152 https://doi.org/10.3389%2ffphar.2020.00978 https://doi.org/10.5172/conu.2007.25.1-2.146 https://doi.org/10.1016/j.sapharm.2021.05.003 https://doi.org/10.3389/fmed.2021.747348 https://www.gov.za/sites/www.gov.za/files/gcis_documents/national-health-insurance.pdf https://www.gov.za/sites/www.gov.za/files/gcis_documents/national-health-insurance.pdf https://doi.org/10.2147/cia.s201039 https://doi.org/10.1016/j.sapharm.2013.05.009 https://doi.org/10.4102/phcfm.v12i1.2323 https://doi.org/10.1186/1478-4491-10-32 https://doi.org/10.4212%2fcjhp.v69i1.1521 https://doi.org/10.1016/j.sapharm.2005.09.006 https://doi.org/10.1016/j.sapharm.2017.04.014 79 ghmj (global health management journal) 2023, vol. 6, no. 2 chuene & moloto hepler, c. d., & strand, l. m. (1999). oportunidades y responsabilidades en la atención farmacéutica. pharmaceutical care españa, 1(1), 35-47. katoue, m. g., & al-taweel, d. (2016). role of the pharmacist in parenteral nutrition therapy: challenges and opportunities to implement pharmaceutical care in kuwait. pharmacy practice (granada), 14(2), 1-11. https://doi.org/10.18549/pharmpract.2016.02.680 king, r. c., & fomundam, h. n. (2010). remodeling pharmaceutical care in sub‐saharan africa (ssa) amidst human resources challenges and the hiv/aids pandemic. the international journal of health planning and management, 25(1), 30-48. https://doi.org/10.1002/hpm.982 lerkiatbundit, s. (2000). predictors of job satisfaction in pharmacists. journal of social and administrative pharmacy, 17(1), 45-50. lin, g., huang, r., zhang, j., li, g., chen, l., & xi, x. (2020). clinical and economic outcomes of hospital pharmaceutical care: a systematic review and meta-analysis. bmc health services research, 20, 1-14. https://doi.org/10.1186/s12913-020-05346-8 mafarafara, n., maluleke, r., mabilo, t., & lentsoane, p. (2019). re-engineering pharmaceutical services–towards nhi. sa pharmaceutical journal, 86(5), 47-49. malakoane, b., heunis, j. c., chikobvu, p., kigozi, n. g., & kruger, w. h. (2020). public health system challenges in the free state, south africa: a situation appraisal to inform health system strengthening. bmc health services research, 20, 1-14. https://doi.org/10.1186/s12913-019-4862-y malan, l., & gous, a. g. s. (2017). role of the pharmacist in delivering point-of-care therapy for inpatients on warfarin at a teaching hospital in south africa. african journal for physical activity and health sciences, 23(4), 44-53. marra, c., johnston, k., santschi, v., & tsuyuki, r. t. (2017). cost-effectiveness of pharmacist care for managing hypertension in canada. canadian pharmacists journal/revue des pharmaciens du canada, 150(3), 184-197. https://doi.org/10.1177/1715163517701109 mayimele, n., meyer, h., & schellack, n. (2015). what role does the pharmacist play in medicine management at ward level?. sa pharmaceutical journal, 82(1), 33-36. mcneely, e. b. (2017). treatment considerations and the role of the clinical pharmacist throughout transitions of care for patients with acute heart failure. journal of pharmacy practice, 30(4), 441-450. https://doi.org/10.1177/0897190016645435 moodley, s., gray, a., schellack, n., venter, f., suleman, f., walker, r. b., ... & eksteen, m. (2021). pharmacistinitiated management of antiretroviral therapy (pimart). south african medical journal, 111(12), 1162-1163. https://doi.org/10.7196/samj.2021.v111i12.16262 mosiane, t., nkonde, k., mahlatsi, g., & mncwangi, n. p. (2022). a review on pharmacy practice in south africa—a higher education perspective. pharmacy, 11(1), 3. https://doi.org/10.3390/pharmacy11010003 naicker, p., schellack, n., godman, b., & bronkhorst, e. (2018). creating and evaluating an opportunity for medication reconciliation in the adult population of south africa to improve patient care. hospital practice, 46(3), 110-120. https://doi.org/10.1080/21548331.2018.1461528 naidoo, v., suleman, f., & bangalee, v. (2021). roles and reimbursement of pharmacists as south africa transitions towards universal health coverage (uhc): an online survey-based study. plos one, 16(9), e0257348. https://doi.org/10.1371/journal.pone.0257348 nassaji, h. (2015). qualitative and descriptive research: data type versus data analysis. language teaching research, 19(2), 129-132. o’reilly, m., & kiyimba, n. (2015). advanced qualitative research: a guide to using theory. sage publications ltd. poh, e. w., mcarthur, a., stephenson, m., & roughead, e. e. (2018). effects of pharmacist prescribing on patient outcomes in the hospital setting: a systematic review. jbi evidence synthesis, 16(9), 1823-1873. https://doi.org/10.11124/jbisrir-2017-003697 riordan, d. o., walsh, k. a., galvin, r., sinnott, c., kearney, p. m., & byrne, s. (2016). the effect of pharmacist-led interventions in optimising prescribing in older adults in primary care: a systematic review. sage open medicine, 4, 1-18. https://doi.org/10.1177%2f2050312116652568 ryan, r. m., & deci, e. l. (2000). self-determination theory and the facilitation of intrinsic motivation, social development, and well-being. american psychologist, 55(1), 68. sello, d. a., & dambisya, y. m. (2014). views of pharmacists on involvement in ward rounds in selected public hospitals in limpopo province. health sa gesondheid, 19(1). schellack, n., & gous, a. g. s. (2011). an overview of the time needed to render critical ward services in a neonatal intensive care unit: documenting the activities of a clinical pharmacist. sa pharmaceutical journal, 78(10), 2933. schellack, n., martins, v., botha, n., & meyer, j. c. (2009). delivery of pharmaceutical services at ward level in a teaching hospital. curationis, 32(1), 74-81. shanika, l. g. t., jayamanne, s., wijekoon, c. n., coombes, j., perera, d., mohamed, f., ... & dawson, a. h. (2018). https://doi.org/10.18549/pharmpract.2016.02.680 https://doi.org/10.1002/hpm.982 https://doi.org/10.1186/s12913-020-05346-8 https://doi.org/10.1186/s12913-019-4862-y https://doi.org/10.1177/1715163517701109 https://doi.org/10.1177/0897190016645435 https://doi.org/10.7196/samj.2021.v111i12.16262 https://doi.org/10.3390/pharmacy11010003 https://doi.org/10.1080/21548331.2018.1461528 https://doi.org/10.1371/journal.pone.0257348 https://doi.org/10.11124/jbisrir-2017-003697 https://doi.org/10.1177%2f2050312116652568 chuene & moloto ghmj (global health management journal) 2023, vol. 6, no. 2 80 ward-based clinical pharmacists and hospital readmission: a non-randomized controlled trial in sri lanka. bulletin of the world health organization, 96(3), 155. https://doi.org/10.2471%2fblt.17.198366 shrestha, s., shrestha, s., & palaian, s. (2019). can clinical pharmacists bridge a gap between medical oncologists and patients in resource-limited oncology settings? an experience in nepal. journal of oncology pharmacy practice, 25(3), 765-768. https://doi.org/10.1177/1078155218784734 schuler, r. s., aldag, r. j., & brief, a. p. (1977). role conflict and ambiguity: a scale analysis. organizational behavior and human performance, 20(1), 111-128. https://doi.org/10.1016/0030-5073(77)90047-2 shulman, r., mckenzie, c. a., landa, j., bourne, r. s., jones, a., borthwick, m., ... & bates, i. (2015). pharmacist’s review and outcomes: treatment-enhancing contributions tallied, evaluated, and documented (protecteduk). journal of critical care, 30(4), 808-813. https://doi.org/10.1016/j.jcrc.2015.04.008 smith, s. e., slaughter, a. a., butler, s. a., buckley, m. s., maclaren, r., & newsome, a. s. (2021). examination of critical care pharmacist work activities and burnout. journal of the american college of clinical pharmacy, 4(5), 554-569. http://dx.doi.org/10.1002/jac5.1408 south african pharmacy council. (2011). scope of practice, supervision of pharmacy support personnel and qualifications. board notice 123 of 2011. government gazette no 34428, 1 july 2011. pretoria: government printers https://www.gov.za/sites/default/files/gcis_document/201409/34428bn123.pdf (accessed 10 september 2023) south african pharmacy council. (2011). pharmacy human resources in south africa. compiled and edited by the office of the registrar. south african pharmacy council (2011). south african pharmacy council. annual report. (2020). available online: https://www.sapc.za.org/media/default/annual%20reports/ar2020%20v1.15%20web.pdf (accessed on 30 august 2023). suleiman, i. a., & onaneye, o. (2011). pharmaceutical care implementation: a survey of attitude, perception and practice of pharmacists in ogun state, south-western nigeria. international journal of health research, 4(2), 91-97. taylor, s., cairns, a., & glass, b. (2020). role theory: a framework to explore health professional perceptions of expanding rural community pharmacists’ role. pharmacy, 8(3), 161. https://doi.org/10.3390/pharmacy8030161 tjin a tsoi, s. l., de boer, a., croiset, g., koster, a. s., van der burgt, s., & kusurkar, r. a. (2018). how basic psychological needs and motivation affect vitality and lifelong learning adaptability of pharmacists: a structural equation model. advances in health sciences education, 23, 549-566. https://doi.org/10.1007/s10459-0189812-7 van der burgt, s. m., nauta, k., kusurkar, r. a., & peerdeman, s. m. (2020). a qualitative study on factors influencing the situational and contextual motivation of medical specialists. international journal of medical education, 11, 111. https://doi.org/10.5116%2fijme.5e88.b9ff world health organisation. (2016). world health statistics 2016: monitoring health for the sdg’s. (2016). available online at: https://apps.who.int/iris/ handle/10665/206498 (accessed 05 september 2023). yong, f. r., garcia-cardenas, v., williams, k. a., & benrimoj, s. i. c. (2020). factors affecting community pharmacist work: a scoping review and thematic synthesis using role theory. research in social and administrative pharmacy, 16(2), 123-141. https://doi.org/10.1016/j.sapharm.2019.05.001 cite this article as: chuene, t.a & moloto, n.b (2023). the untapped skills of hospital pharmacists: how can pharmacists improve service delivery in preparation for national health insurance?, 6(2). 71–80. https://doi.org/10.35898/ghmj-62964 https://doi.org/10.2471%2fblt.17.198366 https://doi.org/10.1177/1078155218784734 https://doi.org/10.1016/0030-5073(77)90047-2 https://doi.org/10.1016/j.jcrc.2015.04.008 http://dx.doi.org/10.1002/jac5.1408 https://www.gov.za/sites/default/files/gcis_document/201409/34428bn123.pdf https://www.sapc.za.org/media/default/annual%20reports/ar2020%20v1.15%20web.pdf https://doi.org/10.3390/pharmacy8030161 https://doi.org/10.1007/s10459-018-9812-7 https://doi.org/10.1007/s10459-018-9812-7 https://doi.org/10.5116%2fijme.5e88.b9ff https://doi.org/10.1016/j.sapharm.2019.05.001 https://doi.org/10.35898/ghmj-62964 https://doi.org/10.35898/ghmj-62964 indonesian scholars’ alliance ghmj (global health management journal) 2025, vol. 8, no. 3 open access research article the relationship between characteristics with medication adherence and quality of life among the pulmonary tuberculosis patients at the cirebon city community lung health center, indonesia asri permata dewi* , niklah zaidah2 , sri marfuati3 1. faculty of medicine, universitas swadaya gunung jati, indonesia (45132); 2. department of basic medicine, faculty of medicine, universitas swadaya gunung jati, indonesia (45132); 3. department of pharmacology, faculty of medicine, universitas swadaya gunung jati, indonesia (45132); *corresponding author’s e-mail: asriprmtdw@gmail.com doi: 10.35898/ghmj-831245 abstract background: tuberculosis (tb) is one of the top ten causes of death worldwide, caused by the mycobacterium tuberculosis germ. adherence to medication is a key factor in successful treatment and efforts to improve the quality of life of tb patients. aims: analyzing the relationship between characteristics with medication adherence and quality of life of pulmonary tb patients at the cirebon city community lung health center. methods: this study used an analytic observation method with a cross sectional design. the measuring instruments used were medical records and questionnaires that had been tested for validity and reliability, with a total of 131 respondents of pulmonary tb patients at the cirebon city community lung health center (bkpm). results : the most common characteristics were adult age 90.8%, female gender 56.5%, secondary education 50.4%, student 28.2%, length of treatment at the advanced stage 59.5%, adherent to taking medication 87.0%, good quality of life 54.2%. based on the chi-square test, the relationship between characteristics and drug compliance from age p-value=0.189, gender p-value=0.320, education p-value=0.447, occupation p-value=0.594, length of treatment p-value=0.014. the relationship between characteristics and quality of life from age pvalue=0.688, gender p-value=0.550, education p-value=0.838, occupation p-value=0.519, length of treatment pvalue=0.604. based on the logistic regression test, the relationship between characteristics and drug compliance from age p-value=0.058, length of treatment p-value=0.006. conclusion: there is no relationship between age, gender, education, and occupation with medication adherence (p>0.05). whereas in the length of treatment there is a relationship with adherence to taking medication. there is no relationship between characteristics and quality of life of pulmonary tb patients (p>0.05). the characteristic most associated with adherence to taking medication is length of treatment (p=0.006). future researchers are advised to explore other factors that may be related to medication adherence and quality of life in patients with pulmonary tb. keywords: characteristics; medication adherence; quality of life; pulmonary tuberculosis patients. received: 22 june 2025 reviewed: 08 july 2025 revised: 05 september 2025 accepted: 13 october 2025. © 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:asriprmtdw@gmail.com https://doi.org/10.35898/ghmj-831245 https://orcid.org/0009-0006-7245-7183 https://orcid.org/0009-0002-2736-4405 https://orcid.org/0009-0006-1320-4848 dewi, et. al. ghmj (global health management journal) 2025, vol. 8, no. 3 372 1. introduction tuberculosis (tb) is one of the 10 leading causes of death worldwide and the leading cause of death from infection. tuberculosis is caused by the germ mycobacterium tuberculosis (kementrian kesehatan ri, 2023). worldwide, an estimated 10.6 million people will have tb in 2022. in 2022, the thirty countries with the highest tb cases accounted for 87% (who global tuberculosis report, 2023). indonesia alone is in second place with the total number of tb cases in 2022 increasing by 677,464 cases (kementrian kesehatan ri, 2023). tb cases in west java in 2022 were reported as 160,661 cases out of a total of 656,154 suspected tb cases, a significant increase in cases (dinas kesehatan provinsi jawa barat, 2022). cirebon city is one of the cities with high pulmonary tb cases (dinas kesehatan kota cirebon, 2021). the number of pulmonary tuberculosis cases in cirebon city in 2020 was 1,371 cases, there was an increase in 2021 of 1,902 cases, in 2022 there were 2,021 cases (sitb, 2022). the community lung health center is a technical implementation unit of the west java provincial office which carries out public health efforts aimed at improving the health status of the community through the provision of health services. according to the data in 2021 the number of tuberculosis cases was 976 cases, in 2022 it decreased by 757 cases, in 2023 it decreased again by 538 cases, and in 2024 it decreased by 235 cases (laporan bkpm kota cirebon, 2024). based on the results of a study conducted by arif et al (2022), it was found that males are more likely to be infected with tb than females. the results of the age characteristics show that people of productive age are more susceptible to tb infection than adults or the elderly, with productive age ranging from 15 to 35 years. people with higher education can also be infected with tb, although those with primary and secondary education are more susceptible to infection. in the study of elementary, middle, and high school education, students are more susceptible to tuberculosis due to a lack of knowledge and information about the spread of tuberculosis. the occupation of each patient does not guarantee immunity from tb infection, as workplace contaminants also have a significant influence, similar to the home environment (arif et al, 2022). adherence to taking medication is a key factor in the success of treatment and is one of the efforts to improve the recovery and quality of life of tb patients. non-compliance of tb patients in taking oat causes low recovery rates, high mortality rates and increased relapse and can occur bacterial resistance to some oat so that it can cause the patient's condition to worsen and have to change drugs and repeat treatment. some people may live longer, but with the burden of chronic disease or disability, so quality of life is a concern for health services. decreased quality of life in tb patients can cause delays in treatment and have a negative impact on treatment continuity so that treatment becomes interrupted or incomplete (kementerian kesehatan ri, 2020). quality of life is a concept that aims to capture the well-being, either of a population or an individual, in both positive and negative terms in its entire existence at a given point in time. for example, common aspects of quality of life include personal health (physical, mental, and spiritual, relationships, educational status, work environment, social status, wealth, sense of security and safety, freedom, autonomy in decision-making, social belonging, and physical environment) (pertiwi, 2012). the relationship between patient characteristics, medication adherence and quality of life is complex and interrelated. patient characteristics affect medication adherence, which in turn affects quality of life. for example, patients with a high level of education tend to be more adherent to treatment, which can then improve their quality of life. however, this relationship can also be moderated by other factors, such as social support and access to healthcare (kementerian kesehatan ri, 2020). studies that comprehensively examine the relationship between patient characteristics, treatment adherence, and quality of life simultaneously are still very limited, especially in cirebon. most studies only focus on one or two variables, without considering the complex interactions between the three variables. this lack of research hinders efforts to design effective and targeted interventions to improve treatment adherence and quality of life of patients in cirebon. this study aims to analyze the relationship between patient characteristics with medication adherence and quality of life in pulmonary tb patients. this study can also be a basic indicator to determine the level of medication adherence and quality of life of pulmonary tb patients, and can be an evaluation material for health workers and pmos (medication swallowing supervisors) to pay more attention to medication adherence of pulmonary tb patients. dewi, et. al. ghmj (global health management journal) 2025, vol. 8, no. 3 373 2. methods 2.1 study design/ research procedures this study used an analytical observation method with a cross sectional design with a total of 131 respondents with pulmonary tb at the cirebon city community lung health center. this study used a non-probability sampling technique with a consecutive sampling approach, namely sampling based on criteria in accordance with what has been made until the number of samples is met. the measuring instrument used is the medical records of pulmonary tb patients at the cirebon city community lung health center, then the drug compliance questionnaire taken from previous research entitled psychology for nursing which contains 20 questions with the results of 2 scales, namely obedient and non-compliant (sunaryo, 2014), then the quality of life questionnaire taken from who contains 25 questions with the results of 5 scales, namely very bad, bad, moderate, good and very good (world health organization, 2012). the inclusion criteria in this study were patients who were willing to become respondents and had signed an informed consent sheet, pulmonary tb patients who were undergoing tuberculosis treatment for at least 2 months in the initial stage and in the advanced stage, and pulmonary tb patients aged > 17 years, exclusion criteria in this study were patients who withdrew or died, patients with incomplete medical record data and treatment books, and pulmonary tb patients with complications or with comorbidities (example: pulmonary tb with hiv +, pleural effusion). 2.2 measurements the independent variables in this study are the characteristics of pulmonary tb patients and the dependent variables are drug compliance and quality of life of pulmonary tb patients. the data collection method in this study uses primary data, namely questionnaires that are in accordance with the research, the first questionnaire for drug compliance of pulmonary tb patients taken from previous research entitled psychology for nursing (sunaryo, 2014) and the second quality of life questionnaire taken from who (world health organization, 2012), after which the questionnaire is tested for validity and reliability first using the first 30 respondents. after that the researcher came to the community lung health center and explained asking for patient consent to take part in the study after filling out the informed consent sheet distributing questionnaires to pulmonary tb patients who fit the criteria until the sample was met in the patient waiting room and in the waiting room for drug collection, after the questionnaire was filled in by the respondents, patient data was collected using secondary data, namely medical records to see the characteristics of respondents from age, gender, education, occupation and length of treatment. primary and secondary data collection on respondents was carried out for one month, namely in june july 2024. after the data is collected, data analysis is then carried out. the drug adherence questionnaire consisted of one section with the aim to determine the drug adherence of pulmonary tb patients which may or may not be related to the characteristics of pulmonary tb patients. this questionnaire consists of 20 questions that have previously been tested for validity and reliability. the quality of life questionnaire is divided into four parts, the first is the physical health domain with the aim of seeing the respondent's physical health which can affect all activities carried out, the second is the psychological domain with the aim of knowing a person's mental state and how to deal with various conditions experienced, then the third is the social relationship domain with the aim of knowing the respondent's social relationships from social relationships, social support and sexual activity, then the last is the environmental domain which aims to find out the environment where the respondent lives and how the respondent socializes with others. this questionnaire consists of 25 questions which have previously been tested for validity and reliability. the results of the validity test of the adherence and quality of treatment questionnaires have a value higher than the r table limit, which is 0.361, stating that the questionnaire is valid. reliability testing was conducted using cronbach alpha. the reliability test results of the medication adherence and quality of life questionnaires showed that the variables had a value > 0.6, which stated that the questionnaire was reliable. dewi, et. al. ghmj (global health management journal) 2025, vol. 8, no. 3 374 2.3 statistical techniques the analysis in this study used univariate analysis with the aim of knowing the frequency distribution of the characteristics of pulmonary tb patients, namely age, gender, education, occupation and length of treatment, as well as drug compliance and the quality of life of pulmonary tb patients. then bivariate analysis using the chisquare test to determine the relationship between characteristics (age, gender, education, occupation, and length of treatment) with drug compliance and determine the relationship between characteristics (age, gender, education, occupation, and length of treatment) with the quality of life of patients with pulmonary tb. multivariate analysis was then conducted using logistic regression test to determine which characteristics (age, gender, education, occupation, and duration of treatment) were most influential in drug adherence and quality of life of pulmonary tb patients. in this multivariate analysis, two variables were used, namely age characteristics and duration of treatment, because these two characteristics had been tested and found to be suitable for inclusion in the multivariate analysis. 2.4 ethical clearance this study has been ethically approved by the ethic committee of faculty of medicine, swadaya gunung jati university, following the seven who standards, with number no.25/ec/fkugj/iv/2024, on april 17th, 2024. 3. results respondent characteristics the following data are the results of a study on the characteristics of age, gender, education, occupation, duration of treatment, medication adherence, and quality of life of pulmonary tb patients at the cirebon community lung health center, which were analyzed univariately and presented in frequency distribution tables and percentages. the results of the study in table 1 show that of the 131 respondents, most were adults (19-59 years) as many as 119 respondents (90.8%) while respondents in the elderly category (≥ 60 years) were 12 respondents (9.2%). most of the respondents were female as many as 74 people (56.5%) and a small proportion were male as many as 57 people (43.5%). some of the respondents with secondary education categories (sma / smk) were 66 people (50.4%), while the low education category (sd / smp) was 37 respondents (28.2%) and the higher education category was 28 people (21.4%). most of the respondents were students as many as 37 people (28.2%), respondents who worked as traders were 19 people (14.5%), respondents who did not work were 18 people (13.7%) while respondents who worked as farmers / livestock farmers and housewives were 14 people (10.7%), and respondents who worked as civil servants / tni / polri were 12 people (9.2%). most of the respondents with advanced stage treatment duration were 78 people (59.5%) while respondents with early stage treatment were 53 people (40.5%). almost all respondents were compliant in taking medication as many as 114 people (87.0%) while respondents who did not comply with taking medication were 17 people (13.0%). in the quality of life of tb patients, most respondents had a good quality of life as many as 71 respondents (54.2%), with a moderate quality of life as many as 55 respondents, and with a poor quality of life as many as 5 people (42%). bivariate analysis bivariate analysis was performed to determine the differences between the independent variables, namely age, gender, education, occupation, and duration of treatment, and the dependent variables, namely medication adherence and quality of life in patients with pulmonary tb. the statistical test used was the chi-square test. table 2 shows the distributions of patients based on age, gender, education, employment, and duration of treatment. the statistical analysis shows that only duration of treatment significantly contribute to medication adherence (p value = 0.014). moreover, table 3 shows the distributions of patients based on age, gender, education, employment, and duration of treatment. the statistical analysis shows that there is no factors significantly contribute to quality of life. dewi, et. al. ghmj (global health management journal) 2025, vol. 8, no. 3 375 table 1. distribution of respondent characteristics variable frequency percentage age adults (19-59 years) elderly (≥60 years old) 119 12 90.8 9.2 gender male female 57 74 43.5 56.5 education low education (elementary/middle school) secondary education (sma/smk) higher education (bachelor's degree) 37 66 28 28.2 50.4 21.4 employment not working pns/tni/polri private employee/laborer housewife student farmer/rancher trader 18 12 17 14 37 14 19 13.7 9.2 13.0 10.7 28.2 10.7 14.5 duration of treatment initial stage (2 months) advanced stage (>2 months) 53 78 40.5 59.5 medication adherence not compliant compliant 17 114 13.0 87.0 quality of life poor moderate good 5 55 71 3.8% 42.0% 54.2% multivariate analysis table 4 shows the results of multivariate analysis in this study, which aims to answer the hypotheses and research objectives regarding the relationship between characteristics and medication adherence and quality of life in patients with pulmonary tb, tested using multiple logistic regression analysis. variables included in the multivariate analysis are those with a p-value < 0.25 in the bivariate analysis. treatment duration is a variable or factor associated with medication adherence among pulmonary tb patients at the cirebon city community lung health center (p 0.006 < α 0.05), while age is not the most significant variable or factor associated with medication adherence among pulmonary tb patients (p 0.058 > α 0.05). treatment duration, specifically respondents in the initial treatment phase, is the most significant variable or factor associated with medication adherence among pulmonary tb patients at the cirebon city community lung health center, where respondents in the initial treatment phase are 5.619 times more likely to be non-adherent in taking their tb medication. dewi, et. al. ghmj (global health management journal) 2025, vol. 8, no. 3 376 table 2. patients’ characteristics to medication adherence variables medication adherence total n (%) p-value compliant noncompliant n % n % age adults (19-59 years old) 105 88.2% 14 11.8% 119 (100%) 0.189 elderly (≥60 years old) 9 75.0% 3 25.0% 12 (100%) gender male 52 91.2% 5 8.8% 57 (100%) 0.320 female 62 83.8% 12 16.2% 74 (100%) education lower education (elementary/middle school) 30 81.1% 7 18.9% 37 (100%) 0.447 secondary education (sma/smk) 59 89.4% 7 10.6% 66 (100%) higher education (bachelor degree) 25 89.3% 3 10.7% 28 (100%) employment not working 14 77.8% 4 22.2% 18 (100%) 0.703 civil servant/tni/police 11 91.7% 1 8.3% 12 (100%) private employee/laborer 17 100% 0 0% 17 (100%) housewife 12 85.7% 2 14.3% 14 (100%) student 31 83.3% 6 16.2% 37 (100%) farmer/rancher 12 85.7% 2 14.3% 14 (100%) trader 17 89.5% 2 10.5% 19 (100%) duration of treatment initial stage (2 months) 41 77.4% 12 22.6% 53 (100%) 0.014 advanced stage (>2 months) 73 93.6% 5 6.4% 78 (100%) table 3. patients’ characteristics to quality of life variables quality of life total n (%) pvalue good moderate poor n % n % n % age adults (15-59 years old) 65 38% 49 29% 55 33% 169 (100%) 0.688 elderly (≥60 years old) 6 50% 6 50% 0 0% 12 (100%) gender male 32 56% 24 42% 1 2% 57 (100%) 0.550 female 39 52% 31 42% 4 6% 74 (100%) education lower education (elementary/middle school) 20 54% 16 43% 1 3% 37 (100%) 0.838 secondary education (sma/smk) 35 53% 29 44% 2 3% 66 (100%) higher education (bachelor degree) 16 57% 10 36% 2 7% 28 (100%) employment not working 10 55% 7 39% 1 6% 18 (100%) 0.519 civil servant/tni/police 7 58% 5 42% 0 0% 12 (100%) private employee/laborer 12 71% 5 29% 0 0% 17 (100%) housewife 8 57% 5 36% 1 7% 14 (100%) student 15 41% 21 57% 1 2% 37 (100%) farmer/rancher 7 50% 7 50% 0 0% 14 (100%) trader 12 63% 5 26% 2 11% 19 (100%) duration of treatment initial stage (2 months) 27 51% 23 43% 3 6% 53 (100%) 0.604 advanced stage (>2 months) 44 56% 32 41% 2 3% 78 (100%) dewi, et. al. ghmj (global health management journal) 2025, vol. 8, no. 3 377 table 4. multivariate analysis 95% c.i.for exp (b) coefficient b p value exp (b) minimum maximum age -1.564 0.058 0.209 0.042 1.053 length of treatment 1.726 0.006 5.169 1.660 19.017 constant -1.468 0.042 0.230 4. discussion based on age characteristics, the majority of respondents were at an adult age (19-59 years) as many as 119 people or around (90.8%). followed by respondents in the elderly category (≥ 60 years) as many as 12 people or around (9.2%). this is in accordance with data from the indonesian ministry of health that 75% of tuberculosis attacks in the productive age group, namely 15-59 years old, which is a group that is quite high in germ infection where at this age a person with high activity and on average has worked so that immunity easily decreases due to stress and high workload. this condition allows a person to be easily attacked by mycobacterium tuberculosis germs (kemenkes ri, 2022). based on gender characteristics, it was found that the majority of respondents had female gender with 74 people or around (56.5%). followed by male respondents with 57 people or around (43.5%). based on this data, it can be concluded that the number of women is greater than men. the results of this study are in line with the previous research which the majority of tuberculosis respondents were female patients as many as 82 people (52.2%) and fewer men as many as 75 people (47.8%) (juliasih et al, 2020). women report more symptoms of the disease and consult a doctor so that the data obtained where people with pulmonary tb are more in women (mientarini et al, 2018). based on educational characteristics, it was found that the majority of respondents had secondary education with 66 people or around (50.4%). followed by respondents who have low education with 37 people or around (28.2%). the lowest percentage is respondents with higher education with 28 people or around (21.4%). based on this data, it can be concluded that the education of respondents in this study is at the secondary education level. the results of this study are in line with the previous research where respondents with tuberculosis patients mostly have secondary education, which education may describe a person's behavior in terms of health, the lower the education, the less knowledge in the health sector, both directly and indirectly can affect physical, biological and social which is detrimental to health and ultimately affects the high incidence of tuberculosis (azalla et al, 2020). based on job characteristics, it was found that the majority of respondents were students as many as 37 people (28.2%), respondents who worked as traders were 19 people (14.5%), respondents who did not work were 18 people (13.7%) while respondents who worked as farmers / livestock farmers and housewives were 14 people (10.7%), and respondents who worked as civil servants / tni / polri were 12 people (9.2%). the results of this study are in line with the previous research which found that the research respondents with tb more in the private category, where tb disease transmission is closely related to the type of work that allows exposure to diseases related to the work environment and socio-economic. one of the factors that support a person can be infected with tb disease is the work environment that is indoors with less sunlight and a poor ventilation system (arisandi et al, 2023). based on the characteristics of the length of treatment, it is known that respondents with advanced treatment dominated as many as 78 people (59.5%) while respondents with early stage treatment were 53 people (40.5%). the results of this study are in line with the previous research which found the majority of respondents underwent treatment for 3-6 months as many as 23 people (50.0%) and respondents who underwent treatment for 1-2 months as many as 20 people (43.5%) (muflihatin et al, 2022). based on drug compliance, it is known that respondents with adherence to taking medication in the obedient category dominated as many as 114 people (87.0%), while adherence to taking medication in the noncompliant category was 55 (42.0%) and poor quality of life was 17 people (13.0%). the results of this study are in line with the previous research which found that the compliance of tuberculosis patients in taking oat during treatment is in the obedient category, compliance in treatment can reflect the patient's behavior in obeying the dewi, et. al. ghmj (global health management journal) 2025, vol. 8, no. 3 378 advice and instructions given by health workers regarding everything that must be done to achieve optimal treatment (syaifiyatul et al, 2020). based on quality of life, it is known that respondents with good quality of life dominate as many as 71 people (54.2%), while moderate quality of life is 55 (42.0%) and poor quality of life is 5 people (3.8%). quality of life is described as a perception or subjective view of pulmonary tb respondents towards satisfaction and acceptance of their condition. the results of this study are in line with the previous research which found that the quality of life of most pulmonary tb patients is a good quality of life, the quality of life of pulmonary tb patients is very important to pay attention to because this infectious disease is chronic and progressive so that it has a broad impact on all aspects of life both physical, social, psychological, and environmental. poor quality of life in patients with pulmonary tb is due to physical health problems that cause disruption of aspects of life, disruption of physical health and long treatment in patients with pulmonary tb (jasmiati et al, 2017). based on the results of statistical tests that age does not have a significant relationship with adherence to taking medication in respondents in the cirebon city community lung health center area obtained a p-value = 0.189, which means that there is no significant relationship. the results of the research that have been carried out are in line with the previous research which found that there is no relationship, there are several reasons people become less compliant with taking medication as they age, these factors involve physical, psychological, and social changes associated with aging. as people age, they tend to experience an increase in the number of medications they must take for various health conditions, the more complex and numerous medications they take, the more difficult it is to adhere to the correct schedule and dosage (bakhtiar et al, 2021). based on the results of statistical tests that gender does not have a significant relationship with drug compliance among respondents in the cirebon city community lung health center area, the p-value = 0.209 means that there is no significant relationship. the results of the research conducted are in line with the previous research which found that there is no relationship between the two variables (salsabila, susanti, & bhakti, 2022). according to notoatmodjo, women pay more attention to their health than men. the level of compliance in the female gender group has more compliance with taking medication than men. men and workers have twice the risk of abandoning treatment, because it is difficult to leave their jobs and difficult to visit health facilities (dewanty et al, 2016). based on the results of statistical tests that education does not have a significant relationship with adherence to taking medication on respondents in the cirebon city community lung health center area obtained a p-value = 0.447, which means that there is no significant relationship. the results of the research that has been done are in line with the previous research which found that there is no relationship among the variables variables. the level of education of tb patients will affect their level of knowledge and absorption in terms of prevention of transmission and treatment of tb. patients who have a poor level of knowledge will tend not to take treatment because for them, taking treatment and not taking treatment will have the same results. the lower the knowledge and education, the lower the patient's awareness of the dangers of the disease to himself and his environment, and the lower his awareness of complete treatment (azalla et al, 2020). based on the results of statistical tests that work does not have a significant relationship with adherence to taking medication on respondents in the cirebon city community lung health center area obtained a p-value = 0.594, which means that there is no significant relationship. the results of the research conducted are in line with the previous research which found that there is no relationship between the two variables (wulandari et al, 2020). certain workers are vulnerable to the incidence of pulmonary tb. this is due to the continuous busyness every day so that they do not have time to seek treatment at health facilities. employment does not always identify a person's behavior to be compliant or non-compliant in taking medication, because it can be caused by their own assumptions that treatment requires money, for transportation purposes or their own needs that must be considered more than the importance of treatment (issusilaningtyas et al, 2019). dewi, et. al. ghmj (global health management journal) 2025, vol. 8, no. 3 379 based on the results of statistical tests that the length of treatment has a significant relationship with adherence to taking medication in respondents in the cirebon city community lung health center area obtained a p-value = 0.014, which means that there is a significant relationship. the results of the research that has been done are in line with the previous research which found that there is a relationship between the respondent characteristics with the medication adherence. there are several things that cause pulmonary tb patients not to consume drugs, namely pulmonary tb drugs must be consumed for a long period of time, the patient will feel cured because of the reduction in disease symptoms after undergoing treatment so that the patient is lazy to continue treatment again, and the side effects caused by the tb drug (dwiningrum et al, 2021). based on the results of statistical tests that age does not have a significant relationship with quality of life in respondents in the cirebon city community lung health center area, the p value = 0.688 means that there is no significant relationship, which in line with the previous research (noviati et al, 2023). productive age still has a sense of motivation to recover, and has high hopes for improving their quality of life, in contrast to sufferers of old age or the elderly who are getting older, of course not a few of them often feel tired and not motivated to recover anymore, so that the increasing age and conditions that are no longer motivated will greatly affect the degree of health which will directly affect the quality of life of these sufferers (djua et al, 2024). based on the results of statistical tests that gender does not have a meaningful relationship with quality of life in respondents in the cirebon city community lung health center area obtained a p-value = 0.550, which means that there is no significant relationship, which in line with the previous research (juliasih nn, 2020). tuberculosis often occurs in men, said to be much higher than women, this is because men are more often found to have smoking habits, drink alcohol, and are often associated with work, so that it can reduce the immune system and tend to have a poor quality of life compared to women (jamayanti, 2014). based on the results of statistical tests that education does not have a meaningful relationship with quality of life in respondents in the cirebon city community lung health center area obtained a p-value = 0.838, which means that there is no significant relationship, which in line with the previous study (djua et al, 2024). according to notoatmodjo's opinion that a person's level of education runs symmetrically with a person's level of knowledge. a person's level of knowledge itself is a process of learning and observing a certain object systematically and gradually. if pulmonary tb patients know the benefits of taking oat regularly and completely can improve recovery and quality of life, then these patients will have a good level of compliance, so that it will further improve their quality of life (nugroho et al, 2023). based on the results of statistical tests that work does not have a significant relationship with quality of life in respondents in the cirebon city community lung health center area obtained a p-value = 0.519, which means that there is no significant relationship. the results of the research conducted are in line with the research of namuwali d, that there is no relationship. employment and social status are important factors for tuberculosis treatment adherence, patients with better economic status are able to pay for transportation and other costs, thus increasing treatment adherence. work is part of and has a greater opportunity to socialize with others, so that they do not think too much about the disease suffered (namuwali, 2019). based on the results of statistical tests that the length of treatment does not have a significant relationship with the quality of life of respondents in the cirebon city community lung health center area obtained a pvalue = 0.604, which means that there is no significant relationship, which in line with the previous study (hidayati et al, 2023). poor quality of life in the initial stage of treatment is due to the fact that the initial stage of treatment is carried out for 1-2 months by taking oat every day, so patients sometimes feel bored with the drugs taken and stop the treatment carried out, this can worsen the quality of life of pulmonary tb patients, besides that it can also cause immunity to the drug (pawenrusi et al, 2020). based on the results of statistical tests obtained that the length of treatment is a variable or factor associated with adherence to taking medication in pulmonary tb patients at the cirebon city community lung health center p value = 0.006. length of treatment, namely respondents with early stage treatment, is the variable or factor most associated with adherence to taking medication in pulmonary tb patients at the cirebon city community lung health center, where respondents in the early stage of treatment have a 5.619 times greater chance of not being compliant in taking tb medication. the main cause of this is that patients do not comply with the provisions and length of treatment regularly to achieve recovery as a result of the low level of public knowledge. health worker support is another factor that can influence the implementation of compliance dewi, et. al. ghmj (global health management journal) 2025, vol. 8, no. 3 380 behavior. the role of drug administration, collaboration of health workers with families who are appointed to accompany when patients take medicine (dwiningrum et al, 2021). interventions that can be carried out are to provide useful information related to pulmonary tb in cirebon city and to increase health promotion about tb in patient waiting rooms, as well as in community groups using appropriate information media. 5. conclusion this study aims to analyze the relationship between patient characteristics with medication adherence and quality of life of pulmonary tb patients. based on the results of the research that has been carried out, the results of the description of age characteristics in pulmonary tb patients are mostly at adulthood (19-59 years), gender characteristics in pulmonary tb patients are mostly female, educational characteristics in pulmonary tb patients are mostly in secondary education (sma / smk), occupational characteristics in pulmonary tb patients are mostly as students, traders, not working and employees / private laborers, characteristics of the length of treatment in pulmonary tb patients are mostly in advanced stage treatment (>2 months), compliance with taking medication in pulmonary tb patients is mostly compliant with treatment, and quality of life in pulmonary tb patients has a good quality of life. then there is no relationship between the characteristics of age, gender, education, and occupation with adherence to taking medication, while in the characteristics of length of treatment there is a relationship with adherence to taking medication in pulmonary tb patients. furthermore, there is no relationship between the characteristics of age, gender, education, occupation, and length of treatment with the quality of life of pulmonary tb patients. then the characteristics of the length of treatment are the characteristics that are most associated with adherence to taking medication in pulmonary tb patients with a p value = 0.006. these findings suggest that interventions to improve adherence should focus on patients in the early stages of treatment. future researchers are advised to explore other factors that may be related to medication adherence and quality of life in patients with pulmonary tb. conflict of interest the authors declare no conflicts of interest for the result. references arif, w. o. n. h., wahyudin, e., & djaharuddin, i. (2022). karakteristik pasien tuberkulosis paru di puskesmas kota baubau sulawesi tenggara. majalah farmasi dan farmakologi, 26(1), 44–47. https://journal.unhas.ac.id/index.php/mff/article/view/14759 arisandi, d., sugiarti, w., & islamarida, r. (2023). karakteristik penderita tuberkulosis paru di kabupaten sleman, d.i. yogyakarta. jurnal formil (forum ilmiah) kesmas respati, 8(1), 64. https://doi.org/10.35842/formil.v8i1.470 azalla, c. r., maidar, & ismail, n. (2020). analisis kualitas hidup penderita tuberkulosis paru terhadap kepatuhan pengobatan tuberkulosis di wilayah kabupaten pidie jaya tahun 2020. badan koordinasi penanaman modal kota cirebon. (2024). laporan bkpm kota cirebon tahun 2024. bkpm kota cirebon. bakhtiar, m. i., wiedyaningsih, c., yasin, n. m., & kristina, s. a. (2021). hubungan karakteristik, kepatuhan, dan outcome klinis pasien tuberkulosis paru di puskesmas kabupaten bantul. majalah farmasi, 17(2), 256–269. https://doi.org/10.22146/farmaseutik.v17i2.60681 dewanty, l. i., haryanti, t., & kurniawan, t. p. (2016). kepatuhan berobat penderita tb paru di puskesmas nguntoronadi i kabupaten wonogiri. jurnal kesehatan, 9(1), 39. https://doi.org/10.23917/jurkes.v9i1.3406 dinas kesehatan kota cirebon. (2021). profil kesehatan kota cirebon tahun 2021. dinas kesehatan kota cirebon. dinas kesehatan provinsi jawa barat. (2022). profil kesehatan jawa barat tahun 2022. dinas kesehatan provinsi jawa barat. djua, n. a., irwan, ahmad, z. f. (2024). faktor-faktor yang mempengaruhi kualitas hidup (quality of life) penderita tb paru. gorontalo journal of health science and community, 8(2), 82–91. https://ejurnal.ung.ac.id/index.php/gojhes/article/view/24855 dwiningrum, r., wulandari, r. y., & yunitasari, e. (2021). hubungan pengetahuan dan lama pengobatan tb paru dengan kepatuhan minum obat pada pasien tb paru di klinik harum melati. jurnal aisyah: jurnal ilmu kesehatan, 6, 209–214. https://doi.org/10.30604/jika.v6is1.788 hidayati, w., mamlukah, m., suparman, r., & iswarawanti, d. n. (2023). faktor-faktor yang berhubungan dengan kualitas hidup pasien tb di balai kesehatan paru masyarakat kota cirebon tahun 2023. journal of health research and science, 3(2), 165– https://journal.unhas.ac.id/index.php/mff/article/view/14759 https://doi.org/10.35842/formil.v8i1.470 https://doi.org/10.22146/farmaseutik.v17i2.60681 https://doi.org/10.23917/jurkes.v9i1.3406 https://ejurnal.ung.ac.id/index.php/gojhes/article/view/24855 https://doi.org/10.30604/jika.v6is1.788 dewi, et. al. ghmj (global health management journal) 2025, vol. 8, no. 3 381 174. https://doi.org/10.34305/jhrs.v3i02.929 issusilaningtyas, e., swandari, m. t. k., & masfu’ah, t. (2019). karakteristik kepatuhan pengobatan pasien tuberkulosis paru di uptd puskesmas cilacap selatan i periode maret 2019. seminar nasional interprofessional education, 95–103. jamayanti, l. (2014). karakteristik penderita tuberkulosis paru di poliklinik paru rumah sakit umum daerah dr. zainoel abidin banda aceh periode januari–mei 2014. universitas syiah kuala. jasmiati, d., karim, d., & huda, n. (2017). hubungan dukungan keluarga dengan kualitas hidup pasien tb paru. jurnal ners indonesia, 7(2), 121–129. juliasih, n. n., mertaniasih, n. m., hadi, c., soedarsono, sari, r. m., & alfian, i. n. (2020). factors affecting tuberculosis patients’ quality of life in surabaya, indonesia. journal of multidisciplinary healthcare, 13, 1475–1480. https://doi.org/10.2147/jmdh.s274386 kementerian kesehatan republik indonesia. (2020). pedoman nasional pelayanan kedokteran tatalaksana tuberkulosis. kementerian kesehatan ri. kementerian kesehatan republik indonesia. (2023). profil kesehatan indonesia tahun 2022. kementerian kesehatan ri. mientarini, e. i., sudarmanto, y., & hasan, m. (2018). the correlation between knowledge and attitude towards the adherence of medication in tuberculosis pulmonary patient on continuation phase in umbulsari jember. jurnal ikesma, 14(1), 11–17. https://doi.org/10.19184/ikesma.v14i1.10401 muflihatin, s. k., milkhatun, & hardianti. (2022). hubungan kepatuhan minum obat dengan kualitas hidup pasien tuberkulosis di wilayah kerja puskesmas segiri samarinda. universitas muhammadiyah kalimantan timur. namuwali, d. (2019). karakteristik demografi dan kualitas hidup penderita tb paru di puskesmas waingapu, sumba timur. jurnal kesehatan, 10(april), 129–134. noviati, e., sukmawati, i., masru’ah, i. i., & rudi, k. (2023). apply dots m-health terhadap peningkatan minum obat dan kualitas hidup pasien tuberkulosis paru. jurnal kesehatan, 5, 3305–3313. https://doi.org/10.31539/joting.v5i2.8024 nugroho, m. a., kumboyono, k., & setyoadi, s. (2023). analisa kepatuhan minum obat anti tuberkulosis: perbandingan penggunaan layanan pesan singkat dengan pengawas minum obat. jurnal akademika baiturrahim jambi, 12(1), 74. https://doi.org/10.36565/jab.v12i1.588 pawenrusi, e. p., jufri, & akbar, m. (2020). gambaran kualitas hidup pada pasien tuberkulosis paru (tb paru) di balai besar kesehatan paru masyarakat (bbkpm) makassar. jurnal mitrasehat, 10(1), 168–177. https://doi.org/10.51171/jms.v10i1.134 pertiwi, r. (2012). hubungan antara karakteristik individu, praktik hygiene dan sanitasi lingkungan dengan kejadian tuberculosis di kecamatan semarang utara tahun 2011. jurnal kesehatan masyarakat universitas diponegoro, 1(2), 18811. salsabila, l. z., susanti, r., & bhakti, w. k. (2022). analisis faktor tingkat kepatuhan minum obat anti tuberkulosis pada pasien tb paru rawat jalan di puskesmas perumnas 1 kota pontianak tahun 2021. jurnal mahasiswa farmasi kedokteran untan, 1–8. sitb. (2022). sistem informasi tuberkulosis berbasis web (sitb) 2022. kementerian kesehatan republik indonesia. sunaryo. (2014). psikologi untuk keperawatan. penerbit buku kedokteran egc. syaifiyatul, h., humaidi, f., & anggarini, d. r. (2020). kepatuhan minum obat anti tuberkulosis pada pasien tbc regimen. jurnal ilmiah farmasi attaamru, 1(1). https://doi.org/10.31102/attamru.v1i1.917 world health organization. (2012). the world health organization quality of life (whoqol)-bref. world health organization. world health organization. (2023). global tuberculosis report 2023. world health organization. wulandari, i. s. m., rantung, j., & malinti, e. (2020). faktor yang berhubungan dengan kepatuhan minum obat pasien tb di wilayah kerja puskesmas parongpong. jurnal keperawatan muhammadiyah, 5(1). https://doi.org/10.30651/jkm.v5i1.4536 cite this article as: dewi, a. p., zaidah, n., & marfuati, s. (2025). the relationship between characteristics with medication adherence and quality of life among the pulmonary tuberculosis patients at the cirebon city community lung health center, indonesia. ghmj (global health management journal), 8(3), 371–381. https://doi.org/10.35898/ghmj-831245 https://doi.org/10.34305/jhrs.v3i02.929 https://doi.org/10.2147/jmdh.s274386 https://doi.org/10.19184/ikesma.v14i1.10401 https://doi.org/10.31539/joting.v5i2.8024 https://doi.org/10.36565/jab.v12i1.588 https://doi.org/10.51171/jms.v10i1.134 https://doi.org/10.31102/attamru.v1i1.917 https://doi.org/10.30651/jkm.v5i1.4536 https://doi.org/10.35898/ghmj-831245 references ghmj (global health management journal) 2024, vol. 7, no. 1 indonesian scholars’ alliance open access research article the influence of female sex worker fellows support and motivation on sexually transmitted diseases (stds) prevention behaviors in makassar city, indonesia zulhijriani, nur cahyani ari lestari, eviyati aini muriana, iin tri marlinawati, dian shofia reny setyanti, putri yunita sari midwifery program, sekolah tinggi ilmu kesehatan bakti utama pati, indonesia. *corresponding author’s email: zulhijriani.2@gmail.com doi: 10.35898/ghmj-71980 abstract background: a sexually transmitted diseases (stds) is an illness that is primarily transmitted through sexual contact. there are around 30 different species of microorganisms, including bacteria, viruses, and parasites, that can be transmitted through sexual activity without protection. the most prevalent conditions include gonorrhea, chlamydia, syphilis, trichomoniasis, chancroid, genital herpes, hiv, and hepatitis b. within society, sexually transmitted diseases (stds) are the most prevalent form of infection. aims: the objective of this study is to ascertain the direct and indirect impact on the prevention of sexually transmitted illnesses in the city of makassar. methods: this study used a cross-sectional design. the study collected samples from 45 consenting individuals who agreed to participate. this study used a structure equation model as an analysis method using smart pls 2.0. results: the findings demonstrated a significant correlation between the support of fellow female sex workers (fsws) and the practice of stds prevention, with a direct impact of 10.26%. additionally, there was a direct influence of stds prevention behavior on motivation, accounting for 10.84%. furthermore, the support of fellow fsws had a substantial impact on motivation, with a direct influence of 29.16%. the overall direct effects have increased by 50.26%. the support of fellow fsws has an indirect influence on stds prevention behavior, increasing motivation by 5.77%. the cumulative impact, both direct and indirect, amounts to 56.03%. the q-square analysis model accounts for 44.1% of the variability in the data and specifically investigates the phenomenon studied. the remaining 55.9% of variability is attributed to other variables that were not addressed in this study. conclusion: hence, the research findings indicate that various factors, including the assistance from fellow female sex workers and motivation, contribute to the promotion of stds prevention behavior. keywords: sexually transmitted diseases (stds), prevention behavior, female sex workers, fellow support, motivation. received: 14 december 2023, reviewed: 25 december 2023, revised: 06 january 2024, accepted: 16 january 2024. © 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:zulhijriani.2@gmail.com https://doi.org/10.35898/ghmj-71980 19 ghmj (global health management journal) 2024, vol. 7, no. 1 zulhijriani, et.al. 1. introduction sexually transmitted diseases (stds) are a significant public health concern globally, with varying prevalence rates across different populations and geographic regions. the prevalence of stds is influenced by a multitude of factors such as sexual behavior, knowledge of stds, preventive practices, and demographic characteristics. several studies have been conducted to understand the prevalence and associated factors of stds in different populations, shedding light on the heterogeneity of sexual behavior and the drivers of transmission. for instance, a study in ethiopia found that previous history of stds, multiple sexual partners, inconsistent condom use, and poor knowledge of stds were associated with a higher prevalence of stds among university students (kassie et al., 2019). similarly, a hospital-based survey in iran revealed a significantly higher lifetime prevalence of stds in women compared to men (fararouei et al., 2023). the prevalence of sexually transmitted diseases (stds) among female sex workers (fsws) is a significant public health concern. studies have consistently shown that fsws are a high-risk group for acquiring and transmitting stds, including hiv and syphilis (halatoko et al., 2017; kakchapati et al., 2017; tura et al., 2023). the susceptibility of fsws to stds is attributed to their sexual behavior, limited access to health services, and engagement in highrisk sexual activities (kakchapati et al., 2017; oza et al., 2014). for instance, research in nepal highlighted that fsws are susceptible to acquiring hiv and syphilis due to their high-risk sexual behaviors (kakchapati et al., 2017). similarly, studies in ethiopia and togo reported a high prevalence of syphilis among fsws, emphasizing the vulnerability of this population to stds (halatoko et al., 2017; tura et al., 2023). additionally, studies in china have addressed the prevalence of neisseria gonorrhoeae and chlamydia trachomatis infections among fsws, indicating the burden of stds in this population (chen et al., 2013; li et al., 2014). furthermore, factors such as vaginal douching have been associated with an increased risk of stds among fsws, as evidenced by a study in china (li et al., 2014). additionally, early life experiences and sexual behavior have been linked to negative effects on reproductive and sexual health among fsws in tijuana, mexico (oza et al., 2014). moreover, a study in indonesia identified various risk factors for chlamydia infection among direct female sex workers, highlighting the complex interplay of factors contributing to std prevalence in this population (rabiah et al., 2018). overall, the prevalence of stds among fsws underscores the urgent need for targeted interventions, access to comprehensive sexual health services, and tailored reproductive health education to mitigate the burden of stds in this vulnerable population (rudi et al., 2020). jalan nusantara is one of the places of prostitution in the city of makassar which is very strategically located because it is close to tourist attractions, making this place easy to visit compared to other places of prostitution. the existence of this phenomenon increases the risk of transmitting sexually transmitted diseases (stds). transmission is becoming more rapid due to the lack of awareness of the use of condoms by guests when dating commercial sex workers in this area. prevention efforts are generally focused on making people aware of stds and also recommending that people whose sex lives are still active can limit the number of sexual dates they have and start using safe methods, such as ' outercourse' and condom use. based on a preliminary study that the author conducted by conducting interviews with 10 fsw in makassar who were guided by a theoretical basis in the form of a questionnaire regarding std prevention behavior, on march 2022, the results showed that 6 (60%) fsw had behavior to prevent stds. still not good and 4 (40%) people have behaved well in preventing stds, namely 3 (30%) people have used condoms every time they have sexual intercourse with their partner, 2 (20%) people have been vaccinated, they are vaccinated against hpv. the female sex workers have not been motivated to try to prevent std, most of their motivation is still low. this research aims to determine the direct and indirect influence and the amount of support from fellow fsw and motivation on the behavior of preventing sexually transmitted diseases in makassar city. symptoms that appear in mental disorders can include hallucinations, illusions, delusions, disturbances in thought processes thinking abilities, and abnormal behavior such as aggressiveness or catatonia. mental disorders can become severe, known as schizophrenia (horan & green, 2019). schizophrenia is a psychotic disorder characterized by significant thoughts, emotions, and behavior disturbances. schizophrenia is a major psychiatric disorder characterized by changes in a person's perceptions, thoughts, affects, and behavior (sari & subandi, 2021; astuti et al., 2020). based on the world mental health report (2016), the number of people with schizophrenia worldwide has reached 24 million people or around 1 in 200 adults (aged 20 years and over). meanwhile, in indonesia, cases of schizophrenia increase every year. based on riskesdas 2018, the prevalence of households with art for the mental disorder schizophrenia or psychosis is 6.7 per mile, which means there are 6-7 households with art for the mental disorder schizophrenia or psychosis per 1000 households. this figure has increased more than three times compared to the 2013 riskesdas results, which were 1.7 per 1,000 households (kementrian kesehatan ri, 2019). zulhijriani, et.al. , et.al. ghmj (global health management journal) 2024, vol. 7, no. 1 20 schizophrenia impacts behavior and conditions that disturb the patient, other people, and the environment (kurniawan et al., 2021). schizophrenia is a complex mental health condition that can be effectively treated with somatic therapy. somatic therapy includes antipsychotic medication, psychosocial therapy, and hospitalization when necessary. with the right treatment, individuals living with schizophrenia can experience significant improvements in their symptoms and quality of life (asher et al., 2017). other research states that the family can carry out medical and non-medical treatment (suryani, hidayah, et al., 2019). other research shows that schizophrenic patients are taken to “dukun” to obtain an explanation of the causes of the illness and also ways to overcome it (bachtiar et al., 2020). the recovery process for schizophrenia survivors requires a collaborative role between various parties, including family and mental health professionals (hidayah et al., 2022). the debate about the recovery process for schizophrenia survivors is still developing. the recovery process is defined as how individuals with mental health challenges regain and develop significant relationships with their family, friends, community, and themselves to overcome the harmful effects of stigma (apostolopoulou et al., 2020). however, riskesdas's (2013) data shows that as many as 1,655 households with schizophrenia still use shackling methods, which means that the stigma is still strong in society. other research shows that shackling of schizophrenic patients is carried out due to ignorance on the part of the family, shame on the part of the family, mental disorders that do not heal, there is no cost for treatment, and the purpose of shackling is to protect odgj so that acts of violence do not occur (puspitosari et al., 2019). based on the background above, researchers are interested in conducting a scoping review regarding the picture of recovery in people with schizophrenia in indonesia based on the views of the survivors, their families, and mental health professionals. 2. methods study design this research uses survey and case study methods with a quantitative approach, meaning that this research emphasizes descriptive statistical analysis with an explanatory research type, namely to explain the influence of support from fellow female sex workers and motivation on std prevention behavior among female sex workers on nusantara street in makassar. the research design used a cross-sectional design, where the research measurements explained in the independent variables were support from fellow female sex workers and motivation. this location was chosen purposefully with the consideration of making it easier to collect data, considering that this location is the localization in makassar. population and samples in this research, female sex workers were used as the research sample. sampling was carried out by researchers using a model a complete modeling basically consisting of a measurement model and a structural model. the measurement model is intended to confirm a dimension or factor based on empirical factors. from this modeling, the number of samples that can represent these conditions in the field is determined. the sample uses quota random sampling, namely, the population becomes the research sample, with the total number of samples being 45 female sex workers in the city of makassar. measurement the measurement method for both variables used in this research uses an interval scale, while the measurement technique uses semantic differential, which has a 5-point scale. on this scale, positive traits are given the greatest value, and negative traits are given the smallest value. likewise, the principle of combining positive-negative and negative-positive is maintained. data collection the primary data collection method used in this research is through instruments in the form of questionnaires or questions obtained by distributing questionnaires, which are carried out by researchers to respondents who comply with the specified criteria. the instrument is in the form of a questionnaire or question containing each indicator in the four variables. the variables in question include those consisting of support from fellow female sex workers and motivation for behavior to prevent sexually transmitted diseases. research data collection was carried out after obtaining a letter of ethical approval from the research ethics commission of the muhammadiyah university of geresik health faculty. 21 ghmj (global health management journal) 2024, vol. 7, no. 1 zulhijriani, et.al. instruments this validity and reliability test is carried out to find out whether the instrument used really measures what needs to be measured and to what extent the instrument used can be trusted or relied upon. validity and reliability testing using smart partial square (pls) is declared valid if it has a loading factor of 0.5–0.6 (still tolerable as long as the model is still in the development stage), but the recommended loading factor is above 0.7. analysis data the research results are presented in the form of a textual table. the presentation of data in tabular form is a systematic presentation of numerical data composed of columns and rows. this presentation is used to present the results of the analysis of primary and secondary data. apart from that, it is also presented in diagram form to make reading easier. research results obtained. meanwhile, data interpretation is presented in narrative form, making it easier to understand the research results. the data analysis technique in this research uses structural equation modeling (sem) with partial least squares (pls). the steps in data analysis using pls are as follows: 1) designing a structural model (inner model) describing the relationship between latent variables based on substantive theory. designing a structural model of the relationship between latent variables is based on the problem formulation or research hypothesis. 2) designing a measurement model (outer model). the outer model, or measurement model, defines how each indicator block is related to the latent variable. the design of the measurement model determines the indicator properties of each latent variable, whether reflective or formative, based on the operational definition of the variable. the reflective model is often also called the principal model, where the indicator measurement covariance is influenced by the latent construct or reflects variations in the latent construct. in the unidimensional constructive reflective model, it is depicted in an elliptical shape with several arrows from the construct to the model indicators. this hypothesizes that changes in the latent construct will influence changes in the indicators. the reflective model must have internal consistency because all indicator measures are assumed to be valid in measuring a construct, so that two indicator measures with the same reliability can be interchanged. even though the reliability (cronbach alpha) of a construct will be low if there are only a few indicators, the validity of the construct will not change if one indicator is removed. the data analysis technique uses structural equation modeling (sem) with partial least squares (pls), which is carried out to thoroughly explain the relationship between variables in the research. sem is used not to design a theory but is more aimed at checking and justifying a model. therefore, the main requirement for using sem is to build a hypothesis model consisting of a structural model and a measurement model in the form of a path diagram based on theoretical justification. sem is a collection of statistical techniques that allow testing a series of relationships simultaneously. the parameter estimation method (estimation) in pls is the least squares method (least squares models). the calculation process is carried out in an iterative manner, and the iteration will stop if a convergent condition has been reached. the estimation of parameters includes three things, namely: 1) a weight estimate is used to calculate latent variable data. 2) path estimate, which connects latent variables and estimates the loading between latent variables and indicators. 3) means and location parameters (regression constant values, intercept) for indicators and latent variables. 4) evaluation of goodness of fit, model measured using r2. dependent latent variable with the same interpretation as regression. for a structural model, q2 predictive relevance assesses how well the model and its parameter estimates generate the observed values. 5) hypothesis testing (resampling bootstrapping): hypothesis testing (β, γ, λ) is carried out using the bootstrap resampling model developed by geisser & stone. the test statistic used is the t statistic, or t test. the application of the resampling method allows the application of freely distributed data without requiring assumptions. the criteria for accepting or rejecting the hypothesis in this research include the following conditions: 1) if the t statistical value < t-table with a significance level of 0.05 (one-tailed, then reject ho and accept ha. 2) if the t statistical value> t-table with a significance level of 0.05 (one-tailed), then accept ho and reject ha. the path analysis model for all latent variables in pls consists of three sets of relationships: (1) inner model which specifies the relationship between latent variables (structural model), measured using q-square predictive relavance with the formula q² = 1-(1-ri²) ( 1-rp²), (2) outer model which specifies the relationship between latent variables and their indicators or manifest variables (measurement model), measured by looking at convergent validity and discriminant validity, convergent validity with a loading value of 0.5 to 0.6 is considered sufficient, for the number of indicators of the latent variable it ranges from 3 to 7, while for discriminant validity it is recommended that the ave value be greater than 0.5 and also by looking at (3) the weight relationship where the case value of the latent variable is still estimated. it is safe to assume that latent and indicator variables, also known as manifest variables, are scaled to zero means and unit variance so that location parameters, also known as constant parameters, can be taken out of the model. zulhijriani, et.al. , et.al. ghmj (global health management journal) 2024, vol. 7, no. 1 22 3. results the data obtained were analyzed using univariate, bivariate, and pls analyses. in univariate analysis, researchers looked for respondent data based on their characteristics, namely age, education, and length of service. after obtaining the characteristics of the respondents, they were categorized. researchers will test significance through the chi square test. the majority of respondents were in the 26–30 years age range, namely 35.6% or 16 fsw; the 31–35 years age range was 28.8% or 13 fsw; the 20–25 years age range was 20% or 9 fsw; and the age range of 35–40 years is 15.6% or 7 fsws. based on the level of education of respondents, it shows that the majority of respondents have an elementary school education of 35.6% or 16 fsw, a junior high school education of 31.1% or 14 fsw, no school or not finished elementary school of 22.2% or 10 fsw, and a high school education of 11.1% or 5 fsw. for respondents' work period, in this study, the majority had a work period of 4-6 years, namely 37.8%, or 17 fsw; those who had a work period of > 6 years, amounting to 28.8%, or 13 fsw; those who had worked 1-3 years, 26.7%, or 12 fsw; and those who had worked < 1 year, 6.7%, or 3 fsw. in the stds prevention behavior variable, the respondent's answer range was between 33 and 75, close to or not far from the theoretical range with the highest value (15–75) with an average value of 49.95 and a standard deviation of 9.43. this shows that the respondent's stds prevention behavior was in the category of good. this also shows that some respondents have made efforts to prevent stds. in the motivation variable, the range of respondents' answers is between 28 and 75, close to or not far from the theoretical range with the highest value (15–75) and an average value of 61.20 with a standard deviation of 13.20. this indicates that respondents consider this motivation to be important in terms of behavior. stds prevention. in the peer support variable fsw, the range of respondents' answers was between 20 and 75, close to or not far from the theoretical range at the highest value (15–75), with an average value of 56.2 and a standard deviation of 16.64. this shows that respondents consider the support of their fellow fsw friends important in terms of stds prevention behavior. based on the results of the chi square test with a significance level of α = 5%, the characteristics of respondents to the stds prevention behavior variable showed a p value > 0.005, which means there is no relationship between the respondent's characteristics and the stds prevention behavior variable. meanwhile, the respondents' educational characteristics on the motivation variable show a p value < 0.005, which means there is a relationship between education and motivation, and the age and work experience characteristics show a p value > 0.005, which means there is no relationship between the characteristics of age and work period on the motivation variable. on the educational characteristics of respondents on the variable support from fellow fsw friends, it shows a p value < 0.005, which means there is a relationship between education and support from fellow fsws friends, and on the characteristics of age and work period, it shows a p value > 0.005, which means there is no relationship between the characteristics of age and work period on the variable. support from fellow fsws. the theories presented led to reflective indicators being used in this study. the smart pls 2.0 app was used for the measurement model, which has convergent and discriminant validity. the variable loading factor values have met the requirements, namely the loading factor values are higher than the outer model evaluation results consisting of loading factor values (convergent validity), discriminant validity of cross loading and ave roots, as well as composite reliability values. table 1. outer loading evaluation validity test results test criteria > 0.5 correlation loading factor outer loading (convergent validity) information support 0.733115 valid emotional support 0.822632 valid assessment support 0.798467 valid needs 0.692753 valid objective 0.886756 valid incentive 0.669270 valid efforts to carry out vaccination 0.511453 valid attempts to use condoms 0.816087 valid efforts to select customers 0.838108 valid 23 ghmj (global health management journal) 2024, vol. 7, no. 1 zulhijriani, et.al. the results of the data processing analysis show that the constructs used to form a research model in the confirmatory factor analysis process have met the goodness of fit criteria that have been determined. the probability value in this analysis shows that the value above is significant, namely 0.5. from the results of the data processing above, it can also be seen that each indicator or dimension forming the latent variable shows good results, namely with high loading factor values where each indicator is greater than 0.5. with these results, it can be said that the indicators forming the latent variables of friend support, motivation, and std prevention behavior have shown good results. the results of the significance of the inner model are arranged in the pls output below by evaluating the reflection of the indicator's t-statistic value on the variables. table 2. evaluation of t-statistic significance test test results test criteria > 1.96 indicator t-statistik t-statistic information support 7.195955 significant emotional support 26.503034 significant assessment support 13.116905 significant needs 7.657639 significant objective 34.185022 significant incentive 7.361898 significant efforts to carry out vaccination 3.141801 significant attempts to use condoms 12.450277 significant efforts to select customers 14.971235 significant the table shows that the t-statistic value reflected on the variable is greater than 1.96, thus indicating that the indicator block has a positive and significant effect on reflecting the variable. the evaluation of the r-square value shows that support from fellow fsws friends contributes to motivation (0.292). the r square value states that the support of fellow fsws is able to explain the motivation variable by 29.2%, and 71.8% is influenced by other factors not studied. meanwhile, the variability in support from other fwss friends of 0.211 was able to explain the variability of the stds prevention behavior construct. the test results on the parameter coefficient between support from fellow fsws friends and motivation show that there is a positive influence of 0.540, while the t-statistic value is 6.273 and is significant at α = 5%. the t-statistic value is far above the critical value (1.96). friend support has a positive effect on stds prevention behavior. the test results on the parameter coefficient between friend support and stds prevention behavior show that there is a negative influence of 0.256, while the t-statistic value is 2.392 and is significant at α = 5%. the t-statistic value is above the critical value (1.96). then motivation also has a positive effect on stds prevention behavior. the test results on the parameter coefficient between motivation and stds prevention behavior show that there is a positive influence of 0.267, while the t-statistic value is 2.421 and is significant at α = 5%. the t-statistic value is above the critical value (1.96). table 3. percentage of influence between variables on the std prevention variable in the model source lv correlation direct rho indirect rho total direct % indirect % total % support from fellow female sex workers 0.401 0.256 0.145 0.252 10.26 3.16 13.42 motivation 0.406 0.267 0.267 10.84 0 10.84 total 21.10 3.16 24.26 the table above shows that the support of fellow fsws has a direct and indirect effect on std prevention behavior. the test results on the parameter coefficient between fsw peer support and std prevention behavior show that there is a direct influence of 10.26%, while the indirect influence of fsw peer support on std prevention behavior through motivation is obtained by switching the path coefficient (support from fsw peer friends to motivation) with the path coefficient (motivation for std prevention behavior), thus getting a value of 5.77%. likewise, the motivation variable shows a direct and indirect effect on std prevention behavior. the test results of the parameter coefficient between motivation and std prevention behavior show that there is a direct effect of 10.84%. meanwhile, there is no indirect effect of motivation on std prevention behavior through friend support, regardless of the factors that influence it. therefore, the value of each of the direct effects of these independent latent variables together shows conformity with the r square value, or, in other words, this states that the variables of support from fellow fsw friends and motivation are able to explain the std prevention behavior variable by 56.03%. zulhijriani, et.al. , et.al. ghmj (global health management journal) 2024, vol. 7, no. 1 24 4. discussion to effectively prevent sexually transmitted diseases (stds), it is crucial to consider a multifaceted approach that encompasses various strategies and interventions. research has shown that the prevention of stds is a critical public health priority (keramat et al., 2022). the prevalence of stds, including syphilis, among specific populations such as female sex workers (fsws) and men who have sex with men (msm) underscores the urgent need for targeted interventions and comprehensive sexual health programs (anteneh et al., 2017; gomes et al., 2017; khandu et al., 2021). additionally, the centers for disease control and prevention (cdc) has reported increasing std rates, emphasizing the necessity for effective prevention strategies (wright et al., 2021). evidently, ehealth modes have been explored as a potential avenue for preventing stds, highlighting the importance of leveraging technology and digital platforms for education, awareness, and intervention delivery (keramat et al., 2022). furthermore, the role of peer education has been recognized as a low-cost and beneficial strategy for preventing aids and other stds, particularly among young individuals (yan et al., 2022). moreover, addressing the social determinants and structural factors that contribute to std disparities is crucial. studies have highlighted the impact of sex work laws and stigmas on increasing hiv risks among sex workers, emphasizing the need to address legal and societal barriers to effective prevention (lyons et al., 2020). additionally, the allocation of resources for std prevention has been identified as a critical factor in mitigating the health and economic burden of stds (chesson & owusu-edusei, 2018). furthermore, educational programs based on behavioral theories have shown promise in promoting preventive behaviors related to stds, emphasizing the importance of tailored interventions and health education (shamsolahi et al., 2021). additionally, the impact of covid-19 on the epidemiology of stds has been recognized, highlighting the need for adaptive and responsive prevention strategies in the face of evolving public health challenges (yan et al., 2022). in examining the influence of female sex workers' characteristics with support from fellow fsw friends, motivation, and std prevention behavior, it is essential to consider the multifaceted nature of this topic. the potential references provide valuable insights into the prevalence of stds among female sex workers (fsws), the impact of social support on hiv prevention, and the role of peer engagement in influencing sexual risk behaviors. by synthesizing the relevant references, a comprehensive understanding of the influence of fsw characteristics, social support, motivation, and std prevention behavior can be achieved. shed light on the high prevalence of hiv and other viral infections among fsws, emphasizing the urgent need for effective std prevention strategies (moayedi-nia et al., 2015; shannon et al., 2015). these references underscore the vulnerability of fsws to stds and the critical importance of addressing this public health concern. insights into the impact of social support and peer engagement on hiv prevention and condom use among individuals involved in sex work (kislovskiy et al., 2022). these references highlight the potential influence of support from fellow fsw friends on motivation and std prevention behavior, particularly in the context of condom use and pre-exposure prophylaxis perceptions. furthermore, valuable perspectives on community empowerment, mobile phone use, and the emerging role of technology in promoting condom use and safe sex practices among fsws. these references underscore the multifaceted nature of interventions aimed at promoting std prevention behavior and the potential influence of social networks and technology on motivation and support from fellow fsw friends (kerrigan et al., 2013; navani-vazirani et al., 2014). in addition, the insights into the prevalence of stds and the associated behavioral factors among fsws, highlighting the complex interplay of individual risk behaviors, social support, and std prevention (huan et al., 2013; tayerih et al., 2019). the influence of support from fellow female sex workers on motivation can be comprehensively examined. the reliance of female sex workers on social support from fellow sex workers to reduce exposure to clientinitiated violence (civ) in china (hail-jares et al., 2015). this indicates the potential for a similar pattern of seeking aid from individuals with shared socio-cultural backgrounds. the study examines the impact of emotional and financial support and the size of the network on both intimate partner violence (ipv) and civ among chinese female street-based sex workers (sbsw). the role of support from other female sex workers in improving the ability to negotiate condom use. the study suggests that peer support enhances the power of female sex workers to negotiate condom use, thereby contributing to hiv prevention efforts (blanchard et al., 2013; isac et al., 2015). the association between social support and hiv risk behaviors, such as condom use, among female sex workers in iran. the study highlights the importance of social support in influencing condom use behavior, indicating that support from peers may play a crucial role in promoting safer sexual practices (shushtari et al., 2021). additionally, social support influences peer-delivered hiv prevention interventions among ugandan female sex workers (mcgowan et al., 2022). the study provides insights into the impact of social support on the 25 ghmj (global health management journal) 2024, vol. 7, no. 1 zulhijriani, et.al. effectiveness of peer-delivered interventions, indicating that support from fellow sex workers may enhance the success of hiv prevention initiatives. 5. conclusion from these findings it can be concluded that the stds prevention behavior variable among fsws on nusantara street is influenced by several variables including the variables of support from fellow fsws and motivation. fsws must have stds prevention behavior when carrying out their work to avoid it. therefore, the support of fellow fsws and the motivation that an fsws has a big influence on behavior in efforts to prevent sexually transmitted diseases. conflict of interest the authors declare no conflicts of interest for the results. references anteneh, z. a., agumas, y. a., & tarekegn, m. (2017). sexually transmitted diseases among female commercial sex workers in finote selam town, northwest ethiopia: a community-based cross-sectional study. hiv/aids research and palliative care. https://doi.org/10.2147/hiv.s127319 blanchard, a., mohan, h. l., shahmanesh, m., prakash, r., isac, s., ramesh, b. m., bhattacharjee, p., gurnani, v., moses, s., & blanchard, j. (2013). community mobilization, empowerment and hiv prevention among female sex workers in south india. bmc public health. https://doi.org/10.1186/1471-2458-13-234 chen, y., li, x., zhang, c., hong, y., zhou, y., & liu, w. (2013). alcohol use and sexual risks: use of the alcohol use disorders identification test (audit) among female sex workers in china. health care for women international. https://doi.org/10.1080/07399332.2011.610535 chesson, h. w., & owusu-edusei, k. (2018). relative impact of different strategies for allocating federal funds for syphilis prevention. sexually transmitted diseases. https://doi.org/10.1097/olq.0000000000000805 fararouei, m., barjoei, m. m. d., izadi, r., afsar-kazerooni, p., & mousavi, m. (2023). point and lifetime prevalence of sexually transmitted diseases based on the definitions of the iranian syndrome surveillance system: a hospital-based survey. archives of clinical infectious diseases. https://doi.org/10.5812/archcid-132178 gomes, n. c. r. c., meier, d. a. p., pieri, f. m., alves, e., albanese, s. p. r., lentine, e. c., arcêncio, r. a., & dessunti, e. m. (2017). prevalence and factors associated with syphilis in a reference center. revista da sociedade brasileira de medicina tropical. https://doi.org/10.1590/0037-8682-0102-2016 hail-jares, k., chang, r., choi, s., huang, z., he, n., & huang, z. j. (2015). intimate-partner and client-initiated violence among female street-based sex workers in china: does a support network help? plos one. https://doi.org/10.1371/journal.pone.0139161 halatoko, w. a., landoh, d. e., saka, b., akolly, k., layibo, y., yaya, i., gbetoglo, d., banla, a. k., & pitche, p. (2017). prevalence of syphilis among female sex workers and their clients in togo in 2011. bmc public health. https://doi.org/10.1186/s12889017-4134-x huan, x., hao, c., yan, h., guan, w., xu, x., yang, h., wang, n., zhang, m., tang, w., gu, j., & lau, j. t. f. (2013). high prevalence of hiv and syphilis among men who have sex with men recruited by respondent-driven sampling in a city in eastern china. asia pacific journal of public health. https://doi.org/10.1177/1010539513480230 isac, s., ramesh, b. m., rajaram, s., washington, r., bradley, j., reza-paul, s., beattie, t., alary, m., blanchard, j., & moses, s. (2015). changes in hiv and syphilis prevalence among female sex workers from three serial cross-sectional surveys in karnataka state, south india. bmj open. https://doi.org/10.1136/bmjopen-2014-007106 kakchapati, s., singh, d. r., rawal, b., & lim, a. (2017). sexual risk behaviors, hiv, and syphilis among female sex workers in nepal. hiv/aids research and palliative care. https://doi.org/10.2147/hiv.s123928 kassie, b. a., yenus, h., berhe, r., & kassahun, e. a. (2019). prevalence of sexually transmitted infections and associated factors among the university of gondar students, northwest ethiopia: a cross-sectional study. reproductive health. https://doi.org/10.1186/s12978-019-0815-5 keramat, a., nourimand, f., sayahi, m., bozorgian, l., & hashempour, z. (2022). a systematic review of ehealth modes in preventing sexually transmitted infections. indian journal of sexually transmitted diseases and aids. https://doi.org/10.4103/ijstd.ijstd_55_22 kerrigan, d., fonner, v. a., strömdahl, s., & kennedy, c. e. (2013). community empowerment among female sex workers is an effective hiv prevention intervention: a systematic review of the peer-reviewed evidence from lowand middle-income countries. aids and behavior. https://doi.org/10.1007/s10461-013-0458-4 khandu, l., tobgay, t., kinley, k., choida, n., tashi, t., wangdi, t., tashi, u., dechenmo, d., choden, k., tsheten, t., gyeltshen, t., zangmo, k., choden, s., & mcfarland, w. (2021). characteristics and population size estimation of female sex workers in bhutan. sexually transmitted diseases. https://doi.org/10.1097/olq.0000000000001417 https://doi.org/10.2147/hiv.s127319 https://doi.org/10.1186/1471-2458-13-234 https://doi.org/10.1080/07399332.2011.610535 https://doi.org/10.1097/olq.0000000000000805 https://doi.org/10.5812/archcid-132178 https://doi.org/10.1590/0037-8682-0102-2016 https://doi.org/10.1371/journal.pone.0139161 https://doi.org/10.1186/s12889-017-4134-x https://doi.org/10.1186/s12889-017-4134-x https://doi.org/10.1177/1010539513480230 https://doi.org/10.1136/bmjopen-2014-007106 https://doi.org/10.2147/hiv.s123928 https://doi.org/10.1186/s12978-019-0815-5 https://doi.org/10.4103/ijstd.ijstd_55_22 https://doi.org/10.1007/s10461-013-0458-4 https://doi.org/10.1097/olq.0000000000001417 zulhijriani, et.al. , et.al. ghmj (global health management journal) 2024, vol. 7, no. 1 26 kislovskiy, y., erpenbeck, s., martina, j., judkins, c. p., miller, e. m., & chang, j. (2022). hiv awareness, pre-exposure prophylaxis perceptions and experiences among people who exchange sex: qualitative and community based participatory study. bmc public health. https://doi.org/10.1186/s12889-022-14235-0 li, j., jiang, n., yue, x., & gong, x. (2014). vaginal douching and sexually transmitted infections among female sex workers: a cross-sectional study in three provinces in china. international journal of std & aids. https://doi.org/10.1177/0956462414543937 lyons, c., schwartz, s., murray, s. m., shannon, k., diouf, d., mothopeng, t., kouanda, s., anato, s., kouamé, a., mnisi, z., tamoufé, u., phaswana‐mafuya, n., cham, b., dramé, f. m., djaló, m. a., & baral, s. (2020). the role of sex work laws and stigmas in increasing hiv risks among sex workers. nature communications. https://doi.org/10.1038/s41467-020-145936 mcgowan, m., roche, s., nakitende, a., wachinger, j., nanyiri, e., amongin, j., nakabuye, a., musoke, d. k., mcmahon, s. a., bärnighausen, t., & ortblad, k. f. (2022). understanding how social support influences peer-delivered hiv prevention interventions among ugandan female sex workers: a case study from hiv self-testing. bmc public health. https://doi.org/10.1186/s12889-022-12836-3 moayedi-nia, s., jozani, z. b., djavid, g. e., entekhabi, f., bayanolhagh, s., saatian, m., sedaghat, a., nikzad, r., aminabad, f. j., & mohraz, m. (2015). hiv, hcv, hbv, hsv, and syphilis prevalence among female sex workers in tehran, iran, by using respondent-driven sampling. aids care. https://doi.org/10.1080/09540121.2015.1109582 navani-vazirani, s., solomon, d., gopalakrishnan, heylen, e., srikrishnan, a. k., & vasudevan, c. k. (2014). mobile phones and sex work in south india: the emerging role of mobile phones in condom use by female sex workers in two indian states. culture health & sexuality. https://doi.org/10.1080/13691058.2014.960002 oza, k. k., silverman, j. g., bojórquez, i., strathdee, s. a., & goldenberg, s. m. (2014). examining negative effects of early life experiences on reproductive and sexual health among female sex workers in tijuana, mexico. international journal of gynecology & obstetrics. https://doi.org/10.1016/j.ijgo.2014.08.014 rabiah, m. g., mutahar, r., & sitorus, r. j. (2018). the risk factors analysis occurrence of chlamydia infection to direct female seks workers (dfsw) in indonesia. e3s web of conferences. https://doi.org/10.1051/e3sconf/20186801024 rudi, a., haryanti, y., masan, l., maretalinia, m., & yulianto, a. (2020). the determinants of sexually transmitted infections (stis) among female sex workers (fsws) in indonesia: the literature review. journal of health epidemiology and communicable diseases, 6(1), 15–24. https://doi.org/10.22435/jhecds.v6i1.3108 shamsolahi, f., mirmolaei, s. t., kasaeian, a., ranjbar, h., & modarres, m. (2021). effect of educational program based on planned behavior theory on preventive behaviors of sexually transmitted diseases of married women. hiv & aids review. https://doi.org/10.5114/hivar.2021.111544 shannon, k., strathdee, s. a., goldenberg, s. m., duff, p. a., mwangi, p., rusakova, m., reza-paul, s., lau, j., deering, k., pickles, m., & boily, m. (2015). global epidemiology of hiv among female sex workers: influence of structural determinants. the lancet. https://doi.org/10.1016/s0140-6736(14)60931-4 shushtari, z. j., mirzazadeh, a., seyedalinaghi, s., hosseini, s. a., sajjadi, h., salimi, y., & snijders, t. a. b. (2021). social support associated with condom use behavior among female sex workers in iran. international journal of behavioral medicine. https://doi.org/10.1007/s12529-021-10017-x tayerih, k., jozani, z. b., golchehregan, h., rostam-afshar, z., taj, l., nasab, s. a., foroughi, m., mirzapour, p., mohraz, m., mahmoodi, z., talebi, z., & abdolbaghi, m. h. (2019). woman’s sexual health knowledge and needs assessment in behavioral clinics and shelters in tehran. journal of family & reproductive health. https://doi.org/10.18502/jfrh.v13i1.1610 tura, j. b., ayalew, j., moreda, a. b., lulseged, s., rameto, m. a., debel, l. n., bedassa, b. b., ebo, g. g., wariso, f. b., belihu, w. b., gutema, e. a., habteselassie, a., tollera, g., hailu, m., & abrahim, s. a. (2023). prevalence of syphilis and associated factors among female sex workers in ethiopia: findings from a multilevel analysis of a national bio-behavioral survey. bmc public health. https://doi.org/10.1186/s12889-023-15745-1 wright, s. s., johnson, d. m., bernstein, k. t., & valentine, j. a. (2021). program-level strategies for addressing sexually transmitted disease disparities: overcoming critical determinants that impede sexual health. sexually transmitted diseases. https://doi.org/10.1097/olq.0000000000001426 yan, j., li, y., & zhou, p. (2022). impact of covid-19 pandemic on the epidemiology of stds in china: based on the gm (1,1) model. bmc infectious diseases. https://doi.org/10.1186/s12879-022-07496-y cite this article as: zulhijriani, z., lestari, n.c.a., muriana e.a., marlinawati, i.t., setyanti, d.s.r., & sari, p.y. (2024). the influence of female sex worker fellows support and motivation on sexually transmitted diseases (stds) prevention behaviors in makassar city, indonesia. ghmj (global health management journal), 7(1). 18–26. https://doi.org/10.35898/ghmj-71980 https://doi.org/10.1186/s12889-022-14235-0 https://doi.org/10.1177/0956462414543937 https://doi.org/10.1038/s41467-020-14593-6 https://doi.org/10.1038/s41467-020-14593-6 https://doi.org/10.1186/s12889-022-12836-3 https://doi.org/10.1080/09540121.2015.1109582 https://doi.org/10.1080/13691058.2014.960002 https://doi.org/10.1016/j.ijgo.2014.08.014 https://doi.org/10.1051/e3sconf/20186801024 https://doi.org/10.22435/jhecds.v6i1.3108 https://doi.org/10.5114/hivar.2021.111544 https://doi.org/10.1016/s0140-6736(14)60931-4 https://doi.org/10.1007/s12529-021-10017-x https://doi.org/10.18502/jfrh.v13i1.1610 https://doi.org/10.1186/s12889-023-15745-1 https://doi.org/10.1097/olq.0000000000001426 https://doi.org/10.1186/s12879-022-07496-y https://doi.org/10.35898/ghmj-71980 indonesian scholars’ alliance ghmj (global health management journal) 2025, vol. 8, no. 2s open access research article the 1st cirebon international health symposium: faculty of medicine, universitas swadaya gunung jati update on non-communicable diseases: global perspective on health challenges and innovation correlation between head midline shift ct-scan with glasgow coma scale in head injury patient at waled general hospital, cirebon, indonesia aditia permana* , nunik royyani2 , evan wahyudy ladala3 1. faculty of medicine, universitas swadaya gunung jati, cirebon, indonesia (45132); 2. department of radiology, faculty of medicine, universitas swadaya gunung jati, cirebon, indonesia (45132); 3. department of public health, faculty of medicine, universitas swadaya gunung jati, cirebon, indonesia (45132). *corresponding author’s e-mail: aditiapermana024@gmail.com doi: 10.35898/ghmj-82s1241 abstract background: findings on a head ct scan could use the midline shift (mls) parameter to assess the severity of head injury. midline shift was also known to serve as an indicator that was frequently associated with the glasgow coma scale (gcs) in head injury patients. a greater degree of midline shift (> 5 mm) indicated a severe head injury that was significantly associated with a lower glasgow coma scale score. the measurement could be performed quickly, although most of the findings that appeared when patients first arrived at the emergency department were generally mild. aims: this study aims to determine the correlation between midline shift on ct-scan head and glasgow coma scale in head injury patients at waled general hospital. methods: this research is analytical observational with a cross-sectional design. the total sampling technique took samples from the medical records of 38 patients out of 81 samples that had been excluded. the study was conducted at waled general hospital in june-july 2024 and analyzed using the spearman correlation test. results: the results showed that most samples did not show a midline shift with 30 patients (78.9%) and had a gcs score of 13-15 with 22 patients (57.9%). a significant relationship exists between the midline shift on head ct-scan with the gcs (p = 0.001, r = -0.770) in head injury patients at waled general hospital. conclusion: most samples did not show a midline shift picture and had a gcs score of 13-15. there was a significant relationship between the midline shift on head ct scans and the gcs in head injury patients at waled general hospital. these findings had important implications in clinical practice, particularly in determining triage priorities, predicting the need for surgical intervention, and monitoring patients intensively. keywords: midline shift; glasgow coma scale; head injury; traumatic brain injury. received: 22 june 2025 reviewed: 14 july 2025 revised: 25 july 2025 accepted: 15 august 2025. © 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:aditiapermana024@gmail.com https://doi.org/10.35898/ghmj-82s1241 https://orcid.org/0009-0009-4482-6182 https://orcid.org/0009-0001-5286-9133 https://orcid.org/0009-0006-5205-3923 permana, et. al. ghmj (global health management journal) 2025, vol. 8, no. 2s 260 1. introduction head injury refers to damage occurring to the head that is not congenital or degenerative but is caused by external mechanical forces, such as impact or physical assault, either directly or indirectly. these injuries can impair consciousness and lead to cognitive, physical, and psychosocial dysfunction. according to the centers for disease control and prevention (cdc), the most common cause of head injury is falling (28%), followed by motor vehicle accidents (20%), impact from a hard object (19%), assault by another person (11%), and suicide attempts (1%) (cdc, 2023). according to the 2018 basic health research (riskesdas) data, the incidence of head injuries in indonesia due to traffic accidents increased by 11.9%, with the highest number caused by motorcycle accidents (72.7%), particularly among young adults aged 15–24 years. in west java, the incidence of head injuries was 12.3%, or 1,986 out of 16,150 cases. in cirebon regency, the number of traffic accidents reached 835 in 2022 (kementrian kesehatan republik indonesia, 2018). the classification of head injuries to assess symptoms and clinical signs is based on the severity of the injury, measured by the patient's level of consciousness using the glasgow coma score (gcs). initial assessment of patients with head injuries is crucial, and the gcs is one of the most frequently used methods due to its simplicity and speed. monitoring the patient's consciousness is expected to aid in achieving better outcomes (syarif et al., 2021). for head injuries, a ct scan is an accurate diagnostic tool for determining the location of lesions and can be performed quickly, although most initial findings in patients admitted to the emergency room are minor (rogan, 2021). the ct scan findings can be evaluated using the midline shift (mls) parameter to assess the severity of the head injury. midline shift is also known to be an indicator of increased intracranial pressure, brain edema, and brainstem injury, which are strongly correlated with the gcs in patients with head injuries.(abdelaziz, 2021) brain midline shift is a crucial diagnostic marker for evaluating the severity of brain compression due to various pathologies. in intracranial pathology examinations, the brain midline shift is an essential diagnostic feature for assessing the extent of brain compression caused by different conditions. midline shift is significant in predicting a patient's likelihood of survival and is used to measure brain symmetry changes, making it an essential indicator of the severity of the condition (qasim, 2021). the study conducted (chaurasia a k. gaur r. et.al, 2021) found that out of a total of 150 head injury patients, 115 showed no midline shift, while 35 showed the presence of a midline shift. the results of the study indicated that patients with severe head injuries (gcs 3–8) had higher mortality and morbidity rates, while those with moderate head injuries (gcs 9–13) were associated with better prognoses and lower mortality. a greater degree of midline shift (> 5 mm) indicated a severe head injury that was significantly associated with high mortality. although various previous studies had investigated the relationship between midline shift on head ct scans and glasgow coma scale (gcs) scores as indicators of head injury severity, the results were not entirely consistent. some studies, such as those conducted by (abdelaziz, i., & aljondi, 2021) and (sah et al, 2014), showed a strong and significant correlation between midline shift and decreased patient consciousness. in contrast, other studies, such as the one reported by (khambhati u, shah r, solanki v, matadar h, 2020), found a weak or insignificant correlation, particularly in cases of diffuse brain injury that did not cause a displacement of the brain’s midline structures. in addition, the study by (tantowijaya b, 2025) showed a significant correlation between the types of intracranial bleeding lesions and the level of consciousness, as assessed by the glasgow coma scale (gcs). these findings reinforced the importance of early radiological evaluation, not only in identifying the type of lesion but also in estimating the clinical severity of head injury patients. that was the reason the researchers became interested in conducting further studies on the relevant population regarding the correlation between midline shift on head ct scans and the glasgow coma scale in head injury patients at waled general hospital, cirebon, indonesia. permana, et. al. ghmj (global health management journal) 2025, vol. 8, no. 2s 261 2. methods study design/research procedures this study employs an observational analytic research method with a cross-sectional approach to assess the correlation between ct scan midline shift findings and the glasgow coma scale in head injury patients at waled general hospital in 2022. this study has received ethical approval from the faculty of medicine ethics committee, universitas swadaya gunung jati, and was subsequently approved by the national unity and political agency (kesbangpol) of cirebon regency. population and samples the population of this study consists of head injury patients who underwent head ct scans at waled general hospital, cirebon regency, in 2022. the sample was selected using inclusion criteria, consisting of patients aged 18 years or older who were diagnosed with a head injury at waled general hospital in 2022, head injury patients who underwent ct scan examinations, and those with documented glasgow coma scale (gcs) assessments. the exclusion criteria include patients under 18 years old and those with a history of neurological deficits not caused by trauma, such as non-hemorrhagic stroke, hemorrhagic stroke, and brain tumors. the total number of samples obtained using the total sampling method from the overall data in 2022 was 81 samples, and after applying the exclusion criteria, it was reduced to 38 samples. measurements radiological data collection was based on the results of head ct scans attached to medical records or data from the radiology department, which had been interpreted by a radiology specialist, indicating the presence or absence of a midline shift. meanwhile, the glasgow coma scale (gcs) was obtained from the examination data of head injury patients at waled general hospital in 2022. statistical techniques data was collected through the medical records of head injury patients at waled general hospital in 2022. the radiological data were based on the results of the head ct scan examinations, as documented in the medical records or from the radiology department and interpreted by a radiologist. these results indicate the presence or absence of a midline shift. the data in this study were analyzed using computer-based statistical software. data analysis was conducted through univariate and bivariate analysis, using spss version 26. data analysis the analysis presented involves the spearman correlation test using statistical software. the data analysis includes univariate and bivariate tests. univariate analysis was performed to describe the frequency distribution of the respondents, the independent variable (midline shift on head ct scans of patients with head injuries), and the dependent variable (glasgow coma scale). bivariate analysis was performed to assess the relationship between the independent and dependent variables. in this bivariate analysis, the spearman correlation test was used, as the operational definitions of both the independent and dependent variables were categorical data, the data were ordinal in scale or not normally distributed and the analysis was conducted using a computer program. ethical clearance this research was conducted in accordance with the research procedures, after obtaining a research permit granted following the thesis proposal examination and ethical review by the health research ethics committee of waled regional general hospital, with the number 000.9.2/053/kepk/2024. permana, et. al. ghmj (global health management journal) 2025, vol. 8, no. 2s 262 3. results the data in this study consists of secondary data obtained from medical records and ct scan results of head injury patients at waled general hospital in 2022, using a cross-sectional approach. a total of 81 samples were collected through the total sampling method, and after applying exclusion criteria, the sample size was reduced to 38. the sample consists of head injury patients aged over 18 years who underwent a ct scan at waled general hospital in 2022. table 1. demographic, clinical, and radiological characteristics of head injury patients at waled general hospital in 2022 age n % adults (19-59 years old ) 27 71.1 elderly (> 59 years old) 11 28.9 gender male 24 63.2 female 14 36.8 severity stages mild head injury 22 57.9 moderate head injury 9 23.7 severe head injury 7 18.4 diagnosis edh (epidural hematoma) 10 26.3 sdh (subdural hematoma) 14 36.8 sah (subarachnoid hemorrhage) 5 13.2 contusio cerebri 3 7.9 edema cerebri 4 10.5 ich (intracerebral hemorrhage) 2 5.3 midline shift findings yes 8 21.1 no 30 78.9 gcs gcs 3-8 7 18.4 gcs 9-12 9 23.7 gcs 13-15 22 57.9 total 38 100 a total of 38 head injury patients were included in the study after applying the inclusion and exclusion criteria. most participants (71.1%) were adults aged 19–59 years, while the remaining 28.9% were elderly (>59 years), indicating that the incidence of head trauma was higher among the productive age group. male patients dominated the sample with 63.2%, which was consistent with global patterns showing that men were more frequently involved in high-risk activities leading to trauma. regarding the severity of head injury as assessed by the glasgow coma scale (gcs), the majority of patients presented with mild head injury (gcs 13–15), accounting for 57.9%, followed by moderate (23.7%) and severe cases (18.4%). this was in line with existing data suggesting that a large proportion of head injury cases in emergency rooms were classified as mild. in terms of diagnosis, the most common lesion found was subdural hematoma (36.8%), followed by epidural hematoma (26.3%) and subarachnoid hemorrhage (13.2%). the remaining cases included cerebral contusions, cerebral edema, and intracerebral hemorrhage. this suggested a diverse spectrum of intracranial pathologies within the cohort, requiring individualized management approaches. permana, et. al. ghmj (global health management journal) 2025, vol. 8, no. 2s 263 when midline shift was evaluated as a radiological indicator of intracranial pressure and mass effect, only 21.1% of patients exhibited this finding, while the vast majority (78.9%) did not. this correlated with the predominance of mild cases in the sample. conversely, severe gcs scores (3–8) were mostly observed in patients with midline shift (87.5%), highlighting the strong inverse relationship between anatomical displacement and the level of consciousness. these distributions established a clear clinical picture: head injuries were more prevalent in adults, particularly males; most cases were mild in severity and did not involve midline shift; however, the presence of midline shift strongly corresponded to lower gcs scores and likely indicated a greater need for urgent intervention. bivariate analysis bivariate analysis was performed to evaluate the relationship between the independent variable and the dependent variable, as well as the strength and direction of the relationship. in this study, bivariate analysis was conducted using the spearman correlation test. table 2. correlation analysis between midline shift on head ct scan and glasgow coma scale (gcs) glasgow coma scale (gcs) total p r gcs 3-8 gcs 9-12 gcs 13-15 n % n % n % n % midline shift yes 7 87.5 1 12.5 0 0 8 21.1 0.000* -0.770 no 0 0 8 26.7 22 73.3 30 78.9 total 7 18.4 9 23.7 22 57.9 38 100 notes: n = frequency, % = percentage * = spearman correlation test based on the bivariate analysis using the spearman correlation test, a correlation coefficient of 0.770 was obtained, with a p-value <0.001, indicating a strong correlation between the two variables. these results also suggest that patients with midline shifts tend to have lower gcs scores. as shown in table 7, among patients with gcs scores of 3-8, 7 (87.5%) exhibited midline shift, while none (0.0%) without midline shift were in this gcs range. for patients with gcs scores of 9-12, 1 patient (12.5%) had a midline shift, while 8 patients (26.7%) did not. lastly, none of the patients with gcs scores of 13-15 showed midline shift, while the remaining 22 patients (73.3%) without midline shift were in this gcs range. to assess the precision of the correlation coefficient, a 95% confidence interval (ci) was calculated. the results showed that the 95% confidence interval for the correlation coefficient ranged from -0.874 to -0.597. figure 1. distribution of midline shift by gcs category permana, et. al. ghmj (global health management journal) 2025, vol. 8, no. 2s 264 4. discussion based on the analysis results on the midline shift ct scan variable in head injury patients, it was found that most of the samples did not exhibit midline shift, accounting for 78.9%. head ct scan results showing midline shift were observed in 21.1% of head injury patients. similar results were obtained in a study conducted by palekar et al., where out of 83 patients with favorable outcomes, a midline shift >5 mm on ct scan was found in only 11 cases (13.25%), and in the poor outcome group of 25 patients, 7 (28%) experienced a midline shift >5 mm, while the remaining 52 did not have a midline shift (palekar et al., 2021). from the analysis of the glasgow coma scale (gcs) variable, it was found that most patients had a gcs score of 13-15, accounting for 57.9%, followed by patients with a gcs of 9-12 at 23.7%, and those with a gcs of 3-8 at 18.4%. these findings are consistent with a study by sah sk et al., where 54% of head injury cases were mild (gcs 13-15), 28% were moderate (gcs 9-12), and 18% were severe (gcs 3-8) (sah et al., 2014). the difference could be attributed to the fact that the most common clinical definition of mild head injury, gcs 1315, is used by over 60% of neurotrauma centers worldwide, while earlier studies used gcs 14-15 or gcs 15 alone as the definition for mild head injury. this could be because patients with a gcs of 13 may have more severe injuries compared to other mild traumatic injury groups (gcs 13-15) (magnusson et al., 2020). the analysis of the midline shift variable with the glasgow coma scale (gcs) showed a significant correlation with a correlation coefficient (r) of -0.770 and a spearman rho significance value of p < 0.001. the correlation value of -0.770 indicates a strong negative correlation. therefore, the hypothesis is accepted, as a significant correlation exists between midline shift on head ct scan and gcs, with a p-value < 0.001. the negative correlation implies that patients with midline shift tend to have lower gcs scores. this finding aligns with the study by sah sk et al., which demonstrated that mixed lesions and midline shift, regardless of lesion background, were significantly associated with lower gcs scores. the more severe the head injury, the lower the gcs score, with a p-value < 0.001. the average gcs for multiple lesions and cases with midline shift (mean ± sd 6.22 ± 1.202) was also statistically significant (p-value < 0.001). analyzing lesion types concerning gcs scores, it was found that (a) multiple lesions had lower gcs scores than single lesions and (b) multiple lesions with midline shift had lower gcs scores than single lesions or multiple lesions without midline shift (sah et al., 2014). in the context of triage in the emergency department, information regarding the presence of a midline shift from head ct scan results was used as a radiological indicator to support the prioritization of patient management. patients with a midline shift and low gcs were at risk of rapid neurological deterioration and therefore required intensive monitoring, early stabilization, and prompt surgical evaluation. thus, the combination of gcs scores and radiological findings such as midline shift enhanced the accuracy of risk stratification and triage decision-making (abdelaziz, i., & aljondi, 2021). additionally, this correlation was also used as a supporting tool to estimate the need for decompressive surgical interventions, such as craniotomy or craniectomy. several studies showed that a midline shift greater than 5 mm was significantly associated with increased intracranial pressure and the presence of an intracranial mass that could lead to brain herniation if not promptly managed(palekar, s. g., jaiswal, m., patil, m., & malpathak, 2021). a low gcs score, when combined with a midline shift, served as a more accurate indicator in determining the urgency of surgical intervention. thus, the integration of clinical findings (gcs) and radiological findings (midline shift) held strategic value in the evidence-based clinical decision-making process, both during the initial diagnostic phase and in planning definitive therapy. this was also in line with recommendations from modern neurotrauma practice guidelines, which emphasized the importance of multimodal evaluation in the management of traumatic brain injuries. although there was a strong negative correlation between midline shift and gcs, some patients in this study exhibited low gcs scores despite the absence of a midline shift. this suggested the presence of alternative mechanisms or confounding factors that could affect the level of consciousness. one possible explanation was the presence of diffuse brain injuries such as diffuse axonal injury (dai), which did not always cause a shift in midline structures but could lead to significant impairment of consciousness. in addition, global cerebral edema, diffuse subarachnoid hemorrhage, or cerebral hypoxia could also result in decreased gcs without producing a permana, et. al. ghmj (global health management journal) 2025, vol. 8, no. 2s 265 detectable midline shift on ct scans(abdelaziz, i., & aljondi, 2021). the study by (khambhati u, shah r, solanki v, matadar h, 2020) found that not all patients with low gcs exhibited a midline shift, and that some patients with mild midline shift still maintained good consciousness. the study concluded that midline shift alone was not sufficient to predict the level of consciousness without considering other factors such as lesion size, location, and brainstem involvement. these differing results could have been due to variations in study design, gcs measurement methods, timing of radiological assessments, or heterogeneity of the patient population. therefore, although the findings in this study supported a relationship between midline shift and gcs, interpretation needed to be made with caution, taking into account that other parameters also played a role in determining the neurological status of the patient. the results of this study supported the findings of (tantowijaya b, 2025), who, in his study at gunung jati regional hospital, cirebon, reported a correlation between the types of brain hemorrhage and gcs scores in head injury patients. in his study, subdural hematomas and intracerebral hemorrhages were more closely associated with significantly reduced levels of consciousness compared to other types of bleeding. these findings were consistent with ours, in which patients with certain lesions, especially those causing midline shift, had lower gcs scores, indicating a heavier lesion burden and higher clinical risk. the limitations of this study include insufficient investigation into the degree of midline shift affecting gcs. many data points were excluded, resulting in a limited sample size. the study was delayed due to the completion of research administration, which caused a delay in data collection. the research location was also quite far, which shortened the data collection period due to limited working hours. inter observer reliability assessment was not conducted in the interpretation of head ct scan results. all radiological interpretations were based on a single report without independent verification by another radiologist, allowing for potential subjectivity in the assessment of midline shift. this study did not involve prospective validation, so the relationship found between midline shift and glasgow coma scale (gcs) scores was merely correlational and based on retrospective data. this design limited the ability to draw causal conclusions and to systematically control for confounding factors. there was also a possibility of selection bias, as several patients were excluded from the analysis due to not meeting the inclusion criteria or having incomplete data. this may have led to limited sample representativeness and reduced the generalizability of the findings to the broader population of patients with head injury. the authors recommended that healthcare facilities adopt an integrative approach combining radiological data with clinical assessment, such as incorporating both gcs scores and midline shift findings into initial assessment algorithms for head injury patients. additionally, the implementation of emergency radiology training including midline shift evaluation as a core clinical competency in emergency units was suggested. 5. conclusion the conclusion drawn is that an increase in the degree of midline shift on head ct scans in patients with mass lesions following head trauma is significantly associated with the severity of head injury (gcs = 3-12) and ultimately results in poorer clinical outcomes. further correlation between ct scan findings and gcs is necessary to predict the severity of head injury and patient outcomes more accurately, rather than treating the two parameters as separate factors. clinically, these findings had important implications for triage practices and the initial management of head injury patients, particularly in the emergency department. early identification of midline shift through head ct scans could be used as an additional indicator to expedite decision-making, such as initiating intensive monitoring, referring to neurotrauma facilities, or considering decompressive surgical intervention. therefore, these results supported the development of evidence-based clinical protocols for managing head injury patients. permana, et. al. ghmj (global health management journal) 2025, vol. 8, no. 2s 266 recommendation for future researchers, it was recommended that further studies be conducted to investigate the degree of midline shift and its relationship with the glasgow coma scale (gcs) or other relevant variables, such as radiographic findings on head ct scans, the number of lesions, or the need for surgical intervention. the timing of the study was also suggested to be reconsidered to enable more effective data collection. the public was encouraged to be more aware and vigilant about the dangers of head injuries, their association with decreased levels of consciousness, and the long‑term effects that might occur. educational institutions were encouraged to use the findings as additional teaching material for medical education, focusing on the characteristics of midline shift on head ct scans and the assessment of the glasgow coma scale (gcs) in head injury patients. this was intended to serve as a learning resource for medical students and other healthcare professionals to help guide clinical decision‑making in patient care. conflict of interest the authors are grateful to the universitas swadaya gunung jati 2025 internal research fund for funding this study. references abdelaziz, i., & aljondi, r. (2021). detection of midline shift from ct scans to predict outcome in patients with head injuries. international journal of biomedicine, 11(1), 18-23. https://doi.org/10.21103/article11(1)_oa3 chaurasia a k. gaur r. et.al. (2021). a study of correlation of degree of midline shift on computed tomography scan and glasgow coma scale in patients of acute traumatic head injury. international surgery journal. https://doi.org/10.18203/23492902.isj20213998 cdc (2023). traumatic brain injury and concussion. internet: https://www.cdc.gov/traumatic-brain-injury/index.html khambhati u, shah r, solanki v, matadar h, daruwala f. (2020). a cross-sectional, observational study. int j radiol diagn imaging kementrian kesehatan republik indonesia. (2018). hasil utama riskesdas 2018. magnusson, b. m., isaksson, e., & koskinen, l. o. d. (2022). a prospective observational cohort study of traumatic brain injury in the northern region of sweden. brain injury, 36(2), 191-198. https://doi.org/10.1080/02699052.2022.2034952 palekar, s. g., jaiswal, m., patil, m., & malpathak, v. (2021). outcome prediction in patients of traumatic brain injury based on midline shift on ct scan of brain. indian journal of neurosurgery, 10(03), 210-215. https://doi.org/10.1055/s-00401716990 qasim, a., rehman, l., javeed, f., gohar, r., & qadir, r. (2022). midline shift as a predictor of outcome in head trauma patients managed conservatively. pakistan journal of neurological surgery, 26(4), 597-604. https://doi.org/10.36552/pjns.v26i4.807 rogan, a., patel, v., birdling, j., lockett, j., simmonds, h., mcquade, d., & larsen, p. (2022). acute traumatic brain injury and the use of head computed tomography scans in the emergency department. trauma, 24(4), 327-336. https://doi.org/10.1177/14604086211023646 sah, s. k., subedi, n. d., poudel, k., & mallik, m. (2014). correlation of computed tomography findings with glasgow coma scale in patients with acute traumatic brain injury. journal of college of medical sciences-nepal, 10(2), 4-9. https://doi.org/10.3126/jcmsn.v10i2.12947 syarif, h., & nadila, n. (2021). glassgow coma scale and outcome on head injury patients in emergency room at general hospital of pemerintah aceh. jurnal keperawatan respati yogyakarta, 8(1), 38-42. https://doi.org/10.35842/jkry.v8i1.587 tantowijaya b. (2025). correlation between types of bleeding brain lesion with glasgow coma scale in head injury patients at gunung jati regional hospital, cirebon, indonesia. global medical and health journal. https://doi.org/10.35898/ghmj81s1166 cite this article as: permana, a., royyani, n., & ladala, e. w. (2025). correlation between head midline shift ct-scan with glasgow coma scale in head injury patient at waled general hospital, cirebon, indonesia. ghmj (global health management journal), 8(2s), 259–266. https://doi.org/10.35898/ghmj-82s1241 https://doi.org/10.21103/article11(1)_oa3 https://doi.org/10.18203/2349-2902.isj20213998 https://doi.org/10.18203/2349-2902.isj20213998 https://www.cdc.gov/traumatic-brain-injury/index.html https://doi.org/10.1080/02699052.2022.2034952 https://doi.org/10.1055/s-0040-1716990 https://doi.org/10.1055/s-0040-1716990 https://doi.org/10.36552/pjns.v26i4.807 https://doi.org/10.1177/14604086211023646 https://doi.org/10.3126/jcmsn.v10i2.12947 https://doi.org/10.35842/jkry.v8i1.587 https://doi.org/10.35898/ghmj-81s1166 https://doi.org/10.35898/ghmj-81s1166 https://doi.org/10.35898/ghmj-82s1241 references ghmj (global health management journal) 2024, vol. 7, no. 1 indonesian scholars’ alliance open access editorial how to engage children and families as part of multidisciplinary health promotion teams andrew john macnab * department of pediatrics, university of british columbia, canada. * the stellenbosch institute for advanced study (stias), wallenberg research center at stellenbosch university south africa. * editor in chief, global health management journal, yayasan aliansi cendekiawan indonesia thailand, indonesian scholars' alliance (inschool). *corresponding author’s email: ajmacnab@gmail.com doi: 10.35898/ghmj-71981 given as a keynote speech at the 2nd polkesraya international conference, health polytechnic palangka raya, indonesia, october 31th, 2023. abstract health promotion is the process we employ as health care providers and policy makers to enable people to increase control over, and to improve, their health. effective health promotion includes several major components, and while policies must be made to promote health, much can be also done by small multidisciplinary teams working with local communities. importantly such teams are most effective where they include members of the target audience for the health promotion initiative. consequently where the health of mothers and children is the priority, to engage the target audience effectively, parents and family members including children should contribute as members of the team. worldwide, education of girls is known to generate multiple health and economic benefits; measures to counter misinformation and use of education programs such as the who health promotion model to provide knowledge accompanied by practical health-related skills are of proven value. effective teams incorporate cultural traits and gender equity into strategies that build resilience and self-regulatory efficacy over social determinants of health. strategies that help individuals and communities to advance towards the un sustainable development goals have obvious merit. health knowledge can be conveyed readily, for example in relation to childhood vaccination, but achieving changes in values, attitudes, and health habits requires effort and innovation by multidisciplinary teams that work synergistically to promote health in an innovative and inclusive manner. the more this is done, the greater the beneficial changes we are likely to achieve. keywords: education for girls; health literacy; immunization; measles; misinformation; who health promoting schools. © 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:ajmacnab@gmail.com https://doi.org/10.35898/ghmj-71981 https://conference.polkesraya.ac.id/ https://conference.polkesraya.ac.id/ macnab, a.j. ghmj (global health management journal) 2024, vol. 7, no. 1 2 1. introduction the united nations human rights commission constitution states that “the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief economic or social condition.” (un human rights commission, 2008). a important way to achieve this is to engage the whole community in efforts to promote health, which means including families, and this means parents, grandparents and children. the reason for this is simple, and best explained by the saying, "the whole is greater than the sum of its parts." this is another way of saying that the synergy that comes from combining the skills and experience of multiple members of the health care team benefits everyone, and makes it more likely that any health issue can be promoted more effectively. so, engaging children and families as part of an interprofessional health care team is relevant and important, and this paper will explains some of the ways their inclusion can be achieved. as is so often the case, the world health organization (who) provides both guidance on why health promotion is important and specific examples that we can follow to achieve it. who statements underline that: • health promotion enables people to improve their health; • the prevention of illness and injury is of central importance; • targeting young people to promote healthy behaviours is more effective, and often easier, than efforts to change unhealthy behaviours already established in adults; • inter-professional collaboration to improve child health based on synergy requires that we involve young people, parents and families in a multidisciplinary team approach. the who ottawa charter for health promotion contains valuable definitions and templates for effective strategies. the charter defines health promotion as “the process of enabling people to increase control over, and to improve, their health”. to reach a state of complete physical, mental and social well-being, an individual or group must be able to identify and to realize aspirations, to satisfy needs, and to change or cope with the environment. health is therefore, seen as a resource for everyday life, not the objective of living. health is a positive concept emphasizing social and personal resources, as well as physical capacities. therefore, health promotion is not just the responsibility of the health sector, but goes beyond healthy life-styles to well-being” (who, 1986. the ottawa charter). important areas for synergy and interdisciplinary team action identified include: • building healthy public policy; • strengthening community action; • creating supportive environments; • reorienting health services, and; • developing personal skills. 2. multidisciplinary teams childhood vaccination is an example of an important health care delivery challenge where we can improve the effectiveness of our health promotion programs through the synergy that comes from working as multidisciplinary teams. as an important reminder, i first want to review the negative impact that the covid pandemic had on child immunization. unicef estimates that worldwide 67 million children missed some or all of their basic recommended vaccinations during the pandemic, and that cases of measles doubled and the incidence of polio greatly increased. an additional and very significant worry is that over the course of the pandemic up to 44% of parents came to believe that their children do not need vaccination. two important learning points from these facts are: 1) education and promotion about important things like vaccination against childhood illnesses cannot be ‘silenced’ in the way that developed during covid, or only happen periodically through campaigns created when there seems to be a crisis. promotion about issues of fundamental importance to a population’s health such as immunization needs to be ‘always on the agenda’ with efforts being made to keep the issue in the mind of the public. 3 ghmj (global health management journal) 2024, vol. 7, no. 1 macnab, a.j. 2) engagement and education of parents on the importance of immunization need our best efforts. and involving parents in any team working to promote immunization has relevance and benefit. we can learn from them how best to present information and come to better understand the concerns that underlie parent’s reluctance to have their children immunized. the global alliance for vaccines and immunization (gavi) aims to extend the full benefit of vaccination against vaccine-preventable diseases to all individuals (who, 2014); the organization’s emphasis is that immunization is one of the most cost-effective ways of improving living standards, health and economic prospects, and this can be a persuasive argument to use in our efforts to build health public policy, reorient health services and strengthen community action (bustreo, okwo-bele & kamara 2015). a summary of gavi’s ‘virtuous cycle’ concept on the benefits of immunization contains useful facts that our teams can use to strengthen vaccine and immunization campaigns (gandhi, 2015). the framework can be summarized as: where a child is vaccinated from birth to 2 years : • this child is likely to be healthier and live longer • she/he will have fewer and less serious illnesses • this lowers care costs for the family and health care system • the family has more money available to spend or save • their child attends school more leading to better academic outcomes • the family’s economic outlook is strengthened across a community where the children are immunized : • the birth rate drops and the health of mothers improves • the whole community becomes more economically stable and productive 3. how teams engage the target population to engage the target population and improve vaccination uptake, effective programs require teams that are multidisciplinary. this means we must include policy makers, health care workers, educators, parents and youth – remember, today’s youth are the parents of tomorrow. it is also helpful when all members of the team understand the value of each of them becoming an advocate for immunization in their own way. there are two learning points in engaging the target population, as below: 1) as health care workers we must reach out and engage with and involve families 2) routine healthcare must include advocates able to educate across society as a reminder for the team on how to effectively engage any target audience and involve them in the health promotion process consider the mnemonic medical explained below: m = meet: preferably ‘face to face’ (but on-line if necessary) follow cultural rules; e = engage; d = discuss: i = implement: a plan that your team agrees on and can deliver; c = collect data: learn and share ‘what works and why’ in your initiative; a = analyze: evaluate and share ‘feedback with your target audience; l = listen: and listen some more to those want to engage. working in multidisciplinary teams we can also use lessons learned from working to overcome vaccine hesitancy during the covid-19 pandemic; innovative strategies to develop a ‘community empowerment approach’ were developed based on principles outlined by who and the lancet commission (macnab, 2023). these are: • adopting ‘people-centered strategies’ • creating ‘innovative education’ • developing ‘novel and improved tools’ • training personnel to ‘respond to local needs’ • using ‘non-traditional’ avenues and outlets macnab, a.j. ghmj (global health management journal) 2024, vol. 7, no. 1 4 4. countering misinformation to be effective, our communication and promotion of health issues needs reliable facts and has to deal with misinformation. a patient’s confidence is based on her/his life experience and prior education on the subject. unfortunately information that many now use to ‘self-educate’ on the internet is incomplete, misleading, or incorrect, and at worse deliberately biased to present a negative point of view. in the context of immunization this is especially problematic; as an example, many parents lost their children during the recent measles epidemic in the philippines as they chose to believe posted information saying that vaccination was either unnecessary or in some cases actually harmful. we all need to be trained to recognize and counter misinformation and the mistrust of immunization that goes with it, and people need to understand that in the context of vaccination, such misinformation is as dangerous as the disease itself (larson, 2018). misinformation on the internet is a serious threat to public health as it is spreads so easily and so many believe completely in what they read. useful strategies our teams can use to counter misinformation include: • reminding everyone that not everything we read online is true or reliable; • learning how to evaluate if facts come from a legitimate source and have a scientific basis; • sharing with each other information of proven validity e.g. from the who, and; • setting a good example by always asking someone we trust to explain facts that we do not understand. 5. challenges and opportunities challenges and opportunities around how we engage parents and families to promote health in children often come from attitudes and perceptions that exist in our culture. a particular challenge is the early marriage of girls and other forms of gender inequality. opportunities in this context include: • empowering women, and; • promoting education for girls. in cultures that empower their women there are many social, health and economic benefits (macnab, 2020). empowered women are better able to provide for their own wellbeing, their health and that of their children is improved and they contribute in a positive way to the economy of their family and community. any measures that reduce child marriage benefit the individual girl and the community as these children are more likely to be able to stay in school to complete their studies which contributes to their future health and prosperity. promoting the education of girls has been identified as probably the best investment that can be made by any country (sippel et al., 2011). girls, and the women they become, derive multiple health benefits from being educated. one example is that motivating girls to stay in school longer results in delayed child-bearing and thus better obstetric and child health outcomes. in this way, educated women come to have smaller families, entire societies benefit from a decline in birth rates, and the children of educated mothers also have significant health advantages. infant survival rates are improved; a mother who can read and write is more likely to have her children immunized than one who is uneducated, and understand the importance of clean water for the prevention of diarrhoeal diseases. and not only does a child of an educated mother have fewer siblings and tend to be healthier, she/he also has a greater likelihood of attending school, and will have more active maternal encouragement to do so (macnab, 2020). what about cultures where there is gender inequity and male dominance that impacts the ability of women to make decisions that have an impact on their health? the situation faced by women in refugee camps in afghanistan is one example. mother and child mortality rates in these camps are among the highest in the world. women want to use contraception to improve their health and that of the children they bear, but all major decisions are made by men, including ones related to a intimate aspects of a woman’s health. in afghanistan many girls marry as teenagers, and most pregnancies are unplanned and typically occur close together, with inter-pregnancy intervals of < 6 months (bartlett et al., 2005). 5 ghmj (global health management journal) 2024, vol. 7, no. 1 macnab, a.j. such short birth intervals increase maternal risk for chronic anemia, hypertension and pre-eclampsia (tsui, mcdonald-mosley, & burke), and are linked to elevated risks of neonatal and infant mortality, and child malnutrition in all low and middle income countries (rutstein, 2005). recognizing this cultural norm in afghanistan, we engaged men as our target audience in a health promotion campaign designed in response to the call from women for ways to improve their access to contraception. men in the camps were invited to men’s groups where one of the activities offered was a discussion group where the objective was to establish dialogue around contraception where the practicalities, and social, health and financial benefits were explained, and any religious concerns voiced could be discussed (aria et al, 2019). our team included leaders from the camps, midwives, educators, a doctor and religious leaders. the team facilitated discussion in a culturally appropriate way in a place where the men present could feel safe (as the groups were strictly for men only). this format allowed free discussions which enable the men to learn facts, gain understanding on the benefits of contraception, and understand its acceptance by the muslim faith through interaction with the imams on the team. the goals of this gender specific intervention were to: 1. inform and empower men to change their attitudes and behaviour around contraception; 2. promote informed spousal dialogue about use of contraception; 3. enable women to access services providing contraception and adopt regular use. the results were: • 664 (74%) of the 900 men enrolled participated in group activities; • 93% the women not using contraception at baseline reported they were able to begin regular use of family planning products; • 264 men (29%) sought family planning products for the first time; • evaluation indicated that most men attending the groups reported acquiring new knowledge, and that their attitude towards their wives using contraception had changed; • the women seeking family planning now often reported that they had had dialogue with their husbands and/or received spousal approval to begin the use of contraception. the overall impact of this team approach to a cultural challenge was that men gained knowledge and understanding that led to their wives being able to have meaningful spousal dialogue and shared decision making about contraception. one refugee summed up the benefit very well: she said “the whole atmosphere in the camps towards family planning has changed it is no longer a taboo subject” (aria et al., 2019). 6. opportunities for girls and boys children of both genders can be engaged equitably through school programs where they learn accurate facts and acquire practical health related skills. the who endorses education as a central health promotion approach, and also reminds us that to be effective what we teach must be relevant to everyday life and acknowledge local culture. any team planning school-based activities should include one or more pupils on the team, as in this way valuable insights are gained about how best to present issues, the most appropriate language for the age group and what explanations of any terminology used are necessary. the team is also far more likely to learn what is and is not working from the point of view of the youth in their target audience where pupils themselves have input into how the evaluation of the program is structured and performed. knowledge transfer within the team through evaluation and further afield through publication is a valuable part of effective health promotion delivery. the who ‘health promoting school’ (hps) model is a good one to follow. the aim of an hps is to achieve “a whole-school approach to enhance health and educational outcomes through teaching and learning experiences initiated in the school” (who, 1997), with the overall goal for children to learn how to care for themselves and for others. and this is achieved through education that provides knowledge through additions to the classroom curriculum and also teaches practical health related skills. macnab, a.j. ghmj (global health management journal) 2024, vol. 7, no. 1 6 this approach using the who hps model is also an important way to advance the un sustainable development goals (sdgs) (macnab & mukisa, 2017), as many of the un sdg objectives can be advanced by: a. increasing children’s health knowledge and awareness; b. developing behaviours, skills and actions that improve their wellbeing, and; c. enabling individuals and communities to increase control over determinants of health. in effective who hps based programmes children learn how to make healthy decisions and take control over life’s circumstances because the process has been shown to promote resilience, self-esteem, male to female dialogue and respect (macnab, 2013). topic areas proven to be useful include: 1. the creation of conditions that are conducive to health through community policies, services, dialogue between agencies and improvement of physical/social conditions 2. how to build capacities for peace and non-violence, shelter, education, food, income, a stable ecosystem, equity, social justice, and sustainable development 3. ways to prevent the leading causes of death, disease and disability in the local community 4. knowledge and practices that positively influence health-related behaviours, beliefs, skills, attitudes, and values there is an important benefit from teams working with schools in this way to promote health, as when children are engaged effectively in well organized school programs, the health culture of the whole community changes. this is because when children learn important knowledge and skills, research shows that the positive traits and attitudes learned at this age can then translate into beneficial health behaviors in adult life (viner et al, 2012). in other words, children our teams educate have the potential to be healthier adults, who in turn also have knowledge and skills that will benefit the health and wellbeing of their children. furthermore, others in the community where there is an hps program also benefit, as children in good programs take home what they learn at school; this influences and informs their siblings and their parents so what they learn also ‘trickles down’ to be ‘learned’ by the family and broader community (macnab, stewart & gagnon, 2014). 7. summary: how inclusive teams can promote health to be effective inter-professional, multidisciplinary teams are needed to promote health, and such teams must engage parents and family members, including children. effective health promotion strategies for such teams include: • building healthy public policy; • strengthening community action; • empowering women and girls; • promoting education for girls; • communication and dialogue to counter misinformation; • making use of culture and beliefs; • educating in school programs based on the who hps model. remember that the ideas and approaches you create and the synergy you generate between your team’s members will be powerful ways to promote health and help prevent diseases and injuries that affect children. society needs all of us to collaborate in order for our efforts to translate into innovative practices and new public policies that benefit our children and their families. conflict of interest the authors declare no conflicts of interest for the results. references aria w, de freitas j, francis m, macnab aj. (2019) engaging afghan men at a societal level to increase women's access to contraception. medical anthropology theory. 6(4):152-165. https://doi.org/10.17157/mat.6.4.732 https://doi.org/10.17157/mat.6.4.732 7 ghmj (global health management journal) 2024, vol. 7, no. 1 macnab, a.j. bartlett, l. a., mawji, s., whitehead, s., crouse, c., dalil, s., ionete, d., & salama, p. (2005). where giving birth is a forecast of death: maternal mortality in four districts of afghanistan, 1999-2002. the lancet, 365(9462), 864-870. https://doi.org/10.1016/s0140-6736(05)71044-8 bustreo, f., okwo-bele, j. m., & kamara, l. (2015). world health organization perspectives on the contribution of the global alliance for vaccines and immunization on reducing child mortality. archives of disease in childhood, 100(suppl 1), s34-s37. https://doi.org/10.1136/archdischild-2013-305693 gandhi, g. (2015). charting the evolution of approaches employed by the global alliance for vaccines and immunizations (gavi) to address inequities in access to immunization: a systematic qualitative review of gavi policies, strategies and resource allocation mechanisms through an equity lens (1999-2014). bmc public health, 15, 1-35. https://doi.org/10.1186/s12889-015-2521-8 larson, h. (2018).the biggest pandemic risk? viral misinformation.. nature, 562(7726): 309-310 https://doi.org/10.1038/d41586-018-07034-4 macnab aj. (2013) the stellenbosch consensus statement on health promoting schools. global health promotion. 20(1), 7881.doi:10.1177/1757975912464252 http://pedsagepub.com. https://doi.org/10.1177/1757975912464252 macnab aj. (2020) the world health organization 'health promoting school' model: a potential avenue for dohad education in africa. in: ''health in transition: translating dohad science to improve future health in africa.' macnab aj, daar a, pauw c (eds). stias book series. sun african media, stellenbosch, south africa. pp 203-231 https://doi.org/10.18820/9781928357759/12 macnab aj. (2023) innovative strategies to promote global health: lessons from the covid-19 pandemic. global health management journal. 6(1): 47-53. https://doi.org/10.35898/ghmj-61956 macnab, a. j., & mukisa, r. (2017). the un sustainable development goals; using world health organization's 'health promoting schools' to create change. global health management journal, 1(1), 23-27. https://doi.org/10.35898/ghmj-1190 macnab, a. j., gagnon, f. a., & stewart, d. (2014). health promoting schools: consensus, strategies, and potential. health education, 114(3), 170-185. https://doi.org/10.1108/he-11-2013-0055 rutstein, s. o. (2005). effects of preceding birth intervals on neonatal, infant and under‐five years mortality and nutritional status in developing countries: evidence from the demographic and health surveys. international journal of gynecology & obstetrics, 89, s7-s24. https://doi.org/10.1016/j.ijgo.2004.11.012 sippel l, kiziak t, woellert f, & klingholz r. (2011). africa's demographic challenges. how a young population can make development possible. berlin institute for population and development. 1-80. isbn: 978-3-9814679-0-1. tsui, a. o., mcdonald-mosley, r., & burke, a. e. (2010). family planning and the burden of unintended pregnancies. epidemiologic reviews. 32(1):152-74. https://doi.org/10.1093/epirev/mxq012 un human rights commission. (2008). the right to health. https://www.ohchr.org/sites/default/files/documents/publications/factsheet31.pdf viner, r. m., ozer, e. m., denny, s., marmot, m., resnick, m., fatusi, a., & currie, c. (2012). adolescence and the social determinants of health. the lancet, 379(9826), 1641-1652. https://doi.org/10.1016/s0140-6736(12)60149-4 world health organization expert committee on comprehensive school health education and promotion. (1997). promoting health through schools (who technical report series no. 870. world health organization. (1986). ottawa charter for health promotion, 1986. world health organization. regional office for europe. world health organization. (2014). european vaccine action plan 2015-2020. world health organization. regional office for europe. cite this article as: macnab, a.j. (2023). how to engage children and families as part of multidisciplinary health promotion teams. ghmj (global health management journal), 7(1). 01–07. https://doi.org/10.35898/ghmj-71981 https://doi.org/10.1016/s0140-6736(05)71044-8 https://doi.org/10.1136/archdischild-2013-305693 https://doi.org/10.1186/s12889-015-2521-8 https://doi.org/10.1038/d41586-018-07034-4 https://doi.org/10.1177/1757975912464252 https://doi.org/10.18820/9781928357759/12 https://doi.org/10.35898/ghmj-61956 https://doi.org/10.35898/ghmj-1190 https://doi.org/10.1108/he-11-2013-0055 https://doi.org/10.1016/j.ijgo.2004.11.012 https://doi.org/10.1093/epirev/mxq012 https://doi.org/10.1016/s0140-6736(12)60149-4 https://doi.org/10.35898/ghmj-71981 template ghmj 2024 ghmj (global health management journal) 2025, vol. 8, no. 3 indonesian scholars’ alliance open access editorial global health education for youth: a humanitarian priority 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 e-mail: ajmacnab@gmail.com doi: 10.35898/ghmj-831259 abstract there may not seem to be an obvious link between the focus of the three events this issue is recognizing. however, in the context of global health and the journals’ mission statement of “shaping a more resilient, inclusive & youth-empowered future” there is a connection. world breastfeeding week aims to raise awareness and encourage more women to breastfeed, international youth day focuses on an age group which includes ‘the parents of tomorrow,’ and humanitarian day pays tribute to humanitarian workers who have given their lives and suffered injuries in the course of their work, including those actively campaigning for the rights of women and girls in the face of gender inequity. in this context, enabling more mothers to breastfeed would bring considerable health and social benefits, youth are key ‘target audience’ to engage and educate on the positive impact breastfeeding can have on their future infants’ lives, and a global humanitarian aim is to balance traditional social norms that favor gender inequity, including those that negatively impact the ability of mothers to breastfeed. keywords: youth; breastfeeding; health education; global health. published: 30 august 2025. © 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) editorial the need for global health education that involves youth is underscored by the three distinct and seemingly unrelated events celebrated in the month of august, world breastfeeding week, international youth day and humanitarian day. in celebrating youth we are acknowledging the parents of tomorrow, and youth worldwide need to understand the impact on future social and emotional health of how they nurture their children. youth are also the demographic whose voices will soon increasingly drive the norms that society follows regarding humanitarian issues related to gender, equity and inclusion. mailto:ajmacnab@gmail.com https://doi.org/10.35898/ghmj-831259 317 ghmj (global health management journal) 2025, vol. 8, no. 3 macnab, a.j. breastfeeding is recognized to be a critical component of infant nutrition and development and to have numerous health benefits (victoria et al. 2016). its importance is underscored by the fact that 45% of child deaths worldwide are attributed to the low number of infants who are breastfed, and low rates also contribute to malnutrition (kinshella et al. 2021). recent data from 24 low and middle income countries (lmics) estimated that because of sub-optimal nutrition 149 million children under the age of five were stunted while 38.9 million were overweight or obese (birhanu et al. 2022). a previous article in ghmj emphasized how the first 1000 days of life from conception to the end of the second year not only contributes to the immediate wellbeing of an infant but also shapes her or his future by having an impact on whether or not she or he develops a non-communicable disease (ncd) in adult life (macnab, 2024). stunting in infancy is strongly associated with ncds such as high blood pressure, heart disease and stroke developing in later life, and infants who gain excessive weight are at a higher risk of becoming obese and developing type 2 diabetes as adults. being breastfed is relevant in this regard as infants fed in this way are far less likely to become stunted or obese. the world health organization (who, 2021) recommendations are that: 1. mothers initiate breastfeeding within the first hour of birth; 2. infants are exclusively breastfed for the first 6 months of life – this means no other foods or liquids are provided, including water, unless medically indicated; 3. infants should be breastfed on demand – this means as often as the child wants, day and night. and no bottles, teats or pacifiers should be used; 4. children should begin eating safe and adequate complementary foods from the age of 6 months, while continuing to breastfeed for up to two years of age or beyond. however, these optimal breastfeeding practices are proving difficult to achieve worldwide and fewer than half of infants in low-and-middle income countries (lmics) are breastfed to these standards (zong et al. 2021). one of the aims of world breastfeeding week is to make more of us aware that who has set a target for 50% of infants worldwide to be exclusively breast fed for 6 months by 2030, but many countries globally are not close to achieving this target, (mohammed et al. 2025) so efforts to promote improvements in breastfeeding practices are urgently needed. youth are an essential sub-group in the population that needs to understand more about the benefits of breastfeeding. this is because knowledge gained in adolescence is known to translate into the health attitudes and behaviors subsequently adopted in adult life. one problem here that needs changing is that young women have been the principal targets for health promotion of breastfeeding, and education teaching other parental roles able to optimize fetal and newborn health through the first 1000 days of life. because of this bias, the responsibility for infant health outcomes has largely fallen on mothers; this is an inappropriate burden and inadvertently deflects attention from other windows for intervention (pentecost et al. 2018). clearly it is relevant for both genders to learn the immediate and long term benefits of optimal infant health and nutrition, and achieving successful breastfeeding is not the sole responsibility of a woman. importantly, fathers who understand the benefits of breastfeeding can significantly support mothers who want to breastfeed, and help them to succeed. in this context, school-based health promotion offers a unique opportunity to engage with youth of both genders at a key age point as they are the parents of tomorrow (tohi et al. 2024). while empowering future mothers and fathers in the practical, social and humanitarian aspects of breastfeeding does require broad engagement within our society, integrating the promotion of breastfeeding practices into health-related school curricula is one approach that offers unique opportunities. by using clear and uncomplicated messaging and innovative means of delivery tomorrow’s parents can be given knowledge and skills about infant nutrition that will enable them to set up healthier trajectories for their children. society-level factors which influence expectations regarding breastfeeding and its acceptability can be also be explained during school-based health promotion; explanations should include myths and misconceptions that exist in the local community and also factors that have a negative and a positive impact such as the limited success with breastfeeding that results from ineffective support for mothers, and how much fathers can contribute by adopting positive roles. macnab, a.j. ghmj (global health management journal) 2025, vol. 8, no. 3 318 the adverse humanitarian consequence of traditional and social norms that overly favor men and boys also negatively impact the ability of many women who wish to breastfeed to do so successfully (macnab et al. 2024). hence including discussion in school-based education of the humanitarian implications of gender inequity and emphasizing the positive role that informed and empathetic males can offer in the context of breastfeeding should be an aim of all of us involved globally in health promotion. research indicates that fathers educated to understand the benefits of breastfeeding can play several significant roles (0gbo et al. 2020). fathers’ knowledge and attitudes significantly influence a mother’s decision to initiate, continue or stop breastfeeding; new mothers who receive verbal encouragement from the baby’s father breastfeed longer and more exclusively; sensitivity to the needs of the nursing mother positively improves breastfeeding practices, as does awareness of how to help prevent and manage breastfeeding difficulties, and even providing more practical help with household chores increases the likelihood that a nursing mother will be able to continue to successfully breastfeed. these are all effective support measures that boys can and should be made aware of. research has also identified that gender bias also influences what facts about breastfeeding boys and girls respectively find most interesting and relevant. boys are significantly more interested in the cost benefits of breastfeeding, (macnab and mukisa. 2018) for instance, that no cost is incurred for formula. also, more boys than girls see the relevance of the potential for the huge healthcare costs currently incurred by governments caring for diabetics to be reduced if fewer adults developed the disease in later life. in contrast girls see more relevance that breast fed babies are ‘easy to comfort, so cry less and feeds during the night are easier,’ and that ‘changing diapers is less gross.’ consequently, in parallel with the need for educators to be aware of the need to discuss the humanitarian elements of the health knowledge and practices they are promoting, they also need to be mindful of gender-based factors influencing the interests of girls and boys in their target audience in order to engage and inform both groups effectively. the who health promoting school model is an effective way to engage and educate boys and girls through school-based programs (macnab. 2013). health promotion is integral to the practice of global health management, and, education across all age groups in our society is central to the transfer of scientific knowledge to inform and potentially influence positive behavior. this applies to the promotion of breastfeeding, where effective educational strategies are important to improve and correct knowledge, attitudes, beliefs, and sociocultural norms. youth must be seen as a critical target audience; as the next generation of parents they need the knowledge and the social awareness to provide the best they can for their future children. they and the rest of us in society can also contribute by viewing the issues surrounding breastfeeding, the challenges a new mother faces, and the ways in which fathers can play a positive role through a humanitarian lens. so this month, the three events being recognized by the journal are linked in various ways, all of which have relevance in the context of global health and the journals’ mission statement of “shaping a more resilient, inclusive and youth-empowered future.” references birhanu f, yitbarek k, bobo ft et al. (2024) undernutrition in children under five associated with wealth-related inequality in 24 low-and middle-income countries from 2017 to 2022. sci rep. 2024, 14(1), 3326. https://doi.org/10.1038/s41598-024-53280-0 kinshella mlw, prasad s, hiwa t et al. (2021). barriers and facilitators for early and exclusive breastfeeding in health facilities in sub-saharan africa: a systematic review. glob health res policy, 6, 1-11. https://doi.org/10.1186/s41256-021-00206-2 macnab aj. (2013). the stellenbosch consensus statement on health promoting schools. global health promotion, 20(1), 78-81. https://doi.org/10.1177/1757975912464252 macnab aj & mukisa r. (2018). priorities for african youth to engage in the dohad agenda. j dev origin health dis, 9(1), 15-19. https://doi.org/10.1017/s2040174417000423 macnab aj. (2024). non-communicable diseases: opportunities to promote future health during the first 1000 day of life. ghmj (global health management journal), 7(3):109-111. https://doi.org/10.35898/ghmj731003 https://doi.org/10.1038/s41598-024-53280-0 https://doi.org/10.1186/s41256-021-00206-2 https://doi.org/10.1177/1757975912464252 https://doi.org/10.1017/s2040174417000423 https://doi.org/10.35898/ghmj-731003 https://doi.org/10.35898/ghmj-731003 319 ghmj (global health management journal) 2025, vol. 8, no. 3 macnab, a.j. macnab aj, besigye i, tusubira b. (2024) sexual and gender related violence against girls in sub-saharan africa: a need for effective interventions. academia mental health and wellbeing, 1(3). https://doi.org/10.20935/mhealthwellb7365 mohammed s, calvert c, webb el et al. (2025). socioeconomic pattern of breastfeeding in sub-saharan africa: an individual participant data meta-analysis of six longitudinal cohorts. bmj public health, 3(1). https://doi.org/10.1136/bmjph-2024-001298 ogbo fa, akombi bj, ahmed ky et al. (2020). breastfeeding in the community-how can partners/fathers help? a systematic review. int j environ res public health, 17(2), 413. https://doi.org/10.3390/ijerph17020413 pentecost m, macnab aj, mayekiso a, ross f. (2018). beyond the dyad: making dohad interventions more inclusive. j dev origin health dis, 9(1), 10-14. https://doi.org/10.1017/s2040174417000629 tohi m, tu'akoi s, vickers mh. (2024). adolescent understanding of concepts related to the developmental origins of health and disease: a pacific perspective. j r soc n z, 1-6. https://doi.org/10.1080/03036758.2024.2363419 victora cg, bahl r, barros aj, et al.(2016). breastfeeding in the 21st century: epidemiology, mechanisms, and lifelong effect. lancet, 387(10017), 475-90. https://doi.org/10.1016/s0140-6736(15)01024-7 world health organization; unicef. (2021).the extension of the 2025 maternal, infant and young child nutrition targets to 2030 who/unicef. https://coilink.org/20.500.12592/2rbp179 zong x, wu h, zhao m et al. (2021). global prevalence of who infant feeding practices in 57 lmics in 2010-2018 and time trends since 2000 for 44 lmics. eclinicalmedicine, 37. https://doi.org/10.1016/j.eclinm.2021.100971 cite this article as: macnab, a.j. (2025). global health education for youth: a humanitarian priority. ghmj (global health management journal), 8(3), 316–319. https://doi.org/10.35898/ghmj-831259 https://doi.org/10.20935/mhealthwellb7365 https://doi.org/10.1136/bmjph-2024-001298 https://doi.org/10.3390/ijerph17020413 https://doi.org/10.1017/s2040174417000629 https://doi.org/10.1080/03036758.2024.2363419 https://doi.org/10.1016/s0140-6736(15)01024-7 https://coilink.org/20.500.12592/2rbp179 https://doi.org/10.1016/j.eclinm.2021.100971 https://doi.org/10.35898/ghmj-831259 ghmj (global health management journal) 2025, vol. 8, no. 2 indonesian scholars’ alliance open access photo essay a decade of growth: from social media to academic friendship yeyentimalla1* , yuyun christyanni1 , sri suryawati2 1. department of nursing, poltekkes kemenkes palangka raya, palangka raya, indonesia, 73111; 2. department of pharmacology and therapeutics, faculty of medicine, public health, and nursing, universitas gadjah mada, yogyakarta, indonesia, 55281. *corresponding author’s e-mail: yeyentimalla@polkesraya.ac.id doi: 10.35898/ghmj-821256 abstract background: friendship is a safe relationship in which individuals can express various facets of themselves. a true friend allows another to be fully themselves in their presence, resulting in personal growth and progress -not only for individuals, but also for institutions, society, and the nation. a friendship that began as a student-teacher relationship and has lasted a decade (2015-2025) was lived, observed, and reflected upon. aims: this photo essay aims to explore how an intially asymmetric relationship between student and teacher gradually grew into an academic friendship. it is intended to inspire readers to nurture safe and trusting connections within their own circles. methods: this case study investigates a student-teacher friendship relationship, highlighting learning points worth sharing publicly. the relationship consciously incorporated emotional communication -emotional intelligent interaction that engages feeling-based expression and empathetic simulation. results: a bond that began between two strangers on facebook evolved into an academic friendship, then into a student-examiner relationship during doctoral study. after the doctoral journey ended, the connection reverted to a stronger friendship. this relationship yielded collaborative works and programs that have benefited both indonesian and global communities. conclusion: this case study offers several takeaways on building meaningful friendship that foster personal growth and benefit the wider environment. keywords: friendship; emotional communication; emotional animation; emotional simulation; emotional crescendo. received: 08 july 2025 reviewed: 16 july 2025 revised: 20 july 2025 accepted: 22 july 2025. © 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:yeyentimalla@polkesraya.ac.id https://doi.org/10.35898/ghmj-821256 https://orcid.org/0009-0009-4807-3798 https://orcid.org/0000-0001-9428-5956 https://orcid.org/0000-0002-3127-2493 yeyentimalla, et. al. ghmj (global health management journal) 2025, vol. 8, no. 2 237 1. introduction abraham maslow (1975) stated that human beings need to be recognized for their potential and developed toward self-actualization -to become fully human. in reality, however, not everyone grows. this can be seen in how a person communicates -especially when their communication shows little desire to connect with others. within academic systems that are burdened with heavy workloads, students often struggle to express their inner selves, while lecturers may find it difficult to perceive students' latent potential through formal classroom encounters alone. this is where emotional communication becomes essential, bridging interpersonal gaps through two key strategies: emotional animation and emotional simulation. this photo essay presents a real-life story of friendship between two women from different backgrounds: a dayak ngaju doctoral student from central kalimantan and a javanese professor. they are nineteen years apart in age, with vastly different cultural roots. their connection began through social media and evolved into face-toface meetings and eventually academic collaboration. such friendship is rare in indonesia, a country steeped in feudal values, especially in higher education. in such a culture, students are expected to “know their place,” (tahu diri, in indonesian) while lecturers are to be honored, obeyed, even loved. this friendship did not render their roles equal in hierarchy, but it created a learning relationship grounded in mutual respect and rooted in culturally resonant care. what makes their bond even more distinct is their shared commitment to practicing emotional intelligence in communication -a model developed by the student in her doctoral research at universitas gadjah mada, yogyakarta. the dissertation revitalized emotional communication within families of drug addiction survivors. this research later formed the basis for a digital emotional communication training module co-authored by both student and professor during the covid-19 pandemic. the module was delivered in an online workshop for 45 rehabilitation mentors across five indonesian cities: palangka raya, yogyakarta, singkawang, medan, and manokwari (yeyentimalla & suryawati, 2021). this intergenerational and intercultural partnership shows how hospitality in human relationships fosters a safe space for growth and transformation. michelle hershberger (1999) emphasizes that hospitality is an invitation into vulnerability and trust. within such spaces, deep transformation becomes possible. the friendship between student and teacher in this essay reveals that emotional communication is not only an academic skill, but also a spiritual encounter, where values are passed down and embodied heart to heart. 2. the journey of friendship naturalistic observation and reflection were conducted on a relationship that was initially informal between a doctoral student in psychology, yeyentimalla, and her external examiner, prof. sri suryawati, a senior professor at the faculty of medicine, universitas gadjah mada (ugm). the relationship began informally on a social media platform, namely facebook. the online friendship began in february 2015. not much personal information is known. even the professor did not use her real name, but posted a profile picture of herself. included in the initial data that was known was the age difference that allowed for the role of student-teacher to be played between two people from different generations, namely generation x meeting the baby boomer generation. the interaction was conducted on facebook in writing using indonesian. several months later, the teacher took the initiative to give her contact number, and their conversation moved to whatsapp -synchronous and fast-paced. in the same year as the beginning of the friendship, december 10, 2015, the teacher invited the student to lunch meeting at bumbu desa, a restaurant in yogyakarta. the first meeting lasted two and half hours in a cheerful atmosphere. they both enjoyed the time together; the entire conversation flowed spontaneously yet remained respectful and filled with warmth (yeyentimalla, 2020; yeyentimalla, 2025). yeyentimalla, et. al. ghmj (global health management journal) 2025, vol. 8, no. 2 238 next, there was a second, third, fourth lunch meeting, and so on at the same or different restaurants. the topics of conversation varied, generally the topics were not agreed upon beforehand. one interesting thing, the student never shared stories about her dissertation journey, it was a kind of taboo to talk about it with a professor who was an online friend at first. in 2016, to be precise on july 16, 2016, part of yeyentimalla's doctoral study journey was to have the experience of being a speaker at a national seminar. she discussed it with director of poltekkes kemenkes palangka raya, head of the institution where she worked. the leader initiated a national seminar, giving yeyentimalla the opportunity to be a speaker with the promoter, namely prof. tina afiatin, and prof. sri suryawati who at that time served as first vice president of the international narcotics of control board (incb), and dr. antar sianturi from the national narcotics agency (badan narkotika nasional). the first national seminar held by the poltekkes kemenkes palangka raya managed to attract 750 participants, the majority of whom came from nursing professions from all over central kalimantan and participants from other provinces. the seminar went well, smoothly, and was beneficial for all participants, as expected (figure 1). figure 1. the first national seminar of the poltekkes kemenkes palangka raya, july 16, 2016 yeyentimalla, et. al. ghmj (global health management journal) 2025, vol. 8, no. 2 239 the internal benefit of the national seminar for the speaker team was that they got to know each other and learned about each other's competencies. when determining the examining team for yeyentimalla's dissertation in 2017, prof. tina afiatin as the promoter approved the proposal of the examined student that prof. sri suryawati be her external examining professor. when she became an examiner, the good relationship between the student and her examiner continued to develop into friendship. lunch meetings were often held, either alone or together with students supervised by the examining professor. likewise, fingertip communication on the whatsapp and facebook platforms was carried out almost every day. on january 31, 2018, prof. sri suryawati acted like an eagle who saved a student from a situation of almost dropping out due to stagnation in the dissertation process. she gave an order to yeyentimalla to write her dissertation in the same room as her. the order, which felt gentle, was very well received by yeyentimalla. the process of writing the dissertation lasted one month. in march 2018, yeyentimalla advanced to the comprehensive exam. because of her achievements, prof. sri suryawati was given the nickname professor eagle (professor rajawali, in indonesian). after completing her doctoral studies with honor on july 29, 2019, yeyentimalla continued to work at eagle nest (petarangan rajawali) and began writing the book “pede bersama professor rajawali: jurus jitu menyelesaikan studi.” the writing process took four months. the next four months were the publishing process by gramedia pustaka utama. this book contains the journey of a dissertation that was brilliantly successful thanks to the communication skills with everyone met along the way. on october 18-19, 2018, poltekkes kemenkes palangka raya -through its staff member yeyentimalla, who was then pursuing doctoral studies at ugm -once again invited prof. sri suryawati to serve as a speaker for a workshop organized by the department of midwifery. the participants were 40 clinical practice supervisors for midwifery students, consisting of midwives from various parts of palangka raya. the workshop focused on training midwives to serve as peer counselors in their clinical roles. on the following day, a guest lecture was held for all students of the midwifery department, featuring prof. sri suryawati along with a speaker from the national population and family planning board (bkkbn). during these two days of activities, yeyentimalla acted as the moderator (figure 2). figure 2. workshop of midwifery department: prof. sri suryawati as speaker, yeyentimalla as moderator yeyentimalla, et. al. ghmj (global health management journal) 2025, vol. 8, no. 2 240 during the dissertation period, the student spent three semesters working the same room as her mentor at the faculty of medicine, universitas gadjah mada (ugm). the first seven semesters of her doctoral journey were based in faculty of psychology but the final three semesters were spent in what they called the ‘eagle nest’ -a space for intensive research, writing and heart-to-heart conversation. the eagle nest was open to all doctoral mentees of prof. sri suryawati (widely known as professor rajawali). it was a nurturing space where students wrote their dissertations, discussed ideas, practiced presentations, and occasionally went out for lunch -always in the spirit kinship. among all the mentees, however, yeyentimalla was the most frequent presence. she often found herself alone there, or sometimes just two of them -student and professor -sharing the room. the student experienced her professor at close range, not just professionally, but in deeply human ways, as though sharing a nest of life. many of her most meaningful memories were born in that space. one such moment was when the professor came down from the second floor one afternoon and went to the faculty canteen to buy gado--gado for them both. at that moment, the student felt as though her teacher had become her mother -someone who cared for her nourishment and wellbeing (yeyentimalla, 2020). figure 3. book review “confidence with professor rajawali”, september 3, 2020 this book review activity (figure 3) is the first book review held by the poltekkes kemenkes palangka raya library, attended enthusiastically by around 400 participants from all over indonesia. because the book review is during the covid-19 pandemic, the series of activities were held online via zoom. in the same year, precisely on november 9, 2020 (figure 4), the poltekkes kemenkes palangka raya held its first international seminar in collaboration with several institutions, including the global health management journal (ghmj). the good relationship between the personnel of the poltekkes kemenkes palangka raya and the ghmj management played a major role in supporting the success of the international seminar. yeyentimalla and prof. sri suryawati were speakers from indonesia along with three other speakers from taiwan, philippines, and canada. seminar participants came from several countries in the world. the total number of participants was 1088 people (yeyentimalla, sera, sinaga, 2022). yeyentimalla, et. al. ghmj (global health management journal) 2025, vol. 8, no. 2 241 figure 4. the first international seminar of the poltekkes kemenkes palangka raya the good relationship between yeyentimalla and prof. sri suryawati continues to produce intellectual works. in 2021, the two of them compiled a digital emotional communication module, responding to the covid-19 pandemic. the module was used in communication training for drug shelter mentors which was enthusiastically attended by 45 mentors (yeyentimalla & halajur, 2020; yeyentimalla & suryawati, 2021). in 2021, institutional cooperation began, namely poltekkes palangka raya with universitas gadjah mada. good relations between people have become cooperative relations between institutions. in november 2021, the module (figure 5) successfully entered the final round of the ministry of health of the republic of indonesia health innovation competition. the module is seen as supporting the acceleration of the transformation of health human resources. although in the end the module did not win the competition, the journey of producing work that is beneficial to the community remains an extraordinary and soul-affirming experience. yeyentimalla, et. al. ghmj (global health management journal) 2025, vol. 8, no. 2 242 figure 5. module by yeyentimalla and prof. sri suryawati figure 6. online birthday celebration of prof. sri suryawati, may 27, 2025 yeyentimalla, et. al. ghmj (global health management journal) 2025, vol. 8, no. 2 243 on may 27, 2025, prof. sri suryawati celebrated her 70th birthday with a meaningful online gathering. the celebration was initiated and thoughtfully organized by one of her former students, who led the event with heartfelt care and reverence. despite her busy schedule -as the same day marked her official retirement from the faculty of medicine at universitas gadjah mada -prof. suryawati graciously made time for this special moment. in figure 6, two authors -both former students of prof. sri suryawati -are seen expressing deep gratitude and joy as they reunite with their beloved teacher, even if only through a zoom call. though separated by nearly 1,000 kilometers, the teacher and her student remained closely connected at heart. to mark this milestone, one student composed an anthology titled professor rajawali: soaring high together. the book was published in april 2025 and sent from palangka raya to the professor’s home in yogyakarta. it arrived on may 17 -ten days before the special day -and was warmly received. a decade has passed, and yet the student remains unwavering in her devotion: reverent in spirit, tender in love, and deeply cherishing the teacher who once guided her with wisdom, dare, and care (yeyentimalla, 2025). their friendship continued digital conversation, collaborative training, and joint reflection sessions. the experience of interacting not only through academic discourse but also through ‘emotional communication’ made the bond more resilient and healing. the friend-teacher figure was not always gentle -sometimes strict, sometimes unpredictable -but always meaningful. the student stayed, learned, and grew. the photos in this essay are not just visual documentation -they are fragments of stories, moments of growth, echoes of struggle and gratitude. each photo is an anchor of memory that illustrates that friendship, when nurtured with honesty and emotional intelligence, does not merely -it transforms both souls involved. 3. reflection friendship is a type of relationship that extends any relationship, including informal relationships between social media users, into formal student-examiner relationships, and develops into relationships in a sense of security, having a positive impact on the growth of the soul and the welfare of society. the relationship between friends is not the only role played, but rather alternates with other paired roles, such as student-teacher, that is also an eternal role. in certain aspects, students do not surpass their teacher. the motor for true friendship is communication that is able to embrace the heart. in the student-teacher relationship here, what is faithfully developed together is intelligent communication. there are two communication techniques based on intelligent feeling, namely emotional animation (yeyentimalla & suryawati, 2021), and emotional simulation (yeyentimalla, 2022). emotional animation is arousing positive valence emotions such as liking, happiness, joy, happiness, respect, gratitude, pity, empathy, and various other positive emotions. what about negative valence emotions? negative emotions are recognized to be controlled. the second finding in this ten-year friendship is emotional simulation. this technique requires recognition of the emotions that arise. thinking about the chronology and consequences of acting in line with those emotions is usually negative. based on this review, and then consciously chosen to display actions that are different from those emotions. for example, feeling angry. so, recognizing and accepting anger, but responding kindly so that bad things don't happen. let us remain faithful in building and tending bridges of friendship -metaphors of connection -for a world made warmer and safer by shared humanity. 4. conclusion friendship is a gift, and when lived with awareness and care, it becomes a powerful force for good. what began as a digital connection between two strangers evolved into an academic friendship, then a mentorship, and eventually into a creative and intellectual partnership. this journey of shared growth and mutual respect reached an emotional crescendo in a moment of deep celebration and gratitude -proof that enduring bonds can be formed when hearts listen dan respond across boundaries of role, culture, age, and distance. yeyentimalla, et. al. ghmj (global health management journal) 2025, vol. 8, no. 2 244 acknowledgment the authors are grateful to the global health management journal (ghmj) for a special invitation the occasion of world friendship day. the first author wrote the manuscript and led the reflection process. the second and third authors contributed through narrative review, reflection, and validation of events. conflict of interest the authors declare that there is no conflict of interest. references maslow, a.h. (1975). some educational implication of the humanistic psychologies. in four psychologies applied to education: freudian, behavioral, humanistic, transpersonal. schenkman publishing company: new york. hershberger, m. (1999). a christian view of hospitality. expecting surprises. a christian view of hospitality: expecting surprises (the giving project series): michele hershberger: 9780836191097: amazon.com: books yeyentimalla, y. (2020). confidence with professor rajawali: the ultimate trick to completing your studies. jakarta: gramedia pustaka utama. pede bersama professor rajawali karya yeyentimalla yeyentimalla, y., & suryawati, s. (2021). educational module. digital communication to connect the hearts of mentors and prospective mentors with families of drug survivors. yogyakarta: prima print. yeyentimalla, y., & halajur, u. (2020) pelatihan komunikasi emosi bagi petugas panti rehabilitasi narkoba (riset aksi partisipatoris). laporan penelitian. poltekkes kemenkes palangka raya, perpustakaan poltekkes kemenkes palangka raya. http://repo.polkesraya.ac.id/2730/ yeyentimalla, y., sera, a.c., & sinaga, d.m. (2022). the first international seminar poltekkes kemenkes palangka raya: the journey full of meaning. global health management journal (ghmj) vol. 5 no. 2. https://doi.org/10.35898/ghmj-52945 yeyentimalla, y., & suryawati, s. (2022). a new drug-free life: the essence of professional’s presence in drug survivor’s family. global health management journal (ghmj) vol. 5 no. 2. https://doi.org/10.35898/ghmj52940 yeyentimalla, y. (2022). emotional awareness for fun digital communication. global health management journal (ghmj) vol. 5 no. 2. https://doi.org/10.35898/ghmj-52931 yeyentimalla, y. (2025). professor rajawali: soaring high together. in let me hold my own soul. antologi. yogyakarta: alineaku. cite this article as: yeyentimalla, y., christyanni, y., & suryawati, s. (2025). a decade of growth: from social media to academic friendship. ghmj (global health management journal), 8(2), 236–244. https://doi.org/10.35898/ghmj-821256 https://www.amazon.com/christian-view-hospitality-expecting-surprises/dp/0836191099 https://www.amazon.com/christian-view-hospitality-expecting-surprises/dp/0836191099 https://ebooks.gramedia.com/id/buku/pede-bersama-professor-rajawali http://repo.polkesraya.ac.id/2730/ https://doi.org/10.35898/ghmj-52945 https://doi.org/10.35898/ghmj-52940 https://doi.org/10.35898/ghmj-52940 https://doi.org/10.35898/ghmj-52931 https://doi.org/10.35898/ghmj-821256 ghmj (global health management journal) 2024, vol. 7, no. 2 indonesian scholars’ alliance 66 open access research article an analysis of the relative importance of healthcare services indicators in south africa: utilities analysis approach shenaaz gani college of accounting sciences, university of south africa, south africa. *corresponding author’s e-mail: shenaazgani2009@gmail.com doi: 10.35898/ghmj-72983 abstract background: there is a wide gap in healthcare access between the poor and the rich in south africa. the government has implemented several policies to address this gap; nonetheless the complaints about poor healthcare delivery exist. aims: the objective of this study is to examine the relative importance of healthcare service indicators in tshwane municipality, south africa. methods: this research uses a utility approach to analyse the relative importance of healthcare service indicators in the context of the tshwane municipality in south africa. the study applies conjoint analysis to better understand healthcare users' preferences for several factors such as service range, waiting time for medications and consultations, waiting time for elective operations, and location. questionnaire was administered on 280 respondents, comprising the following: black – 130, whites – 70, indians – 40, and coloured – 40. the data was collected from both public and private healthcare users, and the results were compared using an independent ttest. results: the study found that there were no statistically significant variations in the mean utilities of public and private healthcare users. the finding suggests that healthcare users' preferences, whether they utilize public or private services, are largely comparable and can be addressed by utilizing unified techniques. the result also demonstrates the most favoured levels for each metric, providing insights into patient preferences and their social impacts. the study further highlights various healthcare preferences of users. conclusion: this finding emphasises that healthcare users have unique expectations, requiring personalised healthcare delivery. the findings have several recommendations for policymakers and healthcare practitioners to improve service delivery and patient satisfaction. keywords: healthcare service indicators; relative importance; utility approach; south africa; healthcare users’ preference. received: 01 may 2024, reviewed: 03 june 2024, revised: 12 july 2024, accepted: 21 july 2024. © 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:shenaazgani2009@gmail.com https://doi.org/10.35898/ghmj-72983 https://orcid.org/0000-0002-8801-6079 ghmj (global health management journal) 2024, vol. 7, no. 2 gani, s. 67 1. introduction healthcare is vital to the well-being of society; hence the quality and availability of healthcare services has a significant impact on the overall health and prosperity of citizens and the economic activities of a country (fei, lu & feng, 2020). understanding which healthcare service indicators matter most to users is, therefore essential for optimising resource allocation and decision-making, especially in the tshwane municipality, which is a diverse and dynamic region in south africa. healthcare delivery in tshwane is a complex enterprise which is affected by many factors such as demographic trends, disease prevalence, economic conditions, and policy interventions (poirier, grépin & grignon, 2020, biddle, wahedi & bozorgmehr, 2020, torkayesh et al., 2021). given the crucial role of healthcare in a society, policymakers, healthcare providers, and other stakeholders need evidence-based assessments of various healthcare indicators (bergvall et al., 2011, mühlbacher & johnson, 2016, helter et al., 2022). the evidence will help them to prioritise and allocate resources effectively and address the diverse health needs of the population (ramsaran-fowdar, 2008, horan et al., 2023). despite acknowledging the significance of healthcare service indicators, there is a dearth of studies that focuses on how these indicators are valued by users in south africa. majority of the prior studies have focused of general or international context, paying little attention in addressing the specific needs and preferences of the local citizens. this gap limits the abilities of policymakers and healthcare professionals to make informed decisions which reflect the unique characteristics of the healthcare landscape in the tshwane municipality. this study aims to fill this gap by using the raw utilities approach to examine the relative importance of healthcare service indicators in tshwane municipality. the raw utility approach is a model that evaluates how much each indicator contributes to the overall healthcare service package. by examining these factors, the study aims to provide insights into the strengths and weaknesses of the current healthcare system in the tshwane municipality. the findings will provide evidence to healthcare providers, policy makers and healthcare practitioners to design effective and patient-centred healthcare services. the evidence will further help to improve resource allocation to meet the various needs of healthcare users. 2. literature review healthcare in south africa the primary health policy reform in south africa aims to address inequity and provide equal access to quality healthcare services for the entire population. this is in response to the significant divide between the public and private health systems, which has been debated in the country for the past two decades (ataguba, day & mcintyre, 2015). while low-income countries spend relatively less on health (us $32 per capita in 2010), south africa, classified as a middle-income country, spends us $645 per capita, significantly exceeding the who's recommended amount for low-income countries (world bank, 2012). however, despite this higher expenditure, health and health outcomes distribution remains unequal (ataguba et al., 2015). south africa's total health expenditure accounted for 8.9% of its gdp in 2018, slightly higher than the oecd average of 8.8%. although south africa's health spending aligns with oecd countries, it may not be adequate, considering its developmental status. wealthier countries with higher gdp per capita tend to spend more on health, and in nearly all oecd countries, health is mainly funded by the public sector. however, south africa differs, with only 48% of health funding coming from public resources (oecd 2014). despite exceeding the spending required for a middle-income country, the south african health system's performance remains poor (mayosi et al. 2012). this is evident in the significant inequities in healthcare access, which show disparities in benefits between the richest and poorest segments of the population (ataguba & mcintyre 2012). ghmj (global health management journal) 2024, vol. 7, no. 2 gani, s. 68 the south african government has been striving to improve equity and healthcare quality for years, with various plans and agreements to address inequality resulting from the apartheid system. however, concerns remain about the progressive deterioration of healthcare quality and the constitutional guarantee of access to healthcare for all citizens (ndoh 2013b). the proposed nhi scheme aims to bridge existing health inequalities and provide equal access to affordable, quality health care for all citizens, regardless of socioeconomic status. however, the gini index indicates that inequality in south africa is growing rather than decreasing (the economist 2012, world bank 2019). national health insurance (nhi) concept in south africa dates back to 1944. still, significant progress was only made after the world health report of 2010 identified it as a means to achieve the millennium development goals (mdgs) (who 2010). various organisations and governments worldwide have been focused on developing affordable national health systems following the commitments made in the millennium declaration in 2000 (goodwin 2008). south african national health insurance (nhi) national health insurance (nhi) is a comprehensive financing approach aimed at ensuring universal access to a complete package of health services for all south african citizens, regardless of social, economic, or other factors influencing their status (mcintyre & van den heever 2007:73). as a mandatory scheme, nhi aims to cover the entire population and is organised into three key areas of health services: primary health care, hospital and specialised services, and emergency medical services, as outlined in the white paper on nhi (doh 2015). at the heart of nhi lies primary health care (phc), a critical component in achieving universal health coverage (uhc). however, it is essential to note that the south african government's definition of phc slightly differ from the global definition (national consultative health forum [nchf] 2012). phc forms the bedrock of the nhi and encompasses various essential services such as health promotion, disease prevention, curative (acute and chronic) clinical services, rehabilitation, and palliative care. the vision for phc under the nhi entails establishing multidisciplinary first-contact points and integrating networks of practices in the private sector and community clinics. the aspiration is to adhere to the "ideal clinic" model, embodying attributes that ensure optimal service delivery. these ideal clinics are characterised by punctuality, dignified patient treatment, adherence to batho pele principles, high hygiene standards, reasonable waiting times, comprehensive and quality services, community collaboration, and promotion of health and socioeconomic development (president jacob zuma – rsa 2014). however, as south africa embarks on stage 2 of nhi implementation with the release of the white paper, achieving equitable access to high-quality health care remains a significant challenge (mayosi et al. 2012). the vast disparity in funding between the public and private sectors makes it unlikely to attain equitable healthcare delivery levels similar to the private sector (mayosi et al. 2012). the costs associated with providing health care of a quality comparable to the private sector pose a considerable financial burden, as evident from the projected budget shortfall for the nhi scheme. projections indicate that nhi would require approximately r1,180 billion to provide coverage for the entire south african population, while the current total government spending for 2018/2019 amounts to r208.8 billion (national treasury 2020:2). when combined with the private sector's total healthcare expenditure of r225 billion, the current total health spend amounts to r434 billion, highlighting a significant shortfall of r746 billion (statssa 2018). this shortfall would necessitate more personal income taxpayers, adding strain to the proposed nhi. presently, the burden of healthcare expenditure falls on only around 4 million principal members of private medical schemes, along with approximately 7.1 million paye personal income taxpayers (council for medical schemes 2018:144, national treasury 2019:34). the remaining 87.8% of the population, about 50.9 million people, do not contribute directly to healthcare expenditure but rely on the r208.8 billion healthcare budget, presenting a substantial and imminent challenge to the successful implementation of nhi. ghmj (global health management journal) 2024, vol. 7, no. 2 gani, s. 69 the nhi represents a transformative health policy in south africa, aiming to offer all citizens universal access to high-quality health services. the emphasis on primary health care as the foundation is crucial in delivering essential health services and ensuring equitable coverage. however, substantial funding and resource allocation challenges must be carefully addressed to guarantee nhi's successful and sustainable implementation. 3. methods the research methodology applied to this study was rankings-based conjoint analysis. the conjoint analysis question was designed to incorporate the rankings-based conjoint analysis technique, where each question differed for each respondent based on the choices made in a set of questions. residents who were eighteen years and older from the four different population groups in south africa, namely black/african, white, coloured and indian and living in the tshwane metropolitan area formed part of the population. the survey had two specific inclusion rules: prospective respondents should be 18 years and older, and should be responsible for their medical costs, levies and decisions. these two rules were implemented to ensure identified respondents could answer the questionnaire. the sample frame for this study comprised respondents who were 18 years or older and responsible for their own medical costs, levies and decisions. the sample frame was established through several sources, such as statssa, which provides census figures on the population of south africa. a non-probability sampling approach was employed by this study as there was no specific probability of an individual forming part of the sample and the selection relied on the subjective judgement of the researcher. when applying conjoint analysis in health care, it is challenging to determine sample sizes and researchers look for guidance from other studies. it was found that sample sizes range from 100 to 300 respondents (orme 2010:39, morgan-davies & waterhouse 2010:388). considering the statistical requirements for this research project, a sample minimum of 200 would have been deemed acceptable, however, based on the calculation performed using a sample size calculator by select statistical services (available at https://select-statistics.co.uk/calculators/sample-size-calculator-population-proportion/), the required sample size would be 281 based on n = 2 300 785. a disproportionate distribution of the target population was made to ensure that the statistical requirements were adhered to. to ensure a minimum of forty respondents in each category, the distribution as presented in table 1 was applied. table 1. respondents per population group population group number of respondents black/african 130 white 70 indian 40 coloured 40 total 280 questionnaire design and administration the questions were presented to the respondents with three scenarios based on nine healthcare indicators. the first scenario was populated based on the respondents' selection in a set of questions (healthcare indicators) and scenarios 2 and 3 were pre-populated and randomly allocated to each respondent. respondents were asked to first rate each scenario on a scale of 1 to 10, where 1 is "not acceptable" and 10 is "highly acceptable". after that the respondents were asked to select which of the three scenarios they would choose. the healthcare indicators and the three scenarios populated are provided in table 2. https://select-statistics.co.uk/calculators/sample-size-calculator-population-proportion/ ghmj (global health management journal) 2024, vol. 7, no. 2 gani, s. 70 table 2. best options for healthcare scenarios indicators definition scenario 1 scenario 2 scenario 3 range of services range of services offered full range of services broader but not comprehensive limited range of services waiting time (general) medications time willing to wait for medication after general consultation medication to be given immediately collect after one day collect after a week waiting time (chronic) medication for chronic medication, time willing to wait in the queue every month to collect your medication no wait two hours four hours waiting time (general) consultation waiting time for: a general consultation (non-life threatening) no wait two hours four hours waiting time (casualty) consultation waiting time for: a visit to casualty no wait two hours four hours choice of treatment prefer to be informed and consulted by doctor doctor nurse waiting time – elective procedure waiting for an elective medical procedure such as a hip replacement one week one month six months location location preferred for the first appointment consultancy room hospital clinic waiting time – specialist waiting time for an appointment with a specialist four weeks eight weeks four months data analysis method the study applied conjoint analysis to examine healthcare users' preferences for several healthcare service indicators such as service range, waiting time for medications and consultations, waiting time for elective operations, and location. the first level of analysis was inferential analysis, which analysed the raw utilities or part-worths of each healthcare indicator. in analysing raw utilities, each indicator was isolated to determine its importance in the overall picture. the utilities in their original form are called "raw" utilities since they came directly from performing a regression analysis as applied by the sawtooth software for the conjoint analysis model. conjoint utilities or part-worths were scaled to an arbitrary additive constant within each indicator and are interval data. the arbitrary origin of the scaling within each indicator was due to the nature of the experimental designs in conjoint analysis and the dummy coding in the design mix (orme 2010:78). sawtooth software incorporates a rescaling method on the utilities so that each indicator has an average range of 100. to characterise the relative importance of each indicator, the study determined how much of a difference each utility made in the overall product or service, in this case, healthcare services. the percentage calculated represented how important that indicator was to the overall package. 4. results raw utilities based on the raw utilities data, each indicator's importance is shown in table 3. the table highlights that the utility with the overwhelming importance is the waiting time for chronic medication at 24.7%, followed by the waiting time for a visit to a casualty at 12.9% and the location for the first appointment at 11.1%. ghmj (global health management journal) 2024, vol. 7, no. 2 gani, s. 71 table 3: relative indicator importance in the utilities healthcare indicators importance percentage waiting time (chronic) medication 24.7% waiting time (casualty) consultation 12.9% location 11.1% consulted by (choice of treatment) 10.4% waiting time (general) medications 9.4% range of services 9.3% waiting time (general) consultation 8.5% waiting time – specialist 7.6% waiting time – elective procedure 6.1% relative importance of utilities at this point of the analysis, it is necessary to determine whether indicators' relative importance differs between public and private healthcare users – via an independent t-test. the results are interpreted based on a 5% level of significance. table 4 shows whether the importance differs between public and private healthcare users. table 4: relative importance of utilities: private versus public healthcare users t-test sig. (2-tailed) result relative importance – range of service 0.721 0.472 insignificant differences relative importance – waiting time (gen) – medication -1.174 0.241 insignificant differences relative importance – waiting time (chronic) – medication 0.101 0.919 insignificant differences relative importance waiting time (gen) – consultation 0.203 0.840 insignificant differences relative importance – waiting time (casualty) – consultation -0.299 0.765 insignificant differences relative importance – consulted by -0.006 0.995 insignificant differences relative importance – waiting time – elective procedure 0.056 0.955 insignificant differences relative importance – location 1.227 0.221 insignificant differences relative importance – waiting time – specialist -0.316 0.752 insignificant differences based on the results in table 4, there are no statistically significant differences in the mean utilities of public and private healthcare users. this is based on all p-values being greater than 0.05. consequently, separate analysis for public and private healthcare users is not necessary. the conjoint analysis question specifically addresses healthcare usage and not whether there are differences within the sample, and for this reason, it would have only been required to do a separate analysis for public or private healthcare and would not be warranted for the other demographic groups identified in the descriptive analysis. continuing with the analysis of the raw utilities, as shown in table 3, the relative importance of an indicator is essentially its share of importance in the overall package. the relative importance for each indicator, as seen in table 3 is derived through the average utility values seen in table 5. these values show ghmj (global health management journal) 2024, vol. 7, no. 2 gani, s. 72 the average utility value for each level tested within the indicator. the relative indicator importance is the difference between the highest and lowest utility level of the indicator, as seen in table 5. the average utilities highlight the importance of each indicator under the different levels. essentially, the importance percentage shown in table 5 is the average of the three levels shown in this table. table 5: average utility values indicator level average utility range of services limited -25.98 broader -20.31 comprehensive 46.29 waiting time (general) medication one week 8.80 one day -45.42 immediately 36.62 waiting time (chronic) medication four hours -138.98 two hours 77.53 immediately 61.44 waiting time (general) consultation four hours 34.57 two hours -20.70 immediately -13.88 waiting time (casualty) – consultation four hours -59.96 two hours 4.57 immediately 55.40 consulted by (choice of treatment) doctor 31.28 nurse -52.33 indifferent 21.05 waiting time – elective procedure six months 21.54 one month 3.23 one week -24.77 location hospital -8.56 clinic 52.66 consultancy rooms -44.10 waiting time – specialist four months 20.22 eight weeks 12.93 four weeks -33.16 table 5 shows the average utility values for each of the indicators. this utility scale runs from -100 to 100 for all the indicators except for "waiting time for a general consultation", which is given on a scale of 200 to 200, with the average or mean utility (mu) being 0. the positive figures shown in this table would indicate the more desirable level of the indicator and negative figures would indicate a less desirable level of the indicator. a positive utility would indicate that the healthcare user is happy or satisfied with this level of the indicator as opposed to a negative utility which would suggest that the healthcare user is unhappy with the level of the indicator. based on the analysis conducted in the descriptive analysis, a valid assumption would be that healthcare respondents would seek to maximise their personal gain. the boxplot analysis highlighted that, indicators such as range of services, waiting time for medication after a general consultation, waiting time for chronic medication, waiting time for a consultation in casualty and to be consulted by a doctor showed that the respondents wanted the absolute best option and were not willing to compromise. for other indicators such as the waiting time to see a specialist, the location of healthcare service, the waiting time ghmj (global health management journal) 2024, vol. 7, no. 2 gani, s. 73 for an elective medical procedure and the waiting time for a general consultation, respondents showed strategic reasoning whereby they were reasonable and rational in their expectation of healthcare services. these choices can be understood through the social interpersonal ontology which has a bearing on the social construction of reality. healthcare respondents had an informed preference, which influenced their choices and behaviours, so they demonstrated patience or rational thinking for some choices. figure 2 presents a visual of each of the indicators in a boxplot to show the data distribution or the skewness through displaying the data quartiles (or percentiles) and averages. a boxplot helps the reader understand which indicator level is most preferred. a normal distribution would be depicted when the median is in the middle of the box and the whiskers are about the same on both sides of the box, indicating that there is symmetry and it is a normal distribution. when the median is closer to the bottom of the box, and the whisker is shorter on the lower end of the box, then the distribution is positively skewed (skewed right). a negatively skewed distribution would be depicted when the median is closer to the top of the box. the whisker is shorter on the upper end of the box, skewed left, helping the reader visually understand whether the preferences are mesokurtic, platykurtic or leptokurtic. the boxplot shows clearly that the mean utility for a "comprehensive" range of services is 46.29, therefore, this distribution would be skewed right, indicating a positive skew (platykurtic distribution) for this level. this would indicate that the respondents' views were extreme regarding this utility. the other two levels, namely "broader" and "limited", have a negative utility as seen on the boxplot, indicating that the respondents were unhappy with this option. it is very clear from this visual that respondents felt very strongly that this utility was necessary. however, the platykurtic distribution indicates strong outliers and healthcare respondents identified wanting comprehensive health care. the indicator "waiting time for medication after a general consultation" has a positive average utility of 36.62 (per table 5) to receive the medication "immediately" and a positive average utility of 8.80 to receive the medication after "one week", however, this option is negatively skewed (leptokurtic). the respondents would thus be the happiest to receive the medication immediately. a negative average utility was recorded to collect the medication in "one day", which is strange, considering that they were not as averse to collecting after one week. however, it is necessary to understand the real living experience of the healthcare respondents. it could be argued that it would be more difficult to take two consecutive days off from work, as opposed to one day this week and one day the following week. the "waiting time for chronic medication" in the boxplot highlights that respondents have a 61.44 average utility for receiving the medication immediately and a 77.53 average utility for receiving the medication after two hours. the option to receive the medication immediately is positively skewed to the right and the option to receive the medication after two hours is skewed to the left, negatively skewed (leptokurtic). the four-hour option received a negative utility, which indicates that the respondents were strongly against this option. given that the respondents selected the second-best option, namely two hours, they were being reasonable in their expectations, understanding that the medication could not be immediately available, and a short waiting period was acceptable. however, the two-hour wait appears to be all they were prepared to accept. this phenomenon can be explained by "group think", where healthcare users waiting for their medication, every month communicate and exaggerate their experiences. the respondents, therefore, demonstrated a complete aversion to waiting for their chronic medication. further, it needs to be understood from this response that individuals respond differently in a situation where they are in pain (such as waiting for medication after a general consultation or a visit to casualty) and waiting for medication when they are not so overrun with pain (such as the waiting time for their chronic medication). the evidence presented through this boxplot indicates that the healthcare respondents were much more demanding in this expectation, which, if compared to the boxplot for "range of services", it is clear to identify the difference in distribution. it should also be noted that this boxplot is the only one with a range of 200 to -200, highlighting strong outliers ghmj (global health management journal) 2024, vol. 7, no. 2 74 figure 2: boxplot for each indicator ghmj (global health management journal) 2024, vol. 7, no. 2 gani, s. 75 the results for "waiting time for a general consultation" again indicate that the respondents were reasonable in their expectations, given that the "four hours" option has a positive average utility of 34.57 and is positively skewed to the right as opposed to the "two hours" option with a negative average utility of -20.70 and the "immediately" option which has a negative average utility of -13.88 and is skewed to the left. the "immediately" option had a wide range of utility levels. hence, some respondents had a positive utility for this option. still, the respondents were clear in their expectation of being consulted within four hours, given the much more concentrated view (the box), and this expectation indicated that they were reasonable in their expectations. this also supports the argument above that the healthcare respondents appeared much more willing to wait for their medication when they were not in pain. the social context influences this choice, which is evident in their social construction of reality. furthermore, the general others encountered in this situation would all be there under different circumstances. they would all be absorbed with their plight and not significantly influenced by their interactions. for "waiting time for a visit to casualty" the "immediately" option has an average utility of 55.40, the "two hours" option has an average utility of 4.57, and the "four hours" option has an average utility of -59.96. the respondents expected to be attended to immediately if they visited casualty. the understanding is that a visit to casualty would normally indicate an urgency or emergency, which explains their expectation to be attended to immediately. the difference between their reasoning in "waiting time for a general consultation" would be the impact of the urgency or emergency, and therefore, they were not prepared to wait. when analysing the utilities for the indicator "consulted by", the option of the "doctor" has the highest average utility with 31.28 and the option of the "nurse" has a negative average utility of -52.33. the "indifference" average utility is 21.05 but is positively skewed to the right. therefore, it is easy to conclude that the respondents would prefer to be attended to by a doctor and felt very strongly about being attended to by a nurse. the preference speaks to the stigma which people have regarding treatment by a nurse. they feel a doctor delivers the best treatment and this is evident from the boxplot. the distribution of utilities for "waiting time for an elective procedure" is seen in figure 2. the boxplot depicts that the "six months" option has an average utility of 21.54 and is positively skewed to the right. the "one month" option has an average utility of 3.23 and is also positively skewed to the right. the third option "one week" has a negative average utility of -24.77 and is skewed to the left. it is clear from this depiction that respondents were again demonstrating their rationality in their choices. they were not unreasonable and selected the "six months" option, considering it is an elective procedure and the health system would have to accommodate more pressing issues before an elective procedure. the "location for the first visit" has three options, the "clinic" option has an average utility of 52.66 and is positively skewed to the right, the "hospital" option has an average utility of -8.56 and is negatively skewed to the left, and the "consultancy rooms" option has an average utility of -44.10. the respondents were clear in their choice: they did not want to be treated at a consulting room and were opposed to being treated at a hospital. their overall choice was to be treated at a clinic. this choice makes sense, given that it is less tedious to travel to a clinic and the process would be more streamlined. again, the respondents demonstrated rational thinking that is socially informed. the "waiting time to see a specialist" is visually depicted with the option with the highest average utility, the "four months" option with 20.22, and it is positively skewed to the right. the "eight weeks" option has an average utility of 12.93 and is also positively skewed to the right. the third option, "four weeks", has a negative average utility of -33.16 and is skewed to the left. the overall preference by the respondents would be a fourmonth wait. this choice represents the longest waiting time of the three options and again indicates healthcare users who were being reasonable or rational in their expectations from an nhi. it also indicates that healthcare users understand that quality consultants or specialists, in this case, generally have longer waiting times. gani, s. ghmj (global health management journal) 2024, vol. 7, no. 2 76 5. discussion this section of the analysis examined the raw utilities to determine each indicator's relative importance and how much of a difference each utility makes in the overall product mix or service basket, in this case, healthcare services. the average relative indicator importance in the unconstrained utilities was first presented, showing the general indicator of importance being the "waiting time for chronic medication" with 24.7%. the average relative indicator importance was calculated based on the average utilities, therefore, to take the analysis a step further, the average utilities for the various option levels within each indicator were then analysed to highlight the importance of each indicator under the different levels. each indicator was analysed to determine which of the levels was most preferred by the healthcare respondents. this finding aligns with previous studies that emphasise waiting times as a significant determinant of patient satisfaction. for instance, authors such as alarcon-ruiz et al. (2019) and mcintyre and chow (2020) and also identified waiting times as a major concern for patients in healthcare settings, echoing the results of this study. the boxplot analysis also highlighted very significantly that the healthcare respondents were not as homogenous a group as identified under the descriptive analysis. there are very strong outliers at the top and the bottom of the boxplots, which would indicate a significant amount of diversity in the respondents' views. despite having concluded through the descriptive analysis that the population group represents a more homogenous population than was envisaged at the start of the analysis, the inferential analysis contradicted this conclusion. although the study has established that healthcare users had a specific preference, the boxplots indicated that although there is an average, the views of the respondents when analysing each indicator showed that there was a range in the spread of the views of the healthcare respondents. unlike the more homogeneous population identified in umar et al. (2023), which concluded that waiting times were uniformly problematic, this study’s analysis shows a more nuanced picture with significant variations in patient views, suggesting that the patient population in tshwane is more heterogeneous than previously thought. given that the descriptive data analysis concluded that the population group was homogenous and the analysis of the raw indicators applying the boxplots showed that the population did indeed consist of substantial outliers, leading the research to conclude that the population was indeed more heterogenous than what the descriptive analysis revealed. the study findings have several important implications for healthcare policymakers, providers, and stakeholders. the study highlights the relative importance of various healthcare service indicators from the perspective of the users. policymakers can use this information to design services that prioritise aspects deemed most crucial by patients, such as reducing waiting times for medication and consultations. a service design approach focused on patients can lead to higher patient satisfaction and improved healthcare outcomes. the study further found no significant differences between public and private healthcare users’ preferences, suggesting that an integrated strategy can be employed for both groups to improve their service experience. interestingly, this result contrasts with the findings of al-neyadi (2018), which identified differences in preferences between these two groups. the study supports the concept of unified strategies, which can improve healthcare services across both sectors. this will encourage collaboration between public and private providers. this view aligns with the opinion of cutler et al. (2019), which emphasises that integrated approaches can improve the overall healthcare delivery. the findings suggest the need for continuous monitoring and evaluation of healthcare services. by regularly assessing patient preferences and satisfaction, healthcare providers and policymakers will obtain valuable feedback for ongoing quality improvement. over time, healthcare providers can adapt their services to meet changing patient preferences and expectations. this finding aligns with cutler et al. (2019), who recommended ongoing quality improvement based on patient feedback. 6. conclusion the tshwane municipality in south africa faces various challenges in providing quality and patient-centered healthcare to its diverse and growing population. various attempts have been made by policymakers and healthcare providers to address these challenges but healthcare users still complain of poor service delivery. as 77 ghmj (global health management journal) 2024, vol. 7, no. 2 gani, s. a result, this research used a utility approach to analyse the relative importance of healthcare service indicators in the context of the tshwane municipality. the study employed a conjoint analysis to understand healthcare users' preferences for several healthcare indicators and factors such as service range, waiting time for medications and consultations, waiting time for elective operations, and location. the study distributed questionnaires to 280 respondents, comprising the following: black – 130, whites – 70, indians – 40, and coloured – 40. the data was collected from both public and private healthcare users, and the results were compared using an independent t-test to determine whether any of the observed differences were statistically significant. the findings revealed a broad range of preferences among healthcare users. the most important healthcare indicators to users were prescription wait times and access to comprehensive services. these results indicate that reducing waiting times and expanding available services could enhance healthcare users’ satisfaction. however, the study uncovered significant outliers among the users’ preferences, which emphasises the diverse needs and expectations of healthcare users. moreover, the study highlighted how social perceptions and stigma influence patient preferences, with a notable preference for doctors over nurses. this evidence suggests the need for interventions to improve the attitudes of all healthcare professionals. the evidence further demonstrated that there were no significant differences in preferences between public and private healthcare users, suggesting that similar strategies could be effective for both public and private healthcare users. in conclusion, this study improves the understanding of the relative importance of healthcare service indicators in the tshwane municipality. policymakers and healthcare providers can make informed decisions to improve service quality, accessibility, and overall patient satisfaction. the study recommends a further study that employs market simulator to explore potential service combinations and their likely acceptance by the community. conflict of interest there is no conflict of interest. nothing to disclosure. references alanazi, a. s., shah, s., abbas, g., hussain, m., saleem, a., khurram, h., ... & alzarea, s. i. (2023). assessing patient satisfaction with community pharmacy services: a large regional study at punjab, pakistan. patient preference and adherence, 1322. https://doi.org/10.2147/ppa.s389053 alarcon-ruiz, c. a., heredia, p., & taype-rondan, a. (2019). association of waiting and consultation time with patient satisfaction: secondary-data analysis of a national survey in peruvian ambulatory care facilities. bmc health services research, 19, 1-9. https://doi.org/10.1186/s12913-019-4288-6 al-harajin, r. s., al-subaie, s. a., & elzubair, a. g. (2019). the association between waiting time and patient satisfaction in outpatient clinics: findings from a tertiary care hospital in saudi arabia. journal of family and community medicine, 26(1), 17-22. https://doi.org/10.4103/jfcm.jfcm_14_18 al-neyadi, h. s., abdallah, s., & malik, m. (2018). measuring patient's satisfaction of healthcare services in the uae hospitals: using servqual. international journal of healthcare management, 11(2), 96-105. https://doi.org/10.1080/20479700.2016.1266804 ataguba, j.e. & mcintyre, d. (2012). paying for and receiving benefits from health services in south africa: is the health system equitable? health policy and planning, 27(1), i35-i45. https://doi.org/10.1093/heapol/czs005 ataguba, j.e., day, c. & mcintyre, d. (2015). explaining the role of social determinants of health-on-health inequality in south africa. global health action, 8(1). https://doi.org/10.3402/gha.v8.28865 bergvall, n., brinck, p., eek, d., gustavsson, a., wimo, a., winblad, b., & jönsson, l. (2011). relative importance of patient disease indicators on informal care and caregiver burden in alzheimer's disease. international psychogeriatrics, 23(1), 73-85. https://doi.org/10.1017/s1041610210000785 biddle, l., wahedi, k., & bozorgmehr, k. (2020). health system resilience: a literature review of empirical research. health policy and planning, 35(8), 1084-1109. https://doi.org/10.1093/heapol/czaa032 council for medical schemes. (2018). annual report 2018. available from: https://www.medicalschemes.com/files/annual%20reports/cmsar2018_19.pdf [accessed 24 april 2019]. cutler, d., skinner, j. s., stern, a. d., & wennberg, d. (2019). physician beliefs and patient preferences: a new look at regional variation in health care spending. american economic journal: economic policy, 11(1), 192-221. https://doi.org/10.1257/pol.20150421 https://doi.org/10.2147/ppa.s389053 https://doi.org/10.1186/s12913-019-4288-6 https://doi.org/10.4103/jfcm.jfcm_14_18 https://doi.org/10.1080/20479700.2016.1266804 https://doi.org/10.1093/heapol/czs005 https://doi.org/10.3402/gha.v8.28865 https://doi.org/10.1017/s1041610210000785 https://doi.org/10.1093/heapol/czaa032 https://doi.org/10.1257/pol.20150421 gani, s. ghmj (global health management journal) 2024, vol. 7, no. 2 78 department of health. (2015). white paper: national health insurance policy: towards universal health coverage. pretoria: government printer. fei, l., lu, j., & feng, y. (2020). an extended best-worst multi-criteria decision-making method by belief functions and its applications in hospital service evaluation. computers & industrial engineering, 142, 106355. https://doi.org/10.1016/j.cie.2020.106355 fischhoff, b., goitein, b., & shapira, z. (2021). the experienced utility of expected utility approaches. in expectations and actions (pp. 315-339). routledge. https://doi.org/10.4324/9781003150879-18 goodwin, n. 2008. national health systems: overview. london, uk: elsevier inc. https://doi.org/10.1016/b978-0123739605.00311-7 gray, e. j., & evangelou, e. (2023). a design utility approach for preferentially sampled spatial data. journal of the royal statistical society series c: applied statistics, 1-23. https://doi.org/10.1093/jrsssc/qlad040 helter, t. m., kaltenboeck, a., baumgartner, j., mayrhofer, f., heinze, g., sönnichsen, a., ... & simon, j. (2022). does the relative importance of the oxcap-mh's capability items differ according to mental ill-health experience?. health and quality of life outcomes, 20(1), 99. https://doi.org/10.1186/s12955-022-02009-6 horan, m. r., srivastava, d. k., bhakta, n., ehrhardt, m. j., brinkman, t. m., baker, j. n., ... & huang, i. c. (2023). determinants of health-related quality-of-life in adult survivors of childhood cancer: integrating personal and societal values through a health utility approach. eclinicalmedicine, 58. https://doi.org/10.1016/j.eclinm.2023.101921 mayosi, b.m., lawn, j.e., van niekerk, a., bradshaw, d., karim, s.s.a., coovadia, h.m. & lancet south africa team (2012). health in south africa: changes and challenges since 2009. the lancet, 380(9858), 2029-2043. https://doi.org/10.1016/s0140-6736(12)61814-5 mcintyre, d., & chow, c. k. (2020). waiting time as an indicator for health services under strain: a narrative review. inquiry: the journal of health care organization, provision, and financing, 57, 1-15. https://doi.org/10.1177/0046958020910305 mcintyre, d & van den heever, a. (2007). social or national health insurance. in: harrison, s, bhana, r & ntuli, a. eds. south african health review. durban, sa: health systems trust. 71-85. mitropoulos, p., vasileiou, k., & mitropoulos, i. (2018). understanding quality and satisfaction in public hospital services: a nationwide inpatient survey in greece. journal of retailing and consumer services, 40, 270-275. https://doi.org/10.1016/j.jretconser.2017.03.004 morgan-davies, c. & waterhouse, t. (2010). future of the hills of scotland: stakeholders' preferences for policy priorities. land use policy, 27(2), 387-398. https://doi.org/10.1016/j.landusepol.2009.05.002 mühlbacher, a. & johnson, f. r. (2016). choice experiments to quantify preferences for health and healthcare: state of the practice. applied health economics and health policy, 14, 253-266. https://doi.org/10.1007/s40258-016-0232-7 national consultative health forum (nchf) (2012). lessons for south africa. national health insurance conference report, gallagher convention centre, johannesburg, 7 to 8 december. national department of health (2020). national health insurance. pretoria: government printer. national department of health. (2013). regulating the quality of health services: benchmarking of approaches, institutions and systems. towards the establishment of an office of health standards compliance (ohsc). available from: http://www.dnaeconomics.com/assets/usealexconstantinoudnaeconomicscom/ohsc-regulating-the-quality-ofhealth-services.pdf [accessed 4 april 2018]. national treasury (2020). estimates of national expenditure 2020. available from: http://www.treasury.gov.za/documents/national%20budget/2020/ene/fullene.pdf [accessed 8 october 2018]. national treasury (2019). budget review 2019. available from: http://www.treasury.gov.za/documents/national%20budget/2019/review/fullbr.pdf [accessed 15 september 2018]. organisation for economic co-operation and development (2014). oecd health statistics 2014: how does south africa compare? available from: http://www.oecd.org/els/health-systems/briefing-note-south-africa-2014.pdf [accessed 27 june 2016]. orme, b. k. (2010). getting started with conjoint analysis: strategies for product design and pricing research. madison, wisconsin: research publishers. 39-50. poirier, m. j., grépin, k. a., & grignon, m. (2020). approaches and alternatives to the wealth index to measure socioeconomic status using survey data: a critical interpretive synthesis. social indicators research, 148(1), 1-46. https://doi.org/10.1007/s11205-019-02187-9 rangasamy, l. (2021). healthcare price changes and expenditures in south africa: some implications for economic policy. development southern africa, 38(4), 607-621. https://doi.org/10.1080/0376835x.2021.1907176 republic of south africa (2014). president jacob zuma: launch of operation phakisa 2. available from: https://www.gov.za/address-president-zuma-launch-operation-phakisa-2-ideal-clinic-realisation-and-maintenancesefako [accessed 13 august 2019]. https://doi.org/10.1016/j.cie.2020.106355 https://doi.org/10.4324/9781003150879-18 https://doi.org/10.1016/b978-012373960-5.00311-7 https://doi.org/10.1016/b978-012373960-5.00311-7 https://doi.org/10.1093/jrsssc/qlad040 https://doi.org/10.1186/s12955-022-02009-6 https://doi.org/10.1016/j.eclinm.2023.101921 https://doi.org/10.1016/s0140-6736(12)61814-5 https://doi.org/10.1177/0046958020910305 https://doi.org/10.1016/j.jretconser.2017.03.004 https://doi.org/10.1016/j.landusepol.2009.05.002 https://doi.org/10.1007/s40258-016-0232-7 http://www.dnaeconomics.com/assets/usealexconstantinoudnaeconomicscom/ohsc-regulating-the-quality-of-health-services.pdf http://www.dnaeconomics.com/assets/usealexconstantinoudnaeconomicscom/ohsc-regulating-the-quality-of-health-services.pdf http://www.treasury.gov.za/documents/national%20budget/2020/ene/fullene.pdf http://www.treasury.gov.za/documents/national%20budget/2019/review/fullbr.pdf http://www.oecd.org/els/health-systems/briefing-note-south-africa-2014.pdf https://doi.org/10.1007/s11205-019-02187-9 https://doi.org/10.1080/0376835x.2021.1907176 https://www.gov.za/address-president-zuma-launch-operation-phakisa-2-ideal-clinic-realisation-and-maintenance-sefako https://www.gov.za/address-president-zuma-launch-operation-phakisa-2-ideal-clinic-realisation-and-maintenance-sefako 79 ghmj (global health management journal) 2024, vol. 7, no. 2 gani, s. statistics south africa (2018). mid-year population estimates 2018. pretoria: statistics south africa. the economist (2012). sad south africa: cry, the beloved country. available from: http://www.economist.com/news/leaders/21564846-south-africa-sliding-downhill-while-much-rest-continent-clawingits-way-up [accessed 18 october 2014]. torkayesh, a. e., pamucar, d., ecer, f., & chatterjee, p. (2021). an integrated bwm-lbwacocoso framework for evaluation of healthcare sectors in eastern europe. socioeconomic planning sciences, 78, 101052. https://doi.org/10.1016/j.seps.2021.101052 umar, m. i., adehi, m. u., & auwal, m. a. (2023). a systematic review of multi-server queueing system: a case of lengthy wait times in hospital medical outpatient department (opd). african journal of advances in science and technology research, 12(1), 01-17. world bank (2019). data: gini index. available from: http://data.worldbank.org/indicator [accessed 12 march 2015]. world bank (2012). world development indicators 2012. washington, dc: world bank. available from: https://openknowledge.worldbank.org/handle/10986/6014 [accessed 23 march 2013]. world health organization (2010). world health report: health systems financing the path to universal coverage. geneva: world health organization. cite this article as: gani, s. (2024). an analysis of the relative importance of healthcare services indicators in south africa: utilities analysis approach. ghmj (global health management journal), 7(2), 66–79. https://doi.org/10.35898/ghmj-72983 http://www.economist.com/news/leaders/21564846-south-africa-sliding-downhill-while-much-rest-continent-clawing-its-way-up http://www.economist.com/news/leaders/21564846-south-africa-sliding-downhill-while-much-rest-continent-clawing-its-way-up https://doi.org/10.1016/j.seps.2021.101052 http://data.worldbank.org/indicator https://openknowledge.worldbank.org/handle/10986/6014 https://doi.org/10.35898/ghmj-72983 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 yeyentimalla1*, sri suryawati2 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 ghmj (global health management journal) 2024, vol. 7, no. 4 indonesian scholars’ alliance open access research article the 1st cirebon international health symposium: faculty of medicine, universitas swadaya gunung jati update on non-communicable diseases: global perspective on health challenges and innovation angiotensin-converting enzyme insertion/deletion (ace i/d) gene polymorphism as a risk factor for essential hypertension hasna nurazizah kuswara* , donny nauphar# , ariestya indah permata sari department of genetics, faculty of medicine, universitas swadaya gunung jati, indonesia. *corresponding author’s e-mail: kuswarahasnanurazizah@gmail.com*; dnauphar@yahoo.com# doi: 10.35898/ghmj-741044 abstract background: hypertension is the leading cause of death globally due to its complications, including coronary heart disease and stroke. in 2018, hypertension cases in west java were the second highest among all populations in indonesia. genetics is one of the unmodifiable risk factors for hypertension. angiotensin-converting enzyme insertion/deletion (ace i/d) gene polymorphism could affect ace production in the renin-angiotensin-aldosterone system (raas), which is linked to the blood pressure regulation. aims: to analyze ace i/d gene polymorphism as a risk factor for hypertension in cirebon. methods: an observational analysis with a case-control design was used in this study. blood samples were collected from 30 hypertensive patients and 30 healthy individuals at talun health center. dna extraction was performed to evaluate polymorphisms using arms-pcr. statistical analyses, including the chi-square test, fisher’s exact test, mann-whitney test, and kruskal-wallis test, were conducted to compare the case and control groups. the odds ratio was calculated to see the risk of the assessed variables, including genotype, allele frequency, and the presence of ace i/d gene polymorphism. results: in the case group, the frequency of the ii genotype was 2 (6.7%), the id genotype was 25 (83.3%), and the dd genotype was 3 (10.0%). in the control group, the frequency of the ii genotype was 2 (6.7%), the id genotype was 26 (86.7%), and the dd genotype was 2 (6.7%). statistically, there was no significant association between ace i/d gene polymorphisms in essential hypertension patients and healthy people (p=0.500; or=1.556; 95% ci=0.241-10.049). conclusion: ace i/d gene polymorphism was not significantly associated with essential hypertension in cirebon, west java, indonesia. keywords: polymorphism, ace gene, insertion-deletion mutation, blood pressure, hypertension. received: 25 september 2024 reviewed: 21 october 2024 revised: 23 november 2024 accepted: 30 november 2024 © 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:kuswarahasnanurazizah@gmail.com mailto:dnauphar@yahoo.com https://doi.org/10.35898/ghmj-741044 https://orcid.org/0009-0008-2203-1824 https://orcid.org/0000-0002-8708-4715 https://orcid.org/0000-0003-4037-937x 181 ghmj (global health management journal) 2024, vol. 7, no. 4 kuswara, et. al. 1. introduction one of the risk factors for diseases that cause death globally is hypertension, including coronary heart disease, ischemic stroke, and hemorrhagic stroke (world health organization, 2023, 2024). hypertension is a condition in which systolic blood pressure ≥140 mmhg and/or diastolic blood pressure ≥90 mmhg (world health organization, 2023). according to the world health organization (who), an estimated 1.13 billion people in the world suffer from hypertension. hypertension accounts for about 12.8% (estimated 7.5 million) of all deaths in the world (world health organization, 2023). the prevalence of hypertension in indonesia is 34.11% of individuals aged ≥18 years, while in west java province, the prevalence of hypertension is 39.6% (badan penelitian dan pengembangan kesehatan kementerian kesehatan ri, 2019). the estimated number of hypertension patients in cirebon regency in 2021 is 648.030, and 73.173, or 11.3% of the total number of hypertension patients, have received medical treatment according to standards (dinas kesehatan kabupaten cirebon, 2021). the estimated number of hypertension patients aged ≥15 years at the talun health center is 12.182 (dinas kesehatan kabupaten cirebon, 2021). essential hypertension and secondary hypertension are the two types of hypertensions that are classified according to their causes. essential hypertension is hypertension of unknown cause. the percentage of essential hypertension is 90%, while the percentage of secondary hypertension, whose cause is known to be 10% (kumar & clark, 2021; tortora & derrickson, 2014). among the factors that cause essential hypertension are genetic factors. an example is the polymorphism of genes that regulate blood pressure, such as angiotensin-converting enzyme (ace). (setiati et al., 2014). the ace gene plays a crucial role in the renin-angiotensin-aldosterone system (raas), which raises blood pressure by converting the inert peptide angiotensin i into the potent vasoconstrictor angiotensin ii. it also deactivates the vasodilator bradykinin (sayed-tabatabaei, oostra, isaacs, duijn, & witteman, 2006). differences in the ace enzymes produced can be caused by mutations in the ace gene. one of the most common variations is the insertion/deletion (i/d) of ace gene. insertion (i) refers to additional deoxyribonucleic acid (dna) segments in the ace gene. on the other hand, deletion (d) denotes the absence of specific segments in the ace gene. possible genotype combinations are ii, id, and dd (eleni et al., 2008; sayed-tabatabaei et al., 2006). the alu 287 bp sequence in intron 16 is where the ace i/d polymorphism is found (sayed-tabatabaei et al., 2006). ace i/d variants have been associated in multiple studies with an increased risk of cardiovascular diseases such as hypertension, stroke, kidney disease, psoriasis, and alzheimer's disease. (sayed-tabatabaei et al., 2006; x. wang et al., 2004). individuals carrying the d allele tend to have higher ace enzyme activity, resulting in increased angiotensin ii production, which can cause vasoconstriction and elevated blood pressure, thereby increasing the risk of essential hypertension (eleni et al., 2008; qadar pasha et al., 2002; l. wang, song, & dong, 2023). studies on ace i/d polymorphisms have produced conflicting results, possibly due to population differences and other risk factors. for instance, research conducted on the ethiopian population found a significant association between the ace i/d polymorphism and the risk of hypertension (birhan, molla, abdulkadir, & tesfa, 2022). a correlation between hypertension and the ace i/d gene polymorphism was discovered in studies conducted on the chinese steelworker community (x. zhang et al., 2022). meanwhile, a study in the hefei region of anhui, china, found no relationship between ace i/d gene polymorphism and hypertension in the hefei region of anhui, china (l. wang et al., 2023). the ace i/d polymorphism was not significantly associated with hypertension in a research conducted in south sulawesi, indonesia, involving 99 non-hypertensive and 104 hypertensive patients. (rasyid, bakri, & yusuf, 2012). to date, no studies have examined the connection between ace i/d polymorphisms and risk factors for hypertension in the population of cirebon, west java, indonesia, in 2024. therefore, this study aims to investigate the role of the ace i/d polymorphism as a risk factor for hypertension in the population of cirebon, west java, indonesia, in 2024. kuswara, et. al. ghmj (global health management journal) 2024, vol. 7, no. 4 182 2. methods study design and research procedures this observational analytical study employed a case-control design to investigate the relationship between ace i/d polymorphism and essential hypertension in cirebon, west java, indonesia. this study compared hypertensive patients, who represented the affected individuals (cases), and healthy individuals as the unaffected controls. participants were selected through purposive sampling based on predefined inclusion and exclusion criteria. the case-control approach determined a total sample size of 60 participants, comprising 30 individuals in the case group and 30 individuals in the control group. the subjects were categorized into two groups: the case group, which included patients diagnosed with essential hypertension according to jnc viii criteria, and those with a history of essential hypertension, receiving antihypertensive medications for more than 3 months. the control group consisted of healthy individuals without a history of essential or secondary hypertension, and who were not taking antihypertensive medications. control subjects were matched with case subjects by age (± 2 years). to reduce bias, patients who were pregnant or breastfeeding, or had a history of diabetes mellitus, renal disease, coronary heart disease, or other cardiovascular disease were excluded from the case group. measurements screening and blood collection of subjects data collection and sample acquisition were conducted between march and august 2024 at the talun public health center in cirebon. genetic analysis was performed at the research laboratory of the faculty of medicine at universitas swadaya gunung jati. after obtaining informed consent, participants who met the study criteria were screened using a questionnaire. clinical characteristics collected during screening included age, gender, occupation, ethnicity, body mass index (bmi), smoking status, dietary habits, and family history of hypertension. furthermore, blood pressure was measured three times, with 3 to 5 minutes between each measurement. blood samples (3–5 cc) were collected at the talun public health center, placed in edta tubes, and sent to the research laboratory at universitas swadaya gunung jati cirebon for genetic analysis. dna extraction the dna extraction was performed using the salting-out method with the tiangen tianamp dna/rna extraction kit. upon completion of the extraction process, the dna was stored at -20 ℃ in the freezer. dna amplification the extracted genomic dna from hypertensive patients was amplified using the arms-pcr technique. the forward primer used was 5’–ctggagaccactcccatcctttct–3’, and the reverse primer was 5’– gatgtggccatcacattcgtcagat–3’. the total volume for the amplification reaction was 25 μl, which included 12.5 μl of pcr taq master mix, 1.0 μl each of upstream and downstream primers, 1.0 μl of dna template, and 9.5 μl of deionized water. the arms-pcr condition included an initial pre-denaturation step at 95 °c for 5 minutes, followed by denaturation at 94 °c for 30 seconds, annealing at 58 °c for 30 seconds, and extension at 72 °c for 40 seconds. starting from denaturation to extension, the cycle was repeated 35 times. a final terminal extension was performed at 72 °c for 5 minutes (x. zhang et al., 2022). pcr visualization an insertion/deletion site characterized the ace i/d polymorphism, and genotypes were identified by visualizing arms-pcr amplification products under an ultraviolet analyzer. the dna fragments were stained with gelred and subjected to electrophoresis on a 1.5% agarose gel in tae buffer for 30 minutes at 100 volts. the expected results were ii genotype (490 bp); id genotype (190 bp, 490 bp); and dd genotype (190 bp). 183 ghmj (global health management journal) 2024, vol. 7, no. 4 kuswara, et. al. statistical techniques statistical analysis was performed using chi-square, fisher’s exact test, mann-whitney, and kruskal-wallis tests to compare case and control groups. odds ratios (or) with 95% confidence intervals (ci) were calculated to assess the risk associated with the variables such as genotype, allele frequency, and the presence of ace i/d gene polymorphism, with significance set at p<0.05. ethical clearance this study was conducted after receiving ethical clearance from the medical research ethics committee of universitas swadaya gunung jati on april 30, 2024, under approval number 29/ec/fkugj/iv/2024. 3. results overview of the characteristics of the research subject based on the results of the analysis of 60 respondents in table 1, it was found that the frequency of the highest age characteristics was around 23 (76.7%) subjects in the age range of 40-59 years in the control group and 22 (73.3%) in the case group. the most dominant frequency of ethnic characteristics was javanese, with 26 (57.8%) in the control group and 19 (42.2%) in the case group. the highest frequency of subjects with a family history of hypertension was observed in the control group, with 27 individuals (90.0%) categorized as having no history of hypertension. the highest frequency of bmi characteristics in both the case and control groups was obesity i, followed by overweight, obesity ii, and normal. in the case group, the frequencies were 13 (43.3%), 6 (20.0%), 6 (20.0%), 4 (13.3%), and 1 (3.3%) subjects, respectively. in contrast, the bmi distribution in the control group was as follows: 12 (40.0%) subjects had obesity i, 10 (33.3%) had overweight, 4 (13.3%) had obesity ii, 4 (13.3%) had normal bmi, and 0 (0.0%) subjects had other bmi categories. table 1. frequency distribution of characteristics of research subjects characteristics n (%) pvalue or (95 % ci) case control total 30 (100) 30 (100) age 18-39 40-59 ≥60 4 (13.3) 22 (73.3) 4 (13.3) 3 (10.0) 23 (76.7) 4 (13.3) 0.800a na sex male female 15 (50.0) 15 (50.0) 15 (50.0) 15 (50.0) 1.000b 1.00 (0.363-2.751) ethnicity javanese non-javanese 19 (42.2) 11 (73.3) 26 (57.8) 4 (26.7) 0.037*b 0.266 (0.073-0.964) family history of hypertension yes no 19 (63.3) 11 (36.7) 3 (10.0) 27 (90.0) 0.000*b 15.545 (3.814-63.359) bmi underweight normal overweight obesity i obesity ii 1 (3.3) 4 (13.3) 6 (20.0) 13 (43.3) 6 (20.0) 0 (0.0) 4 (13.3) 10 (33.3) 12 (40.0) 4 (13.3) 0.533c na smoking yes no 9 (30.0) 21 (70.0) 6 (20.0) 24 (80.0) 0.371b 1.714 (0.523-5.621) *significant (p<0.05) amann-whitney test. bchi-square test. ckruskal-wallis test. kuswara, et. al. ghmj (global health management journal) 2024, vol. 7, no. 4 184 the highest frequency of smoking status was observed in the non-smoking category, with 24 (80.0%) subjects in the control group and 21 (70.0%) in the case group. the p-value for ethnicity and family history of hypertension showed statistical significance (p=0.037; p=0.000), while age, gender, bmi, and smoking did not demonstrate significant associations with the incidence of hypertension (p=0.800; p=1.000; p=0.533; p=0.371). the or (95% ci) value for ethnicity was 0.266 (0.073-0.964), while for family history of hypertension was 15.545 (3.81463.359). the or (95% ci) value for smoking status was 1.714 (0.523-5.621). standard descriptive analysis of research subjects descriptive analysis (table 2) reveals that the case and control groups had the same age range and median age, with a range of 42 years and a median of 51 years. the standard deviation of the case group was 9.640, whereas that of the control group was 9.481. table 2. standard descriptive analysis of research subjects range median std. deviation control age 42 51 9.413 case age 42 51 9.640 total age 42 51 9.448 genotype and allele frequency distribution the genotype frequency distribution of the ace i/d gene was determined using arms-pcr, yielding three possible outcomes: ii (490 bp), id (190 bp, 490 bp), and dd (190 bp). the allele frequency distribution of the ace i/d gene consisted of allele i and allele d, as shown in table 3. according to the table, the most common genotype was id, found in 25 subjects (83.3%) in both the case and control groups. the least common genotype was ii, identified in only 2 subjects (6.7%) in the case group. the most frequent allele in the case group was allele i (51.7%), while in the control group, allele d was more prevalent (51.7%). the p-value for genotype (kruskalwallis test) and allele (fisher’s exact test) did not show significance (p=0.531; p=0.715). the or (95% ci) for the alleles was 1.143 (0.558-2.338). table 3. genotype and allele frequency distribution n (%) p-value or (95% ci) case control genotype ii id dd 2 (6.7) 25 (83.3) 3 (10.0) 3 (10.0) 25 (83.3) 2 (6.7) 0.531a 1.00 (ref) 0.667 (0.102-4.339) 2.25 (0.179-28.254) allele i d 31 (51.7) 29 (48.3) 29 (48.3) 31 (51.7) 0.715b 1.00 (ref) 1.143 (0.558-2.338) akruskal-wallis test. bchi-square test. moreover, table 4 demonstrates that there is no significant association between hypertension and the ace i/d genotype when fisher's exact test is applied. the id+dd vs. ii (reference) comparison yielded an odds ratio (or) of 0.643 and a 95% ci of 0.100–4.153. 185 ghmj (global health management journal) 2024, vol. 7, no. 4 kuswara, et. al. table 4. compound allele analysis n (%) p-value or (95% ci) case control total 30 (100) 30 (100) dd 3 (10.7) 2 (7.4) 1.00 (ref) • id 25 (89.3) 25 (93.6) 0.518a 1.500 (0.230-9.763) dd 3 (60.0) 2 (40.0) 1.00 (ref) • ii 2 (40.0) 3 (60.0) 0.500a 2.250 (0.179-28.254) dd 3 (10.0) 2 (6.7) 1.00 (ref) • id+ii 27 (90.0) 28 (93.3) 0.500a 1.556 (0.241-10.049) ii 2 (6.7) 3 (10.0) 1.00 (ref) • id+dd 28 (93.3) 27 (90.0) 0.500a 0.643 (0.100-4.153) afisher’s exact test gel electrophoresis visualization results figure 1 illustrates the results of gel electrophoresis conducted on 1.5% agarose gel, run for 30 minutes at 100 volts. bands labeled 3, 5, 8, and 11 showed a single band representing ii (490 bp), while bands labeled 1, 4, 6, 7, and 9 showed two bands corresponding to id (190 bp, 490 bp), and bands 2 and 10 indicated a single band for dd (190 bp). figure 1. gel electrophoresis of ace i/d relationship between ace i/d polymorphism and essential hypertension table 5 reveals that 28 (93.3%) subjects in the case group had the ace i/d polymorphism, while only 2 (6.7%) did not. in the control group, 27 (90.0%) subjects had the polymorphism, while 3 (10.0%) did not. due to the small number of subjects in each category, the data did not meet the minimum expected count for the chi-square test. therefore, fisher's exact test yielded a p-value of 0.500, indicating no statistical significance (p>0.05). the or (95% ci) was 1.556 (0.241-10.049), suggesting that subjects with the ace i/d polymorphism were 1.556 times more likely to develop essential hypertension than those without the polymorphism. in this study, the ace i/d polymorphism was considered a risk factor for essential hypertension. kuswara, et. al. ghmj (global health management journal) 2024, vol. 7, no. 4 186 table 5. association of ace i/d gene polymorphism with essential hypertension polymorphism n (%) p-value or (95% ci) case control yes (dd and id) 28 (93.3) 27 (90.0) 0.500a 1.556 (0.241-10.049) no (ii) 2 (6.7) 3 (10.0) 1.00 (ref) total 30 (100.0) 30 (100.0) afisher exact test 4. discussion one of the primary contributors to cardiovascular disease-related mortality is hypertension, a disorder characterized by elevated blood pressure. the complications of hypertension can affect multiple target organs, with the extent of organ damage depending on the severity and duration of high blood pressure. common complications include ischemic heart disease, heart failure, stroke, kidney failure, retinopathy, and other related disorders (muhadi, 2016). family history or genetic predisposition is a significant non-modifiable risk factor for hypertension (rahmadhani, 2021). more than 150 genes have been linked to hypertension, with various genetic variations evolving according to the study population (y. zhang et al., 2019). one of the most critical genes involved in hypertension is the ace gene, which plays a vital role in the raas (sayed-tabatabaei et al., 2006). in this study, a family history of hypertension was statistically significant (p<0.05), with an or (95% ci) of 15.545 (3.814-63.359), indicating that individuals with a family history of hypertension are 15.545 times more likely to develop hypertension than those without such a history. these findings are consistent with a study conducted in 2023 in kendari, indonesia, which also demonstrated a significant association between family history and hypertension risk, where subjects with a family history of hypertension were 12 times more likely to develop the condition (sudayasa, husdaningsih, & alifariki, 2023). this study involved 30 hypertensive patients and 30 healthy individuals. the significance of ethnicity was observed in both groups, with a p-value of 0.037 (p<0.05), similar to the finding from a study conducted in india that also reported a significant association with hypertension in both the case and control groups (qadar pasha et al., 2002). the or (95% ci) for ethnicity was 0.266 (0.073-0.964), suggesting that it may serve as a protective factor against hypertension in this study. a study in banyuwangi, east java, indonesia, showed similar results, indicating that ethnicity was not a risk factor for hypertension (astutik, puspikawati, dewi, mandagi, & sebayang, 2020). bmi characteristics did not show statistical significance in either group, with a p-value of 0.585 (p>0.05), consistent with studies conducted in kazakh populations in china’s barkol pasture (x. wang et al., 2004), mataram, indonesia (rezqi, fathana, & dirja, 2023), and bogor, indonesia (agustiani, anggie nauli, & masitha arsyati, 2023). however, studies conducted in anhui, china (l. wang et al., 2023), lorestan, iran (hadian, zafarmohtashami, chaghervand, & nouryazdan, 2022), and yogyakarta, indonesia (bawazier, sja’bani, haryana, soesatyo, & sadewa, 2010) reported significant associations between bmi and hypertension. smoking status in this study also did not demonstrate statistical significance between the two groups, with a p-value of 0.371 (p>0.05). this finding aligns with studies conducted in banyuwangi (bawazier et al., 2010), and south hulu sungai, kalimantan selatan, indonesia (mufaidah, 2019), which similarly found no significant association between smoking and the incidence of hypertension (hidayat & milenia saputri, 2023). likewise, a recent study in anhui, china, reported no significant association between smoking and essential hypertension (l. wang et al., 2023). the ace gene influences plasma ace levels and blood pressure regulation through the raas. approximately 47% of the variation in serum ace levels is attributed to the insertion/deletion (i/d) polymorphism (sudayasa et al., 2023). in this study, the id genotype was the most common among both case and control groups, followed by the dd and ii genotypes. the most frequent allele in the case group was allele i, while allele d was more prevalent in the control group. genotype and allele frequencies were not significantly associated with hypertension, consistent with findings from a study involving 203 subjects in south sulawesi, indonesia (rasyid et al., 2012). similar results were observed in a cross-sectional study with 69 postmenopausal women in java 187 ghmj (global health management journal) 2024, vol. 7, no. 4 kuswara, et. al. (utami, simamora, idawati, & widjaja, 2024). according to that study, the ii genotype was more prevalent among healthy individuals; however, the dd genotype was exclusively present among hypertensive patients. a study conducted in japan similarly reported no significant association between genotype and allele frequencies among case and control groups (ishigami et al., 1995). in this study, the ii genotype was more frequently observed in healthy individuals. the i allele is associated with lower concentrations of angiotensin ii in tissues and reduced enzyme levels. in contrast, the d allele is linked to higher serum ace levels, resulting in increased angiotensin ii concentration and bradykinin degradation, which leads to hypertension (barley et al., 1994). a study conducted in yogyakarta, indonesia (bawazier et al., 2010) found that the id+dd genotypes were significantly associated with hypertension compared to the ii genotype. however, the comparison between id+dd vs. ii genotypes in this study was not statistically significant, although it suggested a protective effect (or<1). similar results were observed in a study conducted in burkina faso, west africa, where the id+dd vs. ii genotypes were found to be protective, with an or of 0.34 and a 95% ci of 0.14– 0.76 (tchelougou et al., 2015). this study aimed to investigate the association between the risk of hypertension and ace i/d gene polymorphisms. the results indicated no significant association between ace i/d polymorphisms and hypertension; however, the or values suggested that ace i/d polymorphisms could still be considered a risk factor for essential hypertension. these findings are consistent with a study conducted in south sulawesi, indonesia, involving 99 non-hypertensive and 104 hypertensive subjects (rasyid et al., 2012). the lack of significant differences between the two groups in that study suggests that essential hypertension may not be associated with the ace i/d polymorphism. a cross-sectional study in the spanish-mediterranean population also found no association between the ace i/d gene and hypertension, although the d allele was statistically linked to increased serum ace activity (martínez et al., 2000). similarly, a study in the perm region of russia in 2022 reported a risk ratio of 1.87 (95% ci: 1.07–3.61), suggesting that the ace i/d polymorphism may serve as a potential marker for susceptibility to essential hypertension (starkova, dolgikh, kazakova, & legostaeva, 2022). a large-scale analysis of data from 5.561 participants in the nhanes iii survey found limited support for an association between the ace i/d variant and blood pressure or hypertension across various racial and ethnic groups, although significant genotype-sex interactions were observed specifically in mexican americans. overall, there was a notable lack of significant associations in most cases (ned et al., 2012). in contrast, several previous studies have demonstrated a strong association between essential hypertension and the ace i/d gene polymorphism. a case-control study conducted in lorestan province, iran, in 2022 found that the ii genotype increased the incidence of essential hypertension among 102 hypertensive patients and 104 healthy individuals (hadian et al., 2022). in gondar, ethiopia, another case-control study conducted in 2022 discovered a high association between essential hypertension and both the d allele and dd genotype (birhan et al., 2022). additionally, a study involving 725 male steelworkers in china concluded that the dd genotype increased the risk of essential hypertension (x. zhang et al., 2022). a meta-analysis conducted in 2020 on the chinese population also concluded that the ace i/d gene is associated with the development of essential hypertension (xu, chen, li, zhang, & li, 2020). furthermore, a systematic review and meta-analysis found that the d allele of the ace gene is strongly associated as a risk factor for essential hypertension across asian, caucasian, and mixed populations (liu, yi, & tang, 2021). the discrepancies in research findings may be attributed to several factors, including variations in sample size, ethnicity, environment, and lifestyle. this study had a limited sample size because certain factors that could bias hypertension results, such as kidney disease, diabetes mellitus, and alcohol use, were excluded. future research should involve a larger sample size to account for broader demographic differences and ethnic diversity. ethnic diversity worldwide significantly impacts research outcomes because genetic variations can lead to changes in the frequency distribution of ace genotypes within each community (burchard et al., 2003). additionally, environmental factors and lifestyle variations within each ethnicity produce diverse and complex interactions that can affect research outcomes. kuswara, et. al. ghmj (global health management journal) 2024, vol. 7, no. 4 188 lifestyle is one of the risk factors for hypertension, which includes exercise (dida, nayoan, & sir, 2023), diet (frisoli, schmieder, grodzicki, & messerli, 2012), and stress levels (bhelkar, deshpande, & mankar, 2019). aerobic exercise influences blood pressure responses differently based on the ace i/d genotype. in a study involving elderly hypertensive individuals, those with the d/d genotype exhibited impaired mean arterial pressure responses following exercise, particularly during sleep, as well as reduced heart rate variability and nitric oxide release (moreira et al., 2018). high salt intake interacts with the ace i/d polymorphism to affect blood pressure. a study on japanese men found that high salt intake increased blood pressure in individuals with id+ii genotypes but not in those with dd genotypes. this interaction was more pronounced among overweight individuals, leading to diastolic blood pressure of 10.5 mmhg in those with id+ii genotypes compared to dd genotypes (l. zhang et al., 2006). diets high in potassium, soy protein, alpha-linolenic acid, and low in sodium can decrease ace activity and potentially reduce hypertension risk. conversely, diets high in sodium may increase ace activity and contribute to higher blood pressure, especially among individuals with certain ace i/d genotypes (zambrano et al., 2023). therefore, further research is needed to assess these factors comprehensively. this study aims to provide an evaluation for future researchers and create opportunities for subsequent studies to expand knowledge on related topics. 5. conclusion in both the case and control groups, the id genotype was the most commonly observed. essential hypertension was not associated with genotype frequency. the case group exhibited a higher frequency of the i allele, while the control group had a higher frequency of the d allele. there was no significant association between essential hypertension and the frequency of a specific allele. polymorphisms in the ace i/d gene were not significantly associated with essential hypertension. conflict of interest the authors declare that they have no conflicts of interest relevant to the results presented. references agustiani, y., anggie nauli, h., & masitha arsyati, a. (2023). hubungan antara obesitas, kebiasaan merokok dan aktivitas fisik dengan kejadian hipertensi pada lansia di wilayah kerja puskesmas gang kelor. promotor, 6(2), 141–149. https://doi.org/10.32832/pro.v6i4.277 astutik, e., puspikawati, s. i., dewi, d. m. s. k., mandagi, a. m., & sebayang, s. k. (2020). prevalence and risk factors of high blood pressure among adults in banyuwangi coastal communities, indonesia. ethiopian journal of health sciences, 30(6), 941–950. https://doi.org/10.4314/ejhs.v30i6.12 badan penelitian dan pengembangan kesehatan kementerian kesehatan ri. (2019). laporan riskesdas 2018 nasional. in kementerian kesehatan republik indonesia. jakarta: lembaga penerbit badan penelitian dan pengembangan kesehatan ri. barley, j., blackwood, a., carter, n. d., crews, d. e., cruickshank, j. k., jeffery, s., … sagnella, g. a. (1994). angiotensin converting enzyme insertion/deletion polymorphism. journal of hypertension, 12(8), 995. https://doi.org/10.1097/00004872199408000-00014 bawazier, l. a., sja’bani, m., haryana, s. m., soesatyo, m. h. n. e., & sadewa, a. h. (2010). relationship of angiotensin converting enzyme gene polymorphism and hypertension in yogyakarta, indonesia. acta medica indonesiana, 42(4), 192–198. bhelkar, s., deshpande, s., & mankar, s. (2019). association between stress and hypertension among adults more than 30 years: a case-control study. national journal of community medicine│volume, 9(6), 430–433. birhan, t. a., molla, m. d., abdulkadir, m., & tesfa, k. h. (2022). association of angiotensin-converting enzyme gene insertion/deletion polymorphisms with risk of hypertension among the ethiopian population. plos one, 17(11 november), 1–14. https://doi.org/10.1371/journal.pone.0276021 burchard, e. g., ziv, e., coyle, n., gomez, s. l., tang, h., karter, a. j., … pérez-stable, e. j. (2003). the importance of race and ethnic background in biomedical research and clinical practice. the new england journal of medicine, 348(12), 1170– 1175. dida, g. y., nayoan, c. r., & sir, a. b. (2023). the risk factors of hypertension among the elderly in the working area of sikumana primary health care center. journal of public health for tropical and coastal region, 6(1), 21–29. https://doi.org/10.14710/jphtcr.v6i1.17541 https://doi.org/10.32832/pro.v6i4.277 https://doi.org/10.4314/ejhs.v30i6.12 https://doi.org/10.1097/00004872-199408000-00014 https://doi.org/10.1097/00004872-199408000-00014 https://doi.org/10.1371/journal.pone.0276021 https://doi.org/10.14710/jphtcr.v6i1.17541 189 ghmj (global health management journal) 2024, vol. 7, no. 4 kuswara, et. al. dinas kesehatan kabupaten cirebon. (2021). profil kesehatan kabupaten cirebon tahun 2021. dinas kesehatan kabupaten cirebon. eleni, s., dimitrios, k., vaya, p., areti, m., norma, v., & magdalini, g. (2008). angiotensin-i converting enzyme gene and i/d polymorphism distribution in the greek population and a comparison with other european populations. journal of genetics, 87(1), 91–93. https://doi.org/10.1007/s12041-008-0013-7 frisoli, t. m., schmieder, r. e., grodzicki, t., & messerli, f. h. (2012). salt and hypertension: is salt dietary reduction worth the effort? american journal of medicine, 125(5), 433–439. https://doi.org/10.1016/j.amjmed.2011.10.023 hadian, b., zafarmohtashami, a., chaghervand, z., & nouryazdan, n. (2022). angiotensin-converting enzyme gene insertion/deletion polymorphism and hypertension disease. archives of physiology and biochemistry, 128(5), 1165–1169. https://doi.org/10.1080/13813455.2020.1762225 hidayat, t., & milenia saputri, r. (2023). hubungan tingkat ketergantungan nikotin dengan tekanan darah pada kelompok perokok laki-laki dengan hipertensi. jurnal ilmu kesehatan insan sehat, 11(2), 52–57. https://doi.org/10.54004/jikis.v11i2.135 ishigami, t., iwamoto, t., tamura, k., yamaguchi, s., iwasawa, k., uchino, k., … ishii, m. (1995). angiotensin i converting enzyme (ace) gene polymorphism and essential hypertension in japan. 7061(94), 95–97. kumar, d. p. j., & clark, m. l. (2021). kumar and clark’s clinical medicine (10th ed; a. feather, d. randall, & m. waterhouse, eds.). united kingdom: elsevier. liu, m., yi, j., & tang, w. (2021). association between angiotensin converting enzyme gene polymorphism and essential hypertension: a systematic review and meta-analysis. jraas journal of the renin-angiotensin-aldosterone system, 22(1). https://doi.org/10.1177/1470320321995074 martínez, e., puras, a., escribano, j., sanchis, c., carrión, l., artigao, m., … fernández, j. a. (2000). angiotensin-converting enzyme (ace) gene polymorphisms, serum ace activity and blood pressure in a spanish-mediterranean population. journal of human hypertension, 14(2), 131–135. https://doi.org/10.1038/sj.jhh.1000958 moreira, s. r., nóbrega, o. t., santana, h. a. p., sales, m. m., farinatti, p. t. v., & simões, h. g. (2018). impacto del polimorfismo i/d del gen de la enzima conversora de la angiotensina en la presión sanguínea, variacion de la frecuencia cardíaca y óxido nítrico en respuesta a ejercicios aeróbicos en mayores hipertensos. revista andaluza de medicina del deporte, 11(2), 57– 62. https://doi.org/10.1016/j.ramd.2015.10.001 mufaidah, s. (2019). hubungan imt, usia dan kebiasaan merokok terhadap kejadian hipertensi pada nelayan kub pondok layar. journal of community mental health and public policy, 1(2), 1–12. https://doi.org/10.51602/cmhp.v1i2.29 muhadi. (2016). jnc 8 : evidence-based guideline penanganan pasien hipertensi dewasa. cermin dunia kedokteran, 43(1), 54– 59. ned, r. m., yesupriya, a., imperatore, g., smelser, d. t., moonesinghe, r., chang, m. h., & dowling, n. f. (2012). the ace i/d polymorphism in us adults: limited evidence of association with hypertension-related traits and sex-specific effects by race/ethnicity. american journal of hypertension, 25(2), 209–215. https://doi.org/10.1038/ajh.2011.182 qadar pasha, m. a., khan, a. p., kumar, r., ram, r. b., grover, s. k., srivastava, k. k., … brahmachari, s. k. (2002). variations in angiotensin-converting enzyme gene insertion/deletion polymorphism in indian populations of different ethnic origins. journal of biosciences, 27(1 suppl. 1), 67–70. https://doi.org/10.1007/bf02703684 rahmadhani, m. (2021). faktor-faktor yang mempengaruhi terjadinya hipertensi pada masyarakat di kampung bedagai kota pinang. jurnal kedokteran stm (sains dan teknologi medik), iv(i), 52–62. https://doi.org/10.30743/stm.v4i1.132 rasyid, h., bakri, s., & yusuf, i. (2012). angiotensin-converting enzyme gene polymorphisms, blood pressure and pulse pressure in subjects with essential hypertension in a south sulawesi indonesian population. acta medica indonesiana, 44(4), 280–283. rezqi, e. g., fathana, p. b., & dirja, b. t. (2023). hubungan perilaku merokok dan obesitas dengan kejadian hipertensi pada guru sman di kota mataram. intisari sains medis, 14(1), 237–242. https://doi.org/10.15562/ism.v14i1.1569 sayed-tabatabaei, f. a., oostra, b. a., isaacs, a., duijn, c. m. van, & witteman, j. c. m. (2006). ace polymorphisms. lippincott williams & wilkins, 1123–1133. https://doi.org/10.1161/01.res.0000223145.74217.e7 setiati, s., alwi, i., sudoyo, a. w., simadibrata k, m., setiyohadi, b., & syam, a. f. (2014). buku ajar ilmu penyakit dalam. in interna publishing (edisi 6). jakarta: interna publishing. starkova, k. g., dolgikh, о. v., kazakova, о. а., & legostaeva, т. а. (2022). ace i/d genetic polymorphism as a risk factor of essential hypertension. health risk analysis, 7(3), 169–175. https://doi.org/10.21668/health.risk/2022.3.16.eng sudayasa, i. p., husdaningsih, f., & alifariki, l. o. (2023). polymorphism of gene ace i/d and family history of hypertension as the predisposition of hypertension. malaysian journal of medicine and health sciences, 18(2), 236–241. https://doi.org/10.47836/mjmhs.19.2.34 tchelougou, d., kologo, j. k., karou, s. d., yaméogo, v. n., bisseye, c., djigma, f. w., … simpore, j. (2015). renin-angiotensin system genes polymorphisms and essential hypertension in burkina faso, west africa. international journal of hypertension, 2015. https://doi.org/10.1155/2015/979631 tortora, g. j., & derrickson, b. (2014). principles of anatomy and physiology. in physiotherapy (14th ed., vol. 86). united states of america: john wiley & sons, inc. https://doi.org/10.1016/s0031-9406(05)60992-3 utami, s. l., simamora, d., idawati, i., & widjaja, j. h. (2024). ace i/d and a2350g polymorphisms are correlated with body mass index, but not with body weight and essential hypertension: study in javanese postmenopausal women. molecular and cellular biomedical sciences, 8(2), 96. https://doi.org/10.21705/mcbs.v8i2.426 wang, l., song, t. t., & dong, c. w. (2023). association between interactions among ace gene polymorphisms and essential hypertension in patients in the hefei region, anhui, china. journal of the renin-angiotensin-aldosterone system : jraas, 2023, 1159973. https://doi.org/10.1155/2023/1159973 https://doi.org/10.1007/s12041-008-0013-7 https://doi.org/10.1016/j.amjmed.2011.10.023 https://doi.org/10.1080/13813455.2020.1762225 https://doi.org/10.54004/jikis.v11i2.135 https://doi.org/10.1177/1470320321995074 https://doi.org/10.1038/sj.jhh.1000958 https://doi.org/10.1016/j.ramd.2015.10.001 https://doi.org/10.51602/cmhp.v1i2.29 https://doi.org/10.1038/ajh.2011.182 https://doi.org/10.1007/bf02703684 https://doi.org/10.30743/stm.v4i1.132 https://doi.org/10.15562/ism.v14i1.1569 https://doi.org/10.1161/01.res.0000223145.74217.e7 https://doi.org/10.21668/health.risk/2022.3.16.eng https://doi.org/10.47836/mjmhs.19.2.34 https://doi.org/10.1155/2015/979631 https://doi.org/10.1016/s0031-9406(05)60992-3 https://doi.org/10.21705/mcbs.v8i2.426 https://doi.org/10.1155/2023/1159973 kuswara, et. al. ghmj (global health management journal) 2024, vol. 7, no. 4 190 wang, x., wang, s., lin, r., jiang, x., cheng, z., turdi, j., … wen, h. (2004). gnb3 gene c825t and ace gene i/d polymorphisms in essential hypertension in a kazakh genetic isolate. journal of human hypertension, 18(9), 663–668. https://doi.org/10.1038/sj.jhh.1001700 world health organization. (2023). hypertension. retrieved january 10, 2024, from world health organization website: https://www.who.int/news-room/fact-sheets/detail/hypertension world health organization. (2024). global health estimates: life expectancy and leading causes of death and disability. retrieved january 10, 2024, from world health organization website: https://www.who.int/data/gho/data/themes/mortality-andglobal-health-estimates xu, j., chen, j., li, y., zhang, d., & li, x. (2020). association of angiotensin-converting enzyme gene insertion/deletion polymorphism and obstructive sleep apnoea in a chinese population: a meta-analysis. jraas journal of the reninangiotensin-aldosterone system, 21(2). https://doi.org/10.1177/1470320320934716 zambrano, a. k., cadena-ullauri, s., guevara-ramírez, p., ruiz-pozo, v. a., tamayo-trujillo, r., paz-cruz, e., … doménech, n. (2023). genetic diet interactions of ace: the increased hypertension predisposition in the latin american population. frontiers in nutrition, 10(october). https://doi.org/10.3389/fnut.2023.1241017 zhang, l., miyaki, k., araki, j., song, y., kimura, t., omae, k., & muramatsu, m. (2006). interaction of angiotensin i-converting enzyme insertion-deletion polymorphism and daily salt intake influences hypertension in japanese men. hypertension research, 29(10), 751–758. https://doi.org/10.1291/hypres.29.751 zhang, x., wang, y., zheng, y., yuan, j., tong, j., xu, j., … li, x. (2022). effect of ace, ace2 and cyp11b2 gene polymorphisms and noise on essential hypertension among steelworkers in china: a case–control study. bmc medical genomics, 15(1), 1–10. https://doi.org/10.1186/s12920-022-01177-0 zhang, y., shi, f., yu, z., yang, a., zeng, m., wang, j., … ma, x. (2019). a cross-sectional study on factors associated with hypertension and genetic polymorphisms of renin-angiotensinaldosterone system in chinese hui pilgrims to hajj. bmc public health, 19(1223), 1–11. https://doi.org/10.1186/s12889-019-7357-1 cite this article as: kuswara, h. n., nauphar, d., & sari, a. i. p. (2024). angiotensin-converting enzyme insertion/deletion (ace i/d) gene polymorphism as a risk factor for essential hypertension. ghmj (global health management journal), 7(4), 180–190. https://doi.org/10.35898/ghmj-741044 https://doi.org/10.1038/sj.jhh.1001700 https://www.who.int/news-room/fact-sheets/detail/hypertension https://doi.org/10.1177/1470320320934716 https://doi.org/10.3389/fnut.2023.1241017 https://doi.org/10.1291/hypres.29.751 https://doi.org/10.1186/s12920-022-01177-0 https://doi.org/10.1186/s12889-019-7357-1 https://doi.org/10.35898/ghmj-741044 indonesian scholars’ alliance ghmj (global health management journal) 2024, vol. 7, no. 4 open access research article characteristics and endoscopy findings of liver cirrhosis patients at waled hospital, cirebon, indonesia (2020-2023) afifah humaira azahra1* , sedayu2 , ahmad fariz malvi zamzam zein2 1 faculty of medicine, universitas swadaya gunung jati, indonesia, 2 department of internal medicine, faculty of medicine, universitas swadaya gunung jati, indonesia. *corresponding author’s e-mail: afifahhumairaaz@gmail.com doi: 10.35898/ghmj-741071 abstract background: hepatic cirrhosis is a terminal manifestation of chronic liver disease. the causes of cirrhosis in the asia pacific it was caused by hepatitis b. older adults are more likely to experience complications, which might be due to abnormalities in the liver. various complications occurred during the progression from compensated to decompensated, and endoscopic examination showed images of gastroesophageal varices or phg. aims: the aim was to determine the characteristics of liver cirrhosis patients and the endoscopy findings at waled hospital from 2020 to 2023. methods: this research used descriptive observational methods. the sample in this study were patients with liver cirrhosis at waled hospital from 2020-2023, there were 135 sample who were selected using total sampling techniques. information was acquired from medical records of 33 patients who met the consideration rules. results: this study showed that the largest number of patients with liver cirrhosis based on age 45 years old (12.1%), predominantly male (72.7%), with the etiology hepatitis b (69.7%), and all (100%) were in decompensated stage. endoscopy results revealed that the majority of patients experiences esophageal varices and phg (54.5%), with grade 3 esophageal varices (81.8%) and mild grade phg (60.6%) dominating. conclusion: the majority of patients with liver cirrhosis were 45 years old, predominantly male, with the most common etiology hepatitis b, and all were in the decompensated stage. the most common endoscopy results showed esophageal varices and phg, with grade 3 esophageal varices and mild grade phg. keywords: liver cirrhosis, endoscopy findings, gastroesophageal varices, portal hypertensive gastropathy. received: 26 september 2024 reviewed: 23 october 2024 revised: 30 november 2024 accepted: 12 december 2024 mailto:afifahhumairaaz@gmail.com https://doi.org/10.35898/ghmj-741071 https://orcid.org/0009-0004-8723-7541 https://orcid.org/0009-0007-0259-8973 https://orcid.org/0000-0001-7821-3813 azahra, et. al. ghmj (global health management journal) 2024, vol. 7, no. 4 288 1. introduction the last stage of diffuse progressive liver fibrosis is known as liver cirrhosis, and it is marked by the production of regenerating nodules and deformation of the liver architecture. blood vessels in the gaster and esophagus may dilate or varices when the liver architecture deteriorates and vascularization rises. the last stage of chronic liver disease is cirrhosis. during the progression from compensated to decompensated phase, various complication arise, and the prognosis significantly worsens (afzal, tarar, and shah 2018; setiati, alwi, and sudoyo 2014). the etiology of hepatic cirrhosis is highly varied. the three most prevalent causes in the western world are nonalcoholic fatty liver disease (nafld), hepatitis c, and alcohol. on the other hand, hepatitis b virus is the primary cause of (huang et al. 2023). according to the 2017 global burden of disease (gbd) study, it was estimated that there were 112 million cases of compensated cirrhosis and 10.6 million cases of decompensated cirrhosis globally (devarbhavi et al. 2023). the most common side effects of hepatic cirrhosis include liver cancer, hepatorenal syndrome, ascites, spontaneous bacterial peritonitis, esophageal variceal hemorrhage, portal hypertension, and hepatic encephalopathy. complications brought on by the diseases advancement might worsen the prognosis and further impair liver function (setiati et al. 2014). endoscopic examinations are necessary to determine the presence of any complications. endoscopic imaging of patients with liver cirrhosis reveals the most frequent lesion found are esophageal varices and portal hypertensive gastropathy (afzal et al. 2018). a study conducted at ibnu sina hospital makassar from 2018 to 2021 identified 55 patients diagnosed with hepatic cirrhosis, with the majority being male (65.5%) and female (35.5%), predominantly in the age group of 51-60 years (45.5%). hepatitis b was leading the cause (54.5%), and the most frequent complication was ascites (38.2%) (amalia et al. 2023). epidemiology data on hepatic cirrhosis in indonesia remain scarce. in the cirebon region, there is currently no available data regarding the characteristics and endoscopic outcomes of patients with hepatic cirrhosis at waled hospital. due to the lack of information on the characteristics of liver cirrhosis patients, particularly in cirebon, the purpose of this study is to ascertain the characteristics and endoscopy findings on patients with the disease at waled hospital. 2. methods study design/ research procedures this study employed a descriptive observational methos. the sample consisted of cirrhotic patients at waled regional general hospital from 2020 to 2023, selected using a total sampling technique. information was taken from 33 individual’s medical records who met the inclusion criteria, which were as follow: diagnosed with liver cirrhosis, medical records containing data on age, gender, cirrhosis stage, etiology, and endoscopic findings. both inpatients and outpatients provided samples for this research, which had no age restriction. patients with hemochromatosis related liver cirrhosis and those with inadequate medical record data were excluded, resulting in 102 unusable data. the waled regional general hospital health research ethics committee granted ethical approval to this study, with number 000.9.2/051/kepk/v/2024, on may 21th 2024. measurements the sole variable in this study was the examination of patient characteristics (age, gender, etiology, cirrhosis stage) and the endoscopic findings of cirrhosis patients (based on location and grade). the data used in this study were secondary data derived from medical records of cirrhotic patients treated at waled regional general hospital, cirebon, from 2020 to 2023. azahra, et. al ghmj (global health management journal) 2024, vol. 7, no. 4 289 statistical techniques univariate analysis assessed the frequency distribution and percentage of patient characteristics and endoscopic findings. the data were then presented narratively and in tabular form. 3. results out of 135 medical records reviewed, only 33 met the inclusion criteria with the remaining 102 excluded due to incomplete data. the patient’s features in this study were reported in terms of age, sex, etiology, stage, and endoscopic findings. table 1. respondent’s characteristics variables n % age ≤30 1 3.0 31-40 4 12.1 41-50 10 30.3 51-60 10 30.3 ≥61 8 24.2 sex male 24 72.7 female 9 27.3 etiology hepatitis b 23 69.7 hepatitis c 2 6.1 alcohol 1 3.0 dm 5 15.2 hepatitis b, dm 2 6.1 stage compensated 0 0 decompensated 33 100 endoscopic findings by location no varices 1 3.0 esophageal varices 2 6.1 fundal varices 0 0 portal hypertensive gastropathy 0 0 esophageal varices, portal hypertensive gastropathy 18 54.5 esophageal varices, fundal varices, portal hypertensive gastropathy 12 36.4 esophageal varices grade grade 1 2 6.1 grade 2 3 9.1 grade 3 27 81.8 absent 1 3.0 portal hypertensive gastropathy grade mild 20 60.6 severe 10 30.3 absent 3 9.1 total 33 100.0 azahra, et. al. ghmj (global health management journal) 2024, vol. 7, no. 4 290 according to table 1 the data shows that there is 1 (3.0%) patient under 30 years with cirrhosis, 4 (12.1%) patients between 31 and 40 years, 10 (30.3%) patients between 41 and 50 years, 10 (30.3%) patients between 51 and 60 years, and 8 (24.2%) patients above 61 years. most cirrhotic patients were male, with 24 patients (72.7%), followed by female patients with 9 patients (27.3%). the primary etiology was hepatitis b, affecting 23 patients (69.7%), followed by diabetes mellitus (dm) in 5 patients (15.2%), hepatitis c in 2 patients (6.1%), hepatitis b with dm in 2 patients (6.1%), and alcohol in 1 patient (3.0%). all cirrhotic patients were in the decompensated stage, accounting for 33 patients (100%). those esophageal varices and portal hypertensive gastropathy, which affected 18 patients (54.5%) of cirrhotic patients were the most common conditions. patients with esophageal varices, fundal varices, and portal hypertensive gastropathy, which affected 12 patients (36.4%) came next. two patients (6.1%) only had esophageal varices, and 1 patient (3.0%) did not present with varices. the most cirrhotic patients with esophageal varices were in grade 3, affecting 27 patients (84.4%), followed by grade 2 in 3 patients (9.4%), and grade 1 in 2 patients (6.3%). the majority of cirrhotic patients with portal hypertensive gastropathy were in the mild grade, affecting 20 patients (66.7%), followed by the severe grade in 10 patients (33.3%). table 2. cross tabulation between age and sex with cirrhosis liver endoscopic findings total no varices esophageal varices fundus varices portal hypertensive gastropathy esophageal varices, portal hypertensive gastropathy esophageal varices, fundus varices, portal hypertensive gastropathy ≤30 n 0 1 0 0 0 0 1 % 0.0 3.0 0.0 0.0 0.0 0.0 3.0 31-40 n 0 1 0 0 2 1 4 % 0.0 3.0 0.0 0.0 6.1 3.0 12.1 41-50 n 1 0 0 0 3 6 10 % 3.0 0.0 0.0 0.0 9.1 18.2 30.3 51-60 n 0 0 0 0 7 3 10 % 0.0 0.0 0.0 0.0 21.2 9.1 30.3 ≥61 n 0 0 0 0 6 2 8 % 0.0 0.0 0.0 0.0 18.2 6.1 24.3 male n 1 2 0 0 13 8 24 % 3.0 6.1 0.0 0.0 39.4 24.2 72.7 female n 0 0 0 0 5 4 9 % 0.0 0.0 0.0 0.0 15.2 12.1 27.3 total n 1 2 0 0 18 12 33 % 3.0 6.1 0.0 0.0 54.6 36.3 100 according to table 2, esophageal varices are endoscopic findings at ≤30 years of age. the most common endoscopic findings in group over 30 are esophageal varices and portal hypertensive gastropathy. the age group of 41-50 years has the highest endoscopic findings of esophageal varices, fundal varices, and portal hypertensive gastropathy. the majority of portal hypertensive gastropathy and esophageal varices occur in male and in one male patient, varicose veins were not present. and the endoscopic results in female were esophageal varices, portal hypertensive gastropathy, and esophageal varices, fundal varices, portal hypertensive gastropathy. 4. discussion according to this study, the majority of the 33 patients with liver cirrhosis at waled regional hospital were between the ages of 41 and 50 and between the ages of 51 and 60. these results are consistent with research by sarah et al. that found individuals over 40 had a higher risk developing liver cirrhosis, with 33 patients (86.8%) and mutia et al., which found that the highest frequency distribution was in the 51-60 years age group (amalia et al. 2023; virma sarah gita et al. 2023). liver can shrink up to one-third of its initial volume as a result of these modifications, which also include a decreased hepatic blood flow, the deterioration of the sinusoidal vascular system, and reduced bile acid secretion. furthermore, the number of hepatocytes, kupffer cells and sinusoidal capillaries decrease with age. azahra, et. al ghmj (global health management journal) 2024, vol. 7, no. 4 291 additionally, hepatocytes decrease, and fibrosis and steatosis risk rise. the aging process, oxidative stress, and mitochondrial homeostasis all cause the liver become less effective in responding to these stimuli, which increases the likelihood of fibrosis in elderly people (carrier et al. 2019). other factors, aside from the agerelated decline in liver function, such a chronic recurrent liver injury can lead to inflammation and fibrosis. increasing the risk of cirrhosis at a younger age (smith, baumgartner, and bositis 2019). older adults are more likely to experience complications, which might be due to abnormalities in the liver (carrier et al. 2019). the findings in this study also showed that hepatitis b was the most common etiology of liver cirrhosis, which is in line with the study by sarah et al., where hepatitis b was the cause in 28 (73.7%) of patients. similarly, mutiara et al., found hepatitis b to the most prevalent cause of liver cirrhosis, accounting for 30 patients (54.5%) (amalia et al. 2023; virma sarah gita et al. 2023). this is explained by the endemic nature of hepatitis b virus infection in africa and the asia pacific area. hepatitis b is the most common cause of liver cirrhosis in the asia pacific region. an estimated 20 million individuals in indonesia are thought to have hepatitis, with hepatitis b having the highest frequency. according to cda foundation, in 2016 there were 51.100 annual hepatitis b death in indonesia. from an asymptomatic persistent condition to chronic hepatitis, which may ultimately result in cirrhosis, is the progression of hepatitis b infection. every year, about 3% of people with chronic hepatitis go on to develop cirrhosis (huang et al. 2023). due to their delayed diagnosis and treatment, all of the cirrhosis patients in this study were in the decompensated stage, which is line with findings from mutiara et al. study, which showed that 46 (83.6%) of 55 patients were in this stage (amalia et al. 2023). individuals with decompensated liver cirrhosis have a variety of symptoms as a result of reduced hepatic function, which may ultimately result in jaundice or other consequences. in contrast, patients with compensated liver cirrhosis typically have no symptoms at all (pallio et al. 2023). delays in diagnosis might be caused by a patient’s disdain for symptoms that have already appeared or by financial limitations. the majority of cirrhotic patients in this research exhibited portal hypertensive gastropathy (phg) and esophageal varices, with grade 3 esophageal varices and mild grade portal hypertensive gastropathy according to the endoscopic data. this finding is consistent with the study at royal prima general hospital medan suffered from esophageal varices alongside other complications. the esophageal and gastric veins may widen as portal pressure and blood flow rise. additionally, portal hypertension damages the gaster mucosal and submucosal layers, depriving the gastric mucosal cells of enough blood and oxygen. in patients with liver cirrhosis, portal hypertension is caused by two factors: increased portal blood flow and raised intrahepatic vascular resistance. intrahepatic vascular resistance rises when the liver architecture is damaged. damaged from chronic liver disease and intrahepatic endothelial dysfunction lead to the activation of smooth muscle, stellate cells, and myofibroblasts in the portal blood arteries as well as a deficiency of nitric oxide, an intrahepatic vasodilator. meanwhile, those with liver cirrhosis have more endogenous vasodilators, which dilates the splanchnic blood flow to the portal. therefore, the worse the liver function in those with liver cirrhosis, the higher the portal pressure, which eventually results in esophageal varices (adnyasuputra et al. 2024; kalista et al. 2019; wu et al. 2022). furthermore, portal hypertension impairs the blood supply to the stomach mucosa, reducing the mucosa defensive system. this might account for the varices and phg endoscopic results. there is a greater chance of bleeding and bigger varicose veins with higher portal vein pressure (adnyasuputra et al. 2024; wu et al. 2022) this study has some limitations, including time constraints, as the data collection process took a significant amount of time, a tiny sample size could not accurately represent the findings and not all medical records contained complete information. to properly explain the findings, more study with a bigger sample size and other factors is anticipated. 5. conclusion in conclusion, the characteristics of cirrhotic patients at waled regional general hospital from 2020 to 2023 were predominantly those aged 45, accounting for 4 patients (12.1%). the majority of cases occurred in males, with 24 patients (72.7%), and hepatitis b was the most frequent etiology, affecting 23 patients (69.7). all patients were in the decompensated stage (33 patients, 100%). endoscopic findings showed that the most azahra, et. al. ghmj (global health management journal) 2024, vol. 7, no. 4 292 common complications were esophageal varices and portal hypertensive gastropathy, affecting 18 patients (54.5%). most patients with esophageal varices were classified as grade 3 (27 patients; 81.8%), while most patients with portal hypertensive gastropathy were classified as mild grade (20 patients; 60.6%). the age group of 41-50 years has the highest endoscopic findings of esophageal varices, fundus varices, and portal hypertensive gastropathy. to properly explain the findings, more study with a bigger sample size and other factors is anticipated. health services are designed to educate the public about the significance of hepatitis vaccination and early screening for people with liver cirrhosis in order to avert consequences. therefore, it is anticipated that the public will receive a hepatitis vaccination, lead a healthy lifestyle, and receive full treatment for cirrhosis in order to avoid other difficulties. conflict of interest there is no conflict of interest. references adnyasuputra, made agung, i. ketut mariadi, ni made, renny anggreni rena, i. made, and pande dwipayana. 2024. "hubungan riwayat konsumsi alkohol, ukuran varises, derajat sirosis hati terhadap perdarahan varises esofagus pada pasien sirosis hati di rsup prof. i goesti ngoerah gde ngoerah." intisari sains medis | intisari sains medis 15(1):408-13. https://doi.org/10.15562/ism.v15i1.1995 afzal, muhammad, shahida husain tarar, and syed muhammad ali shah. 2018. "spectrum of endoscopic findings in patients with liver cirrhosis due to chronic viral hepatitis." pakistan journal of medical and health sciences 12(1):10-13. amalia, mutiara, prema hapsari hidayati, andi kartini eka yanti, sri vitayani, and sri wahyuni gayatri. 2023. "karakteristik pasien sirosis hepatis." umi medical journal 8(1):53-61. https://doi.org/10.33096/umj.v8i1.244 carrier, paul, marilyne debette-gratien, jérémie jacques, and véronique loustaud-ratti. 2019. "cirrhotic patients and older people." world journal of hepatology 11(9):663-77. https://doi.org/10.4254/wjh.v11.i9.663 devarbhavi, harshad, sumeet k. asrani, juan pablo arab, yvonne ayerki nartey, elisa pose, and patrick s. kamath. 2023. "global burden of liver disease: 2023 update." journal of hepatology 79(2):516-37. https://doi.org/10.1016/j.jhep.2023.03.017 huang, daniel q., norah a. terrault, frank tacke, lise lotte gluud, marco arrese, elisabetta bugianesi, and rohit loomba. 2023. "global epidemiology of cirrhosis aetiology, trends and predictions." nature reviews gastroenterology and hepatology 20(6):388-98. https://doi.org/10.1038/s41575-023-00759-2 kalista, kemal fariz, cosmas rinaldi adithya lesmana, andri sanityoso sulaiman, rino alvani gani, and irsan hasan. 2019. "profil klinis pasien sirosis hati dengan varises esofagus yang menjalani ligasi varises esofagus di rumah sakit dr. cipto mangunkusumo." jurnal penyakit dalam indonesia 6(1):36. https://doi.org/10.7454/jpdi.v6i1.300 pallio, socrate, giuseppinella melita, endrit shahini, alessandro vitello, emanuele sinagra, barbara lattanzi, antonio facciorusso, daryl ramai, and marcello maida. 2023. "diagnosis and management of esophagogastric varices." diagnostics 13(6). https://doi.org/10.3390/diagnostics13061031 setiati, siti, idrus alwi, and aru w. sudoyo. 2014. buku ajar ilmu penyakit dalam. smith, andrew, katrina baumgartner, and christopher bositis. 2019. "cirrhosis: diagnosis and management." american family physician 100(12):759-70. virma sarah gita, adelin prima, and mona letvi. 2023. "karakteristik pasien sirosis hepatis di rumah sakit dr. achmad mochtar bukittinggi periode tahun 2018 2020." jurnal kedokteran nanggroe medika 6(1):6. wu, ran, kunyi liu, chengyi shi, hui tian, and na wang. 2022. "risk factors for portal hypertensive gastropathy." bmc gastroenterology 22(1):1-7. https://doi.org/10.1186/s12876-022-02468-7 cite this article as: azahra, a. h., sedayu, s., & zein, a. f. m. z. (2024). characteristics and endoscopy findings of liver cirrhosis patients at waled hospital, cirebon, indonesia (2020-2023). ghmj (global health management journal), 7(4), 287–292. https://doi.org/10.35898/ghmj-741071 https://doi.org/10.15562/ism.v15i1.1995 https://doi.org/10.33096/umj.v8i1.244 https://doi.org/10.4254/wjh.v11.i9.663 https://doi.org/10.1016/j.jhep.2023.03.017 https://doi.org/10.1038/s41575-023-00759-2 https://doi.org/10.7454/jpdi.v6i1.300 https://doi.org/10.3390/diagnostics13061031 https://doi.org/10.1186/s12876-022-02468-7 https://doi.org/10.35898/ghmj-741071 indonesian scholars’ alliance ghmj (global health management journal) 2025, vol. 8, no. 1 open access research article factors related to personal hygiene of traditional jamu handler in bantul district, indonesia dyah suryani1* , atika rahma indriani1, suyitno2 1 faculty of public health, universitas ahmad dahlan, yogyakarta, indonesia, 2 occupational health and safety program, politeknik medica farma husada mataram, indonesia. *corresponding author’s e-mail: dyah.suryani@ikm.uad.ac.id doi: 10.35898/ghmj-811154 abstract background: foodborne disease is the contamination of pathogenic bacteria that multiply in drinks. traditional jamu handlers, people who process conventional jamu, need to implement and understand the importance of personal hygiene to avoid bacterial contamination. aims: this study aimed to determine the relationship between knowledge, attitude, sanitation facilities and infrastructure, participation in counseling, and level of education with personal hygiene in traditional jamu handlers in kiringan village, bantul district, yogyakarta province, indonesia. methods: this study used a quantitative approach with a cross-sectional design, involving 73 traditional jamu handlers who were selected by simple random sampling from a population of 90 handlers. the dependent variable was the personal hygiene of jamu handlers, measured using an observation checklist and categorized as "appropriate" or "not appropriate" based on an average score of 7.12. independent variables included knowledge, attitudes, sanitation facilities and infrastructure, participation in counseling, and education level, which were assessed using questionnaires and observation sheets. statistical analysis included identification of respondent characteristics to describe the sample and bivariate analysis to evaluate the relationship between independent and dependent variables. results: the finding of this study showed that the level of knowledge, attitude, availability of sanitation facilities, participation in food safety counseling, and education level had a significant relationship with personal hygiene practices in traditional jamu handlers. higher education levels had the most significant impact on improving good hygiene practices. conclusion: personal hygiene of handlers was influenced by knowledge, attitudes, sanitation facilities and infrastructure, participation in food safety counseling, and level of education. it is suggested to increase awareness and implementation of personal hygiene when processing traditional jamu and routinely attend food safety counseling to increase knowledge. keywords: personal hygiene; traditional jamu handlers; food safety counseling; sanitation facilities; education levels. received: 24 december 2024 reviewed: 28 december 2024 revised: 13 january 2025 accepted: 23 january 2025. © 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:dyah.suryani@ikm.uad.ac.id mailto:dyah.suryani@ikm.uad.ac.id https://doi.org/10.35898/ghmj-811154 https://orcid.org/0000-0001-8069-6455 https://orcid.org/0000-0002-6817-7852 suryani, et. al. ghmj (global health management journal) 2025, vol. 8, no. 1 32 1. introduction drinks are part of food to meet basic daily needs. product makers create high-quality beverage innovations to meet basic needs. beverages produced must be free from contamination of hazardous substances such as microorganisms, chemicals, and other contaminants (avîrvarei et al., 2023). according to the world health organization (who), diarrhea cases can occur every year with a total of approximately 1.7 billion cases (world health organization, 2024). in indonesia, the trend of poisoning in 2014 was a total of 186 cases, in 2015 there were a total of 153 cases of poisoning, with various causal factors, ranging from food, natural poisons, pesticides, mixtures and environmental pollution (rhomadhoni et al., 2018). diarrhea-causing agents such as norovirus, salmonella enterica, campylobacter and e. coli. the main causes of death from foodborne diseases are salmonella thypi, taenia solium, hepatitis a virus and aflatoxin (arisanti et al., 2018). according to survey results, in yogyakarta showed that as in the case in yogyakarta, there was an outbreak of food poisoning in 2017 (rokhmayanti & heryantoro, 2017). traditional indonesian drinks with basic ingredients such as turmeric (curcuma longa linn.), kencur (kaempferia galanga), and temulawak (curcuma zanthorrhiza) can be processed by jamu craftsmen by producing kencur, turmeric, and temulawak drinks. jamu is a natural medicine that has been empirically proven to be safe. the jamu concoction business is a business that originates from a jamu depot owned by someone by mixing finished ingredients or natural medicines that have been sold to buyers (sumarni et al., 2019). food and beverage hygiene and sanitation are actions taken to monitor factors involving humans, food, the environment, and objects that have the potential to cause disease. a beverage handler is someone who is in direct contact with drinks starting from the preparation stage of ingredients to the serving stage of drinks (schmidt & piotter, 2020). food safety is the steps taken to prevent contaminants such as chemical compounds, biological organisms, and materials that can harm human health, while ensuring that the food is in accordance with the religious and cultural values of the community, so that it can be consumed safely (suryani et al., 2022). personal hygiene means a healthy individual. personal hygiene is the action taken to maintain a person's health and cleanliness, both physically and mentally (lebelo et al., 2021). a person's behavior is influenced by three categories of factors, namely predisposition, enablers, and reinforcers (suyitno et al., 2024). predisposition includes aspects such as education level, age, knowledge, occupation, and attitude. enablers involve factors such as environmental conditions and distance to health facilities. meanwhile, reinforcing factors include support from community leaders and family (mubarak & chayatin, 2019; notoatmodjo, 2014a). kiringan jamu tourism village is a tourist attraction that has many traditional jamu craftsmen. based on the results of preliminary study observations carried out on march 8, 2023 and june 1, 2023, there were 124 traditional jamu handlers, but 90 were still actively making jamu. data on the number of jamu handlers was obtained from the head of kiringan hamlet. the results of observations that have been carried out 2 out of 4 jamu handlers do not pay attention to hygiene in making traditional jamu. in the first case, the handler did not use ppe such as head coverings, masks, and aprons. in addition, the location for making traditional jamu is close to the bathroom. this can be a risk of contamination of traditional jamu because the bathroom is a dirty place. the second case of jamu handlers also has not implemented the use of ppe. the facilities and infrastructure owned are inadequate such as the absence of closed trash bins. but there is only an open trash bin near the jamu processing area. jamu handlers also still use 1 place for washing equipment and washing hands which can cause contamination of equipment and hands. focusing on traditional herbal medicine artisans as a potential source of contamination is an underexplored research gap, as previous studies have more often discussed the benefits or composition of herbal medicine. this study provides unique insights into the cultural relationships, local customs, and personal hygiene of artisans in bantul, an area with a strong tradition of herbal medicine consumption. in addition, the multidisciplinary approach that includes public health, cultural anthropology, and microeconomics adds strategic value to this study, especially in supporting the development of public health policies and improving the quality and safety of herbal medicine through training and certification of artisans. suryani, et. al ghmj (global health management journal) 2025, vol. 8, no. 1 33 2. methods study design/ research procedures this study uses a quantitative approach with a cross-sectional method. the research sample was 73 traditional jamu handlers in kiringan village, bantul district, yogyakarta province, indonesia. the sample was selected by applying the simple random sampling technique form 90 traditional jamu handlers. the inclusion criteria of the respondents of this study were people who work as traditional jamu sellers, both male and female. living in kiringan village for the past 6 months when the study was conducted, willing to be respondents and not having time, physical, and communication limitations when the study was conducted. the exclusion criteria for this study are as follows: individuals who are not employed as traditional jamu sellers, those who have not resided in the kiringan village for at least six months prior to or during the study period, individuals who are unwilling to participate as respondents, and those who experience physical, communication, or time constraints that may prevent them from effectively engaging in the research process. measurements dependent variable in this study was personal hygiene of traditional jamu handler. this variable aims to determine whether traditional jamu handlers implement personal hygiene when processing traditional jamu. measurement using a nominal scale with scores against the personal hygiene standards of traditional jamu handlers is reduced to; not appropriate, if <mean (7.12) and appropriate, if ≥mean (7.12). data collected by observation checklist. independent variables were knowledge, attitudes, sanitation facilities and infrastructure, outreach participation, and education level. data was collected by administering questionnaires for the knowledge and attitude variables about personal hygiene practices of respondents collected by interview. the variable knowledge that traditional jamu handlers have regarding personal hygiene is measured using a nominal and categorical scale; "not good" if the score is < mean (7) and "good" if the score is ≥ mean (7). the variable attitude that traditional jamu handlers have regarding personal hygiene is measured using a nominal and categorical scale; "not good" if the score is < mean (58) and "good" if the score is ≥ mean (58). on the other hand, the sanitation facilities and infrastructure (not good: if the mean score is <6 and good: if the score is ≥ mean 6), participation in counseling (never attended food safety counseling and have attended food safety counseling), and education level (low if junior high school ≤ and high if high school ≥), variables used observation sheets. based on the results of the validity test on the knowledge statement about personal hygiene of traditional jamu handlers from 20 statements after being tested, 12 statements were eliminated so that 8 statements remained. then on the attitude statement from 20 attitude statements after being tested, 4 statements were eliminated so that 16 statements remained. the statements that were eliminated were caused by the t-value being less than or equal to the r-table value (0.361). the results of the reliability test on the knowledge statement were 0.638 so that it was > 0.060 and the results of the attitude statement were 0.912 so that it was > 0.060 reliable statements. thus, 8 knowledge statements and 16 attitude statements were valid and reliable so that they could be used in the questionnaire instrument. statistical techniques this study was used three analysis technique; respondent characteristics identification and bivariate analysis. the purpose of characteristics identification of respondent is to provide a detailed picture of the characteristics of respondents, such as demographic, socio-economic, or other attributes relevant to the study. by understanding the respondent profile, a better context can be obtained for the data being analyzed. bivariate analysis aims to evaluate the relationship between two variables, namely the independent and dependent variables. through this approach, researchers can find out whether there is a significant statistical relationship between the two, thus helping to understand the relationship between variables in the study. suryani, et. al. ghmj (global health management journal) 2025, vol. 8, no. 1 34 ethical clearance this research has obtained research approval from the research ethics commission of ahmad dahlan university (kep uad) with number 012307111. each respondent was given an explanatory script and consent form before information was collected from each respondent. 3. results the majority of respondents were aged between 55-64 years (31.5%), with other age groups ranging from 25-84 years. most respondents had a good level of knowledge (71.2%), good attitudes (78.1%), and had attended food safety counseling (74.0%). in terms of sanitation facilities and infrastructure, more than half of respondents (56.2%) had good facilities, while the education level of the majority of respondents was high (65.8%). however, personal hygiene practices are still a concern, with the majority of respondents (74.0%) having poor practices. these data indicate a gap between good knowledge and attitudes and the implementation of appropriate hygiene practices. table 1. respondent’s characteristics variables freq. percent age group 25-34 5 6.8 35-44 22 30.1 45-54 15 20.5 55-64 23 31.5 65-74 7 9.6 75-84 1 1.4 level of knowledge poor 21 28.8 good 52 71.2 attitude poor 16 21.9 good 57 78.1 sanitation facilities and infrastructure poor 32 43.8 good 41 56.2 participation in counseling never attended food safety counseling 19 26.0 have attended food safety counseling 54 74.0 level of education high 48 65.8 low 25 34.2 personal hygiene practice poor 54 74.0 good 19 26.0 the majority of respondents were aged between 55-64 years (31.5%), with other age groups ranging from 25-84 years. most respondents had a good level of knowledge (71.2%), good attitudes (78.1%), and had attended food safety counseling (74.0%). in terms of sanitation facilities and infrastructure, more than half of respondents (56.2%) had good facilities, while the education level of the majority of respondents was high (65.8%). however, personal hygiene practices are still a concern, with the majority of respondents (74.0%) having poor practices. these data indicate a gap between good knowledge and attitudes and the implementation of appropriate hygiene practice. suryani, et. al ghmj (global health management journal) 2025, vol. 8, no. 1 35 table 2. bivariate analysis variable personal hygiene practice crude or & ci (95%) p value poor good level of knowledge 1.46(1.17-1.81) 0,019 poor 21 28.8 good 52 71.2 attitude 1.50 (1.25-1.80) 0.018 poor 16 21.9 good 57 78.1 sanitation facilities and infrastructure 1.60 (1.22-2.10) 0.002 poor 32 43.8 good 41 56.2 participation in counseling 1.54 (1.26-1.87) 0.007 never attended food safety counseling 19 26.0 have attended food safety counseling 54 74.0 level of education 2.99 (1.68-5.31) 0.0001 high 48 65.7 low 25 34.3 the results of the bivariate analysis showed that all independent variables had a significant relationship with personal hygiene practices. respondents with a good level of knowledge tended to have better hygiene practices (cor = 1.46; 95% ci: 1.17-1.81; p = 0.019). good attitudes also increased the likelihood of good hygiene practices (cor = 1.50; 95% ci: 1.25-1.80; p = 0.018). the availability of adequate sanitation facilities and infrastructure showed a significant effect on personal hygiene practices (cor = 1.60; 95% ci: 1.22-2.10; p = 0.002). participation in food safety counseling also improved hygiene practices (cor = 1.54; 95% ci: 1.26-1.87; p = 0.007). in addition, higher education level had the most significant impact on personal hygiene practices (cor = 2.99; 95% ci: 1.68-5.31; p = 0.0001). 4. discussion analysis with the chi square test on the knowledge variable is known to have a p-value = 0.019 (p <0.05). so there is a relationship between knowledge and personal hygiene in traditional jamu handlers. the theory of lawrence green which states that behavioral factors influence a person's behavior. one of these factors is predisposition such as knowledge. a person's behavior can be seen from the knowledge they have [8]. knowledge can influence a person's behavior because a lot of good information is absorbed so that they can behave in a positive direction. a person with high knowledge means they tend to do positive things. factors that influence a person's knowledge can be seen from the last education a person has. education can be interpreted as guiding someone to realize certain ideals with the aim of filling a safe, comfortable and happy life. higher education gets more information so that it will make a person aware of their behavior (rukmansyah s et al., 2022). another similar study concluded that in a statistical test, there was a correlation between knowledge and implementation of personal hygiene practices in street food vendors (endriana amiruddin et al., 2021). other studies also indicate that the results of knowledge and cleanliness of food handlers in the canteen (madrdhatillah, 2019). analysis with the chi square test on the attitude variable is known to have a p-value = 0.018 (p <0.05). from the result, it is noted that there is a relationship between attitude and personal hygiene in traditional jamu handlers. lawrence green's theory states that individual behavior can be influenced by various factors, including predisposing factors, such as attitude (pakpahan et al., 2021). attitude has 3 main components, namely behavior, awareness, and feelings. attitude can reflect how a person reacts when involved with the cognitive component that will determine the attitude of the affective component (notoatmodjo, 2014b). attitude can determine the behavior and awareness of traditional jamu handlers to practice personal hygiene. high awareness will have an influence on good personal hygiene. in addition, sufficient knowledge will influence the attitudes of traditional jamu handlers. another similar study found that the results showed a correlation between attitudes and personal hygiene practices of food and beverage handlers (sanliėr et al., 2020). other suryani, et. al. ghmj (global health management journal) 2025, vol. 8, no. 1 36 research that is in line also shows the results a relation between the attitudes and cleanliness and sanitation of street food vendors (akabanda et al., 2017). analysis with the chi square test on the sanitation facilities and infrastructure variable is known to have a p-value = 0.002 (p <0.05). this means that ho is rejected and ha is accepted. so there is a relationship between sanitation facilities and infrastructure and personal hygiene in traditional jamu handlers. lawrence green's theory, enabling factors are sanitation facilities and infrastructure or sanitation facilities. enabling factors consist of resources or organizations to realize environmental change (pakpahan et al., 2021). food traders must have sanitation facilities and infrastructure such as hand washing facilities, clean water, trash bins, toilets, waste disposal, fly and rat control facilities (dewi et al., 2019). adequate sanitation facilities and infrastructure will have an impact on good personal hygiene. if sanitation facilities and infrastructure are inadequate, it will bring in many vectors and diseases. the results of other studies indicate a correlation between supporting facilities and infrastructure with the implementation of hygiene practices by food handlers in elementary schools (kyaw et al., 2018; pitri et al., 2020). analysis with chi square test on the variable of participation in counseling is known to have a p-value = 0.007 (p <0.05). so there is a relationship between participation in counseling and personal hygiene in traditional jamu handlers. lawrence green's theory, counseling is included in the reinforcing factor. counseling can influence someone or receive positive feedback. counseling can change a person's behavior towards health problem. one of the important requirements for handlers who handle food is to have a food hygiene and sanitation training certificate (palupi et al., 2024). food safety counseling can increase knowledge insight for traditional jamu handlers. another study indicated that training on food hygiene and sanitation can improve understanding of aspects such as personal hygiene, equipment cleanliness, and sanitation facilities in respondents who have participated in the training (cataluna & rukmini, 2024). the results of another study stated a correlation between hygiene training for food handlers (insfran-rivarola et al., 2020). analysis with the chi square test on the education level variable is known to have a p-value = 0.000 (p <0.05). this means that ho is rejected and ha is accepted. so there is a relationship between and personal hygiene in traditional jamu handlers. education level is one component of the predisposition factor. education level can influence an individual's tendency to take certain actions. the higher a person's education level, the greater their ability to receive information, so that their knowledge can be broader (pakpahan et al., 2021). education level plays a key role in an individual's learning experience, because a high level of education will provide a lot of information. this information includes aspects such as hygiene and sanitation in food processing which aims to improve food safety (hamsiati et al., 2024). another study showed that the results a correlation between education level and food handler behavior in food processing in restaurants (de andrade et al., 2019). another study did not support the findings of this study, showing that the results there was no significant correlation between the level of education and personal hygiene of street food vendors (akbar et al., 2023). 5. conclusion in sum, this study on factors related to personal hygiene of traditional jamu handlers in kiringan village, bantul, concluded that personal hygiene of handlers was influenced by knowledge, attitudes, sanitation facilities and infrastructure, participation in food safety counseling, and level of education. it is suggested to increase awareness and implementation of personal hygiene when processing traditional jamu and routinely attend food safety counseling to increase knowledge. further researchers are expected to explore new factors that may affect personal hygiene, such as length of work experience and income level. jetis ii health center is suggested to routinely provide counseling, monitor, and evaluate the personal hygiene practices of traditional jamu handlers to ensure the sustainability of its implementation. conflict of interest there is no conflict of interest. suryani, et. al ghmj (global health management journal) 2025, vol. 8, no. 1 37 references akabanda, f., hlortsi, e. h., & owusu-kwarteng, j. (2017). food safety knowledge, attitudes and practices of institutional food-handlers in ghana. bmc public health, 17(1), 40. https://doi.org/10.1186/s12889-016-3986-9 akbar, h. n., lanita, u., & hidayati, f. (2023). faktor faktor yang berhubungan dengan penerapan higiene sanitasi pada kantin sekolah dasar di kota sungai penuh tahun 2022. jurnal kesmas jambi, 7(1), 55–64. https://doi.org/10.22437/jkmj.v7i1.22534 arisanti, r. r., indriani, c., & wilopo, s. a. (2018). kontribusi agen dan faktor penyebab kejadian luar biasa keracunan pangan di indonesia: kajian sistematis. berita kedokteran masyarakat, 34(3), 99–106. https://pdfs.semanticscholar.org/3eff/b3eb0947f23b18f079eb5fb1857dc62eb75e.pdf avîrvarei, a. c., salanță, l. c., pop, c. r., mudura, e., pasqualone, a., anjos, o., barboza, n., usaga, j., dărab, c. p., burja-udrea, c., zhao, h., fărcaș, a. c., & coldea, t. e. (2023). fruit-based fermented beverages: contamination sources and emerging technologies applied to assure their safety. foods, 12(4), 838. https://doi.org/10.3390/foods12040838 cataluna, t., & rukmini, e. (2024). food hygiene and sanitation knowledges and practices of street food vendors: a systematic review. iop conference series: earth and environmental science, 1324(1), 012115. https://doi.org/10.1088/1755-1315/1324/1/012115 de andrade, m. l., rodrigues, r. r., antongiovanni, n., & da cunha, d. t. (2019). knowledge and risk perceptions of foodborne disease by consumers and food handlers at restaurants with different food safety profiles. food research international, 121, 845–853. https://doi.org/10.1016/j.foodres.2019.01.006 dewi, n. u., rahman, a., jayadi, y. i., hartini, d. a., pradana, f., & aiman, u. (2019). are sellers who have low level of knowledge, attitudes and practice selling snacks with harmful food additives? indian journal of public health research & development, 10(8). dyah suryani, piki paslini, & suyitno. (2022). hubungan higiene sanitasi dengan angka kuman pada piring di warung makan, wirogunan, kota yogyakarta. sehatmas: jurnal ilmiah kesehatan masyarakat, 1(3), 404–417. https://doi.org/10.55123/sehatmas.v1i3.686 endriana amiruddin, e., taswin, t., dahmar, d., & rahmalia putri, a. (2021). faktor predisposisi dengan praktik personal hygiene pedagang makanan kaki lima di kotamara kota baubau. kampurui jurnal kesehatan masyarakat (the journal of public health), 3(2), 45–52. https://doi.org/10.55340/kjkm.v3i2.347 hamsiati, andi hasbi, muhammad arif, & nining silvia suni. (2024). the role of sanitation, hygiene, and safety education in enhancing economic efficiency in the food service industry. journal of economic education and entrepreneurship studies, 5(4), 631–643. https://doi.org/10.62794/je3s.v5i4.4530 insfran-rivarola, a., tlapa, d., limon-romero, j., baez-lopez, y., miranda-ackerman, m., arredondo-soto, k., & ontiveros, s. (2020). a systematic review and meta-analysis of the effects of food safety and hygiene training on food handlers. foods, 9(9), 1169. https://doi.org/10.3390/foods9091169 kyaw, p. p., paratthakonkun, c., yaicharoen, r., soonthornworasiri, n., prangthip, p., maneekan, p., zaw, a. p., thu, s. w. y. m., arthan, d., & nilkote, r. (2018). prevalence of intestinal parasite and related factors among school children in suan phueng subdistrict, ratchaburi, thailand. proceedings of the international conference on applied science and health, 3, 13–23. https://publications.inschool.id/index.php/icash/article/view/750 lebelo, k., malebo, n., mochane, m. j., & masinde, m. (2021). chemical contamination pathways and the food safety implications along the various stages of food production: a review. international journal of environmental research and public health, 18(11), 5795. https://doi.org/10.3390/ijerph18115795 madrdhatillah, m. m. (2019). hubungan pengetahuan dan sikap dengan hygiene penjamah makanan dikantin sdn sekecamatan kampar. prepotif: jurnal kesehatan masyarakat, 3(1), 68–79. https://doi.org/10.31004/prepotif.v3i1.444 mubarak, w. i., & chayatin, n. (2019). ilmu kesehatan masyarakat: teori dan aplikasi. notoatmodjo, s. (2014a). ilmu perilaku kesehatan. rineka cipta. notoatmodjo, s. (2014b). pendidikan dan perilaku kesehatan. pt rineka cipta. pakpahan, m., siregar, d., susilawaty, a., tasnim, t., ramdany, r., manurung, e. i., sianturi, e., tompunu, m. r. g., sitanggang, y. f., & maisyarah, m. (2021). promosi kesehatan dan perilaku kesehatan. yayasan kita menulis. palupi, i. r., budiningsari, r. d., khoirunnisa, f. a., & hanifi, a. s. (2024). food safety knowledge, hygiene practices among food handlers, and microbiological quality of animal side dishes in contract catering. italian journal of food safety. https://doi.org/10.4081/ijfs.2024.12554 pitri, r. h., sugiarto, s., & husaini, a. (2020). faktor yang berhubungan dengan praktik hygiene penjamah makanan di sekolah dasar wilayah kerja puskesmas tanjung pinang. journal of healthcare technology and medicine, 6(2), 732. https://doi.org/10.33143/jhtm.v6i2.979 https://doi.org/10.1186/s12889-016-3986-9 https://doi.org/10.22437/jkmj.v7i1.22534 https://pdfs.semanticscholar.org/3eff/b3eb0947f23b18f079eb5fb1857dc62eb75e.pdf https://doi.org/10.3390/foods12040838 https://doi.org/10.1088/1755-1315/1324/1/012115 https://doi.org/10.1016/j.foodres.2019.01.006 https://doi.org/10.55123/sehatmas.v1i3.686 https://doi.org/10.55340/kjkm.v3i2.347 https://doi.org/10.62794/je3s.v5i4.4530 https://doi.org/10.3390/foods9091169 https://publications.inschool.id/index.php/icash/article/view/750 https://doi.org/10.3390/ijerph18115795 https://doi.org/10.31004/prepotif.v3i1.444 https://doi.org/10.4081/ijfs.2024.12554 https://doi.org/10.33143/jhtm.v6i2.979 suryani, et. al. ghmj (global health management journal) 2025, vol. 8, no. 1 38 rhomadhoni, m. n., firdausi, n. j., & herdiani, n. (2018). tren kejadian keracunan makanan diberbagai wilayah di indonesia tahun 2014 dan tahun 2015. medical technology and public health journal, 2(1), 51–65. http://repository.unusa.ac.id/7543/ rokhmayanti, r., & heryantoro, l. (2017). penyelidikan kejadian luar biasa (klb) keracunan makanan di kabupaten gunungkidul daerah istimewa yogyakarta. jurnal formil (forum ilmiah) kesmas respati, 2(2). https://formilkesmas.respati.ac.id/index.php/formil/article/view/66 rukmansyah s, nurul ulfah mutthalib, hidayat, alfina baharuddin, & aulia rahman. (2022). faktor yang berhubungan dengan perilaku penjamah makanan terhadap personal hygiene pada jajanan kue di pasar tradisional. window of public health journal, 3(3), 458–469. https://doi.org/10.33096/woph.v3i3.34 sanliėr, n., sormaz, ü., & güneş, e. (2020). the effect of food safety education on food safety knowledge, attitudes, behaviors of individuals who work in food and beverage departments in turkey. international journal of gastronomy and food science, 22, 100259. https://doi.org/10.1016/j.ijgfs.2020.100259 schmidt, r. h., & piotter, h. m. (2020). the hygienic/sanitary design of food and beverage processing equipment (pp. 267–332). https://doi.org/10.1007/978-3-030-42660-6_12 sumarni, w., sudarmin, s., & sumarti, s. s. (2019). the scientification of jamu: a study of indonesian’s traditional medicine. journal of physics: conference series, 1321(3), 032057. https://doi.org/10.1088/17426596/1321/3/032057 suyitno, s., suryani, d., & jannah, a. a. (2024). determinants of food safety practices in food handlers: a literature review. promotor, 7(3), 414–421. https://doi.org/10.32832/pro.v7i3.706 world health organization. (2024, march 7). diarrhoeal disease. world health organization. https://www.who.int/news-room/fact-sheets/detail/diarrhoeal-disease cite this article as: suryani, d., indriani, a. r., & suyitno, s. (2025). factors related to personal hygiene of traditional jamu handler in bantul district, indonesia. ghmj (global health management journal), 8(1), 31–38. https://doi.org/10.35898/ghmj-811154 http://repository.unusa.ac.id/7543/ https://formilkesmas.respati.ac.id/index.php/formil/article/view/66 https://doi.org/10.33096/woph.v3i3.34 https://doi.org/10.1016/j.ijgfs.2020.100259 https://doi.org/10.1007/978-3-030-42660-6_12 https://doi.org/10.1088/1742-6596/1321/3/032057 https://doi.org/10.1088/1742-6596/1321/3/032057 https://doi.org/10.32832/pro.v7i3.706 https://www.who.int/news-room/fact-sheets/detail/diarrhoeal-disease https://doi.org/10.35898/ghmj-811154 ghmj (global health management journal) 2024, vol. 7, no. 4 indonesian scholars’ alliance open access research article the 1st cirebon international health symposium: faculty of medicine, universitas swadaya gunung jati update on non-communicable diseases: global perspective on health challenges and innovation effectiveness of virtual reality on fatigue and life quality in geriatric patients at kasih nursing home cirebon, indonesia hadrian gani1* , hendry gunawan2 , irene gunawan3 1 faculty of medicine, universitas swadaya gunung jati, indonesia, 2 department of neurology, faculty of medicine, universitas swadaya gunung jati, indonesia, 3 department of internal medicine, faculty of medicine, universitas swadaya gunung jati, indonesia. *corresponding author’s e-mail: hadrian211202@gmail.com doi: 10.35898/ghmj-741009 abstract background: fatigue is a significant challenge for geriatric patients, often leading to vulnerability and a poor quality of life. virtual reality can potentially serve as a therapeutic intervention for fatigue and quality of life by positively influencing geriatric patients' motor and cognitive functions. aims: to analyze the effectiveness of virtual reality training on fatigue and quality of life in geriatric patients at kasih nursing home cirebon, indonesia. methods: the research type was a quasi-experimental design with a pre-test, post-test, and nonequivalent group design. sampling utilized non-probability sampling techniques, specifically total sampling divided into two groups. the intervention group received five treatment sessions over five weeks, each session lasting 15 minutes and conducted on the same days apart. data was collected using the fatigue severity scale and the world health organization quality of life-bref. data analysis employed paired t-tests, independent t-tests, and n-gain scores. results: the results of the paired t-test for the control group showed a non-significant difference in fatigue (p = 0.363 > 0.05). in contrast, the intervention group showed significant improvements in fatigue (p < 0.001) and quality of life (p = 0.049). the independent t-test revealed no significant differences between groups in pre-test scores. however, post-test scores showed significant differences between groups for fatigue (p = 0.048) and quality of life (p = 0.004). the n-gain score test indicated that the virtual reality motor cognitive intervention was effective in reducing fatigue (83.96%) but had a limited impact on quality of life (28.32%). conclusion: virtual reality training is effective against fatigue, however, while there was a significant increase in quality of life after the virtual reality intervention; virtual reality was not significantly effective in improving the overall quality of life of geriatric patients. keywords: virtual reality, fatigue, quality of life, geriatric patients. received: 24 september 2024 reviewed: 16 october 2024 revised: 30 november 2024 accepted: 11 december 2024 © 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:hadrian211202@gmail.com https://doi.org/10.35898/ghmj-741009 https://orcid.org/0009-0007-7954-5693 https://orcid.org/0000-0002-7867-5564 https://orcid.org/0009-0006-5610-3721 ghmj (global health management journal) 2024, vol. 7, no. 4 gani, et. al. 246 1. introduction elderly individuals are defined as individuals aged 60 years and older. geriatric patients are elderly individuals with multiple diseases and/or disorders stemming from declining organ function, psychological, social, economic, and environmental factors. these individuals require integrated healthcare with a multidisciplinary approach that works interdisciplinarily (kemenkes r.i., 2015). according to the badan pusat statistik (bps), the percentage of the elderly population in indonesia was 10.48% in 2022 (direktorat statistik kesejahteraan rakyat, 2022). in cirebon city, there are 37,305 individuals aged 60 and older out of a total population of 341,235 (10.93%), and in cirebon regency, there are 214,078 individuals aged 60 and older out of a total population of 2,315,417 (9.24%) (badan pusat statistika kota cirebon, 2023). geriatric patients often face challenges such as geriatric syndromes. geriatric syndrome is a collection of symptoms commonly found in the elderly population. additionally, geriatric patients are prone to experiencing frailty syndrome, a syndrome characterized by reduced functional capacity and adaptive function, which can be exacerbated by fatigue. the occurrence of fatigue and geriatric syndrome can significantly impact the quality of life (qol) of geriatric patients (kemenkes r.i., 2015). with advancements in science and technology, various medical therapies now utilize assistive devices such as virtual reality (vr) technology. vr involves human interaction with a simulated environment created using computer technology, primarily employing computer graphics and artificial intelligence (communications & mittal, 2020). the application of vr in healthcare plays a crucial role in disease prevention and treatment. vr can be applied to various health domains, including physical and cognitive rehabilitation, surgical planning, and distraction therapy. the advantages of vr include its accessibility for home use via the internet, its ability to mitigate feelings of threat and discomfort, and its consistent, easily manipulated, and interactive nature (communications & mittal, 2020). a study conducted by maulani zn, et al., demonstrated that vr training can improve the quality of life of the elderly by enhancing cognitive and motor function (maulani et al., 2021). this research focused on the objective of examining the effectiveness of virtual reality on fatigue and quality of life in the elderly at kasih cirebon nursing home. 2. methods study design/ research procedures this research was conducted at kasih nursing home cirebon for three months, from may to july 2024. a quasiexperimental study with a pre-test, post-test, unequivalent groups design was employed. both pre-test and posttest measurements were conducted without blinding. the subject was selected using non-probability sampling, specifically total sampling. twelve participants were included and divided into two groups: the intervention group and the control group. these participants met the inclusion criterion of willingness to participate in the study. individuals with stroke, dementia, hearing impairment, or blindness were excluded. measurements in this study, data was collected through pre-test and post-test questionnaires administered to geriatric patients at kasih nursing home, cirebon, before and after a virtual reality motor cognitive training intervention. the intervention group received five sessions of virtual reality training over five weeks, each session lasting 15 minutes and conducted on the same day of the week. the intervention involved virtual world commands such as picking up a ball, placing a ball in a basket, squeezing a ball, painting with the index finger, and pressing a button. the control group received a placebo intervention in the form of a 5-minute upper extremity motor exercise video. the questionnaire was administered through interviews using the fatigue severity scale (fss) to assess fatigue and the world health organization quality of life-bref (whoqol-bref) to assess quality of life. the fss consists of nine statements that describe the severity of fatigue symptoms. for the purpose of interpretation, the scores were categorized into two groups: those who had not experienced fatigue, with scores ranging from 9 to 31, gani, et. al. ghmj (global health management journal) 2024, vol. 7, no. 4 247 and those who had experienced fatigue, with scores ranging from 32 to 63. this questionnaire has been validated and tested for reliability and has also been adapted into the indonesian language. (butarbutar, 2014). for world health organization quality of life-bref questionnaire consists of 26 questions covering 4 domains. the four domains are: physical health consists of seven questions, psychological six questions, social relationships three questions, environment eight questions and also the world health organization quality of life-bref assesses overall quality of life and general health. for the interpretation of the whoqol-bref, it was divided into 2 categories: good quality of life (65-130) and poor quality of life (26-64). this questionnaire has been validated and tested for reliability and has also been adapted into the indonesian language (ch salim et al., 2007). statistical techniques this study used univariate and bivariate analyses. univariate analysis was conducted to observe the frequency distribution of the independent variable (virtual reality) and the dependent variables (fatigue and quality of life). bivariate analysis was conducted to determine the effectiveness of the independent variable (virtual reality) on the dependent variables (fatigue and quality of life). the data was analyzed using parametric statistical tests due to the operational definition of both the independent and dependent variables being numerical data. computer software was used for the analysis. the statistical tests used were the paired t-test, independent samples t-test, and n-gain score. ethical clearance this research was conducted by the research procedure, following the approval of the research permit which was obtained after passing the thesis proposal examination and ethical review by the faculty of medicine, universitas swadaya gunung jati ethics committee, with the number 39/ec/fkugj/v/2024. 3. results the result data was obtained through a pre-test before the intervention and a post-test after the intervention using a fatigue severity scale and world health organization quality of life-bref questionnaire that had been adapted into the indonesian version. univariate analysis table 1 shows that the majority of respondents were ≤ 75 years old (58.3%). when viewed by gender, the majority of respondents were male, with 11 people (91.7%). the subject was divided into two groups: the intervention group, consisting of 6 respondents who received virtual reality training, and the control group, consisting of 6 respondents who did not receive virtual reality training. table 1. frequency distribution of respondent characteristics frequency (n) percentage (%) age ≤75 years old 7 58.3 >75 years old 5 41.7 gender male 11 91.7 female 1 8.3 group intervention 6 50.0 control 6 50.0 based on table 2, the control group's pre-test fatigue score exhibited a mean of 33.50, a standard deviation of 16.754, a median of 29.50, a minimum of 15, and a maximum of 59. post-test scores showed a slight decrease, with a mean of 33.33, a standard deviation of 16.860, a median of 29.00, a minimum of 15, and a maximum of 59. ghmj (global health management journal) 2024, vol. 7, no. 4 gani, et. al. 248 table 2. total questionnaire score variable n 𝒙 ± 𝑺𝑫 me (min-max) control group pre-test score of fatigue 6 33.50±16.75 29.50(15-59) post-test score of fatigue 6 33.33±16.86 29.00(15-59) pre-test score of life quality 6 79.83±6.43 78.00(72-89) post-test score of life quality 6 80.00±6.42 78.50(72-89) intervention group pre-test score of fatigue 6 50.83±10.12 53.00(34-59) post-test score of fatigue 6 16.33±7.47 15.50(9-27) pre-test score of life quality 6 78.50±15.90 80.50(49-95) post-test score of life quality 6 93.50±8.59 95.00(80-101) in contrast, the intervention group's pre-test fatigue score averaged 50.83, with a standard deviation of 10.128, a median of 53.00, a minimum of 34, and a maximum of 59. post-test scores indicated a substantial reduction, with a mean of 16.33, a standard deviation of 7.474, a median of 15.50, a minimum of 9, and a maximum of 27. regarding life quality, the control group's pre-test score averaged 79.83, with a standard deviation of 6.432, a median of 78.00, a minimum of 72, and a maximum of 89. post-test scores showed a slight improvement, with a mean of 80.00, a standard deviation of 6.419, a median of 78.50, a minimum of 72, and a maximum of 89. conversely, the intervention group's pre-test life quality score averaged 78.50, with a standard deviation of 15.897, a median of 80.50, a minimum of 49, and a maximum of 95. post-test scores revealed a significant increase, with a mean of 93.50, a standard deviation of 8.597, a median of 95.00, a minimum of 80, and a maximum of 101. table 3 indicates that, among geriatric patients at kasih cirebon nursing home, both pre-and postintervention, fatigue incidence was divided into two categories: 3 patients (50%) did not experience fatigue, while 3 patients (50%) did. conversely, before the intervention, 100% of the intervention group reported experiencing fatigue. however, post-intervention, none of the respondents in this group reported fatigue. furthermore, regarding the life quality assessment of geriatric patients at kasih cirebon nursing home, both before and after the intervention, the results indicated that all participants in the control group reported a high level of life quality (100%). in contrast, before the intervention, the intervention group comprised 5 individuals (83.3%) with good life quality and 1 individual (17.7%) with poor life quality. following the intervention, all participants in the intervention group reported good life quality. table 3. frequency distribution of categorized fatigue and life quality category control group intervention group pre-test post-test pre-test post-test n % n % n % n % not experiencing fatigue (9-31) experiencing fatigue (31-63) 3 50.0 0 0.0 6 100.0 6 100.0 3 50.0 6 100.0 0 0.0 0 0.0 good life quality (65-130) 6 100.0 6 100.0 5 83.3 6 100.0 poor life quality (26-64) 0 0.0 0 0.0 1 17.7 0 0.0 gani, et. al. ghmj (global health management journal) 2024, vol. 7, no. 4 249 bivariate analysis for the bivariate analysis, the researcher employed a paired t-test to compare pre-and post-test scores within each group, an independent t-test to compare pre-and post-test scores between the control and intervention groups, and calculated the effect size using the n-gain score to assess the efficacy of virtual reality in reducing fatigue and improving the quality of life in geriatric patients. paired t-test based on table 4, the mean pre-test fatigue score for the control group was 33.50, while the mean post-test fatigue score was 33.33. this indicates a slight decrease in perceived fatigue in the control group from the pre-test to the post-test. additionally, table 4 shows that the mean pre-test quality of life score for the control group was 79.83, and the mean post-test quality of life score was 80.00. this suggests a minimal change in perceived quality of life in the control group at the post-test. furthermore, a highly significant difference (p < 0.001) was observed between the pre-test and post-test scores, suggesting a strong relationship between the two. the significance value for both pre-test and post-test was 0.363, which is ≥0.05. this indicates that there was no significant difference between the pre-test and post-test scores in the control group. table 4. paired t-test for control group mean n std. deviation correlation sig. sig. (2-tailed) pre-test fatigue 33.50 6 16.75 post-test fatigue 33.33 6 16.86 pre-test life quality 79.83 6 6.43 post-test life quality 80.00 6 6.42 pre-test & post-test fatigue 0.16 6 0.40 1.000 <0.001 0.363 pre-test & post-test life quality -0.16 6 0.40 0.998 <0.001 0.363 table 5 reveals that the mean pre-test fatigue score for the intervention group was 50.83, while the mean post-test fatigue score was 16.33. this indicates a significant decrease in fatigue occurrence in the intervention group from the pre-test to the post-test. additionally, table 5 shows that the mean pre-test life quality score for the intervention group was 78.50, and the mean post-test quality of life score was 93.50. this suggests a significant improvement in perceived life quality in the intervention group at the post-test. the results presented in table 5 also indicate that there was no statistically significant relationship between the pre-test and post-test scores for both fatigue and life quality. however, the paired t-test results show that there was a significant difference between the pre-test and post-test scores for both fatigue (p < 0.001) and life quality (p = 0.049) after the virtual reality training intervention. table 5. paired t-test for intervention group mean n std. deviation correlation sig. sig. (2-tailed) pre-test fatigue 50.83 6 10.12 post-test fatigue 16.33 6 7.47 pre-test life quality 78.50 6 15.89 post-test life quality 93.50 6 8.59 pre-test & post-test fatigue 34.50 6 8.78 0.537 0.272 <0.001 pre-test & post-test life quality -15.00 6 14.15 0.462 <0.357 0.049 independent t-test table 6's show the levene's test for equality of variances yielded a significance value greater than or equal to 0.05. this indicates homogeneity of variances between the control and intervention groups. given this homogeneity, an independent samples t-test assuming equal variances was employed. the significance value (sig. (2-tailed)) for the fatigue variable was 0.055 for the pre-test and 0.048 for the post-test. for the quality of life variable, the significance values were 0.853 for the pre-test and 0.004 for the post-test. these findings suggest no ghmj (global health management journal) 2024, vol. 7, no. 4 gani, et. al. 250 significant difference (≥0.05) between the pre-test scores of the control and intervention groups. however, a significant difference (<0.05) was observed between the post-test scores of the two groups. table 6. independent t-test result levene’s test for equality of variances t–test for equality of means f sig. sig. (2 tailed) pre-test fatigue 1.57 0.238 0.055 post-test fatigue 3.73 0.082 0.048 pre-test life quality 1.21 0.296 0.853 post-test life quality 0.62 0.448 0.004 n-gain score test the normalized gain (n-gain) score was used in this study to assess the effectiveness of virtual reality motor cognitive training on fatigue and quality of life in geriatric patients. the criteria for determining the level of effectiveness are as follows (sukarelawan et al., 2024): 1) < 40% = ineffective 2) 40 – 50% = less effective 3) 56 – 75% = moderately effective 4) 76% = effective table 7. n-gain score no. fatigue life quality control intervention control intervention n-gain score (%) n-gain score (%) n-gain score (%) n-gain score (%) 1. 0 100 2 42 2. 0 100 0 27 3. 0 74 0 51 4. 6 64 0 17 5. 0 92 0 17 6. 0 74 0 16 mean 1.04 83.96 0.33 28.32 minimum 0 64 0 16 maximum 6 100 2 51 based on the results of the n-gain score test in table 7, it was found that the virtual reality motor cognitive intervention was effective in reducing fatigue, with an average n-gain score of 83.96% in the intervention group. however, it was ineffective in improving quality of life, as the intervention group had an average n-gain score of 28.32%. 4. discussion fatigue profile in geriatric patients the research results from the pre-test on fatigue incidents in the control group showed a mean score of 33.50, while the intervention group showed a mean score of 50.83. furthermore, in the control group, 3 respondents were categorized as suffering from fatigue, and 3 respondents were categorized as not suffering from fatigue. for the intervention group, 6 respondents were categorized as suffering from fatigue. this indicates that 9 out of 12 geriatric patients suffered from fatigue. therefore, it can be concluded that the majority of geriatric patients at kasih nursing home cirebon suffer from fatigue. geriatric patients are more likely to experience fatigue compared to younger individuals. this can occur due to various changes in geriatric patients that affect their physical strength, causing it to weaken. furthermore, limitations in physical activity also lead to geriatric patients experiencing fatigue more easily due to a lack of physical function training. sleep disturbances also contribute to fatigue in geriatric patients, ultimately resulting in gani, et. al. ghmj (global health management journal) 2024, vol. 7, no. 4 251 insufficient rest (ismahmudi & fakhrurizal, 2020). however, based on the results of the post-test on fatigue incidents, both the control group and the intervention group experienced a change with a decrease in the mean score. the post-test mean score in the control group was 33.33, indicating a change in the post-test mean score. however, in the bivariate analysis using the paired t-test, a significance value of 0.363 or ≥0.05 was obtained, meaning that the pre-test and post-test values for the control group did not have a significant difference. for the intervention group, there was also a decrease, especially after receiving virtual reality motor cognitive training. the average post-test score in the intervention group was 16.33, with a significance value in the paired t-test of <0.001 or <0.05, meaning that the pre-test and post-test values for the intervention group had a significant difference. therefore, it can be concluded that both the control and the intervention group experienced a decrease in post-test scores, but the difference in pre-test and post-test scores in the intervention group was more significant compared to the control group. the results of this study are in line with the research conducted by al-sharman, et al. (2019), which stated that the provision of virtual reality intervention affected the occurrence of fatigue (p < .001) (al-sharman et al., 2019). this can be interpreted as virtual reality intervention having a positive impact on addressing fatigue. life quality profile in geriatric patients the results of the pre-test on quality of life in the control group showed a mean score of 79.83, while the intervention group showed a mean score of 78.50. subsequently, all respondents in the control group had a good quality of life, while in the intervention group, there was 1 respondent who had a poor quality of life. this means that 11 out of 12 geriatric patients had a good quality of life. therefore, it can be concluded that the majority of geriatric patients at kasih nursing home cirebon have a good quality of life. the quality of life of geriatric patients is susceptible to decline due to various factors that influence quality of life, such as physical well-being, psychological health, social relationships, and environmental aspects. however, in this study, the majority of geriatric patients at kasih nursing home cirebon have a good quality of life. based on the results of the post-test on quality of life, both the control and intervention groups experienced a change with an increase in the mean score. the post-test mean score in the control group was 80.00. however, in the bivariate analysis using the paired t-test, a significance value of 0.363 or ≥0.05 was obtained, meaning that the pre-test and post-test values for the control group did not have a significant difference. for the intervention group, there was also an increase, especially after receiving virtual reality motor cognitive training. the average post-test score in the intervention group was 93.50, with a significance value in the paired t-test of 0.049 or <0.05, meaning that the pre-test and post-test values for the intervention group had a significant difference. therefore, it can be concluded that both the control and intervention groups experienced an increase in post-test scores, but the difference in pre-test and post-test scores in the intervention group was more significant compared to the control group (kemenkes r.i., 2015; rohmah et al., 2012). the results of this study are in line with the research conducted by maulani zn, et al. (2021), which stated that the application of virtual reality technology has a positive impact on the elderly with cognitive and motor impairments, thus improving the life quality of the elderly. this means that virtual reality can improve the life quality of the elderly (maulani et al., 2021). the effectiveness of virtual reality motor cognitive training based on the results of the paired t-test comparative analysis, it was found that both the control and intervention groups had differences in the mean scores between the pre-test and post-test for both variables. in the control group, the mean score for pre-test fatigue events was 33.50 and decreased to 33.33 at the post-test, similarly for the mean quality of life score where the pre-test mean score was 79.83 and increased at the post-test with a mean score of 80.00. although there were changes in the scores, no changes were found in the frequency distribution of categorization in the control group, where at pre-test 3 people experienced fatigue and at post-test, there were still 3 people who experienced fatigue. meanwhile, for the quality of life variable, both at pre-test and post-test, all geriatric patients in the control group had a good life quality. ghmj (global health management journal) 2024, vol. 7, no. 4 gani, et. al. 252 in the intervention group, a similar occurrence happened where there was a change in the mean scores between the pre-test and post-test. for the pre-test mean score for fatigue events, it was 50.83 and decreased to 16.33 at the post-test, similarly for the mean quality of life score where the pre-test mean score for the intervention group was 78.50 and the post-test mean score increased to 93.50. this change in the mean score was followed by a change in the frequency distribution of categorization where at pre-test 6 geriatric patients suffered from fatigue and at post-test 6 geriatric patients did not suffer from fatigue or no geriatric patients were found to suffer from fatigue. similarly, for the quality of life variable, there was a change in the frequency distribution of categorization where at pre-test 1 geriatric patient had a poor quality of life and at post-test 6 geriatric patients had a good quality of life or no geriatric patients were found to have a poor quality of life. the change in values in the intervention group was more significant compared to the change in values in the control group. on the independent samples t-test, the significance value (sig. (2-tailed)) on the row "equal variances assumed" for the fatigue variable was 0.055 for the pre-test and 0.048 for the post-test. then, for the quality of life variable, it was 0.853 for the pre-test and 0.004 for the post-test. it can be interpreted that there is no significant difference between the pre-test values of the control group and the intervention group. however, there is a significant difference between the post-test values of the control group and the intervention group. the n-gain score test conducted showed that the virtual reality motor cognitive intervention was effective for fatigue, with an average of 83.96% in the intervention group, but not effective for quality of life, as the intervention group had an average of 28.32%. these research findings align with the experimental study conducted by al-sharman et al. (2019), which found that five sessions of virtual reality game intervention can help improve fatigue events and provide health benefits (al-sharman et al., 2019). furthermore, in the research by ranukusuma cm and herawati t (2023), it was confirmed that virtual reality intervention can significantly improve upper extremity motor skills through the repetition of movements in virtual reality exercises that stimulate motor function. additionally, the presence of virtual reality technology attracts patients due to the variation in exercises. (ranukusuma & herawati, 2023). therefore, it can be concluded that the more significant difference in the intervention group compared to the control group is due to the influence of the intervention itself, which is virtual reality. however, this research does not align with the study conducted by maulani zn, et al. (2021) which stated that the application of virtual reality technology has a positive impact on the elderly with cognitive and motor impairments, thus improving the quality of life of the elderly (maulani et al., 2021). this is because the results of this study reveal that the provision of virtual reality motor cognitive training intervention was ineffective on the quality of life of geriatric patients at the kasih cirebon nursing home. several factors may have influenced this occurrence, such as differences in the cognitive level of geriatric patients, social relationships between geriatric patients, and psychological factors in geriatric patients (rohmah et al., 2012). this research supports the hypothesis that virtual reality motor cognitive training is effective in reducing fatigue, and there was a significant improvement in the group that received the intervention. however, the research results are inconsistent with the hypothesis regarding improving life quality, although a significant increase was found after the intervention. virtual reality offers advantages in the healthcare field, one of which is by improving motor function. motor function itself is closely related to the occurrence of fatigue, where in this study, the change in the average value of the intervention group was more significant compared to the control group that did not receive the intervention. thus, the change in fatigue that occurred was also caused by the improvement in motor function of geriatric patients. virtual reality motor cognitive training intervention also focuses on improving cognitive function, which will train the understanding and analysis of geriatric patients. improvements in both motor and cognitive functions indirectly affect changes in the life quality of geriatric patients. it can be concluded that the provision of virtual reality motor cognitive training intervention has an effective impact on the occurrence of fatigue but has no effective impact on the quality of life of geriatric patients at kasih cirebon nursing home. gani, et. al. ghmj (global health management journal) 2024, vol. 7, no. 4 253 limitation the findings of this study should be interpreted with caution due to several limitations. firstly, the study included only 12 geriatric patients. secondly, the research did not use randomization to reduce bias or confounding variables. thirdly, the research participants were predominantly male, making the research data too homogeneous. fourthly, there was a difference in the procedure time between the intervention given to the intervention group and the placebo intervention given to the control group. fifthly, the research time coincided with academic activities, resulting in several days when the researcher was unable to conduct the research. lastly, time constraints during the research were due to the researcher have to adhere to the rules of the nursing home. 5. conclusion virtual reality was effective in significantly improving fatigue. however, while there was a significant increase in quality of life after the virtual reality intervention, virtual reality was not significantly effective in improving the overall quality of life of geriatric patients. for future researchers or those interested in expanding research in this area, it was recommended to conduct studies with a larger sample size, to use randomization to minimize research bias, to implement interventions and placebo interventions with equal procedure durations, to conduct studies with a more heterogeneous sample, and to conduct longitudinal studies to observe more significant changes.. conflict of interest there is no conflict of interest. nothing to disclosure. references al-sharman, a., khalil, h., el-salem, k., alghwiri, a. a., khazaaleh, s., & khraim, m. (2019). motor performance improvement through virtual reality task is related to fatigue and cognition in people with multiple sclerosis. physiotherapy research international : the journal for researchers and clinicians in physical therapy, 24(4), e1782. https://doi.org/10.1002/pri.1782 badan pusat statistika kota cirebon. (2023). kota cirebon dalam angka. https://cirebonkota.bps.go.id/id/publication/2023/02/28/85865e877cb1ea4782791243/kota-cirebon-dalam-angka2023.html butarbutar, d. t. (2014). uji reliabilitas dan validitas fatigue severity scale versi bahasa indonesia pada dokter residen rsup dr. sardjito yogyakarta. pertemuan ilmiah regional xxvi dokter spesialis saraf joglosemarmas, 0–10. ch salim, o., sudharma, n. i., kusumaratna, r. k., & hidayat, a. (2007). validity and reliability of world health organization quality of life-bref to assess the quality of life in the elderly. 26(1), 27–38. communications, c. s. i., & mittal, h. (2020). virtual reality: an overview (issue july). akshaya kumar nayak. direktorat statistik kesejahteraan rakyat. (2022). statistik penduduk lanjut usia 2022 (a. s. mustari, r. sinang, i. maylasari, & b. santoso (eds.)). badan pusat statistik. ismahmudi, r., & fakhrurizal, a. a. (2020). relationship between active physical exercise and sleep quality with physical fatique in elderly on harapan baru samarinda public health care. jurnal ilmu kesehatan, 8(1), 44–48. https://doi.org/10.30650/jik.v8i1.1306 kemenkes r.i. (2015). permenkes no. 67 tahun 2015 tentang penyelenggaraan pelayanan kesehatan lanjut usia di pusat kesehatan masyarakat. kementerian kesehatan indonesia, 16, 89. maulani, z. n., aryanti, k., lestari, n. a. p., silitonga, p. g., cahyaningsih, r. b., sunari, t. b., & pradana, a. a. (2021). efektivitas virtual reality (vr) dalam peningkatan kualitas hidup lansia. jurnal kesehatan holistic, 5(2), 63–74. https://doi.org/10.33377/jkh.v5i2.103 ranukusuma, c. m., & herawati, t. (2023). aplikasi virtual reality dalam rehabilitasi ekstremitas atas pasien post stroke: literature review. prepotif: jurnal kesehatan masyarakat, 7(1), 886-893. rohmah, a. i. n. r., purwaningsih, & bariyah, k. (2012). kualitas hidup lanjut usia. jurnal keperawatan, 3(2), 120–132. sukarelawan, m. i., indratno, t. k., & ayu, s. m. (2024). n-gain vs stacking. (edisi satu). penerbit suryacahya. cite this article as: gani, h., gunawan, h., & gunawan, i. (2024). effectiveness of virtual reality on fatigue and life quality in geriatric patients at kasih nursing home cirebon, indonesia. ghmj (global health management journal), 7(4), 245–253. https://doi.org/10.35898/ghmj-741009 https://doi.org/10.1002/pri.1782 https://cirebonkota.bps.go.id/id/publication/2023/02/28/85865e877cb1ea4782791243/kota-cirebon-dalam-angka-2023.html https://cirebonkota.bps.go.id/id/publication/2023/02/28/85865e877cb1ea4782791243/kota-cirebon-dalam-angka-2023.html https://doi.org/10.30650/jik.v8i1.1306 https://doi.org/10.33377/jkh.v5i2.103 https://doi.org/10.35898/ghmj-741009 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 the government's efforts in tracing covid-19 patients: problems in the community reny sulistyowati department of nursing, poltekkes kemenkes palangka raya, indonesia *corresponding author’s email: reny_sulis@poltekkes-palangkaraya.ac.id doi: 10.35898/ghmj51594 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) coronavirus disease 2019 (covid-19) is a contagious disease caused by severe acute respiratory syndrome coronavirus 2 (sars-cov-2). sars-cov-2 is a new type of coronavirus that has not been previously identified in humans. two types of coronavirus lead to diseases and can cause severe symptoms, namely middle east respiratory syndrome (mers) and severe acute respiratory syndrome (sars) (indonesian ministry of health, 2020). covid-19 has reached almost all indonesian provinces on several occasions. the increase in fatal cases has had an impact on social, economic, political, cultural, defense, and security aspects, as well as the welfare of the people in indonesia. due to this, the indonesian government has stipulated presidential decree number 11 of 2020 concerning the determination of the coronavirus disease 2019 (covid-19) as a health emergency in the community. this decree confirms covid-19 as a health emergency in indonesia, for which the provisions and regulations must be made (indonesian ministry of health, 2020). in addition, the covid-19 dispersal has grown in the range of sufferers and asset losses, expanded affected location coverage, and had implications for broad socio-economic aspects in indonesia. the presidential decree number 12 of 2020 concerning the determination of non-natural disasters has also been issued stating covid-19 as a national disaster. this decree was quickly issued after the world health organization (who) designated covid-19 as a public health emergency of international concern (pheic) on january 30th, 2020. these guidelines are used as a reference for the central government, provincial government, regency/city government, health service facilities, personnel health, and all related parties in making efforts to prevent and control covid-19. the government has announced the use of epidemiological tracking as a control effort, especially for confirmed positive cases. the government has also formed a task force for the acceleration of handling covid-19, which aims to quicken covid-19 management. they intend to achieve this through synergies between ministries/departments and local governments through the presidential decree number 7 (indonesian ministry of health, 2020a) and tiered communication arrangements with the publication of public communication protocol. the latter regulates the provision of information by national government agencies to local governments (indonesian ministry of health, 2020b). in regard to the following protocols, the community refused to be tested despite the schedule having been submitted several days earlier. this is partly due to a lack of knowledge and inaccurate information regarding covid-19. https://dx.doi.org/10.35898/ghmj-51594 23 ghmj (global health management journal) 2022, vol. 5, no. 1 sulistyowati, r even though the government has conveyed a lot of information about covid-19 through television, mass media, and social media, it seems that there are still lots of people who do not fully understand or even oppose the government's efforts to carry out covid-19 rapid tests. a local newspaper stated that the traders in the palangka raya city market refused to be tested for various reasons. one of these reasons was they were afraid of the test results. many locals also argued that the gloves and needles used were not sterile. traders also was afraid of isolation if their rapid test results were declared reactive (faisal, 2020). this would hinder them from carrying out activities such as earning a living for their daily needs (gunawan et al., 2020). the government has made many efforts to increase understanding of covid-19 such as screening confirmed positive cases. if someone has contracted the virus but does not display symptoms (asymptomatic), they can still harm others around them due to fast transmission through droplets. covid-19 can be transferred through direct contact with an infected person and indirect exposure to surfaces or objects contaminated (e.g., a stethoscope or thermometer) (indonesian ministry of health, 2020b). figure 2. scheduling rapid tests by health workers at the sampit district market figure 1. the quite fish market in pasar besar during the scheduled rapid testing sulistyowati, r ghmj (global health management journal) 2022, vol. 5, no. 1 24 the coordination of reverse transcription-polymerase chain reaction (rt-pcr) examinations in each indonesian province and city/regency is under the authority of the provincial health office and city/regency health office, respectively. rapid tests discover antibodies that are produced in reactions to antigens (viruses). generally, new antibodies are formed seven days after infection (aryati, 2020). two main factors that can influence health are behavioral factors and non-behavioral factors. according to bloom, there are three domains of behavior: knowledge-based approach, scientific attitude, and scientific practice (notoatmodjo, 2012). health behavior is influenced and determined by three factors: predisposing factors, supporting elements, and reinforcing (notoatmodjo, 2012). predisposing sociodemographic factors in society include differences in age, sex, education, occupation, educational/occupational background, and area of origin. the sociodemographic characteristics can affect community behavior and public health outcomes (widayati et al., 2012). in a study by syakurah and moudy (2020), a significant correlation was found between individual knowledge and individual attitudes towards covid-19 (p = 0.000). individuals who lacked knowledge were likely to have 4,992 times more chance of showing a negative attitude than individuals with good knowledge. based on social psychology, this is closely related to a person's level of expertise or knowledge of the object in question. although there have been many efforts by the government to increase understanding of covid-19 and prevent its transmission, continuous education is still needed to increase public understanding of covid-19 figure 3. rapid testing by health workers at the karang mulya sub-district, kotawaringin barat district figure 4. rapid testing by health workers at the kotawaringing barat district market 25 ghmj (global health management journal) 2022, vol. 5, no. 1 sulistyowati, r effects. for reference, japan has been declared a country that has succeeded reducing covid-19 cases without strict policies (cnn, 2020); the japan government fostered the following three main pillars as effective strategies to reduce the covid-19 spread. the implementation of these three main pillars is closely related to and has implications for each other (budianto, 2020). 1. early detection and rapid response to deployment clusters. 2. optimization of intensive care facilities, especially for those who are in poor/critical condition. 3. modification of community behavior. consent the respondents have given their consent on photographs used in this study references aryati. 2020. tata laksana skrining dalam pelayanan laboratorium. https://www.pdspatklin.or.id/assets/files/pdspatklin_2020_05_03_21_32_22.pdf accessed date: 07-102020. budianto, f. 2020. tiga pilar utama penanganan covid-19 di jepang. http://psdr.lipi.go.id/news-andevents/opinions/tiga-pilar-utama-penanganan-covid-19-di-jepang-edisi-khusus-covid-19-bagian-4.html. accessed date: 07-10-2020. cnn, i. 2020. jepang berhasil tekan corona tanpa kebijakan ketat. https://www.cnnindonesia.com/internasional/20200526075133-113-506867/jepang-berhasil-tekan-coronatanpa-kebijakan-ketat. accessed date: 07-10-2020. faisal, a. 2020. alasan takut reaktif, sejumlah pedagang pasar kahayan pilih kabur saat petugas lakukan di rapid test, https://kaltengtoday.com/alasan-takut-reaktif-sejumlah-pedagang-pasar-kahayan-pilih-kabursaat-petugas-lakukan-di-rapid-test/. accessed date: 07-10-2020. 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 kemenkes. 2020a. pedoman pencegahan dan pengendalian coronavirus disease (covid-19). https://covid19.go.id/p/protokol/pedoman-pencegahan-dan-pengendalian-coronavirus-disease-covid-19revisi-ke-5. accessed date: 07-10-2020. kemenkes. 2020b. penanganan covid-19 protokol komunikasi publik. in kantor staf presiden. http://ksp.go.id/wp-content/uploads/2020/03/protokol-komunikasi-covid-19.pdf. accessed date: 07-102020. notoatmodjo, s. 2012. promosi kesehatan dan ilmu perilaku. syakurah, r. a., & moudy, j. 2020. pengetahuan terkait usaha pencegahan coronavirus disease (covid-19) di indonesia. higeia (journal of public health research and development), 4(3), 333-346. widayati, a., suryawati, s., de crespigny, c., & hiller, j. e. 2012. knowledge and beliefs about antibiotics among people in yogyakarta city indonesia: a cross-sectional population-based survey. antimicrobial resistance and infection control. biomed central. cite this article as: sulistyowati r. the government's efforts in tracing covid-19 patients: problems in the community. ghmj (global health management journal). 2022; 5(1):22-25. doi:10.35898/ghmj-51594 https://dx.doi.org/10.35898/ghmj-51594 ghmj (global health management journal) 2024, vol. 7, no. 4 indonesian scholars’ alliance open access research article effectiveness of gedong gincu mango leaf extract gel (mangifera indica l. var. gedong gincu) on cut wound healing in male white rats (rattus norvegicus) of the wistar strain azzahro maharani loren1,* , ignatius hapsoro wirandoko1,# , sri marfuati2 1departement of basic medical sciences, faculty of medicine, universitas swadaya gunung jati, indonesia, 2departement of pharmacology, faculty of medicine, universitas swadaya gunung jati, indonesia *corresponding author’s e-mail: azzahromaharani04@gmail.com* , ignatiushapsorowirandoko@gmail.com# doi: 10.35898/ghmj-741041 abstract background: the indonesia basic health research data show the prevalence of wounds including incision/scratches/stab wounds reaches 20.1%. natural herbal products play an important role in the wound healing process functioning as anti-inflammatories, antioxidants, antimicrobials, and collagen formation. mango leaves are often considered waste even though they have many health benefits with the high content of coactive compounds, such as alkaloids, flavonoids, tannins, and saponins which are good for cut wound healing. the use of gel is more stable and controlled release compared to other topical preparations. gedong gincu mangoes originating from west java have unique properties and they are marketed widely in some areas including cirebon. aims: this study aims to identify the most effective concentration of gedong gincu mango leaf extract on cut wound healing in male white rats (rattus norvegicus) of the wistar strain. methods: this study used a post-test-only control group design. the extract gel used three levels of concentration, namely 40%, 50%, and 60%. the positive control used 10% povidone iodine while the negative control used a gel base. the gel was applied to the cut wound twice a day for 14 days. results: the average length of the cut wound was 0.916 cm, 0.912 cm, and 1.050 cm for concentration levels of 40%, 50%, and 60%. for the positive and negative controls, it reached 0.996 cm and 0.702 cm respectively. this indicates no significant difference in the length of the cut wound with a p-value of 0.121 (p>0.05). the wound healing process was effective at a concentration level of 60% as indicated by the disappearance of erythema and edema. conclusion: mango leaf extract gel (mangifera indica l.var. gedong gincu) is effective in healing cut wounds with the disappearance of erythema and edema in male white rats (rattus norvegicus) wistar strain with a concentration of 60%. keywords: natural products, mangifera indica, wound healing, povidone iodine. received: 25 september 2024 reviewed: 19 october 2024 revised: 30 november 2024 accepted: 15 december 2024 © 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:azzahromaharani04@gmail.com* mailto:ignatiushapsorowirandoko@gmail.com https://doi.org/10.35898/ghmj-741041 https://orcid.org/0009-0008-6145-845x https://orcid.org/0009-0004-6024-5605 https://orcid.org/0009-0006-1320-4848 325 ghmj (global health management journal) 2024, vol. 7, no. 4 loren, et. al. 1. introduction wounds are damage or loss of part of the tissue (sjamsuhidajat et al., 2017). the indonesia basic health research data show that in indonesia, the prevalence of wounds including incisions/cuts/stabs reaches 20.1% (riskesdas, 2018). this result ranks third after abrasions/bruises/contusions and sprains. this value is based on national data, while the percentage result in west java reaches 21.4% (riskesdas, 2018). wound healing methods are varied including the use of modern products. natural products made from herbs provide anti-inflammatories, antioxidants, antimicrobials, and collagen formation for the wound healing process with few side effects (el-sherbeni s. a. et al., 2023; trinh x. et al., 2022; criollo-mendoza m. s. et al., 2023). gedong gincu mangoes are exotic and have unique characteristics. these fruits are from west java and spread across majalengka, indramayu, and sumedang districts (ariningsih e. et al., 2021; bangun rhb. et al., 2020; umam k. et al., 2021; sumantri k. et al., 2021). they have been widely distributed and marketed to various regions including cirebon district (awaliyah f. et al., 2020). mango leaves are often considered waste but they have many health benefits as they contain many bioactive compounds (kumar m. et al., 2021). previous studies revealed that mango leaves contain alkaloids, flavonoids, tannins, and saponins. those compounds play a role in the woundhealing process (suhatri et al., 2022). previous studies focusing on the use of gedong gincu mango peel extract gel for cut wound healing showed that mango leaves contain alkaloids, flavonoids, tannins, saponins, phenols, triterpenoids, and steroids. these metabolite compounds have a mechanism of action on the assessment of wound length, erythema, edema, and wound healing time. in this study, the concentration that provides the best wound healing effect was 5% and 10% (fathunnisa, et al., 2024). the topical preparation formulation in the form of mango leaf extract gel with concentrations of 40%, 50%, and 60% according to previous studies with cassava leaf extract on wound healing in new zealand white male rabbits with a good formulation with organoleptic tests, homogeneity tests, ph tests, and gel preparation spread tests, as well as final experiments for the effect on the wound healing process. the concentration of 60% provided the best wound-healing effects (megawati s. et al., 2020). the use of topical preparations in the management of skin diseases is common. gel formulations applied in the management of skin diseases are a safe and effective choice. gels are more stable with more controlled release than other topical preparations. as a topical drug, gels have good absorption (umam k. et al., 2021). based on the explanation above, this study tries to experiment with making gedong gincu mango leaf extract. gedong gincu mangoes originating from west java have unique properties as wound healers with various secondary metabolites. the determination of the sampling concentration refers to previous studies and produced significant results with different gel extracts. therefore, this study aims to identify the use of gedong gincu mango leaf extract as a secondary metabolite in cut wound healing. 2. methods study design/ research procedures this experimental laboratory study used a post-test-only control group design. this study aims to determine the effectiveness of gedong gincu mango leaf extract gel (mangifera indica l. var. gedong gincu) on cut wound healing in male white rats (rattus norvegicus) of the wistar strain. the researcher collected data on the length of the cut wound and the presence of erythema and edema for 14 days. the inclusion criteria were male white rats of the wistar strain aged 2-3 months with a body weight of 150-250 grams and an cut wound on the back. the exclusion criteria were male white rats of the wistar strain who got sick during treatment. the male white rats of the wistar strain that died were dropped out. this research was conducted in the research laboratory of the faculty of medicine, swadaya gunung jati university. preparation of mango gedong gincu leaf extract the preparation of mango leaf extracts used the maceration method. the mango leaves were obtained from plantations in the sedong area, cirebon district. the sun-dried mango leaves were blended and sieved. the results loren, et. al. ghmj (global health management journal) 2024, vol. 7, no. 4 326 were added with 70% ethanol with a ratio of solute and solvent of 1:10. thus, 1 kg of simplicia powder was added with 70% ethanol. the results were macerated for 3x24 hours and stirred twice with a rotary evaporator at a temperature of 50oc. the results were weighted and put into the oven to produce a thick extract. phytochemistry test of mango gedong gincu extract gel for the alkaloid test, 0.5 grams of mango leaf extract extract was added with 1 ml of 2 n hcl and 9 ml of hot distilled water, then filtered. the first tube was added with bouchardat reagent with a positive result if getting blackbrown sediment. dragendorff reagent was added to the second tube with a positive result if getting a white fog sediment (ifmaily i. et al., 2023). hager reagent was added to the third tube with a positive result when getting a yellow sediment. mayer reagent, methanol, and bouchardat reagent were added to the fourth tube and the result was considered positive if getting brownish-black sediment. for the flavonoid test and phenolic test, 0.5 grams of mango leaf extract were added with 2 ml of methanol. they were then filtered and divided into two different tubes. the first tube was added with 10% naoh and considered to have positive results if getting red hydroquinone phenol (ifmaily i. et al., 2023; rusnedy r. et al., 2023). concentrated h2so4 was added to the second tube with a positive indication when getting a red flavonoid compound. for the tannin test, 1 gram of mango leaf extract was added with 10 ml of distilled water and then filtered. the results were added with fecl3 with a positive result if getting a dark blue or greenish black color. for the saponin test, 0.5 grams of mango leaf extract in the test tube was added with 10 ml of distilled water, and then shaken. it was left for 2 minutes and added with 1 drop of hcl 2 n. the results will be positive if getting foams for± 10 minutes (ifmaily i. et al., 2023). for the triterpenoid test, 0.5 grams of mango leaf extract was added with bouchardat reagent. if it gets a red or purple color, it is declared positive. for the steroid test, 0.5 grams of mango leaf extract was added with ether, 3 drops of acetic acid, and 1 drop of concentrated h2so4. if getting a green color, it is declared positive. preparation of gel mango gedong gincu leaf extract table 1 shows the formulation of mango leaf extract gel covering na-cmc and hot distilled water which are homogenized, glycerin, propylene glycol, and methylparaben which are homogenized. mango leaf extracts are added with that formulation with a certain concentration. after getting the gel, it was kept away from sunlight for one night (hasanudin mn. et al., 2023). then, the gel was tested using organoleptic tests, ph tests, homogeneity tests, and spreadability tests (budi s. et al., 2020; nurlatifah n. et al; 2022). tabel 1. gedong gincu mango leaf extract gel formulation ingredient formulations group (grams) k1 (40%) k2 (50%) k3 (60%) kn mango gedong gincu leaf extract 20 25 30 na-cmc 0,5 0,5 0,5 0,5 metyl paraben 0,25 0,25 0,25 0,25 glyserin 5 5 5 5 propylene glycol 2,5 2,5 2,5 2,5 aquadest ad 50 50 50 50 evaluation of mango gedong gincu leaf extract gel preparation results 1. organoleptic test the results of the organoleptic test for gedong gincu mango leaf extract covered the physical form, smell, and color of the gel preparation (budi s. et al., 2020). 327 ghmj (global health management journal) 2024, vol. 7, no. 4 loren, et. al. 2. ph test the ph test aims to assess the acidity level of the gedong gincu mango leaf extract gel preparation. the test used a ph meter (budi s. et al., 2020). a good gel preparation has a value of 4.5-6.5 (nurlatifah n. et al; 2022). 3. homogeneity test the homogeneity test aims to assess the distribution of the gedong gincu mango leaf extract gel content evenly (budi s. et al., 2020). this test was conducted by applying the gel to clear glass and looking at whether coarse grains appear or not. the result of the test is considered good if all groups based on extract concentration do not contain coarse grains (nurlatifah n. et al; 2022). 4. spreadability test this test aims to assess the spreadability of the gedong gincu mango leaf extract gel preparation. a value of 5-7 cm is considered good. this test was carried out by dropping 0.5 grams of gel on an object glass and then covering the top with another object glass. the results were in the form of spreadability value (nurlatifah n. et al; 2022). making cut wounds on male white rats the researcher used white male rats of the wistar strain with cut treatment. before getting the cut, the rats were given 2% lidocaine subcutaneously and got their back fur shaved. the cut area was cleaned with alcohol cotton. the cut was made using a scalpel with a length of ± 2 cm and a depth of ± 0.3 cm. the cut wound healing was based on 3 criteria, namely the length of the cut, erythema stopped, and edema stopped. the gedong gincu mango leaf extract gel was applied twice a day for 14 days. measurements in this research, the independent variable was gedong gincu mango leaf extract gel (mangifera indica l. var. gedong gincu). then, the dependent variable was the cut wound healing in male white rats of the wistar strain. the sample size was based on the federer formula and the determination of the sample used a simple random sampling technique. statistical analysis the cut wound healing was seen from 3 criteria, namely the length of the cut, erythema elliminated, and edema disappeared. the treatment was performed by applying mango leaf extract gel twice a day for 14 days. statistical analysis used spss (statistical package for the social sciences). the data obtained were analyzed using the following steps. the length of the cut was assessed first with a normality test using the shapiro-wilk test because the sample was less than 50, namely only 25 male white rats. second, the homogeneity test used the levene test. third, the comparison test used the one-way annova test when the requirements for normality and homogeneity are met or (p (sig.) > 0.05). then the assessment of erythema and edema was based on direct observation to determine whether the erythema and edema have disappeared or not. ethical clearance this study has received approval from the ethics commission of the faculty of medicine, swadaya gunung jati university, cirebon number 8/ec/fkugj/iv/2024, dated april 8, 2024. the mango plants used in this study have been tested at the unnes biology laboratory with the number 54/un.37/shp/lab. plant taxonomy/iii /2024. male white rats of the wistar strain have an animal identity certificate number 09.141/rtp/vi/2024 which comes from pahlevi's house rats. loren, et. al. ghmj (global health management journal) 2024, vol. 7, no. 4 328 3. results the researcher obtained 311 grams of thick mango leaf extract. the characteristics of this mango leaf extract gel were thick with a blackish-brown color and had a distinctive mango leaf odor and a bitter taste. table 2 shows that the gedong gincu mango leaf extract (mangifera indica l. var. gedong gincu) contains secondary metabolite compounds such as phenolics, flavonoids, tannins, saponins, triterpenoids and steroids. tabel 2. results phytochemistry test phytochemicals reagent results depiction alkaloids bouchardat photo 1 dragendroff photo 2 hager photo 3 mayer+methanol+bauchardat photo 4 fenolics naoh 10% ++ photo 5 flavonoids h2so4 concentration + photo 6 tannins fecl3 +++ photo 7 saponins hcl 2 n +++ photo 8 triterpenoids bouchardat + photo 9 steroids eter+3 drops anhydrous+1 drop of h2so4 concentration + photo 10 description: 1. negative results = (-) 2. positive results: a. weak = (+) b. strong = (++) c. very strong = (+++) d. extremely strong = (++++) table 3 shows that the physical form, odor, and color of gel are in accordance with the extracts used. the physical form of the gel should be semi-solid, have a mango leaf extract odor, and a blackish brown color. the results of the organoleptic test showed that the mango leaf extract gel preparation is as expected. tabel 3. results organoleptic test groups results physical form odor colour 40% concentration semi-solid/viscous mango leaf extract brown-black 50% concentration semi-solid/viscous mango leaf extract brown-black 60% concentration semi-solid/viscous mango leaf extract brown-black gel base semi-solid/viscous don’t have odor pellucid table 4 shows that the concentrations of 40%, 50%, and 60% have good standard normal ph values. the negative control, namely the gel base preparation, did not show a normal ph value. so, concentrations of 40%, 50%, and 60% show good ph results. tabel 4. ph test (photo 11) groups normal value results 40% concentration 4,5-6,5 6 50% concentration 4,5-6,5 6 60% conecntartion 4,5-6,5 6 gel base 4,5-6,5 7 329 ghmj (global health management journal) 2024, vol. 7, no. 4 loren, et. al. photo 1. bouchardat alkaloids (-) photo 2. dragendroff alkaloids (-) photo 3. hager alkaloids (-) photo 4. mayer alkaloids (-) photo 5. phenolics (++) photo 6. flavonoids (+) photo 7. tannins (+++) photo 8. saponins (+++) photo 9. triterpenoids (+) photo 10. steroids (+) photo 11. results of ph test of mango leaf extract gel table 5 shows that the spreadability at concentrations of 40%, 60%, and the negative control obtained good spreadability. the 50% concentration had poor spreadability as indicated by a value of lower than 5-7 cm. tabel 5. spread test groups normal value results depiction 40% concentration 5-7 cm 5,1 cm photo 12 50% concentration 5-7 cm 4,9 cm photo 13 60% concentration 5-7 cm 5,2 cm photo 14 gel base 5-7 cm 5,3 cm photo 15 loren, et. al. ghmj (global health management journal) 2024, vol. 7, no. 4 330 photo 12. 40% consentation photo 13. 50% concentration photo 14. 60% concentration photo 15. gel base table 6 shows that the gel preparations with concentrations of 40%, 50%, 60% and negative control obtained good results that the gel was homogeneous and did not clot. tabel 6. homogeneous test groups results depiction 40% concentration homogeneous, don’t have lumps photo 16 50% consentration homogeneous, don’t have lumps photo 17 60% concentration homogeneous, don’t have lumps photo 18 gel base homogeneous, don’t have lumps photo 19 photo 16. 40% concentation photo 17. 50% concentration photo 18. 60% concentration photo 19. gel base 331 ghmj (global health management journal) 2024, vol. 7, no. 4 loren, et. al. table 7 shows that the average length of the cut wound in each treatment group did not differ significantly. tabel 7. measurement results of the length of the cut wound concentration average length of cut wound (cm) 1 2 3 4 5 40% 1,81 1,83 2,29 1,73 1,63 50% 1,67 1,48 1,86 1,41 2,03 60% 1,71 1,60 1,98 1,68 1,98 (+) 1,46 1,23 1,67 1,50 1,99 (-) 1,68 1,52 1,90 1,93 1,81 table 8 shows that 3 rats did not experience healing of erythema. in the group with a concentration of 60% and positive control, all rats experienced healing of erythema. tabel 8. results of erythema observation group rat erythema disappeared the day the erythema disappeared 40% concentration 1 yes day 14 2 no 3 yes day 11 4 yes day 11 5 yes day 11 50% concentration 1 yes day 13 2 yes day 12 3 no 4 yes day 12 5 yes day 14 60% concentration 1 yes day 12 2 yes day 12 3 yes day 11 4 yes day 11 5 yes day 13 positive control (+) 1 yes day 7 2 yes day 13 3 yes day 11 4 yes day 9 5 yes day 13 negative control (-) 1 yes day 11 2 no 3 yes day 11 4 yes day 12 5 yes day 14 table 9 shows that only group 3 with a concentration of 60% experienced edema healing. at a concentration of 40% and positive control, edema did not disappear in one rat. at a concentration of 50%, two rats whose edema did not disappear. in the negative control with a gel base, edema was difficult to assess in one rat because it was covered by scabs. loren, et. al. ghmj (global health management journal) 2024, vol. 7, no. 4 332 tabel 9. results of edema observation group rat edema disappeared the day the edema disappeared 40% concentration 1 yes day 8 2 no 3 yes day 13 4 yes day 11 5 yes day 10 50% concentration 1 no 2 yes day 14 3 yes day 11 4 yes day 12 5 no 60% concentration 1 yes day 11 2 yes day 13 3 yes day 10 4 yes day 13 5 yes day 10 positive control (+) 1 yes day 6 2 no 3 yes day 11 4 yes day 10 5 yes day 12 negative control (-) 1 yes day 7 2 it’s hard to judge 3 yes day 9 4 yes day 11 5 yes day 14 table 10 shows that this research involved 25 sample rats. so, the normality test used was the shapiro-wilk test. data are considered normally distributed if the significance value is higher than 0.05 (p>0.05). the data are the result of dividing day 14 by day 1. in group 1 with a concentration of 40%, the sig. value was 0.611. in group 2 with a concentration of 50%, the sig. value was 0.232. in group 3 with a concentration of 60%, the sig value was 0.555. in group 4 with the administration of 10% povidone-iodine as a positive control, the sig value was 0.994. group 5 with gel base as a negative control obtained a sig. value of 0.206. so, the results of the normality test presented in table 10 show that the data are normally distributed because the p-value is higher than 0.05. tabel 10. normality test for the cut wound length groups amount sig. description 40% concentration 5 0,611 normal 50% concentration 5 0,232 normal 60% concentration 5 0,555 normal positive control (+) 5 0,994 normal negative control (-) 5 0,206 normal *shapiro-wilk test 333 ghmj (global health management journal) 2024, vol. 7, no. 4 loren, et. al. table 11 shows the results of the homogeneity test using the levene test. the data are homogeneous with a significance value of 0.232 meaning that the p-value is higher than 0.05. tabel 11. results of homogeneous cut wounds variable sig. description length of cut wound 0,232 homogeneous *levene test table 12 shows that the data are normally distributed so it is continued with a one-way anova test to see the effect of treatment on the length of the cut wound based on the group in the sample of male white rats of the wistar strain. a p-value lower than 0.05 (p <0.05) is considered significant. tabel 12. results of one-way annova test kelompok mean±sd sig. 40% concentration 0,916±0,171 50% consentration 0,912±0,107 60% concentration 1,050±0,251 0,121 positive control (+) 0,996±0,309 negative control (-) 0,702±0,101 *one way annova test the treatment group 1 with a concentration of 40% obtained a mean value of 0.916 (photo 20). the treatment group 2 with a concentration of 50% obtained a mean value of 0.912 (photo 21). the treatment group 3 with a concentration of 60% obtained a mean value is 1.050 (photo 22). the treatment group 4 with 10% povidone iodine as a positive control obtained a mean value of 0.996 (photo 23). the treatment group 5 with the administration of gel base as a negative control obtained a mean value of 0.702 (photo 24). the analysis using one-way anova obtained a p-value of 0.121 which is lower than 0.05. thus, there is no significant difference in all treatment groups for cut wounds. photo 20. 40% concentration photo 21. 50% concentration photo 22. 60% concentration loren, et. al. ghmj (global health management journal) 2024, vol. 7, no. 4 334 4. discussion mechanism of secondary metabolite compounds in wound healing process wound healing processes cover 3 important stages, namely the inflammation, proliferation, and remodeling phases. the inflammation phase is characterized by the appearance of erythema and edema (sjamsuhidajat, et al., 2017). previous studies examining cut wounds with gedong gincu mango leaf extract showed that mango leaves contain flavonoids, tannins, phenols, triterpenoids, steroids, alkaloids, and saponins. the optimum concentrations were 5% and 10% which provided the best wound healing effect (fathunnisa, et al., 2024). gedong gincu mango leaves have various secondary metabolite compounds that can help the wound healing process. phytochemical tests show that mango leaves contain phenolic compounds, flavonoids, tannins, saponins, triterpenoids, and steroids. however, they do not contain alkaloids. generally, plants that have close taxonomic classifications will have secondary metabolite compounds that are not much different (julianto ts, et al., 2019). secondary metabolites are the result of biosynthesis metabolism that passes through 3 pathways and the results of this metabolism can be influenced by some factors (anggraito yu, et al., 2018). secondary metabolite compounds in plants depend on plant growth conditions, such as season, year, and environment. plant growth is influenced by genetic factors in the biosynthesis metabolism pathway for the formation of secondary metabolite compounds (li y, et al., 2020). this contradicts the results of a previous study that obtained positive alkaloid results (suhatri, et al., 2022). flavonoids are compounds with a chemical formula of c6c3c6 whose fifteen-carbon basic framework consists of two benzene rings (a and b) and is connected by a heterocyclic pyran ring (c) (julianto ts, 2019). flavonoids are secondary metabolite compounds that work by inhibiting the migration of leukocyte cells that appear after getting wound, encouraging the formation of apoptosis, and maintaining cell survival (anisa n, et al., 2019; al-khayri jm, et al., 2022). in this study, erythema and edema did not disappear in the concentrations of 40% and 50%. the inflammatory phase is influenced by other secondary metabolic compounds, namely phenolics and tannins. in the wound healing process, phenolics work by counteracting free radicals to prevent tissue damage and inhibiting the formation of enzymes that work in the inflammatory phase, namely the cyclooxygenase enzyme (anisa n, et al., 2019). tannins are natural compounds contained in various plants (das ak, et al., 2020). the molecular weight of tannins ranges from 500-3000 (gallic acid ester) and higher than 20,000 (proanthocyanidins) (julianto ts, 2019; anisa n, et al., 2019). tannins function to prevent free radicals, reduce edema, and prevent pus in wounds (suhatri, et al., 2022; anggraito yu, et al., 2018). in the negative control with a gel base, rats discharged pus from their wounds indicating that the mango leaf extracts prevent the formation of pus because the negative control was not provided with the mango leaf extract. tannins act as anti-inflammatories and antibacterials by reducing mucosal permeability and strengthening mucosal bonds causing difficulties for bacteria to penetrate wounds and inhibit bacterial proliferation. therefore, the cut wound heals faster without being worsened by a bacterial infection (mustika s.y., et al., 2020). photo 23. positive control (+) photo 24. negative control (-) 335 ghmj (global health management journal) 2024, vol. 7, no. 4 loren, et. al. saponins have properties like soap and detergent because they contain a fat-soluble group (sugar) in one molecule (das ak, et al., 2020). shaking saponin can produce foam on the surface of the water because saponin has the property of reducing the tension on the surface of the water (mustikasari sy, et al., 2020). saponins can strengthen the edges of open wounds to close faster. saponin plays a role in the formation of collagen and tissue epithelialization in the proliferation phase. besides, saponin encourages the formation of type 1 collagen which helps wound healing process (sjamsuhidajat, et al., 2017; mustikasari sy, et al., 2020; anggraeni pp, et al., 2023). most of the rats in each treatment group closed their wounds on day 4. gedong gincu mango leaves contain other secondary metabolite compounds, namely steroids. ki et al (2011) revealed that steroids play a role in the epithelialization mechanism, where the epithelium will be formed faster enabling faster closure of epithelialization (dewi a.a., et al., 2020). based on the phytochemical tests, gedong gincu mango leaves contain secondary metabolite compounds, namely triterpenoids. triterpenoids inhibit ros (reactive oxygen species) interference in the wound-healing process. thus, the presence of triterpenoids can reduce interference with the healing process. besides, triterpenoids act as compounds that increase antioxidant activity (vitale s, et al., 2022). this compound helps the wound healing process. cut wound healing process in different concentration levels treatment groups with 40% concentration levels show that the average length of the cut wound is not significantly different as the cut line does not disappear until the last day of the treatment. erythema and edema disappeared and almost all rats experienced wound healing. however, the 2nd rat did not experience healing indicated by the presence of erythema, edema, and abscesses. a total of 4 treatment rats experienced healing until the last day of treatment. negative alkaloids in gedong gincu mango leaves affect the wound healing process. the 2nd rat did not experience the wound-healing process. the treatment groups with 50% concentration levels show a difference in the average length of the cut wound. erythema and edema did not completely disappear in all rats. only 2 rats in this group experienced the wound-healing process. this shows that this concentration level is not as good as the 40% concentration level. based on the spreadability test of the mango leaf extract, the 50% concentration showed poor spreadability, namely less than 5 cm. the group with 60% concentration level shows a difference in the average length of the cut wound. in all rats, erythema and edema disappeared with wound healing until the last day of treatment. in this group, the day of wound healing did not differ much among rats. this shows that the 60% concentration is good for the woundhealing process. the positive control used 10% povidone iodine. previous studies revealed that the use of 10% povidoneiodine does not have an anti-inflammatory and antiseptic effect and can interfere with collagen synthesis because it can attack healthy cells (mustikasari sy, et al., 2020). in this group, erythema disappeared in all treated rats, but the edema did not disappear in the 2nd rat. the negative control uses a gel base to ensure whether the mango extract plays a role in the wound healing process. based on the result of the study, the negative control showed wound healing in four rats only. however, in the second rat, there is no healing process, erythema does not disappear, and edema is difficult to assess due to being covered by scars. this means that the gel base gel does not contain mango leaf extract so it does not contain secondary metabolite compounds. tannin affects the discharge of pus. the gel base does not contain this compound, so pus comes out of the wound. previous studies with the same concentration of 40%, 50%, and 60% with topical extract gel preparations from cassava leaves. this study assessed the percentage of cut wound length on wound healing. the highest concentration of 60% provided the best effect in accelerating the wound healing process (megawati s. et al., 2020). the same concentration of 40%, 50%, and 60% in this study showed insignificant results on the length of the cut wound. however, for other wound healing criteria, namely erythema and edema, a concentration of 60% is the best concentration for eliminating erythema and edema. loren, et. al. ghmj (global health management journal) 2024, vol. 7, no. 4 336 another study with concentrations of 5%, 10%, and 15% of gedong gincu mango extract showed the best cut wound healing at the concentrations of 5% and 10%. the best healing of erythema and edema was at a concentration of 5% and 10% respectively on the same day (fathunnisa. et al., 2024). in this research, based on the length of the cut wound, the wound healing criteria were not significant in all treatment groups. however, at a concentration of 40%, 4 out of 5 rats experienced healing until the end of the study. at a concentration of 50%, 3 out of 5 rats experienced healing. at a concentration of 60%, all rats experienced a healing process for both erythema and edema. in the positive control group, the use of 10% povidone-iodine indicated that all rats experienced healing with the disappeared erythema. however, only 4 rats experienced healing with the disappeared edema with no influence on the length of the cut wound between the positive control and other treatment groups. moreover, in this study, the best concentration to eliminate erythema and edema in all rats was 60%. the group with 50% concentration has good quality in terms of shape, smell, color, and ph with poor spreadability. the 60% concentration was able to eliminate erythema and edema. the 60% concentration was the best concentration in eliminating erythema and edema until the last day of treatment in five rats compared to the other groups. results of statistical testing and wound healing the significance of the length of the cut wound was tested using one-way anova test. it obtained a p-value of 0.121 which is higher than 0.05. the statistical test showed that the length of the cut wound was not significant among all treatment groups. the intervention group with 60% concentration level experienced healing with erythema and edema disappearing in all treated rats. 5. conclusion mango leaf extract (mangifera indica l.var. gedong gincu) contains secondary metabolite compounds such as flavonoids, phenolics, tannins, saponins, triterpenoids, and steroids. this extract has good quality in terms of shape, smell, color, ph, and poor spreadability at a concentration of 50%. mango leaf extract gel has no effect on the length of the cut wound in male white rats of the wistar strain. the group with a concentration of 60% can make erythema and edema disappear in male white rats of the wistar strain. mango leaf extract gel (mangifera indica l.var. gedong gincu) managed to help heal cut wounds in male white rats (rattus norvegicus) of the wistar strain. 6. limitations this study has two limitations. first, the levels of active substances in mango leaf extract that affect the wound healing process have not been tested. therefore, the extent to which the active substance influences the woundhealing process cannot be identified. second, the levels of toxicity and toxic substances contained in gedong gincu mangoes are not known yet. gedong gincu mango leaves have not been tested. thus, which substances that have side effects on wound healing cannot be identified. 7. clinical and future studies further studies are expected to prepare extracts with different treatments, and leaf extract gels with dependent variables of burns or cuts. further studies can examine different topical preparations, creams, ointments or gel fractions, not only on the length of the wound, but also the width and area of the wound to assess its effectiveness. . conflict of interest the authors declare no conflict of interest for the results. 337 ghmj (global health management journal) 2024, vol. 7, no. 4 loren, et. al. references sjamsuhidajat, r., zunilda s. bustami, leo, arya rendy kristandyo, aryandhito widhi nugroho, bisono, theddeus o h prasetyono, reno budiman, ignatius riwanto, paul tahalele. 2017. buku ajar ilmu bedah masalah, pertimbangan klinis bedah, dan metode pembedahan. 4th ed. jakarta: egc. badan penelitian dan pengembangan kesehatan ri. 2018. "laporan riskesdas 2018 nasional.pdf." lembaga penerbit balitbangkes: 156. el-sherbeni, s. a., and w. a. negm. 2023. "the wound healing effect of botanicals and pure natural substances used in in vivo models." inflammopharmacology 31(2): 755-72. https://doi.org/10.1007/s10787-02301157-5 trinh, xuan tung et al. 2022. "a comprehensive review of natural compounds for wound healing: targeting bioactivity perspective." international journal of molecular sciences 23(17). https://doi.org/10.3390/ijms23179573 marilyn s. criollo-mendoza et al. 2023. "wound healing properties of natural products: mechanisms of action." molecules 28: 598. https://doi.org/10.3390/molecules28020598 ariningsih, ening et al. 2021. "kinerja agribisnis mangga gedong gincu dan potensinya sebagai produk ekspor pertanian unggulan." forum penelitian agro ekonomi 39(1): 49. https://doi.org/10.21082/fae.v39n1.2021.49-71 bangun, rita herawaty br. 2020. "potensi komoditi mangga gedong gincu dalam pengembangan wilayah dan perekonomian kabupaten majalengka." jurnal sosial ekonomi pertanian 16(3): 213-25. megawati, sefi, nur'aini nur'aini, and dewi kurniasih. 2020. "uji efektivitas gel ekstrak etanol 96% daun singkong (manihot esculenta crantz.) pada penyembuhan luka sayat kelinci jantan galur new zealand white." jurnal farmagazine 7(1): 1. https://doi.org/10.47653/farm.v7i1.159 umam, khoirul, rokhani hasbullah, and mohamad solahudin. 2021. "karakteristik dan kelayakan finansial usahatani mangga gedong gincu di kabupaten indramayu." jurnal keteknikan pertanian 9(3): 119-26. https://doi.org/10.19028/jtep.09.3.119-126 sumantri, kosasih. 2021. "strategi pemasaran mangga gedong gincu kabupaten sumedang." agrivet : jurnal ilmuilmu pertanian dan peternakan (journal of agricultural sciences and veteriner) 9(2): 200-205. https://doi.org/10.31949/agrivet.v9i2.1749 awaliyah, fitri, and bobby rachmat saefudin. 2020. "efisisensi pemasaran komoditas mangga gedong gincu di kabupaten cirebon." paradigma agribisnis 3(1). https://doi.org/10.33603/.v3i1.3543 fathunnisa f, marfuati s, fitriani h. 2024. "effectiveness of mango gedong gincu peel extract gel ( mangifera indica l .) on cut wounds in male wistar white rats ( rattus norvegicus )." ghmj (global health management journal) 7(3): 1-9. https://doi.org/10.35898/ghmj-731060 kumar, manoj et al. 2021. "mango (mangifera indica l.) leaves: nutritional composition, phytochemical profile, and health-promoting bioactivities." antioxidants 10(2): 1-23. https://doi.org/10.3390/antiox10020299 suhatri, fidiyani, dwi, nia azzahra, and muslim suardi. 2022. "effectiveness of mango leaf extract (mangifera indica l) on healing of second level cut wound in male white mice (mus musculus)." jurnal kesehatan terapan 9: 66-71. https://doi.org/10.54816/jk.v9i2.520 ifmaily, ifmaily, ulfa anggraini, and putri rizki fitriani. 2023. "pengaruh salep ekstrak biji buah mangga arumanis (mangifera indica l ) terhadap penyembuhan luka eksisi secara in vivo." jurnal ventilator: jurnal riset ilmu kesehatan dan keperawatan 1(4): 362-77. https://doi.org/10.59680/ventilator.v1i4.830 rusnedy, rahmayati, mira febrina, and cindy patika sari. 2023. "uji aktivitas wound healing ekstrak etanol buah averrhoa bilimbil. (belimbing wuluh) pada mencit putih jantan (mus musculus)." pharmacon: jurnal farmasi indonesia 20(1): 50-60. https://doi.org/10.23917/pharmacon.v20i1.22677 https://doi.org/10.1007/s10787-023-01157-5 https://doi.org/10.1007/s10787-023-01157-5 https://doi.org/10.3390/ijms23179573 https://doi.org/10.3390/molecules28020598 https://doi.org/10.21082/fae.v39n1.2021.49-71 https://doi.org/10.47653/farm.v7i1.159 https://doi.org/10.19028/jtep.09.3.119-126 https://doi.org/10.31949/agrivet.v9i2.1749 https://doi.org/10.33603/.v3i1.3543 https://doi.org/10.35898/ghmj-731060 https://doi.org/10.3390/antiox10020299 https://doi.org/10.54816/jk.v9i2.520 https://doi.org/10.59680/ventilator.v1i4.830 https://doi.org/10.23917/pharmacon.v20i1.22677 loren, et. al. ghmj (global health management journal) 2024, vol. 7, no. 4 338 muhammad nurul hasanudin, muhammad alfian, moch. fathul mujib. 2023. "uji aktivitas gel ekstrak etanol 70% daun kitolod (isotoma longiflora (l.) c presl) terhadap penyembuhan luka sayat pada mencit (mus musculus)." sains indonesia: jurnal ilmiah nusantara 1: 118-28. budi, setia, and mila rahmawati. 2020. "pengembangan formula gel ekstrak pegagan (centella asiatica (l.) urb ) sebagai antijerawat." jurnal farmasi dan ilmu kefarmasian indonesia 6(2): 51. https://doi.org/10.20473/jfiki.v6i22019.51-55 nurlatifah, nurlatifah et al. 2022. "formulasi sediaan gel dari ekstrak etanol herba pegagan (centella asiatica (l) urb)." journal of pharmaceutical and health research 3(1): 10-14. https://doi.org/10.47065/jharma.v3i1.1366 julianto, tatang shabur. 2019. fitokimia tinjauan metabolit sekunder dan skrining fitokimia. yogyakarta: universitas islam indonesia. anggraito, yustinus ulung et al. 2018. fakultas matematika dan ilmu pengetahuan alam universitas negeri semarang metabolit sekunder dari tanaman : aplikasi dan produksi. li, yanqun et al. 2020. "the effect of developmental and environmental factors on secondary metabolites in medicinal plants." plant physiology and biochemistry 148(january): 80-89. https://doi.org/10.1016/j.plaphy.2020.01.006 anisa, nurul et al. 2019. "efektifitas anti inflamasi daun mangga (mangifera indica) terhadap luka bakar derajat dua the effectiveness of anti inflation mangoes leaves (mangifera indica) against burns degrees two." jurnal b-dent viii(1): 1-7. https://doi.org/10.35580/sainsmat81101182019 al-khayri, jameel m. et al. 2022. "flavonoids as potential anti-inflammatory molecules: a review." molecules 27(9). https://doi.org/10.3390/molecules27092901 das, atanu kumar et al. 2020. "review on tannins: extraction processes, applications and possibilities." south african journal of botany 135(october): 58-70. https://doi.org/10.1016/j.sajb.2020.08.008 mustikasari, susi yanuari, ignatius hapsoro wirandoko, and ika komala. 2020. "efektifitas ekstrak daun afrika (vernonia amygdalina) terhadap ketebalan epitelisasi pada luka insisi mencit." jurnal kedokteran & kesehatan 6(3): 12-18. anggraeni putri, puspa, moralita chatri, and linda advinda. 2023. "characteristics of saponin secondary metabolite compounds in plants karakteristik saponin senyawa metabolit sekunder pada tumbuhan." serambi biologi 8(2): 251-58. dewi, ayu utami, and imam adi wicaksono. 2020. "review artikel: tanaman herbal yang memiliki aktivitas penyembuhan luka." jurnal farmaka universitas padjadjaran 18(2): 191-207. vitale, stefania et al. 2022. "phytochemistry and biological activity of medicinal plants in wound." molecules 27(11): 1-30. https://doi.org/10.3390/molecules27113566 cite this article as: loren, a. m., wirandoko, i. h., & marfuati, s. (2024). effectiveness of gedong gincu mango leaf extract gel (mangifera indica l. var. gedong gincu) on cut wound healing in male white rats (rattus norvegicus) of the wistar strain. ghmj (global health management journal), 7(4), 324–338. https://doi.org/10.35898/ghmj-741041 https://doi.org/10.20473/jfiki.v6i22019.51-55 https://doi.org/10.47065/jharma.v3i1.1366 https://doi.org/10.1016/j.plaphy.2020.01.006 https://doi.org/10.35580/sainsmat81101182019 https://doi.org/10.3390/molecules27092901 https://doi.org/10.1016/j.sajb.2020.08.008 https://doi.org/10.3390/molecules27113566 https://doi.org/10.35898/ghmj-741041 indonesian scholars’ alliance ghmj (global health management journal) 2025, vol. 8, no. 2s x open access research article the 1st cirebon international health symposium: faculty of medicine, universitas swadaya gunung jati update on non-communicable diseases: global perspective on health challenges and innovation angiotensin converting enzyme 2 (ace2) g8790a gene polymorphism as a risk factor for essential hypertension nazaul husna1* , donny nauphar2 , tiar masykuroh pratamawati2* 1. faculty of medicine, universitas swadaya gunung jati, cirebon, indonesia (45132); 2. department of genetics, faculty of medicine, universitas swadaya gunung jati, cirebon, indonesia (45132). *corresponding author’s e-mail: drtyarladala@gmail.com; nazaulh12@gmail.com doi: 10.35898/ghmj-82s1231 abstract background: globally, the number of people with hypertension has doubled, from 650 million to 1.3 billion. the world health organization reported that hypertension is responsible for more than 10 million deaths every year. essential hypertension is a multifactorial condition with genetics as one of the factors. genome-wide association study has identified several genes associated with hypertension, one of which is the angiotensin converting enzyme 2 (ace2) gene. essential hypertension may be predisposed to by the g8790a polymorphism of the ace2 gene, which is hypothesized to interfere with the normal function of the renin angiotensin system (ras). aims: the purpose of this study is to determine whether the ace2 g8790a gene polymorphism in cirebon, west java, indonesia, is associated with an increased risk of essential hypertension. methods: this is a case-control study conducted at the talun health center, cirebon regency, aprilaugust 2024, involving 30 essential hypertensive patients and 30 healthy controls. the study population comprised adults aged 30 to 72 years. data was obtained through the examination of blood pressure, dna extraction, pcr-rflp with alui restriction enzyme, and then visualization of the results with gel electrophoresis. the chi-square test technique and the odds ratio (or) computation were used to analyze the data. results: the g allele was higher in the case group 33 (55%), while the a allele was higher in the control group 34 (56.7%). the statistical analysis showed that there was no significant link between the ace2 g8790a gene variation and essential hypertension, with a p-value of 0.592 (p > 0.05) (or = 0.750; ci = 0.262–2.151). conclusion: the ace2 gene g8790a polymorphism and the rate of hypertension in cirebon, west java, were not significantly correlated. further research is required on a larger scale to investigate the effects of gene combinations or interactions with other locus genes on essential hypertension. keywords: ace2 gene; g8790a polymorphism; essential hypertension. received: 10 july 2025 reviewed: 14 july 2025 revised: 27 july 2025 accepted: 15 august 2025. © 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:drtyarladala@gmail.com mailto:nazaulh12@gmail.com https://doi.org/10.35898/ghmj-82s1231 https://orcid.org/0009-0008-1515-0526 https://orcid.org/0000-0002-8708-4715 https://orcid.org/0000-0002-2844-9307 husna, et. al ghmj (global health management journal) 2025, vol. 8, no. 2s 286 1. introduction hypertension is a dangerous condition that can lead to major side effects like heart attack, stroke, retinopathy, and renal failure (unger et al., 2020). it is occurred when the systolic blood pressure (sbp) rises by more than 140 mmhg and/or the diastolic blood pressure (dbp) rises by more than 90 mmhg (kemenkes, 2021). the update jnc-8 guideline recommendation divides hypertension into two categories: primary hypertension (90% of the cases), which people have an unknown etiology, and secondary hypertension (10% of the cases), which people have a known cause for their high blood pressure (olin & pharm, 2018). since hypertension typically has no symptoms, it is known as the "silent killer" because most people are unaware of their illness until they have clinical difficulties such as kidney damage, heart failure, stroke, heart attack, and many other health issues. (p2ptm kemenkes ri, 2024). globally, there are now 1.3 billion hypertensive individuals, up from 650 million previously (zhou et al., 2021). over 10 million fatalities are attributed to hypertension each year, more than all other health risks combined, according to the world health organization (who) (world health organization, 2023). with a prevalence of 34.1% among those over the age of 18, west java is now the second-highest area (kemenkes ri, 2018). the estimated number of hypertension patients in cirebon regency in 2021 is 648,030, and 73,173, or 11.3% of the total number of hypertension patients, have received medical treatment according to standards (dinas kesehatan kabupaten cirebon, 2021). essential hypertension is a manifestation of the presence of hemodynamic imbalance of the cardiovascular system, the cause of which is multifactorial, including relating to genetic factors, the environment, and the centers of regulation of hemodynamics (alwi, 2014). patients with essential hypertension often experience a wide range of symptoms, including headache, irregular heartbeat, visual abnormalities, chest discomfort, nausea, vomiting, and convulsions. nowadays, a digital blood pressure monitor is used to take three readings of blood pressure at 5-minute intervals in order to detect essential hypertension. the patient will have an ecg and blood glucose tests after being diagnosed with high blood pressure to rule out diabetes and other cardiovascular diseases. treatments for essential hypertension include angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, calcium channel blockers, diuretics, and beta-blockers. age, sex, and genetics are unmodifiable risk factors for hypertension; risk variables that can be modified include smoking, a low-fiber diet, dyslipidemia, excessive salt intake, a sedentary lifestyle, stress, obesity, and alcohol use (p2ptm kemenkes ri, 2024). in most genetic research related to hypertension, the reninangiotensin system (ras), one of the physiological systems that controls blood pressure, is the source of the candidate genes (lu et al., 2012). renin-angiotensin-aldosterone system (raas) genes, such as those involved in making aldosterone, ace2, ace, and others, are linked to a higher risk of hypertension. furthermore, there is a correlation between the ace2 gene and essential hypertension, diabetes mellitus, coronary heart disease, and the severity of covid-19. these studies include findings from pan (2023), yan et al. (2008), m. yang, zhao, xing, and shi (2015), and younas, ijaz, and choudhry (2022). the ace2 gene manufactures the protease enzyme angiotensin converting enzyme 2, which sticks to the surface of cell membranes in the heart, blood vessels, kidneys, intestines, testicles, and lungs (chappell, marshall, alzayadneh, shaltout, & diz, 2014). this gene has 805 amino acids and is located on the xp22.2 chromosome (ace2 gene, 2023). ace2 is an ace homologue that maintains blood pressure homeostasis by regulating negative ras, which maintains a balance between vasoconstrictor and vasodilator actions (burrell, johnston, tikellis, & cooper, 2004). the g8790a gene polymorphism of ace2 is a restriction enzyme truncation site located in the fourth base of the third intron adjacent to the exon and shows that this locus can alter the alternative splicing of mrna and affect ace2 gene expression. the g8790a gene polymorphism of ace2 causes changes in the amount of ang serum (1–7) that functions to inhibit vasoconstriction, which can lead to increased blood pressure (li, 2012). blood pressure is currently associated with genetic causes. many polymorphisms that raise an individual's risk of acquiring high blood pressure have been found by researching genes that produce monogenic forms of hypertension and pathways related to blood pressure regulation (lupton, chiu, & lind, 2011). there is no recent research on the ace2 g8790a gene polymorphism being a risk factor for high blood pressure in cirebon, west java, indonesia. this study was conducted to determine whether the ace2 g8790a gene polymorphism in cirebon, west java, is associated with an increased risk of essential hypertension. husna, et. al. ghmj (global health management journal) 2025, vol. 8, no. 2s 287 2. methods study design and research procedures an analytical study was carried out at the talun health center in cirebon regency from april to august 2024 to examine the link between essential hypertension and the g8790a gene variation of the angiotensin converting enzyme 2 (ace2). participants were selected using purposive sampling according to established inclusion and exclusion criteria. the case-control study identified a sample size of 60 participants, with 30 individuals in the case group and 30 individuals in the control group. inclusion criteria for the case group included (1) a diagnosis of essential hypertension based on the updated eighth joint national committee (jnc-8) guideline recommendations and (2) a family history of hypertension. the exclusion criteria include (1) patients who are pregnant or lactating, and (2) patients with hypertension who also have diabetes, kidney disease, liver disease, stroke, or other cardiovascular disease. the control group's members fit the same inclusion and exclusion criteria as the case group, and they were diagnosed as nonhypertensive based on the same diagnostic standards. control subjects were matched to case subjects based on age (± 2 years). to minimize bias, patients who were pregnant or breastfeeding or had a history of diabetes mellitus, renal disease, coronary heart disease, or other cardiovascular diseases were excluded from the case group (kuswara et al., 2024). the researchers collected demographic data and measured the blood pressure of all study subjects throughout the study. measurement blood samples were collected from the peripheral vein. the samples were thereafter kept at ambient temperatures in tubes treated with edta. participants who fulfilled the research criteria were evaluated by a questionnaire administered by a physician to ensure accurate data entry. clinical characteristics gathered during screening include age, gender, and familial history of hypertension. additionally, blood pressure was assessed three times, with an interval of 3 to 5 minutes between each test. blood samples (3–5 cc) were obtained at the talun public health centre, transferred to edta tubes, and transferred to the research laboratory at universitas swadaya gunung jati cirebon for genetic analysis. dna from leukocytes was extracted using the qiaamp kit (qiagen, tokyo, japan) following the recommended protocol. instruments the gene polymorphisms were amplified using the restriction fragment length polymorphism (rflp) and polymerase chain reaction (pcr) techniques. the amplification process contained 12.5 μl of pcr taq master mix, 1.0 μl of upstream and downstream primers, 1.0 μl of dna template, and 9.5 μl of deionized water, for a total volume of 25 μl. we used pcr-rflp for ace2 g8790a, using the forward primer 5'–catgtggtcaaaaggatatct– 3' and the reverse primer 5'–aaagtaaggttggcagacat–3'. the following conditions were used for the pcr: 5 minutes of pre-denaturation at 94°c, 32 cycles of denaturation at 94°c for 40 seconds, 30 seconds of annealing at 58°c, 30 seconds of extension at 72°c, and 5 minutes of terminal extension at 72°c. the ace2 g8790a pcr products were subjected to a water bath reaction with alui endonuclease at 37°c for 3–16 hours. the resulting mixture was then electrophoresed on a 1.5% agarose gel and stained with 1.0 μl gel red/ethidium bromide. a uv analyzer was used to determine genetic polymorphism. statistical analysis with the essential hypertension serving as the dependent variable and the ace2 g8790a gene polymorphism serving as the independent variable, univariate analysis is used to characterize the study sample by displaying the frequency distribution of each study variable. the chi-square test is used to compare results in bivariate analysis, including category variables. odds ratios (or) with 95% confidence intervals (ci) were calculated to evaluate the risk associated with variables including genotype, allele frequency, and the presence of gene polymorphism, with significance established at p<0.05. husna, et. al ghmj (global health management journal) 2025, vol. 8, no. 2s 288 ethical clearance the ethics committee of the faculty of medicine at universitas swadaya gunung jati in cirebon, indonesia, authorized the study protocol and ensured that it adhered to the 1975 declaration of helsinki and its revisions' ethical guidelines. each patient signed a written informed consent form prior to the study. prior to enrollment, written informed permission was obtained from each patient. for patients who were younger than 18, written agreement was acquired from their parents or legal guardians. 3. results respondent characteristics in table 1, it can be seen that all research subjects were 60 people. the matching process between the case group and the control group resulted in no differences in the frequency distribution of gender and age among the research subjects. the frequency distribution of characteristics in the case group who had a family history of hypertension was 19 subjects (63.3%), and who did not have a family history of hypertension was 11 subjects (36.7%), while in the control group who had a family history of hypertension was 3 subjects (10%), and who did not have a family history of hypertension was 27 subjects (90%). table 1. participant's demographic information genotypic data in the case group, the genotype distribution for ace2 g8790a is gg 12 (40%), ga 9 (30%), and aa 9 (30%). in the control group, the genotype distribution is gg 10 (33.3%), ga 6 (20%), and aa 14 (46.7%). the g allele distribution in the case group is 33 (55%) and 26 (80%) within the control group, while the a allele distribution is 27 (45%) in the case group and 34 (56.7%) in the control group. p-value for genotype (p=0.393) and allele (p=0.201) did not show significance (table 2). table 2. genotype and allele distribution for ace2 g8790a variables case (n=30) control (n=30) p-values genotype n% n% gg 12(40%) 10(33.3%) 0.393a ga 9(30%) 6(10%) aa 9(30%) 14(46.7%) allele g 33(55%) 26(43.3%) 0.201a a 27(45%) 34(56.7%) achi-square test characteristics case control n % n % age <45 8 26.7% 8 26.7% >45 22 73.3% 22 73.3% total 30 100% 30 100% sex male female total 15 50.0% 15 50.0% 15 50.0% 15 50.0% 30 100% 30 100% family history of hypertension yes no total 19 63.3% 3 10% 11 36.7% 27 90% 30 100% 30 100% husna, et. al. ghmj (global health management journal) 2025, vol. 8, no. 2s 289 figure 1. pcr-rflp product of ace2 g8790a polymorphism on an agarose gel, digestion outcome: lane (1) dna marker; (2) aa=281 bp+185 bp; (3) gg=466 bp; and (4) ga=466 bp+281 bp+185 bp bivariate analysis bivariate analysis results indicated that the prevalence of polymorphisms was greater in the control group, with 20 subjects (66.7%), compared to the case group, which comprised 18 subjects (60%). the adjusted chi-square test (pearson chi-square) yielded a p-value of 0.592 (p>0.05), indicating no significant association between the ace2 g8790a gene polymorphism and the occurrence of essential hypertension. further analysis yielded an odds ratio (or) of 0.750, indicating that individuals with the ace2 g8790a gene polymorphism are not at significant risk for developing essential hypertension and have a protective factor 25% greater than those without the ace2 g8790a gene polymorphism (p=0.592; or=0.750; ci=0.262-2.151). table 3. the polymorphism of ace2 g8790a and essential hypertension polymorphism ace2 g8790a case group control group p-values or (95%ci) n% n% polymorphism + 18(60%) 20(66.7%) 0.592a 0.750 (0.2622.151) polymorphism 12(40%) 10(33.3%) a pearson chi-square test 4. discussion many genes, environmental factors, and their interactions influence the complex aetiology of essential hypertension. its exact mechanism of action is still unknown. according to studies, the raas is crucial for blood pressure management, maintaining the proper balance of water and salt in the body, and modifying the tissues in the cardiovascular system (y. l. yang et al., 2015). the raas system may be negatively regulated by ace2 (zhang et al., 2022). the main part of the ras, ang ii, is converted by ace2 into ang 1-7, which helps widen blood vessels, and it also changes angiotensin i (ang i) into ang 1-9 by cutting off one piece (imai, kuba, ohto-nakanishi, & penninger, 2010). husna, et. al ghmj (global health management journal) 2025, vol. 8, no. 2s 290 in this study, the prevalence of the gg genotype (homozygous wild type) was higher in the case group, comprising 12 people (40%), compared to the control group, which had 10 subjects (33.3%). the occurrence of genotype ga (heterozygous mutant) was higher in the case group, with 9 cases (30%), compared to the control group, which had 6 subjects (10%). the prevalence of the aa (homozygous mutant) genotype was higher in the control group, with 14 individuals (46.7%), compared to the case group, which had 9 individuals (30%). the analysis yielded an odds ratio of 0.750 and a confidence interval of 0.262-2.151, with a p-value of 0.592 (p>0.05). this result is not consistent with the previous study conducted in dongxiang, china, which found that the frequency of the ace2 allele 8790a was considerably greater in essential hypertension patients than in controls (p<0.0001) (yi et al., 2006). the study's findings are in line with earlier research in anglo-celtic australian subjects with hypertension (n=152) and normotension (n=193), who reported that snp rs2285666 was not associated with hypertension (benjafield, wang, & morris, 2004). another research study in xinyang county, china, provides no evidence that ace2 g8790a is involved in a hereditary susceptibility to orthostatic hypotension or hypertension (fan et al., 2009). this study’s outcome also agrees with the current meta-analysis, which suggests there may be no connection between the ace2 g8790a gene polymorphism and the higher risk of essential hypertension in the chinese population (pan, 2023). the response to essential hypertension appeared unaffected by the genetic polymorphism of ras in our study. the function of ras in physiological processes explains our findings. essential hypertension is predominantly attributed to four factors: intravascular volume, autonomic nerve stimulation, the reninangiotensin system (ras), and the integrity of blood vessel walls. the underlying causative changes may not be associated with ras (sherwood, 2016). genetic influences on complex traits in indonesia may be limited or dependent on context, varying among loci, populations, and environmental conditions. this research corresponds with earlier indonesian investigations about gene-disease correlations, including the rs9939609 fto gene polymorphism associated with obesity in cirebon (pratamawati et al., 2024) and the ace i/d polymorphism related to essential hypertension in cirebon (kuswara et al., 2024). both studies employ identical geographic and demographic contexts in cirebon. this study also indicated a non-significant or context-dependent relationship between gene polymorphisms and the complex diseases analyzed in the cirebon population of west java. the ace2 gene at snp rs2285666 exhibits variations between ethnicities, distinguished by the presence of minor allele frequency (maf). maf denotes the frequency of less common alleles and may fluctuate within a population and between different ethnic groups. in population genetics, maf denotes the extent of genetic variation within an individual, population, and species. in this study, the frequency of the g allele was 0.49, while the frequency of the a allele was 0.51. according to maf data from dbsnp ncbi, the japanese population exhibited a g allele frequency of 0.50 and an a allele frequency of 0.50. in the vietnamese population, the frequency of the g allele is 0.51, while that of the a allele is 0.49. in the korean population, the frequencies of the g and a alleles are 0.48 and 0.52, respectively. this research suggests that the minor allele frequency distribution in the indonesian population closely resembles those of other asian groups, including japan, vietnam, and korea. limitations should be noted. the study's sample size is insufficiently large. to assess the genetic basis of essential hypertension dysregulation, more research is needed to investigate polymorphisms in other gene loci that encode pathways related to the sympathetic nervous system, ras, vascular system, or kidney system. the researchers were unable to assess the hardy-weinberg equilibrium in the control group due to inadequate sample size. sex-stratified analysis is necessary to ascertain if hemizygous males and heterozygous or homozygous females exhibit distinct genetic risk profiles. moreover, a haplotype-based methodology may enhance our comprehension of the interactions among various ace2 variations. more research is recommended with larger groups of people and better statistics to improve our understanding of the link between essential hypertension and ace2 g8790a. husna, et. al. ghmj (global health management journal) 2025, vol. 8, no. 2s 291 5. conclusion this study did not find an association between ace2 g8790a and essential hypertension in our sample. genetic screening for g8790a is not currently indicated in this population. further research is required on a larger scale to investigate the effects of gene combinations or interactions with other locus genes on essential hypertension. replication that includes functional assays and a comprehensive investigation of ace2 polymorphisms is crucial to validate the biological relevance of these findings. this study has several limitations, such as a limited sample size and a single-center design, which may restrict the generalizability of the results. conflict of interest the authors declare no conflicts of interest for the results. references ace2 gene. (2023). retrieved from https://www.genecards.org/cgi-bin/carddisp.pl?gene=ace2 alwi, i. (2014). buku ajar ilmu penyakit dalam jilid ii edisi vi. interna publishing. benjafield, a. v., wang, w. y. s., & morris, b. j. (2004). no association of angiotensin-converting enzyme 2 gene (ace2) polymorphisms with essential hypertension. american journal of hypertension, 17(7), 624–628. https://doi.org/10.1016/j.amjhyper.2004.02.022 burrell, l. m., johnston, c. i., tikellis, c., & cooper, m. e. (2004). ace2, a new regulator of the renin-angiotensin system. trends in endocrinology and metabolism, 15(4), 166–169. https://doi.org/10.1016/j.tem.2004.03.001 chappell, m. c., marshall, a. c., alzayadneh, e. m., shaltout, h. a., & diz, d. i. (2014). update on the angiotensin converting enzyme 2-angiotensin (1-7)-mas receptor axis: fetal programing, sex differences, and intracellular pathways. frontiers in endocrinology, 5(jan), 1–13. https://doi.org/10.3389/fendo.2013.00201 fan, x. h., wang, y. b., wang, h., sun, k., zhang, w. l., song, x. d., … hui, r. t. (2009). polymorphisms of angiotensin-converting enzyme (ace) and ace2 are not associated with orthostatic blood pressure dysregulation in hypertensive patients. acta pharmacologica sinica, 30(9), 1237–1244. https://doi.org/10.1038/aps.2009.110 imai, y., kuba, k., ohto-nakanishi, t., & penninger, j. m. (2010). angiotensin-converting enzyme 2 (ace2) in disease pathogenesis. circulation journal, 74(3), 405–410.https://doi.org/10.1253/circj.cj-10-0045 kemenkes. (2021). pedoman nasional pelayanan kedokteran tata laksana hipertensi dewasa. kementerian kesehatan ri, 1–85. kemenkes ri. (2018). hasil riset kesehatan dasar tahun 2018. kementrian kesehatan ri (vol. 53). kuswara, h. n., nauphar, d., & sari, a. i. p. (2024). angiotensin-converting enzyme insertion/deletion (ace i/d) gene polymorphism as a risk factor for essential hypertension. ghmj (global health management journal), 7(4), 180–190. https://doi.org/10.35898/ghmj-741044 li, y. y. (2012). lack of association of ace2 g8790a gene mutation with essential hypertension in the chinese population: a metaanalysis involving 5260 subjects. frontiers in physiology, 3 sep(september), 1–7.https://doi.org/10.3389/fphys.2012.00364 lu, n., yang, y., wang, y., liu, y., fu, g., chen, d., … zheng, y. (2012). ace2 gene polymorphism and essential hypertension: an updated meta-analysis involving 11,051 subjects. molecular biology reports, 39(6), 6581–6589. https://doi.org/10.1007/s11033-012-1487-1 lupton, s. j., chiu, c. l., & lind, j. m. (2011). a hypertension gene: are we there yet? twin research and human genetics, 14(4), 295–304. https://doi.org/10.1375/twin.14.4.295 olin, b. r., & pharm, d. (2018). hypertension : the silent killer : updated jnc-8 guideline recommendations. p2ptm kemenkes ri. (2024a). faktor risiko hipertensi yang dapat diubah dan tidak dapat diubah. retrieved from https://p2ptm.kemkes.go.id/infographic/faktor-risiko-hipertensi-yang-dapat-diubah-dan-tidak-dapat-diubah p2ptm kemenkes ri. (2024b). mengenal penyakit hipertensi. pan, y. (2023). angiotensin-converting enzyme 2 g8790a polymorphisms are associated with covid-19 severity. journal of infection in developing countries, 17(6), 819–825. https://doi.org/10.3855/jidc.17762 pratamawati, t. m., sadji, a. a. e. b., brajadenta, g. s., & nauphar, d. (2024b). association of rs9939609 fto gene polymorphism as a risk factor of obesity in adults. ghmj (global health management journal), 7(1), 27–32. https://doi.org/10.35898/ghmj-71967 sherwood, l. (2013). introduction to human physiology. brooks/cole, cengage learning. unger, t., borghi, c., charchar, f., khan, n. a., poulter, n. r., prabhakaran, d., … schutte, a. e. (2020). 2020 international society of hypertension global hypertension practice guidelines. hypertension, 75(6), 1334–1357. https://doi.org/10.1161/hypertensionaha.120.15026 https://www.genecards.org/cgi-bin/carddisp.pl?gene=ace2 https://doi.org/10.1016/j.amjhyper.2004.02.022 https://doi.org/10.1016/j.amjhyper.2004.02.022 https://doi.org/10.1016/j.tem.2004.03.001 https://doi.org/10.3389/fendo.2013.00201 https://doi.org/10.1038/aps.2009.110 https://doi.org/10.1253/circj.cj-10-0045 https://doi.org/10.35898/ghmj-741044 https://doi.org/10.3389/fphys.2012.00364 https://doi.org/10.1375/twin.14.4.295 https://p2ptm.kemkes.go.id/infographic/faktor-risiko-hipertensi-yang-dapat-diubah-dan-tidak-dapat-diubah https://doi.org/10.3855/jidc.17762 https://doi.org/10.35898/ghmj-71967 https://doi.org/10.1161/hypertensionaha.120.15026 husna, et. al ghmj (global health management journal) 2025, vol. 8, no. 2s 292 world health organization. (2023). global report on hypertension. yan, q., xu, c., li, z., zhou, p., ye, r., li, m., & jiang, c. (2008). [relationship of angiotensin-converting enzyme 2 gene polymorphisms and vulnerability to coronary heart disease in patients with type 2 diabetes mellitus]. nan fang yi ke da xue xue bao = journal of southern medical university, 28(8), 1365–1368. https://pubmed.ncbi.nlm.nih.gov/18753062/ yang, m., zhao, j., xing, l., & shi, l. (2015). the association between angiotensinconverting enzyme 2 polymorphisms and essential hypertension risk: a metaanalysis involving 14,122 patients. jraas journal of the renin-angiotensin-aldosterone system, 16(4), 1240–1244. https://doi.org/10.1177/1470320314549221 yang, y. l., mo, y. p., he, y. s., yang, f., xu, y., li, c. c., … long, l. (2015). correlation between renin-angiotensin system gene polymorphisms and essential hypertension in the chinese yi ethnic group. jraas journal of the renin-angiotensinaldosterone system, 16(4), 975–981. https://doi.org/10.1177/1470320315598697 yi, l., gu, y. h., wang, x. l., an, l. z., xie, x. d., shao, w., … zhang, d. l. (2006). association of ace, ace2 and uts2 polymorphisms wih essential hypertension in han and dongxiang populations from north-western china. journal of international medical research, 34(3), 272–283. https://doi.org/10.1177/147323000603400306 younas, h., ijaz, t., & choudhry, n. (2022). investigation of angiotensin-1 converting enzyme 2 gene (g8790a) polymorphism in patients of type 2 diabetes mellitus with diabetic nephropathy in pakistani population. plos one, 17(2 february), 1–16. https://doi.org/10.1371/journal.pone.0264038 zhang, x., wang, y., zheng, y., yuan, j., tong, j., xu, j., … li, x. (2022). effect of ace, ace2 and cyp11b2 gene polymorphisms and noise on essential hypertension among steelworkers in china: a case–control study. bmc medical genomics, 15(1), 1–10. https://doi.org/10.1186/s12920-022-01177-0 zhou, b., carrillo-larco, r. m., danaei, g., riley, l. m., paciorek, c. j., stevens, g. a., … zuñiga cisneros, j. (2021). worldwide trends in hypertension prevalence and progress in treatment and control from 1990 to 2019: a pooled analysis of 1201 population-representative studies with 104 million participants. the lancet, 398(10304), 957–980. https://doi.org/10.1016/s0140-6736(21)01330-1 cite this article as: husna, n., nauphar, d., & pratamawati, t. m. (2025). angiotensin converting enzyme 2 (ace2) g8790a gene polymorphism as a risk factor for essential hypertension. ghmj (global health management journal), 8(2s), 285–292. https://doi.org/10.35898/ghmj-82s1231 https://pubmed.ncbi.nlm.nih.gov/18753062/ https://doi.org/10.1177/1470320314549221 https://doi.org/10.1177/1470320315598697 https://doi.org/10.1177/147323000603400306 https://doi.org/10.1371/journal.pone.0264038 https://doi.org/10.1186/s12920-022-01177-0 https://doi.org/10.1016/s0140-6736(21)01330-1 https://doi.org/10.35898/ghmj-82s1231 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 template ghmj 2024 ghmj (global health management journal) 2025, vol. 8, no. 2s indonesian scholars’ alliance open access research article the 1st cirebon international health symposium: faculty of medicine, universitas swadaya gunung jati update on non-communicable diseases: global perspective on health challenges and innovation correlation between motivation and professional identity of medical students of universitas swadaya gunung jati, cirebon, indonesia mega silvia maulidia mustopa1* , tissa octavira permatasari2 , catur setiya sulistiyana2 1. faculty of medicine, universitas swadaya gunung jati, indonesia (45132); 2. department of medical education, faculty of medicine, universitas swadaya gunung jati, indonesia (45132). *corresponding author’s e-mail: megasilviamaulidya693@gmail.com doi: 10.35898/ghmj-82s1237 abstract background: professional identity plays an important role for doctors in their practice. the important role of professional identity in medical education, namely learning the professionalism of doctors and being responsible for the duties of being a student and the rules that make it more responsible to patients. professional identity is influenced by external and internal factors, one of which is motivation which plays an important role in medical education can foster creativity which makes the learning process a transformational experience that is important for the development of a strong professional identity. objective: to determine the relationship between motivation and professional identity of students of the faculty of medicine, universitas swadaya gunung jati, cirebon, indonesia. aims: to determine the relationship between motivation and professional identity of students of the faculty of medicine, universitas swadaya gunung jati, cirebon, indonesia. methods: this research is an analytic observational study with a cross-sectional approach. respondents were selected through stratified random sampling technique, resulting in 295 respondents consisting of undergraduate and professional students. the study used primary data using the academic motivation scale (ams) questionnaire and professional identity with spearman analysis. results: this study involved 295 medical students (64.4% female and 35.6% male) from various academic stages, including undergraduate semesters 2, 4, 6, 8, and professional (clinical) phases from 2018 to 2019. across all groups, most students had a good level of motivation (52.4-67.9%) and a high or very high professional identity. spearman correlation analysis showed a significant positive relationship between motivation and professional identity (p= 0.000, r= 0.333). conclusion: there is a significant positive relationship between motivation and professional identity. keywords: academic motivation; professional identity; medical students. received: 22 june 2025 reviewed: 07 july 2025 revised: 14 august 2025 accepted: 15 august 2025. © 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:megasilviamaulidya693@gmail.com https://doi.org/10.35898/ghmj-82s1237 https://orcid.org/0009-0007-9225-7565 https://orcid.org/0000-0001-8748-0593 https://orcid.org/0000-0002-7574-7745 305 ghmj (global health management journal) 2025, vol. 8, no. 2s mustopa, et al 1. introduction professional identity is a self-image that develops gradually over time, in which the characteristics, values, and norms of the medical profession are internalized so that individuals think, act, and behave like a doctor. professional identity can also increase self-confidence in carrying out the role of a doctor, both for those who have entered practice and those who are still in the preclinical stage. however, many medical students do not fully understand the meaning of professional identity and have not been able to develop this identity effectively. as a result, they often face difficulties in interacting with patients, behaving professionally, and performing the role of a doctor. therefore, it is important for academics to pay attention to medical education and professional identity development in order to provide educational tools that can produce better future doctors (park et al, 2022). one important factor in professional identity development is motivation. motivation plays an important role in medical education, where students need to be motivated and committed to lifelong learning in order to complete their medical studies on time. this includes participation in lectures, as well as understanding all the material taught in medical school. motivation helps to reduce psychological stress due to the amount of coursework and encourages the spirit to study harder (apriana, 2020). the study by susani, et al. (2018) found a positive and direct correlation between motivation and professional identity. the participation of learners in education is intricately linked to their self-concept and aspirations. an interdependent and cohesive relationship exists between academic drive and identity, manifesting in the daily dynamics of medical students' lives. a study by wasityastuti et al, (2018), identified a strong positive association between intrinsic motivation and professional identity. therefore, researchers seek to comprehend the formation of the professional identity of students during both the academic and professional (clinical) phases, with motivation being a significant influencing factor. this study aims to determine the correlation between motivation and the professional identity of students in the faculty of medicine, universitas swadaya gunung jati, cirebon, indonesia. 2. methods study design the study was conducted in april 2024 at universitas swadaya gunung jati's faculty of medicine in cirebon city. this study is an analytical observational study that uses a cross-sectional approach. the data was gathered using questionnaires or primary data given directly to respondents. this study aims to determine the correlation between motivation and the professional identity of students in the faculty of medicine, universitas swadaya gunung jati. measurements the study involved students from the faculty of medicine, universitas swadaya gunung jati, including those at undergraduate stages (semesters 2, 4, 6, and 8) and those in the professional (clinical) phase from the classes of 2018 and 2019, considering the inclusion and exclusion criteria. the inclusion criteria for sampling were students who are actively enrolled as undergraduate and professional students at the faculty of medicine, universitas swadaya gunung jati, and students who agreed to participate in the study. the exclusion criteria were students who did not complete their identity information and students who did not fill out the questionnaires completely. the independent variable in this study was the student’s motivation, while the dependent variable in this study was their professional identity. the sampling method used in this study was stratified random sampling is a sampling method in which the population is divided into several distinct groups or strata defined by academic stage (undergraduate semesters 2, 4, 6, and 8; professional (clinical) phase 2018 and 2019), and then a random sample is taken from each stratum. mustopa, et al ghmj (global health management journal) 2025, vol. 8, no. 2s 306 instruments this study collected data directly using a questionnaire filled out by respondents, namely undergraduates in the faculty of medicine at universitas swadaya gunung jati in their 2nd, 4th, 6th, and 8th semesters, up to the professional (clinical) phase. the motivation questionnaire instrument was adapted from a previous study by natalya, (2018) validation of academic motivation scale: short indonesian language version. the reliability test results showed a cronbach's alpha value of over 0.7, with all corrected item correlations above 3. the factor analysis results also indicated that all items were grouped according to their dimensions, as did the correlation analysis results. the professional identity instrument was adapted from previous research by susani, (2018) model identitas profesional mahasiswa kedokteran universitas gadjah mada. there are three components in the instrument: comfort (questions 1-5), willingness to engage (questions 6-10), and effectiveness (questions 11-17). table 1. operational definition variables definition measurement tool results scales motivation an internal drive that encourages individuals to act or achieve a goal. academic motivation scale (ams) questionnaire consisting of 14 items, each with 5 responses: 1 = strongly disagree, 2 = disagree, 3 = neutral, 4 = agree, 5 = strongly agree low motivation = 14-31 sufficient motivation = 32-51 good motivation = 52-70 ordinal professional identity attributes that must be possessed by both medical students and practicing doctors. questionnaire consisting of 17 items. the scale ranges from 1 to 7, where 1 means very inappropriate and 7 means very appropriate, with an additional option for not applicable (n/a). minimum = 0 ; maximum = 7 very low = 17-37 low = 38-58 medium = 59-79 high = 80-100 very high = 101-119 ordinal statistical techniques data analysis included univariate analysis that described the characteristics of respondents, motivation levels, and professional identity. bivariate analysis aimed to determine the relationship between motivation and professional identity. spearman's test was used to analyze ordinal variables. potential confounding variables were examined descriptively and discussed as study limitations. incomplete questionnaires and missing demographic data were excluded based on the predefined exclusion criteria. ethical clearance this research has been approved by the ethics committee of the faculty of medicine, universitas swadaya gunung jati. ethical clearance (ec) number: 67c/fkugj/v/2024. all subjects provided informed consent, and confidentiality was maintained throughout the study. 3. results respondent characteristics the total number of participants in this study, as indicated in table 2, is 295. the distribution of undergraduate students is as follows: semester 2 (17.6%), semester 4 (19.7%), semester 6 (18.0%), semester 8 (14.9%), professional phase 2019 (15.6%), and professional phase 2018 (14.2%). the predominant participants in this study were women. a total of 295 individuals responded, with 190 (64.4%) identifying as women and 105 (35.6%) identifying as men. 307 ghmj (global health management journal) 2025, vol. 8, no. 2s mustopa, et al table 2. respondents’ characteristics table 3. level of motivation student’s stage measurement results frequency (n) percentage (%) semester 2 low motivation sufficient motivation good motivation total 0 19 33 52 0.0% 36.5% 63.5% 100.0% semester 4 low motivation sufficient motivation good motivation total 0 23 35 58 0.0% 39.7% 60.3% 100.0% semester 6 low motivation sufficient motivation good motivation total 0 17 36 53 0.0% 32.1% 67.9% 100.0% semester 8 class professional (clinical) phase 2019 class professional (clinical) phase 2018 low motivation sufficient motivation good motivation total low motivation sufficient motivation good motivation total low motivation sufficient motivation good motivation total 0 15 29 44 0 15 31 46 0 20 22 42 0.0% 34.1% 65.9% 100.0% 0.0% 32.6% 67.4% 100.0% 0.0% 47.6% 52.4% 100.0% characteristics frequency (n) percentage (%) student’s stage semester 2 52 17.6% semester 4 58 19.7% semester 6 53 18.0% semester 8 44 14.9% class professional (clinical) phase 2019 46 15.6% class professional (clinical) phase 2018 42 14.2% total 295 100.0% gender male 105 35.6% female 190 64.4% total 295 100.0% mustopa, et al ghmj (global health management journal) 2025, vol. 8, no. 2s 308 based on the results in table 3, in semester 2, the majority have a good level of motivation (63.5%). in semester 4, the majority also have a good level of motivation, with 35 respondents (60.3%). in semester 6, most students have a good level of motivation, with 36 respondents (67.9%). in semester 8, the majority have a good level of motivation (65.9%). for the professional phase 2019, the majority has a good level of motivation (67.4%), and for the professional phase 2018, the majority has a good level of motivation (52.4%). table 4. professional identity category measurement results frequency (n) percentage (%) semester 2 very low low medium high very high total 0 3 17 23 9 52 0.0% 5.8% 32.7% 44.2% 17.3% 100.0% semester 4 very low low medium high very high total 0 1 12 35 10 58 0.0% 1.7% 20.7% 60.3% 17.2% 100.0% semester 6 very low low medium high very high total 0 1 11 27 14 53 0.0% 1.9% 20.8% 50.9% 26.4% 100.0% semester 8 class professional (clinical) phase 2019 class professional (clinical) phase 2018 very low low medium high very high total very low low medium high very high total very low low medium high very high total 0 0 3 26 15 44 0 0 3 16 27 46 0 0 1 19 22 42 0.0% 0.0% 6.8% 59.1% 34.1% 100.0% 0.0% 0.0% 6.5% 34.8% 58.7% 100.0% 0.0% 0.0% 2.4% 45.2% 52.4% 100.0% 309 ghmj (global health management journal) 2025, vol. 8, no. 2s mustopa, et al based on the results in table 3, in semester 2, the majority have a high level of professional identity (44.2%). in semester 4, the majority also have a high level of professional identity (60.3%). in semester 6, most students have a high level of professional identity (50.9%). in semester 8, the majority have a high level of professional identity (59%). for the professional phase 2019, the majority has a very high level of professional identity (57%), and for the professional phase 2018, the majority has a very high level of professional identity (52%). relationship between motivation and professional identity the bivariate analysis of the relationship between motivation and professional identity reveals a correlation with a p-value of 0.000 (<0.05), indicating a significant relationship between motivation and professional identity among medical students at universitas swadaya gunung jati. however, the correlation coefficient (r = 0.333) suggests a weak correlation with a positive or direct relationship. table 5. relationship between motivation and professional identity motivation professional identity very low low medium high very high total pvalue r low enough good total 0 0 0 0 0 1 4 5 0 28 19 47 0 67 79 146 0 13 84 97 0 109 186 295 0.000 0.333 table 6 presents a bivariate analysis that demonstrates the varying links between motivation and professional identity across different stages of schooling. there was no significant association in semester 2 (n = 52; p = 0.960, r = -0.007). there was a weak but significant positive relationship between semester 4 (n = 58) and semester 6 (n = 53) (p = 0.015, r = 0.317; p = 0.020, r = 0.318, respectively). there was a moderate to strong positive connection in semester 8 (n = 44) (p = 0.000, r = 0.588). there was a considerable favorable association between the 2019 professional (clinical) phase students (n=46) and the 2018 professional (clinical) phase students (p=0.000, r=0.665). on the other hand, there was a moderate positive connection (p=0.000, r=0.529). 4. discussion overviewed motivation the research examined the motivation levels of students in the faculty of medicine at universitas swadaya gunung jati. the findings indicated that a majority (63.1%) exhibited strong levels of motivation. the motivation levels by academic stage are as follows: second-semester students (63.5%), fourth-semester students (60.3%), sixth-semester students (67.9%), eighth-semester students (65.9%), professional phase 2019 (67.4%), and professional phase 2018 (52.4%). this study corroborates prior research indicating that both undergraduate and professional students exhibit high levels of motivation. several variables contribute to this, both internal to the individual and affecting interpersonal dynamics. intrapersonal characteristics pertain to aspects such as goal-setting, altruism, a sense of responsibility, persistence, independence, collaboration, readiness to initiate, and a willingness to make sacrifices. (novianti et al, 2022; suparyanto et al, 2021; yusuf, 2013) additional studies indicate that students aspiring to become physicians from the outset, coupled with a desire to serve others or exhibit empathy, are more likely to be intrinsically driven, hence facilitating rapport between doctors and patients. furthermore, pupils must exhibit responsibility to regulate their thoughts, activities, and personal inclinations. this assists kids in establishing priorities and perspectives in both educational and other aspects of life (novianti et al, 2022). mustopa, et al ghmj (global health management journal) 2025, vol. 8, no. 2s 310 table 6. relationship between motivation and professional across academic stages relationship between motivation and professional identity in semester 2 students motivation professional identity very low low medium high very high total pvalue r low enough good total 0 0 0 0 0 1 2 3 0 6 11 17 0 9 14 23 0 3 6 9 0 19 33 52 0.960 -0.007 relationship between motivation and professional identity in semester 4 students motivation professional identity very low low medium high very high total p-value r low enough good total 0 0 0 0 0 0 1 1 0 9 3 12 0 12 23 35 0 2 8 10 0 23 35 58 0.015 0.317 relationship between motivation and professional identity in semester 6 students motivation professional identity very low low medium high very high total pvalue r low enough good total 0 0 0 0 0 0 1 1 0 6 5 11 0 10 17 27 0 1 13 14 0 17 36 53 0.020 0.318 relationship between motivation and professional identity in semester 8 students motivation professional identity very low low medium high very high total p-value r low enough good total 0 0 0 0 0 0 0 0 0 3 0 3 0 12 14 26 0 0 15 15 0 15 29 44 0.000 0.588 relationship between motivation and professional identity among 2019 professional (clinical) phase students motivation professional identity very low low medium high very high total p-value r low enough good total 0 0 0 0 0 0 0 0 0 3 0 3 0 10 6 16 0 2 25 27 0 15 31 46 0.000 0.665 relationship between motivation and professional identity among 2018 professional (clinical) phase students motivation professional identity very low low medium high very high total p-value r low enough good total 0 0 0 0 0 0 0 0 0 1 0 1 0 14 5 19 0 5 17 22 0 20 22 44 0.000 0.529 311 ghmj (global health management journal) 2025, vol. 8, no. 2s mustopa, et al interpersonal variables are social aspects influencing an individual's motivation to learn, such as attending class, comprehending the content, receiving feedback, and the desire for further knowledge. a problem-based learning (pbl) curriculum enables students to identify and resolve clinical issues, thereby increasing the likelihood of task completion. feedback enhances student performance and increases their engagement in learning. (novianti et al, 2022; suparyanto et al, 2021; hafida, 2023). overviewed professional identity based on the results of this study on professional identity among students at the faculty of medicine, universitas swadaya gunung jati, it was found that the majority of students have a high level of professional identity (49.5%). by academic stage, the professional identity levels are as follows: second-semester students have a high professional identity (44.2%), fourth-semester students (60.3%), sixth-semester students (50.9%), eighth-semester students (59.1%), professional phase 2019 (58.7%), and professional phase 2018 (52.4%). the formation of professional identity is a continuous process. many factors influence the development of an individual's professional identity throughout their lives. the development of professional identity can begin even before one starts their profession or career. a prospective medical student may already have a professional identity before starting their education (sari et al, 2019; adams et al, 2006). this study is consistent with previous research that states that new students who begin their studies already possess a good professional identity. this is because these students are able to recognize themselves as part of their interaction group or differentiate themselves from other groups, allowing them to seek role models to emulate or reject. similarly, other studies have shown that those who have received education better understand the roles and responsibilities of their profession (lestari et al, 2022; goldie, 2012; rees et al, 2018). previous research explains that several factors influence professional development, including social experiences, educational context, perceived fit with the profession, demographic characteristics, professional image, professional experiences, and individual personal development. motivation and participation influence the development of professional identity in medical students. students can participate in their professional identity development by engaging in various activities. both internal factors, such as academic motivation, and external factors, such as the learning environment, impact professional identity development (sari et al, 2019). correlation between motivation and professional identity of medical students using spearman's test to examine the data in this study, it was discovered that most highly motivated students had a strong sense of professional identity. the p-value was 0.000 (<0.05), and the r value was 0.333, indicating a high correlation between motivation and professional identity. the correlation is good, but the association's strength is poor. these findings are consistent with previous research, which found that incoming students had a strong sense of who they are as professionals before beginning their studies. this is consistent with earlier studies, which have demonstrated that students who understand the medical sector better have a greater sense of their professional identity. furthermore, students that desire to go to medical school are usually very motivated, which helps them maintain their professional identity throughout their education (adams et al, 2006). according to the findings, the relationship between motivation and professional identity varies by semester and clinical phase. it decreases in semester 2 before increasing in semesters 4, 6, 8, and the professional stages of 2019 and 2018.this is consistent with earlier research that indicates that professional identity develops gradually from the beginning to the end, or clinical, phases. the average professional identification score has increased, indicating how students feel about the characteristics of their job or sector. academic motivation is critical for developing a professional identity since it influences behavior and establishes success criteria (wasityastuti et al, 2018). the second semester of this study produced a non-significant result, with a p-value of 0.960 (>0.05) and an rvalue of -0.070, indicating a negative relationship with extremely weak correlation strength. this means that professional identity may decline as motivation rises. the comfort component of professional identity received the lowest rankings. students are still getting acclimated to things and have difficulty shifting their way of thinking to fit into medical school. this is consistent with earlier studies, which have indicated that first-year students had the mustopa, et al ghmj (global health management journal) 2025, vol. 8, no. 2s 312 highest motivation scores both internally and externally. however, their high desire does not necessarily translate into a strong professional identity because they do not have many opportunities to practice medicine, which can decrease their professional identity scores. furthermore, this non-statistically significant result may be influenced by other factors that affect motivation that have not been adequately studied, such as age, gender, race, income level, education level, parental support, faculty support, independence, individual competence, and exposure to the desired field of work. personal preferences or external influences, such as parents pressuring their children to attend medical school or new students who are unsure about their professional path, may also play a role (wasityastuti et al, 2018; suparyanto et al, 2021; lestari et al, 2022). this study has several limitations; it focuses only on the relationship between motivation and professional identity, ignoring other factors that may influence both motivation and professionalism. it was difficult to ensure that everyone who completed the questions online answered honestly, accurately, and in accordance with their own beliefs. this study was conducted at single institution, which may limit the generalizability of the findings. the data collection relied on self-reported questionnaires, which may introduce response bias. despite these issues, this is the first study at the faculty of medicine, universitas swadaya gunung jati, to examine the relationship between motivation and professional identity in medical students. because of the high response rate and the fact that universitas swadaya gunung jati is cirebon's only medical school, the findings can also be applied to medical students. a questionnaire was utilized to collect the responses, and only the researcher knew who the responders were, ensuring that students were honest. 5. conclusion there is a significant positive relationship between motivation and professional identity. the findings indicate that most medical students at universitas swadaya gunung jati have good level of motivation and a high professional identity. statistical analysis revealed a significant positive relationship between motivation and professional identity, although the correlation strength was weak. these results suggest that enhancing student’s motivation may contribute to the development of their professional identity. medical education institutions are expected to continuously ensure the development of professional identity by more explicitly internalizing learning within the medical curriculum. this way, students will be better prepared and more confident in shaping their professional identity as future doctors. for future research, it is necessary to employ open-ended questionnaires to explore in greater depth the factors that influence the formation of professional identity among medical students. conflict of interest there is no conflict of interest. nothing to disclosure. references adams k, hean s, sturgis p, clark jm. (2006). investigating the factors influencing professional identity of first‐year health and social care students. learn heal soc care. 5(2):55–68. http://dx.doi.org/10.1111/j.14736861.2006.00119.x apriana r. (2020). faktor-faktor yang berpengaruh terhadap motivasi belajar mahasiswa kedokteran. jurnal medika hutama, 2(01 oktober), 382-389. retrieved from https://jurnalmedikahutama.com/index.php/jmh/article/view/97 goldie j. (2012). the formation of professional identity in medical students: considerations for educators. med teach. 34(9). https://doi.org/10.3109/0142159x.2012.687476 hafida an. (2023). hubungan antara motivasi akademik dengan indeks prestasi akademik mahasiswa fakultas kedokteran (studi observasional pada mahasiswa fakultas kedokteran universitas islam sultan agung). 6–31. https://repository.unissula.ac.id/id/eprint/30692 lestari e, destiana l. (2022). pengaruh tingkat pendidikan terhadap identitas profesional (studi pada mahasiswa program studi kedokteran umum universitas islam sultan agung). 232–41. https://jurnal.unissula.ac.id/index.php/kimukes/article/view/20297 http://dx.doi.org/10.1111/j.1473-6861.2006.00119.x http://dx.doi.org/10.1111/j.1473-6861.2006.00119.x https://jurnalmedikahutama.com/index.php/jmh/article/view/97 https://doi.org/10.3109/0142159x.2012.687476 https://repository.unissula.ac.id/id/eprint/30692 https://jurnal.unissula.ac.id/index.php/kimukes/article/view/20297 313 ghmj (global health management journal) 2025, vol. 8, no. 2s mustopa, et al natalya l. (2018). validation of academic motivation scale: short indonesian language version. anima indones psychol j. 34(1):43–53. https://doi.org/10.24123/aipj.v34i1.2025 novianti a, widjaja y. (2022). eksplorasi faktor-faktor yang memengaruhi motivasi belajar mahasiswa fakultas kedokteran universitas tarumanagara tahap akademik. tarumanagara med j. 4(1):30– 40. https://doi.org/10.24912/tmj.v4i2.17849 park gm, hong aj. (2022) “not yet a doctor”: medical student learning experiences and development of professional identity. bmc med educ. dec 1;22(1). https://doi.org/10.1186/s12909-022-03209-w rees ce, monrouxe l v. (2018). who are you and who do you want to be? key considerations in developing professional identities in medicine. med j aust. 209(5):202–3. https://doi.org/10.5694/mja18.00118 sari mi, oktaria d, oktafany. (2019). hubungan efikasi diri dan identitas profesional mahasiswa fakultas kedokteran universitas lampung. jk unila [internet];3(november):321–5. available from: https://doi.org/10.23960/jkunila.v3i2.pp321-325 suparyanto dan rosad (2021). faktor-faktor prediktor identitas profesional (professional identity) mahasiswa s1 kedokteran umum. taufiqur rahman [internet]. available from: https://repository.unissula.ac.id/id/eprint/23880 susani yp, retno rahayu g, sanusi r, suryo prabandari y, mardiwiyoto h, et al. (2018). developing a model of professional identity in medical students: the role of motivation and participation. j pendidik kedokt indones indones j med educ.;7(3):159–69. https://doi.org/10.22146/jpki.41831 wasityastuti w, susani yp, prabandari ys, rahayu gr. (2018). correlation between academic motivation and professional identity in medical students in the faculty of medicine of the universitas gadjah mada indonesia. educ medical [internet]. 19(1):23–9. available from: http://dx.doi.org/10.1016/j.edumed.2016.12.010 yusuf m. (2013). hubungan motivasi belajar dengan indeks prestasi akademik mahasiswa program studi ilmu keperawatan fakultas kedokteran unsyiah banda aceh. idea nurs j [internet]. 4(3):124–31. available from: http://jurnal.unsyiah.ac.id/inj/article/view/1509/1398 cite this article as: mustopa, m. s. m., permatasari, t. o., & sulistiyana, c. s. (2025). correlation between motivation and professional identity of medical students of universitas swadaya gunung jati, cirebon, indonesia. ghmj (global health management journal), 8(2s), 304–313. https://doi.org/10.35898/ghmj-82s1237 https://doi.org/10.24123/aipj.v34i1.2025 https://doi.org/10.24912/tmj.v4i2.17849 https://doi.org/10.1186/s12909-022-03209-w https://doi.org/10.5694/mja18.00118 https://doi.org/10.23960/jkunila.v3i2.pp321-325 https://repository.unissula.ac.id/id/eprint/23880 https://doi.org/10.22146/jpki.41831 http://dx.doi.org/10.1016/j.edumed.2016.12.010 http://jurnal.unsyiah.ac.id/inj/article/view/1509/1398 https://doi.org/10.35898/ghmj-82s1237 template ghmj 2024 ghmj (global health management journal) 2025, vol. 8, no.3 indonesian scholars’ alliance open access research article evaluation of the implementation of sharia-based pharmaceutical service standards (a qualitative case study) elmiawati latifah* , prasojo pribadi , heni lutfiyati , cut dewi bunga department of pharmacy, faculty of health science, universitas muhammadiyah magelang, indonesia, 56172. *corresponding author’s e-mail: elmiawatilatifah@unimma.ac.id doi: 10.35898/ghmj-831265 abstract background: national health laws and best practices from other countries have helped indonesia set standards for pharmaceutical services. however, there is still limited research on the application of sharia principles in pharmacy services, particularly within community pharmacies. these standards are based on ideas from the quran, hadith, and fatwas from well-known islamic scholars. they put these ideas into action by making sure that medicines don't contain any illegal substances, being sensitive to gender issues, and providing services that respect patients' dignity, as islamic teachings say they should. aims: this study aims to evaluate the implementation of sharia-based pharmaceutical service standards through a qualitative case study at the muhammadiyah charity education pharmacy. this pharmacy's unique role as an integrated platform for pharmacy education, community service, and the application of islamic values makes it an appropriate context for examining the implementation of sharia-compliant pharmaceutical services. methods: a qualitative case study design was used, involving observations and semi-structured interviews. nvivo 12 software was employed for thematic and cluster analysis. data were coded inductively by independent researchers and validated through consensus. pearson correlation coefficients were used to identify the strongest relationships between service quality items. the informants involved were 1 pharmacist and 3 pharmaceuticals technical staff. results: reliability, responsiveness, empathy, tangibles, and assurance are the themes that emerged from this study. the studies found that in the reliability dimension, fulfilling order service and distributor reliability showed the highest correlation (r=0.98), emphasizing the importance of commitment and trust in sharia-based service. in the responsiveness dimension, the most significant relationship (r=1.00) emerged between complaint resolution and clear division of duties, reflecting the role of communication and accountability. for assurance, the highest correlation (r=0.96) indicated the critical role of clear, understandable information in building trust. the empathy dimension revealed that prioritizing humanity and non-discriminatory service (r=0.52) aligned closely with the values of justice and compassion. lastly, in the tangibles (physical) dimension, the presence of a patient prayer space showed a strong link to perceptions of cleanliness and professionalism (r=0.67), although implementation was still limited. conclusion: by combining islamic ethical principles with service quality metrics, the application of sharia-based service standards in pharmaceutical care improves patient satisfaction. however, some aspects still need improvement, especially the physical facilities and assurance under heavy workload. these findings provide insightful guidance on how to develop appropriate interventions, such as training programs, sops, and infrastructure modifications, to ensure pharmaceutical services comply with sharia law while improving overall service quality for lawmakers, educational institutions, and businesses providing islamic-based pharmaceutical services. keywords: sharia pharmacy, pharmaceutical services, servqual, qualitative research received: 18 july 2025 reviewed: 17 august 2025 revised: 7 september 2025 accepted: 12 october 2025. © 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:elmiawatilatifah@unimma.ac.id https://doi.org/10.35898/ghmj-831265 https://orcid.org/0000-0002-3328-3700 https://orcid.org/0000-0001-7408-2924 https://orcid.org/0000-0003-4423-256x https://orcid.org/0009-0002-8836-1494 353 ghmj (global health management journal) 2025, vol. 8, no. 3 latifah et al. 1. introduction sharia-based pharmaceutical service standards are service guidelines that incorporate islamic principles into all facets of pharmaceutical care, such as spiritual responsibility, gender sensitivity, ethical behavior, and the assurance of halal products. these guidelines, which are based on the qur'an, hadith, and islamic jurisprudence, guarantee that pharmacy services adhere to sharia values and professional standards. every activity carried out by a muslim should be based on islamic teachings derived from the qur'an and hadith, including in conducting business. a business founded on sharia principles is one that operates by considering how profits are obtained and utilized in accordance with islamic law. a pharmacist who applies sharia principles in pharmaceutical services will gain benefits not only materially but also spiritually, achieving well-being in both this world and the hereafter. piety in islam means always being mindful of allah; therefore, in running a pharmacy business, a pharmacist will avoid negative behaviors such as lying, fraud, and deception toward customers (ariyadi, 2018). pharmaceutical care is the pharmacist's responsibility to the patient in terms of providing and ensuring the proper use of pharmaceutical preparations to achieve the desired therapeutic outcomes (kemenkes ri, 2016). the servqual model, consisting of five main dimension’s reliability, responsiveness, assurance, empathy, and tangibles along with fundamental islamic ethics, is integrated into the conceptual framework of this study. sharia law can be used to contextualize each servqual dimension: reliability reflects the values of istiqamah (consistency in goodness) and amanah (trustworthiness). responsiveness is associated with the concepts of ihsan (providing the best service) and tabligh (communicative and informative). assurance emphasizes justice and sidq (honesty). empathy is consistent with the principles of ta'awun (mutual assistance) and rahmah (compassion). physical expressions reflect the values of comfort, thaharah (cleanliness), and environments that encourage spiritual growth, such as prayer rooms. significant gaps still exist in the application of sharia principles at the pharmacy level, despite the development of sharia-based healthcare services in hospitals and the halal certification of certain pharmaceutical products. because it exemplifies the fusion of pharmaceutical services, education, and islamic values, the muhammadiyah charity foundation educational pharmacy was selected. this pharmacy is relevant for a thorough evaluation of the application of sharia-based pharmaceutical service standards since it exhibits an institutional commitment to sharia principles as a member of the muhammadiyah charity foundation. the absence of standard operating procedures (sops) governing service etiquette based on gender and spiritual values, the lack of an integrated system to ensure product halalness, physical facilities that do not support comfortable worship, and pharmacists' poor comprehension of sharia principles are some of the main weaknesses. pharmacy implementation is still irregular and not well documented. to determine the degree to which sharia principles are incorporated into pharmaceutical services especially in muhammadiyah, runs educational pharmacies, which have a high potential for implementation, this study is essential. the network visualization in figure 1 illustrates a map of previous research developments related to halal pharmacy, which are connected to opportunities, business, growth, and the halal value chain. in the cluster shown in orange, previous studies related to sharia hospitals demonstrate research variable relationships with theory, halal lifestyle, muslim consumers, and religiosity. previous studies on the perspective of islamic economics in pharmacy marketing practices revealed that, in terms of products, some items still lack halal certification, making them not fully compliant with islamic economic principles. however, in terms of pricing, location, and promotion, the application of islamic economic principles has been fulfilled (nurhasan, 2020). the implementation in sharia pharmacies reflects the principles of good corporate governance by prioritizing pharmacy management based on the values of siddiq (truthfulness), tabligh (transparency), amanah (trustworthiness), and fathanah (wisdom). a previous study examined the compliance of the spatial layout and the pharmaceutical preparation storage system at the pharmaceutical logistics unit of sultan agung semarang hospital, based on the guidelines for pharmaceutical service standards in hospitals and islamic principles. the results showed that the compliance of the spatial layout reached 94.75%, while the storage system had a compliance rate of 90.91%. however, compliance based on islamic principles was only 25%, which was categorized as poor (zulfitri et al., 2024). latifah et al. ghmj (global health management journal) 2025, vol. 8, no. 3 354 figure 1. network visualization of previous research variables this study used the servqual model to measure patient satisfaction with pharmaceutical services by assessing five dimensions of service quality. the results showed that the empathy dimension had the highest score, while tangibles had the lowest score, although both still fell within the "very satisfied" category (pazri et al., 2023). previous studies on consumer satisfaction with service quality at karunia sehat baru pharmacy based on sharia values highlighted that the empathy dimension, when aligned with sharia principles, can strengthen the relationship between the pharmacy and consumers, creating positive interactions that benefit both parties (fathnin et al., 2023). the use of servqual indicators which consist of reliability, responsiveness, assurance, empathy, and tangibles enables a comprehensive evaluation of pharmacy services, not only from a technical perspective but also in terms of human interaction, which is highly important in sharia-based services. values such as honesty, trustworthiness, justice, and empathy are part of sharia ethics and are highly relevant to the servqual dimensions. with servqual, we can measure the extent to which these values are internalized and reflected in pharmacy services. servqual-based research will identify the strengths and weaknesses of the service; provide a basis for service improvement in line with sharia expectations; enhance customer satisfaction, comfort, and loyalty; most studies on sharia-based healthcare still focus on hospitals, and few have specifically; examined pharmacies as the frontline in medication services; assessed non-clinical service aspects from a sharia perspective. this study will fill a gap in the literature and expand the scope of research on sharia-based healthcare services, particularly in the context of pharmaceutical services. most studies on sharia-based pharmaceutical services still use quantitative approaches that focus on patient satisfaction through surveys or servqual scores. however, few have explored in depth how sharia principles are implemented in daily practice. a qualitative approach is crucial for exploring the perceptions, experiences, and meanings constructed by pharmacists in applying islamic values in services. using a qualitative case study, this research fills this gap by generating a richer, more comprehensive, and reflective contextual understanding of the implementation process of sharia-based pharmaceutical service standards. a review of previous research findings shows that the element of sharia-based services has a positive impact, although it is not the primary factor in determining patient preferences. this potential increases further once trust in the pharmacy’s reputation and the quality of its pharmaceutical services is established. the urgency of this study lies in addressing the community’s need for spiritually-based pharmaceutical services, as services aligned with sharia principles offer additional benefits, particularly for muslim patients. currently, indonesian society shows a positive attitude and trend toward sharia-compliant services; however, the number of sharia-based healthcare facilities remains limited (rizki et al., 2025). based on the aforementioned background, the aim of this study is to evaluate the implementation of sharia-based pharmaceutical service standards (a qualitative case study at the educational pharmacy of muhammadiyah charitable enterprise). this study examines the implementation of pharmaceutical service standards not only based on existing regulations but also from the perspective of islamic economics and ethics. this forms the novelty of the research, as previous studies have largely focused on regulatory and managerial aspects without comprehensively integrating sharia principles. 355 ghmj (global health management journal) 2025, vol. 8, no. 3 latifah et al. 2. methods research method overall, this study is non-experimental research with a descriptive-analytical and case study design. the data was collected qualitatively, which is a research method used to study natural conditions of the object, where the researcher serves as the key instrument. data collection techniques were carried out through triangulation, data analysis was inductive, and qualitative research results emphasize meaning rather than generalization (smit & onwuegbuzie, 2018). this qualitative approach was conducted using two research methods: observation and interviews. the research setting was the educational pharmacy of muhammadiyah charitable enterprise in magelang, central java, during january 2025. all attributes were synthesized from a literature review, in which sharia pharmaceutical services include the dimensions of reliability, responsiveness, empathy, tangibles, and assurance (fathnin et al., 2023). data collection the first stage of the research used the observation method, conducted by observing the pharmaceutical service processes and the availability of standard operating procedures (sops) at the educational pharmacy. the aim was to understand the existing condition of pharmaceutical services at the educational pharmacy in the context of sharia competency implementation. this observational approach involved data collection through the human senses, by systematically and meaningfully watching and listening. this qualitative study employed purposive sampling, which involves intentionally selecting informants based on specific criteria relevant to the research objectives. because of their expertise, familiarity, and hands-on involvement in sharia-compliant pharmaceutical service procedures at the muhammadiyah charity board educational pharmacy, informants were chosen. among the inclusion criteria that were applied were at least two years of experience working at the pharmacy where the study was conducted maintaining a current; pharmacy personnel registration certificate in compliance with relevant laws; direct participation in the provision of pharmaceutical services (as a pharmacy technician or a pharmacist). the informants involved were 1 pharmacist and 3 pharmaceuticals technical staff. the second stage of the research used the interview method, aimed at identifying the implementation of sharia values in pharmaceutical services. a review of pertinent research on sharia-compliant healthcare services, specifically in pharmacy practice, served as the foundation for the development of the interview guide. the purpose of the questions was to investigate how the five servqual dimensions assurance, responsiveness, empathy, tangibles, and reliability are understood and applied from an islamic standpoint. two academic pharmacists with backgrounds in qualitative research and islamic pharmacy ethics reviewed the draft interview questions to increase their credibility. their input helped to improve the questions' cultural suitability, clarity, and alignment with the study's goals. the guide was piloted on a pharmacist who satisfied the inclusion criteria but was left out of the final sample prior to official data collection. the flow, comprehensibility, and usefulness of the semi-structured questions were evaluated with the aid of this pilot. based on the pilot, a few minor changes were made, like streamlining terminology and rewording a few questions to improve the narrative flow. triangulation of observational data, peer discussions among research team members, and member checking during interviews to verify participant interpretations were all used to support validation. the researcher acted as a passive observer in the pharmacy setting during the non-participatory observations. the pharmaceutical service process was the main subject of the observations, and this included: patient consultation: face-to-face communication between the patient and the pharmacist that covers topics such as drug information delivery, language usage, and sharia-compliant manners and service etiquette. medication dispensing: from getting the prescription to giving the drug, including pharmaceutical technicians' participation, correctness of the process, and transaction transparency. observance of standard operating procedures: this includes observing current sops with regard to pharmaceutical technical aspects as well as islamic ethics (e.g., room separation, use of islamic attributes, and professionalism). physical facilities include spaces that uphold sharia principles, such as prayer rooms, cleanliness, halal signage, and, when applicable, the segregation of patient areas for men and women. the observations, which lasted four hours a day on average for a month in january 2025, covered both latifah et al. ghmj (global health management journal) 2025, vol. 8, no. 3 356 peak and regular pharmacy operating hours. field notes that methodically and reflectively detailed the context, behavior, and processes of interactions were used to collect data. when no new themes or information surfaced from the final observations and interviews, data saturation was deemed to have been reached. all of the informants shared consistent thematic patterns that covered the servqual's five dimensions and how they relate to sharia values. the consistency of responses from informants and the triangulation of interview results, service observations, and sop documents were used to evaluate the adequacy of the data. to preserve the credibility of the data, this procedure was strengthened with peer debriefing, audit trails, and member checking. data analysis during the discussions and in-depth face-to-face interviews, audio recordings were used. the researchers involved in the study transcribed the recordings verbatim and conducted accuracy checks. nvivo 12 software was used to perform descriptive content analysis of the transcripts. two independent researchers (el and cdb) coded the translated transcript data using an inductive approach. the researchers applied standard procedures in making decisions related to coding rules and theme development, relying on consensus. agreement on coding was reached through discussions to resolve any differences of opinion among the researchers. the identified codes were then used to determine themes and subthemes. this study used a number of qualitative data validation techniques to preserve the validity of the results. standard operating procedure (sop) documents, observations, and interview results were compared to perform triangulation. to ensure accurate interpretation, informants were asked to review the summary of findings as part of the member checking process. additionally, by recording their presumptions and possible biases at every stage of the analysis, the researchers engaged in reflexivity. to assess the coherence of codes and emerging themes, researchers also engaged in peer debriefing. two additional researchers evaluated, reviewed, or revised the emerging themes and subthemes, and the entire team discussed them collectively. the final report summarized the coded texts, reflecting the researchers’ collective understanding of the textual data. italicized text represents direct quotations from the informants. the results of the data analysis were visualized in the form of cluster analysis. pearson correlation coefficients were used to identify the strongest relationships between service quality items. ethical clearance this research has obtained ethical clearance from the health research ethics committee (kepk) of universitas muhammadiyah magelang with no.0238/kepk.fikes/ii.3.au/f/2025. 3. results the implementation of sharia-based services is reviewed from five dimensions, namely reliability, responsiveness, empathy, tangibles, and assurance, which are explored through interviews and observations at an educational pharmacy. 3.1. reliability dimensions based on the nvivo cluster analysis results, the highest pearson correlation values in the reliability dimension are presented in table 1, with a visualization of all items shown in figure 1. the reliability of sharia-based pharmaceutical services can be explained by several correlations that were discovered based on the findings of the pearson correlation analysis of the reliability dimension in nvivo (table 1). a statistical tool for evaluating linear relationships between two variables is the pearson correlation coefficient. with values ranging from -1 to 1, this gauges how closely they are related. the absolute value of the pearson coefficient, near to 1 when the correlation is stronger and near to 0 when it is weaker, is positively correlated with the strength of the correlation between the variables (ahsina & zahra, 2025). 357 ghmj (global health management journal) 2025, vol. 8, no. 3 latifah et al. table 1. clustered table based on pearson correlation (reliability dimension) code a code b pearson correlation coefficient nodes\\reliability dimension\fulfilling order service as promised nodes\\reliability dimension\fulfilling order service as promised\distributor reliability 0.982446 nodes\\reliability dimension\fast and accurate service nodes\\reliability dimension\fast and accurate service\adequacy of staff and number of patients 0.878452 nodes\\reliability dimension\providing information accurately and honestly nodes\\reliability dimension\providing information accurately and honestly\expiration date information 0.833437 nodes\\reliability dimension\providing information accurately and honestly nodes\\reliability dimension\providing information accurately and honestly\drug stockout 0.723081 nodes\\reliability dimension\fulfilling order service as promised nodes\\reliability dimension\providing information accurately and honestly\drug stockout 0.506230 nodes\\reliability dimension\providing information accurately and honestly\drug stockout nodes\\reliability dimension\fulfilling order service as promised\distributor reliability 0.503746 nodes\\reliability dimension\providing information accurately and honestly nodes\\reliability dimension\fulfilling order service as promised 0.449152 nodes\\reliability dimension\providing information accurately and honestly nodes\\reliability dimension\fulfilling order service as promised\distributor reliability 0.435540 3.1.1. reliable service fulfilment (fulfilling orders as promised) the highest correlation (0.982) was found between the item pair "fulfilling order service as promised" and its subtheme "distributor reliability," suggesting that a pharmacy's capacity to deliver on service commitments is highly influenced by distributor reliability. this demonstrates how important external supply networks distributor partners are to preserving the legitimacy of pharmaceutical services, especially when it comes to placing orders and acquiring prescription drugs. 3.1.2. service and workload accuracy a strong correlation (0.878) was found between the item "fast and accurate service" and "adequacy of staff and number of patients," suggesting that the adequacy of pharmacists in relation to the patient load has a significant impact on service speed and accuracy. a key component of reliability in service in sharia-compliant pharmacies is human resource management. 3.1.3. drug information transparency transparency in communicating actual drug stock and expiration dates has a significant impact on perceptions of service reliability, as evidenced by the high correlation between "providing information accurately and honestly" and the subthemes "expiration date information" (0.833) and "drug stockout" (0.723). in addition to being a component of professional service, accurate information also reflects sharia principles' values of integrity and openness. 3.1.4. relationships among subthemes the moderate correlation found between "providing information accurately and honestly" and "fulfilling order service as promised" (0.449), along with other subthemes like "distributor reliability" (0.435), suggests that the ability to meet patient needs is closely linked to information honesty. this illustrates how reliability dimensions are integrated, meaning they impact one another rather than existing independently. latifah et al. ghmj (global health management journal) 2025, vol. 8, no. 3 358 figure 1. item clustered by-word similarity (reliability dimension) the figure 1 shows the results of word clusters on the reliability dimension, where several items form an intriguing pattern of closeness in meaning. the items “fulfilling order service as promised” and “distributor reliability” are in a very close cluster, indicating that service certainty and distributor reliability are closely related aspects in the perception of pharmaceutical service reliability. this cluster is also close to “drug stockout,” which reinforces the importance of drug availability as part of fulfilling service promises. the items “providing information accurately and honestly” and “expiration date information” are clustered together, confirming that accurate information, especially regarding drug expiration dates, is central to trustworthy service. meanwhile, “fast and accurate service” and “adequacy of staff and number of patients” indicate the relationship that speed and accuracy of service are strongly influenced by the adequacy of pharmaceutical personnel. the item “the implementation of surah an-nahl verse 91” is separate from the other clusters, indicating that the religious value aspect has different textual characteristics but remains relevant in strengthening the principle of trustworthiness in sharia pharmaceutical services. this narrative shows that service reliability is built through a combination of information accuracy, certainty of service fulfillment, speed of service, and the application of sharia values. 3.2. responsiveness dimension based on the nvivo cluster analysis results, the highest pearson correlation values in the responsiveness dimension are presented in table 2, with a visualization of all items shown in figure 2. table 2. clustered table based on pearson correlation (responsiveness dimension) code a code b pearson correlation coefficient nodes\\responsiveness dimension\resolving customer complaints accurately and responsibly nodes\\responsiveness dimension\division of duties and functions in problem-solving 1.000000 nodes\\responsiveness dimension\pharmaceutical staff are easy to contact\supporting each other through whatsapp group communication nodes\\responsiveness dimension\pharmaceutical staff are easy to contact 0.937934 nodes\\responsiveness dimension\pharmaceutical staff are easy to contact nodes\\responsiveness dimension\pharmaceutical staff are easy to contact\never turning off the phone 0.525531 important conclusions were drawn from the responsiveness dimension's pearson correlation analysis using nvivo (table 2), which showed how much an efficient coordination and communication system supports pharmaceutical services' responsiveness. a narrative explanation based on the items' highest correlation values is provided below: 359 ghmj (global health management journal) 2025, vol. 8, no. 3 latifah et al. 3.2.1. methodical problem solving (1.000 correlation) the items "resolving customer complaints accurately and responsibly" and "division of duties and functions in problem-solving" were found to be perfectly correlated (1.000). this finding suggests that a clear division of responsibilities and functions among pharmacy staff is crucial to the accurate and responsible handling of patient complaints. this illustrates how the concepts of tanzhim (good organization) and mas'uliyyah (responsibility) serve as the cornerstone for offering responsive and solution-focused services in the context of sharia compliant services. 3.2.2. effective response to inter-staff communication (correlation = 0.937) "supporting each other through whatsapp group communication" and "pharmaceutical staff are easy to contact" were found to be highly correlated. this suggests that the availability of unofficial channels of communication, like whatsapp groups, significantly supports direct accessibility to pharmacy staff. this medium facilitates quick information sharing, fosters staff support for one another, and improves teamwork in meeting patient needs immediately. such behavior is consistent with the islamic tenet of ta'awun, or reciprocal aid. 3.2.3. commitment to service via readiness (correlation = 0.526) additionally, there was a moderate correlation between the sub-item "never turning off the phone" (0.526) and the item "pharmaceutical staff are easy to contact." this indicates that active team communication and individual willingness to stay in touch with patients are the foundations of pharmacy staff accessibility. this mindset embodies the value of istiqamah (consistency) and a commitment to providing patients with prompt service whenever they require it. figure 2. item clustered by-word similarity (responsiveness dimension) the cluster results (figure 2) indicate that timeliness and preparedness related items, like "responsive in serving customers," "80% of pharmacies open on time," and "never turning off the phone," are closely related and represent the sharia pharmaceutical services' trustworthiness principle. in contrast, the item "the implementation of qs. al-isra verse 34 and qs. al-inshirāh" is distinct and highlights how religious values influence the dependability of services. the things that are closely related to each other "division of duties and functions in problem-solving," "resolving customer complaints accurately and responsibly," and "supporting each other through whatsapp group communication" showcase how crucial collaboration and communication are when managing complaints. by linking the responsiveness cluster with communication, the item "pharmaceutical staff are easy to contact" upholds the importance of ta'awun (mutual assistance) in providing patients with timely and accessible pharmaceutical services. latifah et al. ghmj (global health management journal) 2025, vol. 8, no. 3 360 3.3. assurance dimension based on the nvivo cluster analysis results, the highest pearson correlation values in the assurance dimension are presented in table 3, with a visualization of all items shown in figure 3. table 3. clustered table based on pearson correlation (assurance dimension) code a code b pearson correlation coefficient nodes\\assurance dimension\ensuring that the information has been well received by the patient nodes\\assurance dimension\ensuring that the information has been well received by the patient\confirmation to the patient 0.961882 nodes\\assurance dimension\assurance of non-expired medications\storage using the fefo method nodes\\assurance dimension\assurance of non-expired medications 0.834133 nodes\\assurance dimension\friendly and polite in service\influenced by fatigue and service overload nodes\\assurance dimension\friendly and polite in service 0.817622 nodes\\assurance dimension\pharmaceutical personnel have good knowledge nodes\\assurance dimension\pharmaceutical personnel have good knowledge\collaborative brainstorming among pharmaceutical professionals and across pharmacies 0.812802 nodes\\assurance dimension\ensuring the confidentiality of patient data nodes\\assurance dimension\ensuring the confidentiality of patient data\computer access in the pharmacy is restricted 0.748126 nodes\\assurance dimension\pharmaceutical personnel have good knowledge nodes\\assurance dimension\pharmaceutical personnel have good knowledge\limitations in the use of special medications 0.702617 nodes\\assurance dimension\assurance of non-expired medications\product return to the distributor nodes\\assurance dimension\assurance of non-expired medications 0.692996 nodes\\assurance dimension\friendly and polite in service\maintaining a clear boundary between personal matters and professional responsibilities nodes\\assurance dimension\friendly and polite in service 0.615198 nodes\\assurance dimension\assurance of non-expired medications\regular monitoring nodes\\assurance dimension\assurance of non-expired medications 0.505143 nodes\\assurance dimension\assurance of non-expired medications\storage using the fefo method nodes\\assurance dimension\assurance of non-expired medications\product return to the distributor 0.457549 the quality of pharmaceutical services can be explained by several correlations found based on the pearson cluster data analysis of the assurance dimension in nvivo (table 3). 3.3.1. verification of patient knowledge the significance of making sure patients fully comprehend the medication information given as a form of assurance to prevent misuse was highlighted by the extremely high correlation (0.962) between the item pair "ensuring that the information has been well received by the patient" and "confirmation to the patient." 3.3.2. assurance of non-expired drugs the following sub-items had a strong correlation with the theme "assurance of non-expired medications": "fefo method of storage" (0.834) , "return of product to distributor" (0.693) , "regular monitoring" (0.505). all three outline technical protocols that help ensure the stability of pharmaceutical inventories and stop the distribution of out-of-date drugs. 361 ghmj (global health management journal) 2025, vol. 8, no. 3 latifah et al. 3.3.3. service ethics and friendliness the following were significantly correlated with the theme "friendly and polite in service": "influenced by service overload and fatigue" (0.818) , "maintaining a clear boundary between professional responsibilities and personal matters" (0.615). this suggests that the ability of employees to maintain professionalism and the working environment both have an impact on a friendly attitude. knowledge and cooperation among pharmacy staff the following had a strong correlation with the theme "pharmaceutical personnel have good knowledge": "collaborative brainstorming across pharmacies and among pharmaceutical professionals" (0.813), "restrictions in the utilization of specialized drugs" (0.703). this highlights how crucial teamwork and knowledge sharing are to delivering high quality service. 3.3.4. pharmacy staff knowledge and collaboration the theme "pharmaceutical personnel have good knowledge" correlated strongly with: "collaborative brainstorming among pharmaceutical professionals and across pharmacies" (0.813), "limitations in the use of specialty medications" (0.703). this emphasizes the importance of collaboration and knowledge updates to provide quality service. 3.3.5. protection of patient data according to information security principles, limiting access to pharmacy systems is an essential step in preserving patient data confidentiality, as the theme "ensuring the confidentiality of patient data" with "computer access in the pharmacy is restricted" (0.748) illustrates. figure 3. item clustered by-word similarity (assurance dimension) the figure's five clusters (figure 3) demonstrate the close relationships between the assurance dimension's items: first, the drug safety and data protection cluster highlight the significance of keeping an eye on expiration dates and protecting patient confidentiality; second, pharmacist knowledge and cooperation serve as the foundation for patient trust; third, protocols like fefo storage and drug returns guarantee that patients only receive safe medications; fourth, patient confirmation of information ensures correct comprehension; and fifth, the application of religious values and service ethics, including awareness of the effects of fatigue, strengthens friendliness and professionalism in pharmaceutical services. latifah et al. ghmj (global health management journal) 2025, vol. 8, no. 3 362 3.4. empathy dimension the empathy dimension of pharmaceutical services is analyzed based on the results of the nvivo cluster analysis (table 4). 3.4.1. strong association in the humanity aspect the item pair with the highest pearson coefficient (0.518) was "prioritizing a sense of humanity" and "not discriminating based on economic status." this suggests that the two items have a strong connection in meaning and a strong similarity in wording, which illustrates the importance of treating patients fairly and humanely regardless of their financial situation. such behavior embodies the values of compassion and equality (rahmah) in pharmaceutical services that adhere to sharia law. 3.4.2. poor association in spoken communication on the other hand, the item pairs "asking about the patient's complaints and symptoms" and "saying greetings (salaam), thank you, sorry, and praying for the patient" only had a coefficient of 0.115. this suggests a low correlation in wording, meaning that while both are a component of empathetic communication, the proactive action of asking about the patient's complaints is less directly linked to the use of courteous verbal expressions. overall, this table shows that the social justice empathy components are more conceptually integrated than the verbal communication components, which, although significant, seem more distinct in the data's word patterns. based on the nvivo cluster analysis results, the highest pearson correlation values in the empathy dimension are presented in table 4, with a visualization of all items shown in figure 4. table 4. clustered table based on pearson correlation (empathy dimension) code a code b pearson correlation coefficient nodes\\empathy dimension\prioritizing a sense of humanity nodes\\empathy dimension\not discriminating based on economic status 0.517548 nodes\\empathy dimension\saying greetings (salaam), thank you, sorry, and praying for the patient nodes\\empathy dimension\asking about the patient's complaints and symptoms 0.115000 the outcomes of the empathy dimension word clustering, which grouped five essential components of empathy-based pharmaceutical care, are shown in figure 4. the first cluster highlights social sensitivity and respect for human values without discriminating against patients by combining the two elements of "not discriminating based on economic status" and "prioritizing a sense of humanity." "implementation of the quran, surah al-qasas 77," "asking about the patient's complaints and symptoms," and "saying greetings (salaam), thank you, sorry, and praying for the patient" make up the second cluster. similar terms that highlight face-toface communication with patients and the application of religious principles that promote kindness, compassion, and decency bind all three together. this pattern highlights that while social justice and humanity are the primary pillars of empathy in sharia-based pharmaceutical care, verbal communication and religious behavior are essential to fostering patient comfort and trust. figure 4. item clustered by-word similarity (empathy dimension) 363 ghmj (global health management journal) 2025, vol. 8, no. 3 latifah et al. 3.5. physical dimension based on the nvivo cluster analysis results, the highest pearson correlation values in the physical dimension are presented in table 5, with a visualization of all items shown in figure 5. table 5. clustered table based on pearson correlation (physical dimension) code a code b pearson correlation coefficient nodes\\physical dimension\there is no prayer area for patients yet nodes\\physical dimension\there is no prayer area for patients yet\there are two large mosques near the pharmacy 0.672537 nodes\\physical dimension\there is no prayer area for patients yet nodes\\physical dimension\there is no prayer area for patients yet\there is a prayer room for the pharmacy staff 0.636995 nodes\\physical dimension\the pharmacy is strategically located or easily accessible nodes\\physical dimension\the appearance of the pharmaceutical staff is neat and covers the aurat (modesty according to islamic guidelines) 0.036504 the physical dimension of pharmaceutical services is analyzed based on the nvivo cluster analysis results (table 5), as follow: 3.5.1. patient worship facilities and nearby mosque neighborhood (correlation = 0.673) the items "there is no prayer area for patients yet" and "there are two large mosques near the pharmacy" have the highest correlation (0.673). this study highlights the natural differences that patients experience with the surrounding environment while evaluating the physical capabilities of pharmacy facilities. in the context of sharia-based pharmaceutical services, such an observation is related to the principle of paying attention to the benefit, where in the service provider is expected to provide easy access to worship in a form that is silent and non-toxic, including in health facilities. 3.5.2. employee and staff worship facilities (correlation = 0.637) the items "there is no prayer area for patients yet" and "there is a prayer room for the pharmacy staff" also have a high correlation (0.637). this finding indicates that there is a gap in worship facilities between staff and patients, which is very important to the respondents. this suggests that the principles of fairness and equality in providing assistance, especially concerning spiritual needs, are of utmost importance. from a sharia perspective, the principle of justice and the glorifying humans indicates that everyone's spiritual needs should be met in a calm manner. 3.5.3. islamic staff appearance and location strategy (correlation = 0.037) the items that had the highest correlation (0.037) were "the pharmacy is strategically located or easily accessible" and "the appearance of the pharmaceutical staff is neat and covers the aurat (modesty according to islamic guidelines)." perceptions of staff adherence to islamic appearance values and the pharmacy's accessibility were explained in detail by service users. accordingly, location strategy is not entirely insensitive to staff members' religious or professional beliefs. the aspects of good appearance and service accessibility are two independent pillars that must be simultaneously examined to support holistic service. key concerns in the public's perceptions of sharia-compliant pharmaceutical services are grouped in the dendrogram that results from a cluster analysis based on wording similarities in the physical dimension items (figure 5). the respondents' emphasis on the topic of religious facilities is reflected in the close clustering of the first three items: the absence of a patient prayer room, the presence of a staff prayer room, and the existence of two mosques close to the pharmacy. a distinct but closely related theme of religious facilities includes items pertaining to parking lots and restroom cleanliness. the significance of islamic cleanliness and appearance overall is emphasized by the items pertaining to the pharmacy's cleanliness and appearance as well as the staff's tidy and modest appearance, which form a separate cluster. lastly, the item pertaining to the pharmacy's strategic location is the one that is located farthest away from the cluster, suggesting that opinions regarding accessibility are evaluated separately from those regarding cleanliness and religious facilities. this cluster pattern demonstrates that three major themes cleanliness/appearance, accessibility, and religious facilities are separate latifah et al. ghmj (global health management journal) 2025, vol. 8, no. 3 364 but equally significant in sharia-compliant physical pharmacy service standards. figure 5. item clustered by-word similarity (physical dimension) the three most notable service gaps were insufficient integration of empathy in clinical communication, limited educational communication during periods of high workload, and spiritual facilities (lack of a patient prayer space). strengthening sharia-based sops, offering islamic ethics training in pharmaceutical communication, and reorganizing physical facilities to accommodate both patient comfort and worship are all necessary to close these gaps. observational findings: sharia alignment and gaps in practice during non-participatory observation at the educational pharmacy of muhammadiyah charitable enterprise, several behaviors and conditions were found that both reflect and contradict sharia principles in pharmaceutical services. on the positive side, staff were observed consistently greeting patients with islamic expressions such as salaam, thanking them, and showing humility through apologies, reflecting values of rahmah (compassion), tawadhu’ (humility), and akhlaq (good manners), which are integral to islamic ethics. staff appearance was also largely in accordance with sharia guidelines, including modest dress and covered aurat, reflecting a professional and religiously respectful image. however, certain contradictions were also apparent. one key observation was the absence of a dedicated prayer area for patients, despite its importance as part of creating a spiritually supportive environment. while the pharmacy is located near two large mosques and has a private staff prayer space, the lack of a patientaccessible worship facility limits inclusive spiritual accommodation. however, it is contrary to the islamic values of al-‘adalah (justice) and ikram al-insan (honoring human dignity). additionally, sops incorporating gender sensitivity, islamic service etiquette, or guidelines for maintaining halal assurance were found to be either lacking or not consistently implemented. the prayer room for staff, for instance, was combined with the compounding area, which may compromise privacy and cleanliness principles emphasized in thaharah (purity) and ithqan (excellence in performance). furthermore, during busy hours, staff were observed prioritizing speed over friendly interaction due to fatigue and workload, at times neglecting the islamic value of ihsan (doing one’s best) in interpersonal service. these observations underscore the need for infrastructure improvements, strengthened sops, and spiritual competence training to ensure alignment between sharia principles and actual practice. 4. discussion 4.1. theme: commitment to service reliability as a trust in sharia pharmaceutical services sub theme: fulfilling service promises (al-wafa’ bil ‘ahd) as a form of moral and spiritual responsibility; maintaining patient trust necessitates reliance on reliable distributors; the values of trustworthiness, honesty (shidq), and professionalism (itqan) are integrated into service practices. in the context of implementing sharia-based services, the reliability dimension is a crucial element that reflects the pharmacy's consistency and accuracy in fulfilling promises and meeting customer expectations. two key subaspects identified through cluster analysis with the highest correlation values are fulfilling order service as 365 ghmj (global health management journal) 2025, vol. 8, no. 3 latifah et al. promised and distributor reliability. these aspects are directly related to the pharmacy's ability to deliver services as promised, in terms of order timing, medication quality, and accuracy in delivering prescriptions or patient requests. in sharia-based service, fulfilling promises (al-wafa’ bil ‘ahd) is a fundamental principle emphasized in qs. al-ma’idah: 1 and qs. an-nahl: 91. the strong correlation with the reliability dimension indicates that commitment to service promises is a key indicator for patients in assessing whether pharmacy services align with sharia principles. timely and committed service not only enhances trust but also represents part of the amanah (trust and responsibility) in healthcare services (dusuki & abdullah, 2024). distributor reliability relates to the supplier's ability to maintain the availability, authenticity, and timely delivery of stock to the pharmacy. in sharia-based services, this aspect is linked to the concepts of honesty (shidq) and professionalism (itqan) within the supply chain. pharmacies aiming to implement sharia principles must ensure that their distributor partners are trustworthy and reliable, in order to avoid repeated stockouts or delays that could negatively impact patients. reliance on inconsistent distributors will directly affect the pharmacy’s ability to deliver on promised services, thereby putting the reliability of the pharmacy itself at risk. the perspectives of pharmacist provided insight into the implementation of the reliability dimension in sharia-based pharmaceutical services is supported by the following interview quote: “if the order is not picked up at that moment, we need to first ensure whether there is a distributor who can deliver it. this means that when the patient is present and we do not have the medication in stock, we must confirm that the distributor we work with has the medication, is ready to ship it, and when it will arrive at the pharmacy. if we do not have clear information regarding that, we will not promise or accept the order for that medication” (pharmacist at the educational pharmacy) this study aligns with previous research that examined the influence of pharmaceutical service quality on outpatient satisfaction, focusing on five service quality dimensions, including reliability. the findings revealed that the reliability dimension has a significant impact on patient satisfaction, highlighting the importance of pharmacies in fulfilling service promises and ensuring the availability of medications according to patient needs (sunarto et al., 2025). another study also discusses the importance of measuring service quality within the pharmaceutical supply chain, particularly from the distributor's perspective. distributor reliability in delivering pharmaceutical products on time and according to specifications is a key factor in ensuring that pharmacies can fulfill their service promises to patients. this research highlights that distributor reliability directly affects a pharmacy’s ability to provide consistent and trustworthy services (parmata et al., 2016). reliability in providing products and services that comply with sharia principles, including fulfilling service promises and distributor reliability, is also identified as an important factor in meeting the expectations of muslim customers (noor, 2025). 4.2. theme: responsiveness as a demonstration of concern and preparedness in sharia pharmacy services subtheme: open communication and clear division of duties in complaint handling based on table 2, the following are item pairs with the highest correlation values, indicating similarity in context and meaning between themes: "resolving customer complaints accurately and responsibly" and "division of duties and functions in problem-solving" (correlation: 1.000). these two themes are closely related, where a clear division of duties among pharmaceutical staff in handling issues greatly affects the effectiveness of resolving customer complaints. this indicates that a well-structured work system supports responsiveness in service. "pharmaceutical staff are easy to contact" (correlation: 0.937) also shows that, in sharia-based services, ease of access to pharmaceutical personnel is important to provide a sense of security and prompt response to patients. additionally, "pharmaceutical staff are easy to contact" has a relatively high correlation with "resolving customer complaints accurately and responsibly" (correlation: 0.526). this indicates a fairly strong relationship between the ease of contacting pharmaceutical staff and the speed of complaint resolution. it illustrates that a quick response is not only about technical ability, but also about open communication. latifah et al. ghmj (global health management journal) 2025, vol. 8, no. 3 366 the perspectives of technician provided insight into the implementation of the responsiveness dimension in sharia-based pharmaceutical services is supported by the following interview quote: “if there’s any urgent information, we place it in the group. for example, if i’m a bit slow to respond, another staff member can reply or is aware of something urgent in the group. this means we almost never mute phone calls or the whatsapp group. in other words, even though we’re not on standby with our phones 24 hours a day, none of us keeps them on silent” (technicians at the educational pharmacy). this finding is in line with studies that emphasize the importance of standard procedures and division of authority in pharmacies to ensure good practices and professional protection in pharmaceutical services (brahmono et al., 2023). in addition, ease of communication with pharmaceutical staff is also closely related to the speed of resolving customer complaints. previous studies have shown that effective communication within pharmaceutical organizations plays an important role in improving product quality and customer satisfaction. this emphasizes that a quick response depends not only on technical aspects but also on the openness and effectiveness of communication between patients and pharmaceutical staff (hidayatullah & aesthetika, 2024). 4.3. theme: assurance of security and trust in sharia pharmacy services subtheme: transparent information and friendly communication as core elements of assurance the highest correlation (0.96) was found in the item “ensuring that the information provided is understandable”, indicating the foundation of patient trust in services. this means that a good understanding of information creates a strong sense of security. the items “assurance of non-exploitation” and “ensuring that the information provided is understandable” (0.83) reflect the link between communication transparency and trust in the integrity of services. the correlation between “friendly and polite pharmaceutical staff” and “ensuring that the information provided is understandable” (0.81) shows that friendly and polite staff tend to provide explanations that are easier to understand, enhancing the overall perception of service quality. the correlation between “ensuring the confidentiality of patient information” and “ensuring that the information provided is understandable” (0.75) indicates that information comprehension is often associated with confidentiality assurance, showing how effective communication correlates with trust in maintaining the privacy of personal data. another study highlights those good pharmaceutical services which include information and education communication, the speed of medication service, and the friendliness of pharmacy staff, are important factors in assessing patient satisfaction. this quality of service not only meets professional standards but also enhances the patient's positive perception of the services provided (juwita et al, 2023). a study conducted at the pharmacy department of dungus madiun hospital also showed that the quality of services provided by pharmaceutical staff has a significant impact on patient satisfaction. good service quality, including the friendliness and politeness of pharmacy staff, contributes to increased patient satisfaction. research conducted at dr. rm. djoelham binjai hospital examined the assurance dimension in pharmaceutical services, which includes the polite and friendly attitude of the staff. the results indicated that this aspect is significantly related to patient satisfaction, affirming that the positive attitude of pharmacy staff enhances patients’ sense of safety and trust in the services provided (hervina et al., 2019). the implementation of the assurance dimension in sharia-based pharmaceutical services at this pharmacy faces several challenges, including the high volume of patient visits, which causes pharmaceutical staff to prioritize speed over friendliness due to time constraints. in addition, the perspectives of technician provided insight into the pharmaceutical staff’s knowledge regarding the provision of information on special preparations needs to be improved. “however, it's not 100% or every day that the staff here are friendly—there are certainly times when they feel exhausted. especially at night, when fatigue sets in and there are crowds of patients, speed becomes the priority and friendliness is set aside” 367 ghmj (global health management journal) 2025, vol. 8, no. 3 latifah et al. “usually, when it comes to special preparations, the patients are more familiar with them because they’ve used them before. meanwhile, we ourselves have never even opened them. maybe that’s also one of our shortcomings and something we’ll need to discuss further. but generally, for special preparations, if the patient requests them, they usually already know how to use them. if not, they will typically ask, and we have brochures or leaflets that explain how the medication should be used, and we provide education as well” (pharmacist at the educational pharmacy). 4.4. theme: empathy as a pillar of justice and compassion in sharia pharmacy services subtheme: non-discriminatory service and islamic personal communication the highest correlation (0.517) was found between the items: “prioritizing a sense of humanity” and “not discriminating based on economic status.” this indicates that services upholding humanitarian values are closely related to fair treatment regardless of the patient's economic status. in the context of sharia, these two items reflect the values of justice (‘adl) and compassion (rahmah). pharmaceutical staff who prioritize humanitarian aspects tend to provide equal services to all patients, without social or economic bias. a moderate correlation was found between the items “saying greetings (salaam), thank you, sorry, and praying for the patient” and “asking about the patient's complaints and symptoms” (0.115). although the correlation is not particularly strong, the relationship remains relevant as it shows that polite verbal communication (greetings, prayers, expressions of gratitude) tends to go hand-in-hand with clinical communication (asking about complaints/symptoms). this reflects the integration of islamic ethics and professional competence. previous studies have also shown that the empathy dimension, particularly those reflecting attentiveness, equality, and personal communication has a significant impact on patient satisfaction. the correlation between “not discriminating based on economic status” and “prioritizing a sense of humanity” supports these findings (arini et al., 2023). the study at bebesen public health center found that the empathy dimension in the quality of pharmaceutical services has a significant relationship with outpatient satisfaction. this indicates that the attention and care shown by pharmaceutical staff to patients greatly contribute to improving service satisfaction (iriyanti & yusran, 2021). a meta-analysis examined the influence of healthcare workers' empathetic attitudes on patient satisfaction. the results showed that healthcare providers who demonstrated empathy significantly increased patient satisfaction, with an odds ratio of 2.10 (rahayuningsih & cahyaningrum, 2023). a previous study at kimia farma pharmacy in rantauprapat analyzed the influence of service quality dimensions on customer satisfaction. the results showed that empathy had a positive and significant effect on customer satisfaction, with a t-value of 9.289 and a significance level of 0.000 (broto, 2020). the perspectives of pharmacist and technician provided insight into the implementation of the empathy dimension in sharia-based pharmaceutical services is supported by the following interview quote: “as for offering greetings and saying thank you, from our side, inshaallah it is sufficient we have indeed implemented it. as for apologizing, we also do that, whether it's due to giving the wrong change or the wrong quantity of medicine, and we don't feel the need to make excuses. we always ask for forgiveness and the patient's understanding” (technicians at the educational pharmacy) “i believe, inshaallah, it has already been implemented because the customers of unimma medika pharmacy are very diverse, and i think the staff serve patients without discriminating based on their status” (pharmacist at the educational pharmacy). 4.5. theme: physical environment and facilities in sharia pharmacy services. subtheme: worship space and cleanliness as key aspects of sharia-compliant physical standards the highest correlation (0.672) indicates that the presence of worship facilities, particularly a prayer room (musholla) for patients, is considered important and frequently appears alongside discussions related to the physical aspects of service. the item “there is no prayer area for patients” shows a relatively strong correlation with “the pharmacy is clean and has an attractive appearance” (0.637). this suggests that patients or visitors latifah et al. ghmj (global health management journal) 2025, vol. 8, no. 3 368 associate a complete and clean physical environment, including the availability of a prayer area, as part of a professional and spiritually friendly service. informants stated that “there is no prayer area for patients”, but also mentioned the presence of two large mosques near the pharmacy. the pharmacy provides a prayer room specifically for staff, but not yet for public use. this indicates that there is already an awareness of spiritual needs, but the implementation in terms of physical facilities is not yet comprehensive. a strategically located pharmacy is typically associated with patient accessibility and comfort, including the perception of professionalism. the neat appearance of pharmaceutical staff, in accordance with sharia values (covering the aurat), reflects ethics and an islamic image. this correlation suggests that some patients or visitors may associate easy access with expectations of staff appearance that is both professional and islamic. however, since the correlation value is still low, it may also indicate that these two aspects do not often appear together in patients' perceptions, or that staff appearance is not yet directly seen as a reflection of the overall quality of physical service. “as for a prayer area for patients, we have not provided one yet, because we are located between two large mosques that are more suitable for performing prayers. the available prayer space for staff is combined with the compounding room, as there is some available space there”. (technicians at the educational pharmacy) “for patient restrooms, we direct them to the public toilet, which is also very spacious and clean” (pharmacist at the educational pharmacy). previous studies have shown that the presence of worship facilities, such as a prayer room (musholla) for patients, is considered important and frequently appears in discussions about the physical aspects of service. this aligns with research emphasizing that sharia-based services that address the spiritual needs of patients can enhance their satisfaction and loyalty (broto, 2020). the pharmacy has provided a dedicated prayer room for staff, demonstrating an awareness of the spiritual needs of employees. however, it is necessary to consider providing similar facilities for patients in order to enhance the overall quality of service. other studies have shown that the implementation of sharia principles in service, including the provision of worship facilities, contributes to increased patient satisfaction (alfarizi & arifian, 2023). in general, the pharmacy's application of sharia-based pharmaceutical service standards shows excellent performance in the empathy, dependability, and responsiveness dimensions, where values like empathy, dependability, and organized communication are comparatively well-practiced. staff members handled complaints with a clear division of responsibilities, constant ethical behavior, and attention to patient needs, all of which are in line with sharia principles like rahmah, amanah, and tanzhim. but there were clear flaws in the tangibles and assurance dimensions. patient confidence and the perception of the quality of care could be weakened by staff members' lack of awareness of specialized preparations and their propensity to put speed ahead of friendliness during busy times. most significantly, there is a clear discrepancy between spiritual expectations and the actual infrastructure of services, as evidenced by the lack of a designated prayer area for patients and the inadequate sops pertaining to islamic service etiquette. strong interpersonal service fosters trust and satisfaction, but these institutional and physical support gaps may compromise the service experience's overall professionalism and comprehensive sharia compliance. the interplay between these dimensions implies that without corresponding procedural and physical reinforcement, even robust ethical and communication practices may not be sufficient. theoretical contribution: including islamic moral principles in servqual this study shows how the servqual model can be improved by directly incorporating islamic ethical values into each of its five fundamental dimensions: assurance, responsiveness, empathy, tangibles, and reliability. this would help to match the evaluation of service quality with the moral and spiritual demands of muslim patients. a modified servqual model (sharia-servqual) could be suggested to explicitly incorporate fundamental islamic principles into its measurement framework rather than just interpreting servqual through an islamic lens. in order to ensure that islamic values are not viewed as ancillary interpretations but rather as essential elements of the conceptualization, measurement, and enhancement of service quality, a sharia-servqual model would enable culturally congruent service assessment and development. for islamic healthcare professionals, scholars, and 369 ghmj (global health management journal) 2025, vol. 8, no. 3 latifah et al. legislators seeking to operationalize maqāṣid al-sharī‘ah (the goals of islamic law) in patient care and service design, this adaptation would be especially helpful. the limitation of this study lies in the use of nvivo and pearson correlation analysis between items within the servqual dimensions, which provides an overview of strong thematic relationships but does not indicate causality. therefore, the correlation results need to be further confirmed through a quantitative or mixed-methods approach. since this study examines the integration of sharia values, there is a need to strengthen the evaluation instruments for service standards that are truly sharia-based in a systematic and structured manner, which, to date, are still not widely available or nationally standardize. 5. conclusion by employing the servqual framework to critically assess the application of sharia-based pharmaceutical service standards, this study achieved its goal. strong alignment with islamic values such as trust (amanah), responsibility (mas’uliyyah), honesty (sidq), and compassion (rahmah) was observed in the relatively well-executed dimensions of reliability (r = 0.98), responsiveness (r = 1.00), assurance (r = 0.96), and empathy (r = 0.52). nonetheless, there were clear limitations in the tangibles dimension (r = 0.67), especially because patients lacked access to prayer facilities and there was insufficient structural support for spiritual care. these results suggest that the creation of sops that specifically incorporate islamic ethics, staff training, and the improvement of infrastructure that facilitates worship should be given top priority by policymakers and pharmacy managers. future research should employ a combination of methodologies to confirm these results and investigate the creation of a modified servqual framework, such as sharia-servqual, that includes ethical-spiritual indicators. while moral conduct and interpersonal consideration are evident in practice, the lack of procedural and structural support may impede comprehensive sharia compliance, highlighting the necessity of aligning infrastructure, service systems, and values. conflict of interest we declare no conflicts of interest. references ahsina, k., & zahra, l. f. (2025). the balanced scorecard and hospital performance: a qualitative study using nvivo. international journal of auditing and accounting studies, 7(1), 1-22. https://doi.org/10.47509/ijaas.2025.v07i01.01 alfarizi, m., & arifian, r. (2023). patient satisfaction with indonesian sharia hospital services: halal healthcare tool and implications for loyalty-wom. asian journal of islamic management (ajim), 18-35. https://doi.org/10.20885/ajim.vol5.iss1.art2 arini, h. d., agus, i. w., & kusumayadi, g. (2023). analisis kepuasan pasien terhadap pelayanan kefarmasian di puskesmas ii denpasar selatan. acta holistica pharmaciana, 5(1), 30–41. https://doi.org/10.62857/ahp.v5i1.139 ariyadi, a. (2018). bisnis dalam islam. jurnal hadratul madaniyah, 5(1), 13–26. https://doi.org/10.33084/jhm.v5i1.158 brahmono, a., saragi, s., & andayani, n. (2023). gambaran efektifitas penerapan 5 standar operasional prosedur (sop) pelanggan do pbf bina prima sejati jakarta barat. jurnal riset kefarmasian indonesia, 5(3), 322–355. https://doi.org/10.33759/jrki.v5i3.396 broto, b. e. (2020). analisis pengaruh dimensi kualitas pelayanan terhadap kepuasan pelanggan apotek kimia farma rantauprapat. ecobisma (jurnal ekonomi, bisnis dan manajemen), 7(2), 95–108. https://doi.org/10.36987/ecobi.v7i2.1764 dusuki, a. w., & abdullah, n. i. (2024). maqasid al-shariah, maslahah, and corporate social responsibility (2007). american journal of islam and society, 41(1), 10–35. https://doi.org/10.35632/ajis.v41i1.3417 fathnin, f. h., sunandari, a. s., & mumpuni, w. d. (2023). kepuasan konsumen terhadap kualitas pelayanan di apotek karunia sehat baru berdasarkan nilai-nilai syariah. indonesian journal of medical and pharmaceutical science, 2(1), 12–20. https://doi.org/10.47509/ijaas.2025.v07i01.01 https://doi.org/10.20885/ajim.vol5.iss1.art2 https://doi.org/10.62857/ahp.v5i1.139 https://doi.org/10.33084/jhm.v5i1.158 https://doi.org/10.33759/jrki.v5i3.396 https://doi.org/10.36987/ecobi.v7i2.1764 https://doi.org/10.35632/ajis.v41i1.3417 latifah et al. ghmj (global health management journal) 2025, vol. 8, no. 3 370 hervina, harahap, j., & syamsul, d. (2019). analisis kepuasan pasien kulit kelamin terhadap pelayanan farmasi di rsud dr.rm.djoelham. jumantik (jurnal ilmiah penelitian kesehatan), 4(2), 190–198. https://doi.org/10.30829/jumantik.v4i2.5629 hidayatullah, m. f., & aesthetika, n. m. (2024). pengelolaan keluhan pelanggan yang efektif di industri farmasi. manajemen pelayanan kesehatan, 1(1), 1–13. https://doi.org/10.47134/mpk.v1i1.2632 iriyanti, m., & yusran, m. (2021). hubungan mutu pelayanan kefarmasian dengan kepuasan pasien rawat jalan di puskesmas bebesen kabupaten aceh tengah. serambi saintia (jurnal sains dan aplikasi), 10(1), 49–55. https://doi.org/10.51556/ejpazih.v10i2.158 juwita, a. d., qalbi desri, n., & permatasari, d. (2023). patient satisfaction with pharmaceutical services at a hospital outpatient pharmacy in west sumatra, indonesia. jurnal farmasi dan ilmu kefarmasian indonesia, 10(3), 324–330. https://doi.org/10.20473/jfiki.v10i32023.324-330 kemenkes ri. (2016). peraturan menteri kesehatan republik indonesia nomor 73 tahun 2016 tentang standar pelayanan kefarmasian di apotek. in kementerian kesehatan ri. noor, n. (2025). halal service quality: systematic review, conceptual model and future research. journal of islamic accounting and business research. https://doi.org/10.1108/jiabr-06-2024-0211 nurhasan, a. (2020). pengaruh pelayanan kefarmasian terhadap kepuasan pasien di ruang farmasi klinik daqu sehat malang menggunakan parameter karakteristik pelayanan islami. doctoral dissertation, universitas islam negeri maulana malik ibrahim. http://etheses.uin-malang.ac.id/22430/2/15670028.pdf parmata, u. m. d., b., sankara, r. b., & rajashekhar, b. (2016). measuring service quality in pharmaceutical supply chain – distributor’s perspective. international journal of pharmaceutical and healthcare marketing, 10(3), 258–284. https://doi.org/10.1108/ijphm-07-2015-0035 pazri, l., pramestyani, e., & dewi, m. (2023). tingkat kepuasan pasien terhadap pelayanan farmasi di apotek simpang purwakarta. cakrawala medika: journal of health sciences, 2(1), 133–138. https://doi.org/10.59981/kwtvm250 rahayuningsih, l., & cahyaningrum, n. (2023). pengaruh sikap empati tenaga kesehatan terhadap kepuasan pasien: meta analisis. infokes: jurnal ilmiah rekam medis dan informatika kesehatan, 13(2), 122–127. https://doi.org/10.47701/infokes.v13i2.3130 rizki, i. f., hardiyanti, a. m., & rismayanti, r. (2025). the impact of sharia value-based service quality at karya sehat pharmacy purwokerto on consumer satisfaction. journal of pharmaceutical and sciences, 402–411. https://doi.org/10.36490/journal-jps.com.v8i1.618 smit, b., & onwuegbuzie, a. (2018). observations in qualitative inquiry: when what you see is not what you see. international journal of qualitative methods, 17(1). https://doi.org/10.1177/1609406918816766 sunarto, i. n., sabilu, y., & yuniar, n. (2025). the influence of workload, work stress, work motivation and organizational commitment on nurse performance in the intensive room at bahteramas regional hospital, southeast sulawesi province in 2023. world journal of advanced research and reviews, 25(1), 1165–1175. zulfitri, sagitasari, y., & hussana, a. (2024). evaluasi sistem penyimpanan sediaan farmasi berdasarkan standar pelayanan kefarmasian rumah sakit dan syariat islam di rsi sultan agung semarang. indonesian journal of pharmacy and natural product, 7(1), 91–100. https://doi.org/10.35473/ijpnp.v7i01.2301 cite this article as: latifah, e., pribadi, p., lutfiyati, h., & bunga, c. d. (2025). evaluation of the implementation of shariabased pharmaceutical service standards (a qualitative case study). ghmj (global health management journal), 8(3), 352–370. https://doi.org/10.35898/ghmj-831265 https://doi.org/10.30829/jumantik.v4i2.5629 https://doi.org/10.47134/mpk.v1i1.2632 https://doi.org/10.51556/ejpazih.v10i2.158 https://doi.org/10.20473/jfiki.v10i32023.324-330 https://doi.org/10.1108/jiabr-06-2024-0211 http://etheses.uin-malang.ac.id/22430/2/15670028.pdf https://doi.org/10.1108/ijphm-07-2015-0035 https://doi.org/10.59981/kwtvm250 https://doi.org/10.47701/infokes.v13i2.3130 https://doi.org/10.36490/journal-jps.com.v8i1.618 https://doi.org/10.1177/1609406918816766 https://doi.org/10.35473/ijpnp.v7i01.2301 https://doi.org/10.35898/ghmj-831265 template ghmj 2024 ghmj (global health management journal) 2025, vol. 8, no. 3 indonesian scholars’ alliance open access perspectives beyond tradition: time to reform peer review ahmed a. mosa1,* , jodi ramadhan haji2 , ameen m. mohammad2 1. college of medicine, university of zakho, zakho, kurdistan region, iraq (12); 2. college of medicine, university of duhok, duhok, kurdistan region, iraq (1006 aj). *corresponding author’s e-mail: ehmad.a.mosa@gmail.com doi: 10.35898/ghmj-831264 abstract peer review is a cornerstone of research practice and scientific publishing, serving as a bridge between new proven science and presumably false scientific findings. however, the process often experiences delays, inconsistencies, biases, and deficiencies in the availability of qualified reviewers, so consequently fails to meet the needs of both the authors and the journals. this perspective outlines core challenges associated with peer review and proposes recommendations to enhance the efficacy of the process and improve the overall quality of reviews. recommendations include providing different types of incentives to reviewers, developing a structured and guidelines-based reviewing system, and greater rigor over reviewer selection. additionally, the incorporation of artificial intelligence now needs to be considered. keywords: peer review; guidelines; artificial intelligence; journals; open access. received: 20 july 2025 reviewed: 29 july 2025 revised: 02 september 2025 accepted: 11 november 2025. © 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) perspectives peer review is a process in which original papers are evaluated by reviewers to assess the scientific and technical quality of the paper (ali & watson, 2016). although its roots can be traced back to the royal society in london as early as 1665, the modern form of the peer review system emerged in the mid-1970s (ali & watson, 2016; walbot, 2009). the peer review process has received widespread support since it serves as a way to distinguish between new proven science and potentially erroneous scientific reporting. despite its significance, there are several shortcomings surrounding this process that may compromise its integrity and cause potential delays in the submission process. to date, some publishers have implemented initiatives to establish a more structured and efficient peer review system; however, the desired outcomes have not yet been achieved (candal-pedreira et al., 2023). this perspective presents key challenges associated with the peer review process and suggests recommendations for improvement. peer review is often a lengthy, inconsistent, and sometimes unfair process that requires very competent individuals in their field of specialization to adequately evaluate a paper within their field. however, many of these individuals devote limited time and attention to the review process because of their personal and professional obligations, as well as contributing their time with no compensation. in turn, the publication and review process of a manuscript can be significantly disrupted, putting an additional burden on the authors, editors, journals, and publishers (drozdz & ladomery, 2024). moreover, the peer review is inherently subjective. as a result, it is vital to appoint reviewers who have experience in relevant fields and are interested in the topic. lack of interest in the subject or restricted availability of spare time may result in impaired judgment and poor decision making, potentially mailto:ehmad.a.mosa@gmail.com https://doi.org/10.35898/ghmj-831264 https://orcid.org/0000-0003-1985-6995 https://orcid.org/0009-0003-7020-0649 https://orcid.org/0000-0001-9093-2319 413 ghmj (global health management journal) 2025, vol. 8, no. 3 mosa et. al. overlooking the quality and novelty of the paper (marcoci et al., 2022). establishing a well-organized and structured peer review system will offer mutual benefits to all parties involved in this process (authors, reviewers, journals, publishers, and the broader scientific community). a good reviewer should provide constructive feedback to the authors as well as the journal editor; where necessary, authors also benefit from reviewers’ comments that show them how their paper can be improved. where a paper is rejected, it is also helpful if the publisher is able to offer to transfer the manuscript, along with reviewers' comments, to another journal within the same publishing group. a competent, objective, and equitable evaluation and review of research is a key obligation of publishing journals and a duty that editors owe to the scientific community and society. however, due to the vast amount of scientific manuscripts being written nowadays and the overwhelming need for a very large number of qualified reviewers, we need to take several steps in order to make the review process more effective and improve overall review quality (hanson et al., 2024; mosa et al., 2023). some publishers have begun to adopt a more flexible system that offers incentives to reviewers, with the aim of encouraging greater participation in reviewing activities. also, since most publishers charge the authors article processing charges (apcs), a portion of these fees can be allocated to provide a symbolic cash reward to reviewers for each research paper reviewed. in addition, the journals might establish a scoring system to provide scores to reviewers depending on the integrity and timeliness of their evaluation. subsequently, based on these scores, the reviewers may be eligible for benefits, such as apc discounts and fast-track consideration for their submitted papers. furthermore, publishers and journals should provide clear guidelines for reviewers by obligating them to respond to different questions regarding different aspects of the paper raised by the journal editor, and indicating whether each aspect is adequately discussed or not, and if not, whether improvements are possible and how the authors can make such improvements. this approach will encourage authors to submit more complete manuscripts, and reviewers will know what to critique and provide feedback on it (drozdz & ladomery, 2024). given current advancements, the integration of artificial intelligence (ai) into the peer review process represents a viable option. research has shown the efficacy of ai in peer review and demonstrated good agreement between ai evaluations and human reviewers (liang et al., 2024; biswas et al., 2023). the ai can aid journal editors in assessing submitted manuscripts prior to peer review by determining eligibility for review, adherence to journal and reporting standards, and identifying data fabrication. it can also assist in alleviating biases associated with authors and their affiliations (bauchner & rivara, 2024; nashwan & ahmed, 2025). in summary, while peer review is an essential component of scientific practice, it faces challenges that interfere with its efficiency and fairness, which must be addressed. bias, subjectivity, and limited time availability cause delays and inconsistencies. the peer review process needs to be thoroughly examined to achieve optimal effectiveness. improving this process will lead to better outcomes for all parties involved in this process. conflict of interest there is no conflict of interest. references ali, p. a., & watson, r. (2016). peer review and the publication process. nursing open, 3(4), 193-202. https://doi.org/10.1002/nop2.51 bauchner, h., & rivara, f. p. (2024). use of artificial intelligence and the future of peer review. health affairs scholar, 2(5), qxae058. https://doi.org/10.1093/haschl/qxae058 biswas, s., dobaria, d., & cohen, h. l. (2023). chatgpt and the future of journal reviews: a feasibility study. the yale journal of biology and medicine, 96(3), 415. https://doi.org/10.59249/skdh9286 https://doi.org/10.1002/nop2.51 https://doi.org/10.1093/haschl/qxae058 https://doi.org/10.59249/skdh9286 mosa et. al. ghmj (global health management journal) 2025, vol. 8, no. 3 414 candal-pedreira, c., rey-brandariz, j., varela-lema, l., pérez-ríos, m., & ruano-ravina, a. (2023). challenges in peer review: how to guarantee the quality and transparency of the editorial process in scientific journals. anales de pediatría (english edition), 99(1), 54-59. https://doi.org/10.1016/j.anpede.2023.05.006 drozdz, j. a., & ladomery, m. r. (2024). the peer review process: past, present, and future. british journal of biomedical science, 81, 12054. https://doi.org/10.3389/bjbs.2024.12054 hanson, m. a., barreiro, p. g., crosetto, p., & brockington, d. (2024). the strain on scientific publishing. quantitative science studies, 5(4), 823-843. https://doi.org/10.1162/qss_a_00327 liang, w., zhang, y., cao, h., wang, b., ding, d. y., yang, x., vodrahalli, k., he, s., smith, d.s., yin, y., mcfarland, d.a., & zou, j. (2024). can large language models provide useful feedback on research papers? a large-scale empirical analysis. nejm ai, 1(8), aioa2400196. https://doi.org/10.1056/aioa2400196 marcoci, a., vercammen, a., bush, m., hamilton, d. g., hanea, a., hemming, v., wintle, b.c., burgman, m., & fidler, f. (2022). reimagining peer review as an expert elicitation process. bmc research notes, 15(1), 1-7. https://doi.org/10.1186/s13104-022-06016-0 mosa, a. a., mahmood, a. j., farooq, k. f., haji, j. r., jacksi, d., mohamed-saqid, d. k., & mnasakan, t. r. (2024). medical students’ knowledge, attitude, practice, and perceived barriers towards medical research: a crosssectional study. galician medical journal, 31(1), 1-7. https://doi.org/10.21802/e-gmj2023-a09 nashwan, a. j., & ahmed, s. k. (2025). from rejection to redirection: reimagining the culture of academic publishing. research evaluation, 34, rvaf025. https://doi.org/10.1093/reseval/rvaf025 walbot, v. (2009). are we training pit bulls to review our manuscripts?. journal of biology, 8(3), 24. https://doi.org/10.1186/jbiol125 cite this article as: mosa, a. a., haji, j. r., & mohammad, a. m. (2025). beyond tradition: time to reform peer review. ghmj (global health management journal), 8(3), 412–414. https://doi.org/10.35898/ghmj-831264 https://doi.org/10.1016/j.anpede.2023.05.006 https://doi.org/10.3389/bjbs.2024.12054 https://doi.org/10.1162/qss_a_00327 https://doi.org/10.1056/aioa2400196 https://doi.org/10.1186/s13104-022-06016-0 https://doi.org/10.21802/e-gmj2023-a09 https://doi.org/10.1093/reseval/rvaf025 https://doi.org/10.1186/jbiol125 https://doi.org/10.35898/ghmj-831264 template ghmj 2024 ghmj (global health management journal) 2025, vol. 8, no.3 indonesian scholars’ alliance open access review toxic inequities: the global health burden of pesticide exports to lowand middle-income countries steven shin1* , haejin jung2 1. department of chemistry, university of wisconsin-madison, wisconsin, us, 53706; 2. college of nursing, sungshin women’s university, seoul, republic of korea, 02844. *corresponding author’s e-mail: sshin99@wisc.edu doi: 10.35898/ghmj-831263 abstract background: the continued export of banned pesticides from high-income countries (hics) to lowand middle-income countries (lmics) remains a critical yet under-addressed global health issue. these hazardous chemicals are legally shipped to nations with weaker regulatory frameworks. as a result, workers and communities in lmics face disproportionate exposure to toxic substances that contribute to acute poisoning, developmental disorders, and chronic disease. aims: this paper examines the international trade of banned pesticides through view of global health equity and frames these practices as a form of structural violence that endangers lmic populations and violates the right to health. methods: this qualitative study uses document and policy analysis of international trade records, legal frameworks, and public health literature. it outlines the legal mechanisms and policy gaps, such as the weaknesses of the rotterdam convention and the permissiveness of export laws in the eu, u.s., and switzerland that enable the ongoing flow of hazardous substances. results: pulling on case studies, epidemiological evidence, and international human rights frameworks, the paper investigates the health impacts of pesticide exposure and highlights the ethical failures related to current trade practices. conclusion: our synthesis foregrounds the research gap and advances a rights-based, structuralviolence framing that clarifies the policy mandate. we suggest aligning export bans with domestic prohibitions, strengthening rotterdam prior-informed-consent and enforcement, and financing transitions to ipm, biopesticides, and agroecology in lmic supply chains. keywords: banned pesticides; export regulation; lmics; structural violence; rotterdam convention. received: 18 july 2025 reviewed: 17 august 2025 revised: 7 september 2025 accepted: 03 october 2025. © 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:sshin99@wisc.edu https://doi.org/10.35898/ghmj-831263 https://orcid.org/0009-0001-9340-4690 https://orcid.org/0009-0008-0801-4868 337 ghmj (global health management journal) 2025, vol. 8, no. 3 shin & jung 1. introduction many pesticides that cause cancer, poisoning, nerve damage, and birth defects are banned in high-income countries. but companies in these countries still send them to lowand middle-income countries. the world bank says about 30% of farm workers in these areas are poisoned by pesticides each year. this leads to around 200,000 deaths annually (world bank group, 2018). this problem is worse because of unfair trade rules. countries like the u.s., switzerland, and those in the eu ban these pesticides at home but still let companies export them abroad. from 2015 to 2019, more than 81% of pesticides banned in the u.s. were shipped to lower-income countries (donley, 2024). figure 1. exports of banned eu pesticides (2022): top recipient countries by volume made by author using pan europe, 2024. the european union reflects this same pattern. a 2024 investigation by pan europe found that eu-banned pesticides were shipped to over 80 countries, with the top five importers being lmics (pan europe, 2024). these exports are maintained by loopholes in international trade law and weak enforcement of global agreements. this includes the rotterdam convention and asymmetric power relations that favor exporting nations. as a result, the global pesticide economy functions as a one-way flow of risk. chemicals considered too dangerous for use in hics are sent to lmics and threaten public health and the environment. this study aims to examine how current legal frameworks, trade policies, and governance gaps enable the export of banned pesticides from hics to lmics, and to analyze their health and ethical implications through the lens of global health equity. while prior reports and advocacy documents have described pesticide-related harms in lmics, few academic studies have explicitly linked these outcomes to the structural features of global trade and legal regimes, particularly using a human rights and structural violence framework. this study addresses that gap. the paper focuses on pesticide-related health outcomes, international trade practices, and ethical frameworks, structured into sections that present the methods, results, discussion, and proposed solutions. this paper argues that the export of banned pesticides constitutes structural violence. by analyzing this issue through the view of global health equity, the paper examines pesticide-related health outcomes in lmics. this criticizes the legal systems that enable this imbalance and discusses alternative models that could mitigate harm. through this analysis, the study contributes to ethical reform in international agricultural practices. the risk is especially high in lowand middle-income countries. health systems in these areas are underfunded, and worker protections are weak. farmers and other laborers often use toxic pesticides without safety gear or training. this puts them in constant danger. studies from west africa and south asia show that many farm workers suffer from skin rashes, breathing problems, nerve damage, and liver disease (handford et al., 2015). shin & jung ghmj (global health management journal) 2025, vol. 8, no. 3 338 the harm doesn’t stop with the workers. pesticides often end up in water sources used for drinking and cooking. over time, these chemicals build up in people’s bodies. this leads to more cancer, hormone problems, and birth issues. these chemicals stay in the soil and water for years and cause long-term damage, especially in areas already struggling with poor health care. few syntheses connect hic export of domestically banned active ingredients to structural violence and states’ human-rights obligations in lmics. this paper bridges the gap by mapping export pathways, regulatory asymmetries, and health outcomes across jurisdictions. 2. methods study design and data sources this study uses a qualitative approach to explore how pesticide exports from high-income countries (hics) affect health in lowand middle-income countries (lmics). especially, it uses document and policy analysis of international trade records, legal frameworks, and public health literature. the study focuses on published research, trade records, laws, and global agreements to look at health risks, legal gaps, and ethical concerns. operational definitions “banned pesticide” means an active ingredient prohibited for domestic use by a national authority, regardless of export permissions. “lmics” follow the world bank’s current classification for the study period. search strategy search strategy included journal articles from pubmed and scopus and reports from the world health organization (who), the food and agriculture organization (fao), and the world bank. search terms were “banned pesticide exports,” “pesticide trade lmic,” “structural violence pesticides,” and “pesticide health impacts" publications from 2000 to 2024. eligibility criteria inclusion criteria were studies or reports addressing pesticide exports from hics to lmics, sources containing information on health outcomes, legal frameworks, or policy analysis, english-language publications, and publicly available documents. exclusion criteria included studies without clear relevance to pesticide exports, laboratorybased toxicology studies without trade or policy context, and duplicate records. thematic content analysis sources were analyzed using thematic content analysis. contents were from global health equity, environmental justice, and structural violence. this process involved coding material for recurring themes related to trade mechanisms, health impacts, and ethical implications. rationale for qualitative/document-based approach a qualitative and document-based method was chosen because it allows investigation of both legal and health dimensions across multiple contexts without the resource and ethical constraints. limitations limitations are reliance on secondary/public sources, which may omit underreported pesticide-related harms in lmics. the absence of fieldwork interviews also means the analysis depends on the accuracy and completeness of existing records. findings may reflect publication bias toward better-documented events and english-language sources, which can underrepresent some regions. ethical considerations this study analyzed publicly available sources only. no human or animal participants were involved, and formal ethics approval was not required. because the research only uses public sources and does not involve people or animals, no ethics approval was needed. 339 ghmj (global health management journal) 2025, vol. 8, no. 3 shin & jung 3. results from 2000 to 2024, exports of domestically banned active ingredients from hics to lmics persist. paraquat, chlorpyrifos, and atrazine are the most frequently observed in trade flows linked to acute poisoning clusters and chronic exposure risks. in 2024 alone, u.s. pesticide exports totaled $4.83 billion, with most value shipped to lmics. medical consequences of pesticide exposure in lmics in many lowand middle-income countries, pesticide exposure causes more than just short-term poisoning. the chemicals used are often highly toxic and tied to serious health problems. these include problems with fertility, brain development, chronic illness, and early death. the danger grows when workers don’t have proper gear, medical systems are weak, and doctors aren’t trained to spot pesticide-related illness. chlorpyrifos is still exported to lmics, even though it’s banned in many places. it’s known to harm children’s brain development. studies show that babies exposed before birth can have lower iq, memory problems, and more behavior issues (rauh et al., 2006). paraquat is also widely sold. it’s deadly if swallowed or breathed in. it can scar the lungs, shut down the kidneys, and there’s no treatment. over time, it’s been linked to higher rates of parkinson’s disease, especially in male farm workers (tanner et al., 2011). other chemicals, like atrazine and ddt, affect hormones. atrazine has been tied to delayed puberty, lower sperm count, and birth defects (hayes et al., 2010). ddt is banned in most rich countries but still used in some places to control mosquitoes. it has been linked to higher breast cancer risk in women (cohn et al., 2007). ongoing exposure to pesticides is also linked to cancer, liver problems, and autoimmune disease. in many lmics, doctors may miss the link because records are poor and testing is too expensive. many health workers are not trained to recognize pesticide-related illnesses (london et al., 2012). women and children face more risk than others. in farming communities, women often handle treated crops without protective gear or training (jaga & dharmani, 2003). children are at even greater risk because of their size and developing bodies. a study in rural brazil found more cases of developmental delays in children living near pesticide-treated fields (panis et al., 2022). figure 2. health effects reported by pesticide class in brazilian epidemiological studies. made by author using data source: panis et al., 2022. the health impacts of pesticide exposure vary depending on chemical class. organochlorines, although widely banned, persist in the environment and are strongly associated with cancer and birth defects. carbamates are also responsible for serious acute and chronic health effects in agricultural settings. the brazilian systematic review illustrates how multiple classes of pesticides contribute to overlapping, serious health outcomes in lmic populations (panis et al., 2022). shin & jung ghmj (global health management journal) 2025, vol. 8, no. 3 340 these findings show observable health effects across multiple regions and pesticide classes. they are drawn directly from documented studies and reports and interpreted as evidence of systemic policy failure and global inequity. in short, the medical harms of pesticide exposure in lmics are systemic outcomes of policy failures and global indifference. these effects are not unfortunate side effects of agricultural development. they are foreseeable consequences of unequal global governance. any evaluation of pesticide trade must centre lived realities of those facing direct, often unrecognized, harm. beyond brazil and west africa/south asia, additional documented cases reveal similar patterns of harm. in sri lanka, pesticide self-poisoning remains a leading cause of acute poisoning in rural areas, with incidence rates reaching 447 cases per 100,000 people annually. in ghana, surveillance of food markets found that 26.5% of vegetables exceeded european union maximum residue limits for pesticides (bempah et al., 2012). these findings highlight that the health risks associated with banned pesticide exports are widespread and an ongoing threat to public health in multiple lmic contexts. evidence of double standards in trade although hics have enforced strict bans on many hazardous pesticides for domestic use, the same chemicals are exported to lmics. for example, the eu reduced pesticide risks through the ‘farm to fork’ strategy. this aims to cut pesticide use by 50 percent and increase organic farming to 25 percent of total agricultural land by 2030 (european commission, 2020). however, this progressive plan is sabotaged by an export policy that permits the international trade of prohibited pesticides. a 2020 investigation by greenpeace revealed that in just one year, eu countries exported over 81,000 metric tons of chemicals banned for domestic use due to their severe toxicity (dowler, 2020). this includes paraquat, atrazine, and chlorpyrifos. these exported pesticides often end up in lmics, where agricultural labor has less oversight. for instance, in brazil, more than a dozen pesticide formulations containing banned substances in the eu were imported and used between 2019 and 2020. these included bayer’s propineb, associated with reproductive harm, and ascenza agro’s chlorpyrifos, associated with neurodevelopmental disorders in children (pan europe, 2024). current regulations require prior informed consent from importing countries, but they still allow the export of substances banned domestically so long as procedural requirements are met (european parliament, 2012). the united states exhibits a similar regulatory contradiction. under the federal insecticide, fungicide, and rodenticide act, pesticide companies are allowed to manufacture and export products that are not approved in the u.s. (u.s. environmental protection agency epa, 2024). this means that u.s. manufacturers can legally ship neurotoxicants like 1, 3-dichloropropene to latin american countries. these chemicals are frequently used in banana, tobacco, and soybean plantations, where laborers work with limited protective equipment and minimal access to healthcare (donley, 2024). figure 3. top u.s. pesticide export destinations (2024); lmics highlighted. made by author using observatory of economic complexity, 2025. 341 ghmj (global health management journal) 2025, vol. 8, no. 3 shin & jung in 2024, u.s. pesticide exports totaled $4.83 billion, with more than 50 percent destined for lmics. these included brazil ($1.11b), mexico ($532m), and india ($158m). even countries with less environmental oversight received substantial volumes. canada ($1.57b) was the only high-income country with a larger import volume than low-income countries. this underscores an imbalance. while the u.s. preserves domestic pesticide safety, it contributes to the international circulation of harmful chemicals in vulnerable settings (oec, 2025). the data above are primarily qualitative and descriptive. however, integrating quantitative indicators could further illustrate the persistence and scale of these double standards. 4. discussion policy gaps and failures toxic pesticides are known to cause serious harm. still, current laws do not protect the people most exposed. many rules are shaped by politics, not health. even when laws exist, they are often not enforced. the rotterdam convention is one of the main global rules on pesticide trade. it says that exporters must get permission before sending certain dangerous chemicals to another country. this sounds protective in theory. but the treaty only lists a few chemicals. countries that make and sell pesticides often block efforts to expand the list. even when a chemical is on the list, it can still be sold. the treaty does not ban trade. it only asks for paperwork and approval from the importing country. this creates a gap. companies can keep selling banned pesticides with little oversight. many lowand middle-income countries do not have enough staff, money, or training to review the risks or block the imports (handford et al., 2015). these problems show up in national laws too. in the european union, certain pesticides are banned for local use. but companies can still export those same pesticides to other countries with weaker rules (european parliament, 2012). switzerland does something similar. switzerland restricts several toxic pesticides inside the country. still, firms like syngenta export harmful ones, including atrazine and paraquat, to other nations. in 2020, the government blocked the export of five such chemicals, but many others were not included (public eye, 2020). these laws focus more on permission than on safety. they hide the deeper problems with how pesticide trade is managed. without stronger global rules and real enforcement, these exports will keep putting people at risk. a brief comparative analysis shows that the eu, u.s., and switzerland all maintain domestic bans on specific hazardous pesticides, but their export regulations differ in scope. the eu allows export under prior informed consent procedures, the u.s. permits export of unregistered pesticides with minimal restrictions, and switzerland applies partial bans covering only select chemicals. these differences create uneven global governance and opportunities for regulatory evasion. global health inequity framing the export of hazardous pesticides from hics to lmics is not just a matter of policy inconsistency. it represents a global health injustice embedded in power imbalances. the exposure has the greatest impact on low-income and politically marginalized communities. these countries often lack the tools, environmental safeguards, or adequate healthcare. one useful concept related to this injustice is structural violence. structural violence means the systematic ways in which social, economic, and political arrangements harm communities by limiting access to resources or protections essential for health and survival (farmer, 2004). in the context of pesticide exports, structural violence shows when laborers in lmics are exposed to chemicals considered too dangerous for domestic use in hics. they lack protective gear and regulatory safeguards. the right to health further emphasizes the inequity embedded in these trade practices. article 12 of the international covenant on economic, social, and cultural rights declares that every person is allowed to ‘the highest attainable standard of physical and mental health’ (united nations general assembly, 1966). this foundational right is disregarded when toxic substances are exported to nations without safe handling. the persistent disconnect between legal rights and life conditions illustrate a deeper failure in global health governance. shin & jung ghmj (global health management journal) 2025, vol. 8, no. 3 342 structural violence extends this framing to trade agreements. it operates through national export policies and multilateral systems that limit a country’s ability to restrict imports for health reasons. industry owners argue that pesticide exports support agricultural productivity and economic development. however, these justifications overlook the disproportionate health burdens and long-term environmental damage. these counterarguments directly strengthen the ethical case for reform. moral and political responsibility of pesticides challenges policymakers, corporations, and multilateral institutions to consider what is legally permitted and ethically defensible. this framing echoes broader decolonial critiques in global health and calls for the dismantling of exploitative systems. proposed solutions and alternatives fixing the global pesticide problem takes more than small technical changes. we need to consider how policies treat health, fairness, and the environment. turning to agroecology is one way to cut back on toxic pesticide use. policy change can also close legal gaps that let these exports continue. one of the most direct steps is to ban the export of banned pesticides. in 2020, france passed a law to stop this kind of export. the decision came after strong public pressure and concern about double standards (pan europe, 2024). switzerland followed with a smaller ban on five of the most toxic chemicals. these cases show that change is possible when there is political will. but most exporters still allow sales of pesticides they will not use themselves. making france’s rule a global standard would help bring fairness and accountability. policy reform is not enough. we must also change how food is grown. one option is integrated pest management (ipm). this mixes natural and mechanical ways to manage pests and uses pesticides only when needed. it includes crop rotation, pest tracking, and insects that eat harmful bugs. research shows ipm can cut pesticide use by up to 90% without lowering crop yields. in some cases, yields even improve (pretty & bharucha, 2015). biopesticides are another safer option. they come from nature—bacteria, minerals, or plant oils. examples include bacillus thuringiensis, neem oil, and pyrethrin. these break down fast and are less harmful to people and nature (pan europe, 2024). still, use remains low. many areas lack money, public support, and local production. more funding and local factories are needed to make biopesticides easier to access. agroecology offers a full-system shift. it uses compost, mixed planting, and better soil care to manage pests and grow strong crops. examples from cuba, senegal, and sikkim show that this kind of farming can succeed when backed by policy, training, and market access (copping & menn, 2000). to sum up, ending banned pesticide exports is important, but not enough. a real solution also needs better global laws, safer pest control, and strong support for farmers. we can break the cycle of toxic farming and health inequality only by acting on all of these aspects. 5. conclusion banned-pesticide exports from hics to lmics perpetuate preventable, inequitable harm. trade, regulatory, and health evidence show how current practices conflict with states’ duties to protect health. this study found that these exports are enabled by legal loopholes in international agreements, permissive export policies in the eu, u.s., and switzerland, and insufficient enforcement capacity in importing countries. case studies from brazil, sri lanka, ghana, west africa, and south asia demonstrate consistent patterns of disproportionate health burdens and environmental contamination. this is not just about a few legal gaps. it is part of how global pesticide trade works. weak rules, like the rotterdam convention, and loose national laws allow this trade to go on. market pressure also plays a big role. health and ethics are often ignored. the result is the same: poisonings, chronic disease, and a growing divide in global health. these outcomes are not accidents. they are the result of policies that put profit first. this paper has offered real ways to fix the problem. examples of policy recommendations are adopting national bans on the export of prohibited pesticides, expanding global enforcement mechanisms under multilateral agreements, and strengthening monitoring systems to track and penalize violations. international agencies such as the who and fao should play a central role in coordinating these efforts and supporting lmic governments. 343 ghmj (global health management journal) 2025, vol. 8, no. 3 shin & jung national bans like the one in france, stronger global enforcement, and better accountability are all possible. we also already have working solutions in farming. ipm, biopesticides, and agroecology can reduce toxic use without lowering crop yield. some even raise it. but these options are not supported enough. the problem is not technology; it is lack of political will and industry pushback. as rachel carson warned decades ago, it is not right to see the harm and do nothing. urgent and coordinated reform can solve double standards in pesticide trade and protect both public health and the environment. silence in the face of related illness and death must end. we need fair policies, funding for safe alternatives, and a strong global push for justice. to fix the toxic imbalance in farming, we must face the ethics of trade, the failure of law, and the unequal burden of risk. real global health must deal with all of this. conflict of interest the author declares no competing interests. references bempah, c. k., donkor, a. k., yeboah, p. o., dubey, b., & osei-fosu, p. (2012). a preliminary assessment of consumer’s exposure to organochlorine pesticides in fruits and vegetables and the potential health risk in accra metropolis, ghana. food and chemical toxicology, 50(11), 3601–3607. https://doi.org/10.1016/j.fct.2012.07.038 cohn, b. a., wolff, m. s., cirillo, p. m., & sholtz, r. i. (2007). ddt and breast cancer in young women: new data on the significance of age at exposure. environmental health perspectives, 115(10), 1406–1414. https://doi.org/10.1289/ehp.10260 copping, l. g., & menn, j. j. (2000). biopesticides: a review of their action, applications and efficacy. pest management science, 56(8), 651–676. https://doi.org/10.1002/1526-4998(200008)56:8<651::aidps201>3.0.co;2-u donley, n. (2024, january 18). us pesticide regulation is failing the hardest-hit communities: it’s time to fix it. brookings. https://www.brookings.edu/articles/us-pesticide-regulation-is-failing-the-hardest-hit-communitiesits-time-to-fix-it/ dowler, c. (2020, september 9). thousands of tonnes of banned pesticides shipped to poorer countries from british and european factories. greenpeace unearthed. https://unearthed.greenpeace.org/2020/09/10/bannedpesticides-eu-export-poor-countries/ u.s. environmental protection agency. (2024). summary of the federal insecticide, fungicide, and rodenticide act. https://www.epa.gov/laws-regulations/summary-federal-insecticide-fungicide-and-rodenticide-act european commission. (2020). farm to fork strategy: for a fair, healthy and environmentally-friendly food system. https://food.ec.europa.eu/horizontal-topics/farm-fork-strategy_en european parliament. (2012). regulation (eu) no 649/2012 concerning the export and import of hazardous chemicals. https://eur-lex.europa.eu/legal-content/en/txt/?uri=celex:32012r0649 farmer, p. (2004). an anthropology of structural violence. current anthropology, 45(3), 305–325. https://doi.org/10.1086/382250 handford, c. e., elliott, c. t., & campbell, k. (2015). a review of the global pesticide legislation and the scale of challenge in reaching the global harmonization of food safety standards. integrated environmental assessment and management, 11(4), 525–536. https://doi.org/10.1002/ieam.1635 hayes, t. b., khoury, v., narayan, a., nazir, m., park, a., brown, t., ... & gallipeau, s. (2010). atrazine induces complete feminization and chemical castration in male african clawed frogs (xenopus laevis). proceedings of the national academy of sciences, 107(10), 4612–4617. https://doi.org/10.1073/pnas.0909519107 jaga, k., & dharmani, c. (2003). global surveillance of ddt and dde levels in human tissues. international journal of occupational medicine and environmental health, 16(1), 7–20. london, l., beseler, c., bouchard, m. f., bellinger, d. c., colosio, c., grandjean, p., ... & stallones, l. (2012). neurobehavioral and neurodevelopmental effects of pesticide exposures. neurotoxicology, 33(4), 887–896. https://doi.org/10.1016/j.neuro.2012.01.005 https://doi.org/10.1016/j.fct.2012.07.038 https://doi.org/10.1289/ehp.10260 https://doi.org/10.1002/1526-4998(200008)56:8%3c651::aid-ps201%3e3.0.co;2-u https://doi.org/10.1002/1526-4998(200008)56:8%3c651::aid-ps201%3e3.0.co;2-u https://www.brookings.edu/articles/us-pesticide-regulation-is-failing-the-hardest-hit-communities-its-time-to-fix-it/ https://www.brookings.edu/articles/us-pesticide-regulation-is-failing-the-hardest-hit-communities-its-time-to-fix-it/ https://unearthed.greenpeace.org/2020/09/10/banned-pesticides-eu-export-poor-countries/ https://unearthed.greenpeace.org/2020/09/10/banned-pesticides-eu-export-poor-countries/ https://www.epa.gov/laws-regulations/summary-federal-insecticide-fungicide-and-rodenticide-act https://food.ec.europa.eu/horizontal-topics/farm-fork-strategy_en https://eur-lex.europa.eu/legal-content/en/txt/?uri=celex:32012r0649 https://doi.org/10.1086/382250 https://doi.org/10.1002/ieam.1635 https://doi.org/10.1073/pnas.0909519107 https://doi.org/10.1016/j.neuro.2012.01.005 shin & jung ghmj (global health management journal) 2025, vol. 8, no. 3 344 observatory of economic complexity. (2025). pesticides in united states (hs4 3808). retrieved august 1, 2025, from https://oec.world/en/profile/bilateral-product/pesticides/reporter/usa pan europe. (2024, september 24). double standards, double risk: banned pesticides in europe’s food supply. https://www.pan-europe.info/sites/pan-europe.info/files/public/resources/pressreleases/24092024_double%20standards%2c%20double%20risk.pdf panis, c., kawassaki, a. c. b., crestani, a. p. j., pascotto, c. r., bortoloti, d. s., vicentini, g. e., ... & candiotto, l. z. p. (2022). evidence on human exposure to pesticides and the occurrence of health hazards in the brazilian population: a systematic review. frontiers in public health, 9, 787438. https://doi.org/10.3389/fpubh.2021.787438 pretty, j., & bharucha, z. p. (2015). integrated pest management for sustainable intensification of agriculture in asia and africa. insects, 6(1), 152–182. https://doi.org/10.3390/insects6010152 public eye. (2020, october 14). the federal council bans the export of five pesticides banned in switzerland. https://www.publiceye.ch/en/media-corner/press-releases/detail/the-federal-council-bans-the-export-of-fivepesticides-banned-in-switzerland rauh, v. a., garfinkel, r., perera, f. p., andrews, h. f., hoepner, l., barr, d. b., ... & whyatt, r. w. (2006). impact of prenatal chlorpyrifos exposure on neurodevelopment in the first 3 years of life among inner-city children. pediatrics, 118(6), e1845–e1859. https://doi.org/10.1542/peds.2006-0338 tanner, c. m., kamel, f., ross, g. w., hoppin, j. a., goldman, s. m., korell, m., ... & langston, j. w. (2011). rotenone, paraquat, and parkinson’s disease. environmental health perspectives, 119(6), 866–872. https://doi.org/10.1289/ehp.1002839 united nations general assembly. (1966). international covenant on economic, social and cultural rights. united nations treaty series, 993, 3. https://www.ohchr.org/en/instruments-mechanisms/instruments/internationalcovenant-economic-social-and-cultural-rights world bank group. (2018, march 7). responsible agricultural investment (rai): knowledge into action notes series. https://www.worldbank.org/en/topic/agriculture/publication/responsible-agricultural-investment cite this article as: shin, s., & jung, h. (2025). toxic inequities: the global health burden of pesticide exports to lowand middle-income countries. ghmj (global health management journal), 8(3), 336–344. https://doi.org/10.35898/ghmj-831263 https://oec.world/en/profile/bilateral-product/pesticides/reporter/usa https://www.pan-europe.info/sites/pan-europe.info/files/public/resources/press-releases/24092024_double%20standards%2c%20double%20risk.pdf https://www.pan-europe.info/sites/pan-europe.info/files/public/resources/press-releases/24092024_double%20standards%2c%20double%20risk.pdf https://doi.org/10.3389/fpubh.2021.787438 https://doi.org/10.3390/insects6010152 https://www.publiceye.ch/en/media-corner/press-releases/detail/the-federal-council-bans-the-export-of-five-pesticides-banned-in-switzerland https://www.publiceye.ch/en/media-corner/press-releases/detail/the-federal-council-bans-the-export-of-five-pesticides-banned-in-switzerland https://doi.org/10.1542/peds.2006-0338 https://doi.org/10.1289/ehp.1002839 https://www.ohchr.org/en/instruments-mechanisms/instruments/international-covenant-economic-social-and-cultural-rights https://www.ohchr.org/en/instruments-mechanisms/instruments/international-covenant-economic-social-and-cultural-rights https://www.worldbank.org/en/topic/agriculture/publication/responsible-agricultural-investment https://doi.org/10.35898/ghmj-831263 template ghmj 2024 ghmj (global health management journal) 2025, vol. 8, no. 2s indonesian scholars’ alliance open access research article the 1st cirebon international health symposium: faculty of medicine, universitas swadaya gunung jati update on non-communicable diseases: global perspective on health challenges and innovation relationship analysis of risk factors concerning the incidence of pulmonary tuberculosis in children at panti abdi dharma hospital, cirebon, indonesia annisa shintya pratama1* , defa rahmatun nisaa2 , nanang ruhyana3 1. faculty of medicine, universitas swadaya gunung jati, cirebon, indonesia, 45132; 2. department of paediatrics, faculty of medicine universitas swadaya gunung jati, cirebon, indonesia, 45132; 3. department of public health, faculty of medicine universitas swadaya gunung jati, cirebon, indonesia, 45132. *corresponding author’s e-mail: defa.suwarto@gmail.com doi: 10.35898/ghmj-82s1228 abstract background: tuberculosis (tb) is an infectious disease caused by the mycobacterium tuberculosis germ. the germs are spread from people with tb through the air. nearly a quarter of the world’s population is infected with mycobacterium tuberculosis germs and 11% are children. aims: to analyze the association of risk factors that most influence the incidence of pulmonary tuberculosis in children at panti abdi dharma hospital, cirebon city in 2024. methods: using a cross sectional analytical observational approach, systematic sampling technique on 138 respondents using bivariate analysis (chi-square) and multivariate analysis (logistic regression). results: the results showed that risk factors associated with the incidence of tuberculosis in children were age (p-value 0.002), gender (p-value 0.027), father's education (p-value 0.032) and parents' socioeconomic status (p-value 0.001). the risk factor that most influenced the incidence of tuberculosis was parents' socioeconomic status (exp(b) value 3.798). conclusion: in the 10 risk factors studied, 4 risk factors were found to have an association with the incidence of tuberculosis in children, namely child age, child gender, father's education, and parents' socioeconomic status. the most influential risk factor in this study was parents' socioeconomic status. keywords: risk factors; relationship analysis; pulmonary tuberculosis; child health. received: 21 june 2025 reviewed: 09 july 2025 revised: 22 july 2025 accepted: 15 august 2025. © 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:defa.suwarto@gmail.com https://doi.org/10.35898/ghmj-82s1228 https://orcid.org/0009-0007-2661-3074 https://orcid.org/0009-0009-2993-0782 https://orcid.org/0009-0000-9505-8835 pratama, et. al. ghmj (global health management journal) 2025, vol. 8, no. 2s 294 1. introduction tuberculosis (tb) is an infectious disease caused by the germ mycobacterium tuberculosis. the germs spread from people with tb through the air. the mycobacterium tuberculosis germ usually attacks the lung organ, but can also attack other than the lung (extra-pulmonary). almost a quarter of the world's population is infected with mycobacterium tuberculosis germs. about 89% of tb patients are adults (56.5% men and 32.5% women) and 11% are children (kemenkes, 2022) worldwide there are an estimated 10 million cases of tb in 2020, 10.3 million cases in 2021, and 10.6 million cases in 2022 (who, 2023). in 2022 indonesia itself is in second place after india with the most cases of about 10% of the world's 87% of tb cases amounting to 969,000 cases per year. when compared by gender, the number of cases in men is higher than in women by 58.0% and 42.0% in women. meanwhile, based on the age group, the highest number of cases was found in the age group 45-54 years, which amounted to 16.5%, followed by the age group 0 ̶ 14 years, which amounted to 15.3%. the highest number of cases was reported from provinces with large populations, one of which is west java (kemenkes, 2022). reported tb cases in west java in 2022 amounted to 160,661 cases out of 656,154 suspected tb cases (kemenkes, 2022). the highest tb cases were in bogor regency, bandung city and bekasi city, which accounted for 6 ̶14% of the total new cases in west java. cirebon city is one of the cities with a high number of pulmonary tb cases (profil kesehatan jawa barat, 2022). risk factors for tb transmission in children are the same as for tb in general, depending on the level of transmission, length of exposure and body resistance (kemenkes, 2023). the results of several studies related to risk factors for pulmonary tb in indonesia and other countries show that the incidence of pediatric pulmonary tb is influenced by factors related to child factors, parental factors, socioeconomic factors, environmental factors and contact with adult pulmonary tb patients. the risk factors for tb in children are parental knowledge, bcg vaccination history, the behavior of tb patients at home such as smoking habits and length of contact (abimulyani et al., 2023). the risk factors for tb in children are parental knowledge (almira et. al., 2023). the risk factors for tb in children are parental knowledge (nurilhami et al., 2023). the risk factors for tb in children are parental knowledge, nutritional status, and smoking habits (sutriyawan et. al., 2022). the most risk factors for tb in children are age 0 ̶4 years and female gender (ekawati, 2022). the risk factors for tb in children are parents' education level (agustian et al., 2022). this shows that there are many risk factors that can influence the occurrence of pulmonary tb in children, originating from both the children themselves and their parents. this study can serve as a basic indicator for identifying these risk factors. therefore, the purpose of this study is to determine the relationship between risk factors and the incidence of pulmonary tb in children at panti abdi dharma hospital, cirebon city, in 2024. 2. methods study design/ research procedures this study is an analytical observational with a cross sectional approach with a sample size of 138 respondents within the research period of 2 months. sampling method with systematic sampling technique, namely sampling technique based on the order of the population number given a serial number. the sample of this study were pediatric patients aged 0-17 years who visited the panti abdi dharma hospital, cirebon city in may-june 2024 with inclusion criteria, namely children aged 0-17 years, parents who were willing to respond by filling out informed consent and filling out questionnaire data, and exclusion criteria, namely not willing to be interviewed / not willing to be a research subject and the required data was not available / the questionnaire was not filled in completely. the way to get a sample is that the researcher waits in the waiting room of the pediatric poly and the researcher gives a serial number to each newly arrived patient until the number of samples per day is fulfilled by doing informed consent and giving a questionnaire. 295 ghmj (global health management journal) 2025, vol. 8, no. 2s pratama, et. al. table 1. operational definition in the questionnaire no variables definition results measuring scale independent variables 1 age the age of the child from birth to the time of diagnosis of pulmonary tb 1 = ≤1 years ordinal 2 = >1 ̶5 years 3 = >5 ̶10 years 4 = >10 ̶15 years 5 = >15 ̶17 years 2 gender the child's natural physical characteristics that distinguish between male and female 1 = male nominal 2 = female 3 nutrition the nutritional status of the child measured anthropometrically based on the bw/tb index from the standard z score of bw/tb before the diagnosis of pulmonary tb 1= malnutrition : <-3sd ordinal 2 = undernutrition : -3sd until <-2sd 3 = good nutrition : 2sd until 1sd 4 = over-nutrition : >2sd until 3sd 4 exclusive breastfeeding history breastfeeding status only without other food and drink until 6 months of age, for patients <6 months of age, breastfeeding status only without other food and drink 1 = not exclusively breastfed ordinal 2 = exclusive breastfeeding 5 birth weight child's weight at birth 1 = lbw (<2500gr) ordinal 2 = normal (≥2500gr) 6 bcg immunization history bcg immunization history asked and seen from the immunization book 1 = no nominal 2 = yes 7 history of contact tb patients presence of family members diagnosed with tb 1 = no nominal 2 = yes 8 father’s education formal education of the child's father 1 = not graduated elementary school ordinal 2 = elementary school graduate 3 = junior high school graduate 4 = senior high school graduate 5 = college 9 mother’s education formal education of the child's mother 1 = not graduated elementary school ordinal 2 = elementary school graduate 3 = junior high school graduate 4 = senior high school graduate 5 = college 10 parents’ socioeconomic status the average monthly income of the mother and father compared to the minimum wage (umr) of cirebon city (≥2.4 million) 1 = ≥2,4 million ordinal 2 = <2,5 million 11 smoking behavior of family the presence of family members who smoke in the house 1 = no ordinal 2 = yes dependent variables 12 pulmonary tuberculosis pediatric patients who meet the pediatric tb scoring system / have been diagnosed with pulmonary tb by a doctor 1 = no nominal 2 = yes pratama, et. al. ghmj (global health management journal) 2025, vol. 8, no. 2s 296 measurements shown in table 1, the independent variables in this study were age, gender, nutritional status, exclusive breastfeeding history, birth weight, bcg immunization history, direct contact with tuberculosis patients in children, as well as educational status, socioeconomic status of parents and smoking behavior in family members, while the dependent variable in this study was the incidence of pulmonary tuberculosis in children. the author took primary data, namely questionnaires from previous researchers, irma surya kusuma in 2011 which has been validated, tested for reliability, and well-adapted and distributed them to respondents who had filled out informed consent. the questionnaire consists of 4 sections, namely general data which aims to determine the order of the respondent's number and the date of data collection obtained, respondent data which aims to determine the identity of parents/guardians of children as research samples, child characteristics which aim to determine the identity of children as research samples, and risk factors that may or may not be related to the incidence of pulmonary tb in children. this section consists of 4 sections, namely general data which aims to determine the order of the respondent number and the date of data collection obtained, respondent data which aims to determine the identity of the parents/guardians of the child as a research sample, child characteristics which aim to determine the identity of the child as a research sample, and risk factors that may or may not be related to the incidence of pulmonary tb in children. statistical techniques the analysis conducted in this study is univariate analysis which aims to determine the description or distribution of each independent variable, then bivariate analysis which aims to determine whether or not there is a relationship between risk factors as independent variables to the incidence of pulmonary tb in children as the dependent variable using the chi-square test, then multivariate analysis which aims to determine the risk factors that are most influential on the incidence of pulmonary tb in children using logistic regression test. ethical clearance this study has been ethically approved by the ethic committee of faculty of medicine, universitas swadaya gunung jati, following the seven who standards, with number no.44/ec/fkugj/v/2024, on 06th may 2024. 3. results respondent characteristics table 2 summarizes the distribution of the characteristics of the most respondents is the age group >1─5 years as many as 80 people (58%), male gender as many as 74 people (58%), malnutrition status as many as 41 people (30%), the history of exclusive breastfeeding as many as 83 people (60%), normal birth weight as many as 129 people (93%), there was a history of bcg immunization as many as 126 people (91%), there was no history of contact with tb patients as many as 124 people (90%), as well as father's education finishing high school as many as 73 people (53%), mother's education finishing high school as many as 69 people (50%), socio-economic status of parents below umr as many as 79 people (57%) and the presence of smoking behavior of family members as many as 109 people (79%). 297 ghmj (global health management journal) 2025, vol. 8, no. 2s pratama, et. al. table 2. respondents’ characteristics variables n % age ≤1 years 16 12 >1 ̶5 years 80 58 >5 ̶10 years 32 23 >10 ̶15 years 8 6 >15 ̶17 years 2 1 gender male 74 58 female 64 46 nutrition malnutrition 36 26 undernutrition 41 30 good nutrition 40 29 over-nutrition 21 15 exclusive breastfeeding history no 55 40 yes 83 60 birth weight lbw (<2500gr) 9 7 normal (≥2500gr) 129 93 bcg immunization history no 12 9 yes 126 91 history of contact tb patients no 124 90 yes 14 10 father’s education not graduated elementary school 0 0 elementary school graduate 30 22 junior high school graduate 24 17 senior high school graduate 73 53 college 11 8 mother’s education not graduated elementary school 0 0 elementary school graduate 34 25 junior high school graduate 24 17 senior high school graduate 69 50 college 11 8 parents’ socioeconomic status ≥rmw 59 43 <rmw 79 57 smoking behavior of family no 29 21 yes 109 79 bivariate analysis table 3 shows the distributions of patients based on age, gender, nutrition status before diagnosis, exclusive breastfeeding history, birth weight, bcg immunization history, history of contact tb patients, father’s and mother’s education, parents’ socioeconomic status and smoking behavior of family. the statistical analysis shows that age significantly contribute to tuberculosis children (p value = 0.002), gender significantly contribute to tuberculosis children (p value = 0.016), father’s education significantly contribute to tuberculosis children (p value = 0.032) and socioeconomic status of parents significantly contribute to tuberculosis children (p value = 0.001). pratama, et. al. ghmj (global health management journal) 2025, vol. 8, no. 2s 298 table 3. bivariate analysis variables tb status total n (%) p-value tb non tb n % n % age ≤1 years 7 5% 9 7% 16 (12%) 0.002 >1 ̶5 years 63 46% 17 12% 80 (58%) >5 ̶10 years 22 16% 10 7% 32 (23%) >10 ̶15 years 2 1% 6 4% 8 (6%) >15 ̶17 years 2 1% 0 0% 2 (1%) gender male 45 33% 29 21% 74 (54) 0.016 female 51 37% 13 9% 64 (46%) nutrition status before diagnosis malnutrition 30 22% 6 4% 36 (26%) 0.215 undernutrition 27 20% 14 10% 41 (30%) good nutrition 26 19% 14 10% 40 (29%) over-nutrition 13 9% 8 6% 21 (15%) exclusive breastfeeding history no 39 28% 16 12% 55 (40%) 0.780 yes 57 41% 26 19% 83 (60%) birth weight lbw (<2500gr) 7 5% 2 1% 9 (7%) 0.722 normal (≥2500gr) 89 64% 40 29% 129 (93%) bcg immunization history no 9 7% 3 2% 12 (9%) 1.000 yes 87 63% 39 28% 126 (91%) history of contact tb patients no 84 61% 40 29% 124 (90%) 0.227 yes 12 9% 2 1% 14 (10%) father’s education elementary school graduate 23 17% 7 5% 30 (22%) 0.032 junior high school graduate 20 14% 4 3% 24 (17%) senior high school graduate 49 36% 24 17% 73 (53%) college 4 3% 7 5% 11 (8%) mother’s education elementary school graduate 26 19% 8 6% 34 (25%) 0.267 junior high school graduate 16 12% 8 6% 24 (17%) senior high school graduate 49 36% 20 14% 69 (50%) college 5 4% 6 4% 11 (8%) parents’ socioeconomic status ≥rmw 32 23% 27 20% 59 (43%) 0.001 <rmw 64 46% 15 11% 79 (57%) smoking behavior of family no 19 14% 10 7% 29 (21%) 0.594 yes 77 56% 32 23% 109 (79%) 299 ghmj (global health management journal) 2025, vol. 8, no. 2s pratama, et. al. multivariate analysis the prevalence ratio of age, gender, father’s education parents’ and socioeconomic status with tuberculosis in children was analyzed using binary logistic regression test with 95% ci. table 4. multivariate analysis variables b sig. exp(b) 95% c.i for exp (b) lower upper step 1a age -.222 .390 .801 .483 1.328 gender .989 .017 2.689 1.194 6.057 father's education -.272 .269 .762 .470 1.234 parents’ socioeconomic status 1.190 .005 3.287 1.425 7.582 constant -.901 .574 .406 step 2a gender .982 .017 2.669 1.188 5.998 father's education -.226 .345 .798 .499 1.275 parents’ socioeconomic status 1.190 .005 3.286 1.426 7.573 constant -1.561 .267 .210 step 3a gender 1.000 .015 2.717 1.214 6.081 parents’ socioeconomic status 1.334 .001 3.798 1.734 8.315 constant -2.609 .003 .074 table 4 shows that parent’s socioeconomic status the most significant associated variable with tuberculosis in children (p<0,001, or = 3.798, c.i = 95%). the conclusion of this study is that nutrition status before diagnosis, exclusive breastfeeding history, birth weight, bcg immunization history, history of contact with tb patients, mother's education and smoking behaviour of family did not have a significant association with the incidence of childhood tuberculosis. age, gender, father's education and parent’s socioeconomic status have a significant association the incidence of childhood tuberculosis, with parent’s socioeconomic status being the most significant associated variable on the incidence of pulmonary tb in children at panti abdi dharma hospital in cirebon city. 4. discussion age based on table 3, it can be seen that age has a significant relationship with the incidence of pulmonary tb in children at panti abdi dharma hospital in cirebon city with a sig. (p-value) of 0.002 (<0.05), which means there is a significant relationship. based on the theory in the book pediatric respirology by the indonesian pediatric association, the risk factor for tb in children is age. children aged <5 years have a greater risk of experiencing progression of infection to tb disease because their cellular immunity is not fully developed (immature). however, this risk gradually decreases with age. in addition, the results of this study are in line with dianita's research (2022) which states that there is a significant relationship between age and the incidence of childhood tb. this proves that children aged <5 years are at risk of suffering from tb compared to children aged >5 years. children aged <5 years are more at risk of contracting tb disease because childhood is a period of rapid growth and development and the immune system is not yet fully formed so that at that age they still have a low immune system and are more susceptible to diseases including pulmonary tb. pratama, et. al. ghmj (global health management journal) 2025, vol. 8, no. 2s 300 gender based on table 3, it can be seen that age has a significant relationship with the incidence of pulmonary tb in children at panti abdi dharma hospital in cirebon city with a sig. (p-value) of 0.027 (<0.05), which means there is a significant relationship. in addition, the results of this study are in line with dianita’s research (2022) which states that tb cases are more prevalent in daughter than son. nutritional status based on table 3, it can be seen that nutritional status does not have a significant relationship with the incidence of pulmonary tb in children at panti abdi dharma hospital, cirebon city with a sig. (p-value) of 0.215 (>0.05), which means there is no significant relationship. based on the theory in the book technical guidelines for the management of child and adolescent tuberculosis indonesia 2023 by the ministry of health of the republic of indonesia, children and adolescents with severe acute malnutrition are at high risk of developing tb due to low cellular immunity. severe acute malnutrition associated with tb is poor nutrition. in addition, the results of this study are in line with zulkarnain's research (2023) which states that there is no relationship between nutritional status and the incidence of tb in children, where according to researchers someone who has an abnormal nutritional status can affect a person's immune system so that they are susceptible to infectious diseases, one of which is tb. however, there are still respondents whose nutritional status is normal and suffer from tb. exclusive breastfeeding history it can be seen at table 3, exclusive breastfeeding does not have a significant relationship with the incidence of pulmonary tuberculosis in children at panti abdi dharma hospital, cirebon city with a sig value. (p-value) of 0.928 (>0.05), which means there is no significant relationship. based on the theory in the book national guidelines for medical services for tuberculosis management by the ministry of health of the republic of indonesia 2020, infectious diseases in children can be prevented by exclusive breastfeeding. breast milk has the ideal nutritional content for children's growth and development. breast milk contains carbohydrates, fat, protein, nutrients and antibodies that can inhibit growth and increase the body's defense system against pathogenic germs. children who are not breastfed or exclusively breastfed have an impact on low nutritional status, which affects the body's resistance to infections including tb and hiv infections. in addition, the results of this study are in line with flores's research (2020) which states that there is no relationship between exclusive breastfeeding history and the incidence of tb in children. birth weight based on table 3, it can be seen that birth weight does not have a significant relationship with the incidence of pulmonary tb in children at panti abdi dharma hospital, cirebon city with a sig. (p-value) of 0.722 (>0.05), which means there is no significant relationship. the babies with low birth weight have a smaller chance of survival and are more susceptible to diseases, especially infectious diseases such as tb infection. low birth weight tends to have impaired cognitive development, mental retardation, and is more prone to infections that can result in illness or even death (pristya et al, 2020). bcg immunization history bcg immunization history does not have a significant relationship with the incidence of pulmonary tb in children at panti abdi dharma hospital, cirebon city with a sig. (p-value) of 1.000 (>0.05). based on the theory in the book technical guidelines for the management of child and adolescent tuberculosis indonesia 2023 by the ministry of health of the republic of indonesia, the administration of the bcg vaccine, which contains attenuated mycobacterium bovis, aims to provide protection against the occurrence of tb disease. although its effectiveness varies (up to 90%), it is very useful in preventing severe tb. in addition, the results of this study are in line with dianita's research (2022) which states that there is no relationship between bcg immunization and the incidence of tb in children. this proves that children with bcg immunization status are still at risk of tb. 301 ghmj (global health management journal) 2025, vol. 8, no. 2s pratama, et. al. contact history with adult tb patients based on table 3, it can be seen that contact history does not have a significant relationship with the incidence of pulmonary tb in children at panti abdi dharma hospital, cirebon city with a sig. (p-value) of 0.227 (>0.05), which means there is no significant relationship. based on the theory in the book pediatric respirology by the indonesian pediatric association, the most important source of tb infection in children is exposure to infectious adults, especially with positive bta. the risk of transmission of germs from adults to children will be higher if the adult patient has bta positive sputum, extensive infiltrates, or cavities in the upper lobes, sputum production is abundant and watery, cough is productive and strong, and there are unhealthy environmental factors, especially poor air circulation. in addition, the results of this study are in line with rita & qibtiyah's research (2020) which states that there is no relationship between contact history and the incidence of tb in children. this is evidenced by the national indicators of tb control based on the number of suspected screening; there is a relationship between the contact history of tb patients and the incidence of tb in children with a value that cannot exceed the value of 3-5%. father's education it can be seen at table 2, father's education has a significant relationship with the incidence of pulmonary tb in children at panti abdi dharma hospital, cirebon city with a sig. (p-value) of 0.032 (<0.05), which means there is a significant relationship. in addition, the results of this study are in line with research by dias (2022) which states that there is a relationship between father's education and the incidence of tb in children. this is evidenced by the level of education will affect a person to have knowledge related to disease prevention and also healthy housing so that someone who has sufficient knowledge will carry out a healthy and clean lifestyle. in addition, the father is the head of the family where the father's education level will affect the type of work that will be related to the economic status of parents and nutritional status in children. mother's education contrary with the fathers education, maternal education does not have a significant relationship with the incidence of pulmonary tb in children at panti abdi dharma hospital, cirebon city with a sig. (p-value) of 0.267 (>0.05), which means there is no significant relationship. in addition, the results of this study are in line with research by dias (2022) which states that there is no relationship between maternal education and the incidence of tb in children. parents' socioeconomic status in this recent study, it is noted that the socioeconomic status of parents has a significant relationship with the incidence of pulmonary tuberculosis in children at panti abdi dharma hospital, cirebon city with a sig. (p-value) of 0.001 (<0.05). based on the theory in the book pediatric respirology by the indonesian pediatric association, poverty is one of the main causes of the increasing number of tb cases in children, especially in developing countries. in addition, the results of this study are in line with sihaloho et al. research (2021) which states that there is a relationship between the socioeconomic status of parents and the incidence of tb in children. this is evidenced by the smaller a person's income, the possibility of contracting tb is very high because it cannot meet proper health requirements. someone who has a high income tends to be able to maintain the cleanliness of their living environment, drink clean water and maintain the quality of their food so that the tendency to contract tb is lower. smoking behavior of family members it can be seen that the smoking behavior of family members does not have a significant relationship with the incidence of pulmonary tb in children at panti abdi dharma hospital, cirebon city with a sig. (p-value) of 0.760 (>0.05), which means there is no significant relationship. in addition, the results of this study are in line with nurjana & tjandrarini research (2019) which states that the absence of a relationship between smoking behavior of family members and the incidence of tb in children may be influenced by several things including the level of cigarette addiction of family members. the lower the level of cigarette addiction, the less exposure to cigarette pratama, et. al. ghmj (global health management journal) 2025, vol. 8, no. 2s 302 smoke to children so that it does not have a major effect on children's health. another factor is the manner of smoking, smoking outside the home or not close to the child will reduce exposure to cigarette smoke to children. most influential variable the most influential variable on the incidence of pulmonary tb in children at panti abdi dharma hospital in cirebon city is the low socioeconomic status of parents because it is 3.798 times more likely to get tb than the female gender. socioeconomic status has the most influence on the incidence of tb. this is consistent with previous research that individuals with low income have a greater chance of developing tb disease than those with high income. community income can affect individual health, where people who have low income will find it difficult to get access to good food, resulting in a nutritional balance that is vulnerable to disruption and a decreased immune system. in addition, the stress associated with financial instability contributes to a decreased immune system which increases the risk of tb. this research process has limitations and is not fully adequate because several aspects still need to be improved in future studies. the limitations of this study include the first study in a panti abdi dharma hospital and there are several other factors that have not been studied such as parental knowledge and parental employment status. 5. conclusion based on the results of a study conducted at panti abdi dharma hospital in cirebon city with a total sample of 138 people, it was found that the risk factors that showed a significant association with the incidence of tuberculosis in children were age (p-value 0.002), gender (p-value 0.016), father's education (p-value 0.032) and parents' socioeconomic status (p-value 0.001) which were the most influential risk factors for the incidence of tuberculosis in children. researchers hope that the results of this study will make changes to public health interventions, especially in cases of childhood tuberculosis such as nutrition programs, tb screening in low-income groups and improving parental education. however, it should be remembered that this study is a cross-sectional study, so it is recommended that future researchers can examine other characteristics such as retrospective studies. conflict of interest the authors declare no conflicts of interest for the results. references abimulyani y, kainde yy, mansyur tn, san n, siregar a. analisis faktor risiko tb paru anak yang tinggal serumah dengan penderita tb paru dewasa. j pharm heal res. 2023;4(2):312–8. https://doi.org/10.47065/jharma.v4i2.3671 agustian, m.d., masria, s. and ismawati (2022, january). hubungan usia, jenis kelamin dan tingkat pendidikan dengan kejadian tb paru di wilayah kerja puskesmas cibadak kabupaten sukabumi. in bandung conference series: medical science (vol. 2, no. 1, pp. 1120-1125). almira fn, rakhmawati w, hendrawati s, asriyani maryam nn. pengetahuan orang tua dengan anak tuberkulosis di rsud dr. soeselo tegal. j surya med. 2023;9(2):161–7. https://doi.org/10.33084/jsm.v9i2.5685 ekawati d. pengaruh faktor risiko, usia, jenis kelamin dan status imunisasi pada kasus tb paru anak di puskesmas merdeka. koloni j multidisiplin ilmu. 2022;1(3):965–71. flores, j. a., coit, j., mendoza, m., leon, s. r., konda, k., lecca, l., & franke, m. f. (2021). is exclusive breastfeeding for six-months protective against pediatric tuberculosis?. global health action. 2021 jan 1;14(1):1861922. https://doi.org/10.1080/16549716.2020.1861922 kemenkes ri. petunjuk teknis tata laksana tuberkulosis anak dan remaja indonesia 2023. 2023. kemenkes ri. profil kesehatan indonesia 2022. pusdatin.kemenkes.go.id. 2022. https://doi.org/10.47065/jharma.v4i2.3671 https://doi.org/10.33084/jsm.v9i2.5685 https://doi.org/10.1080/16549716.2020.1861922 303 ghmj (global health management journal) 2025, vol. 8, no. 2s pratama, et. al. nurilhami, i. t., rakhmawati, w., maryam, n. n. a., & hendrawati, s. (2023). gambaran pengetahuan dan sikap orang tua yang memiliki anak dengan tuberkulosis di rsud bandung kiwari: knowledge and attitude among parents of children with tuberculosis in rsud bandung kiwari. jurnal ilmiah keperawatan (scientific journal of nursing), 9(2), 248-256. https://doi.org/10.33023/jikep.v9i2.1442 nurjana, m. a., & tjandrarini, d. h. (2019). risiko tuberculosis paru pada balita di daerah kumuh indonesia. prosiding poltekkes kemenkes palu, 1(1), 18-29. pristya, t. y., novitasari, a., & hutami, m. s. (2020). pencegahan dan pengendalian bblr di indonesia: systematic review. indonesian journal of health development, 2(3), 175-182. profil kesehatan jawa barat. profil kesehatan jawa barat 2022. 2022. https://www.scribd.com/document/696468666/profil-kesehatan-provinsi-jawa-barat-tahun-2022 rita, e., & qibtiyah, s. m. (2020). hubungan kontak penderita tuberkulosis terhadap kejadian tuberkulosis paru pada anak. indonesian journal of nursing sciences and practice, 3(1), 35-41. sihaloho, e. d., amru, d. s., agustina, n. i., & tambak, h. s. p. (2021). pengaruh angka kemiskinan terhadap angka tuberkulosis di indonesia. jabe (journal of applied business and economic), 7(3), 325-337.. https://doi.org/10.30998/jabe.v7i3.6470 sutriyawan a, nofianti n, halim r. faktor yang berhubungan dengan kejadian tuberkulosis paru. j ilm kesehat. 2022;4(1):98–105. https://doi.org/10.36590/jika.v4i1.228 zulkarnain, d. w. (2023). hubungan status gizi dengan kejadian tuberkulosis pada anak balita di puskesmas x kabupaten bekasi. bekasi: stikes mitra keluarga. cite this article as: pratama, a. s., nisaa, d. r., & ruhyana, n. (2025). relationship analysis of risk factors concerning the incidence of pulmonary tuberculosis in children at panti abdi dharma hospital, cirebon, indonesia. ghmj (global health management journal), 8(2s), 293–303. https://doi.org/10.35898/ghmj-82s1228 https://doi.org/10.33023/jikep.v9i2.1442 https://www.scribd.com/document/696468666/profil-kesehatan-provinsi-jawa-barat-tahun-2022 https://doi.org/10.30998/jabe.v7i3.6470 https://doi.org/10.36590/jika.v4i1.228 https://doi.org/10.35898/ghmj-82s1228 ghmj (global health management journal) 2025, vol. 8, no. 3 indonesian scholars’ alliance open access research article soul stunting in higher education: four case narratives from the campus counseling room in indonesia yeyentimalla* department of nursing, poltekkes kemenkes palangka raya, palangka raya, indonesia, 73111. *corresponding author’s e-mail: yeyentimalla@polkesraya.ac.id doi: 10.35898/ghmj-831270 abstract background: soul stunting is a term used by the researcher to describe the arrested growth of a student’s inner life, characterized by difficulties in managing emotions, building healthy relationships, and responding wisely to life’s challenges. as both researcher and counselor, the author engaged directly with the participants in a real counseling setting, allowing for an authentic observation and intervention in their soul development. this condition often originates in family upbringing patterns and can persist into university years, affecting academic engagement, social relationships, and career readiness. while conceptual discussions on emotional intelligence and student development are abundant, most remain theoretical or survey-based, with limited impact on real behavioral change. the present study addresses that gap through an action-oriented, practice-based approach. the aim of the present study is to explore the phenomenon of soul stunting among university students through four real case narratives from the campus counseling room, focusing on five dimensions of soul development: emotional maturity, empathy, the ability to build healthy relationships, reflective rather than reactive thinking, and effective problem-solving. it also demonstrates how emotionally intelligent communication can serve as an effective strategy for restoring and strengthening these aspects of students’ soul development. methods: this qualitative case study was conducted through real counseling experiences in diverse natural settings, including campus counseling rooms, cafés, practice fields, public spaces, social media, and whatsapp conversations. the counselor, bringing more than two decades of cultivating emotionally intelligent communication skills, particularly through emotional discernment, served as the primary instrument for data collection and interpretation. data were gathered through participant observation, in-depth interviews, and reflective field notes. ethical considerations included concealing participant identities and omitting formal informed consent to preserve the natural flow of interactions and avoid behavioral manipulation. results: analysis of four authentic counseling narratives revealed that emotional discernment, as a form of tacit knowledge, plays a pivotal role in identifying, addressing, and transforming soul stunting. conclusion: findings offer practical implications for campus counseling services, policy-making, and family-based interventions. keywords: soul stunting; emotional discernment; tacit knowledge; family engagement. received: 31 july 2025 reviewed: 11 august 2025 revised: 31 august 2025 accepted: 02 september 2025. © 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:yeyentimalla@polkesraya.ac.id https://doi.org/10.35898/ghmj-831270 https://orcid.org/0009-0009-4807-3798 yeyentimalla, y. ghmj (global health management journal) 2025, vol. 8, no. 3 327 1. introduction indonesia is actively addressing the issue of physical stunting, a condition of impaired physical growth in children. however, beyond the topics of nutrition and height, there is another form of stunting that is harder to recognize: soul stunting. this is not about underdeveloped bodies, but about the stagnation of the human soul. in this context, soul stunting refers to arrested development in emotional maturity, empathy, reflective thinking, and the capacity to build healthy relationships. unfortunately, this issue is rarely discussed. in the campus counseling room, i have encountered students who appear physically healthy and academically functional, yet show signs of emotional immaturity, particularly in how they relate to others, including their parents. these signs manifest in closed-off behavior, passive or explosive communication patterns, and a narrow worldview. they seem alive, yet in many aspects, their souls appear folded and shrinking. from maslow’s perspective, humans are designed to grow toward self-actualization and become fully human. however, this potential does not unfold automatically. it must be seen, nurtured, and supported by emotionally safe environments. when a child grows up in an environment lacking recognition, filled with pressure, or devoid of emotional safety, that potential may wither before it can bloom. the signs are evident: poor relational skills, fear of failure, and fragile self-esteem. in this context, emotional discernment can be understood as a form of tacit knowledge, personal, context-dependent understanding that is difficult to articulate verbally yet deeply embedded in lived experience. polanyi (1966) emphasized that “we can know more than we can tell,” highlighting the intuitive nature of much human understanding. nonaka and takeuchi (1995) later expanded this concept through the seci model, which explains the transformation of knowledge through socialization, externalization, combination, and internalization. this perspective reinforces the idea that profound emotional growth often emerges from sustained and embodied interaction rather than from abstract instruction. in this counseling-based action research, tacit knowledge plays a crucial role, as success depends heavily on the researcher’s ability to sense, interpret, and respond appropriately to emotional cues, especially when dealing with deeply rooted psychological patterns such as soul stunting. this paper presents four real case narratives from the campus counseling room, where students often arrive with inner restlessness but without the language to express it. three of them, namely meri, sinta, and novin, show deep-rooted signs of soul stunting, gradually eroding their personal agency. the fourth, marissa, demonstrates soul strength, serving as a contrast that highlights the potential for emotional growth. in this paper, i do not merely report the cases, but also explore how emotionally intelligent communication can serve as a pathway to healing the soul, gently yet earnestly. while conceptual discussions on emotional intelligence, parenting styles, and student development are abundant, most remain theoretical or survey-based, resulting in limited impact on actual behavioral change. very few studies adopt an action-oriented approach in which the researcher is directly involved in authentic counseling interactions, observing as well as influencing emotional growth in natural settings. this current investigation addresses that gap by presenting a qualitative case study grounded in real counseling experiences, where emotionally intelligent communication, particularly through emotional discernment, is applied both as a research lens and as an intervention strategy. therefore, the present study aims to examine the phenomenon of soul stunting among university students through four real case narratives from the campus counseling room. the analysis focuses on five key dimensions of soul development, namely emotional maturity, empathy, the ability to build healthy relationships, reflective rather than reactive thinking, and effective problem-solving, and explores how emotionally intelligent communication, particularly through emotional discernment, can be applied both as a research lens and an intervention strategy to foster growth in these areas. yeyentimalla, y. ghmj (global health management journal) 2025, vol. 8, no. 3 328 2. methods this research is a case study that i conducted in a counseling guidance setting that is not confined to a physical space. counseling sessions can take place in cafés, in field practice areas, in other public spaces, on social media, or through online conversations such as whatsapp. in this research, i define the “counseling room” broadly as any context of interaction that is safe, purposeful, and constructive, where conversations aim to guide participants to understand themselves, strengthen character, and develop personal resilience. this approach allowed me to observe counseling dynamics in contexts that are natural and relevant to the participants’ daily lives. my presence in the counseling room served not only as a data collector but also as an interpreter of the emotional interactions taking place. a case study in counseling settings requires emotional discernment, the ability to distinguish, respond to, and care for the nuances of participants’ emotions accurately without intervening or distorting their original experiences. high personal integrity serves as the foundation of my entire research process, ensuring that every step is conducted ethically and truthfully. i have built this competence through a distinctive personal journey: growing up in a family environment marked by soul stunting, then choosing to move forward to pursue master’s and doctoral degrees in psychology. my consistent interest in emotionally intelligent communication, combined with extensive experience in building and maintaining relationships with diverse groups of people, has shaped a mature socio-emotional sensitivity. for more than two decades, i have trained myself in attentive listening, lived out emotional communication in daily life, and applied it in both professional and personal contexts (yeyentimalla, 2025; yeyentimalla, et al., 2025). this background has enabled me to capture meanings hidden behind verbal and nonverbal expressions, enrich the analysis, and provide a depth of findings rarely achieved by conventional qualitative studies. i understand this competence as a form of tacit knowledge, a type of knowledge that is real and impactful in solving life problems but difficult to teach to others, especially to those who are unaware that they have communication problems. in the field of knowledge management, explicit knowledge refers to knowledge that can be easily articulated and shared through documentation, while tacit knowledge originates from personal experience, context, and intuition, elements that are difficult to transfer into written manuals. the emotionally intelligent communication that i practice is a form of tacit knowledge that i have developed through two decades of attentive listening and relationship building with a wide variety of individuals. this experience enriches the analysis and distinguishes the present study from conventional qualitative approaches. data collection was carried out through participant observation, in-depth interviews, and reflective note-taking during interactions in the various counseling spaces described above. i conducted participant observation by engaging directly in conversations while maintaining my position as a researcher who records the dynamics of interaction. in-depth interviews were conducted flexibly, following the natural flow of conversation so that participants felt safe to share their experiences and feelings. in addition, i wrote reflective notes immediately after each session to capture nonverbal details, emotional nuances, and situational contexts that might be overlooked if relying solely on audio recordings. all data were then analyzed thematically, taking into account both explicit meanings expressed and implicit meanings inferred, in line with the characteristics of a qualitative case study. in this research, i did not use a formal informed consent procedure for participants. instead, i chose to disguise all participants’ identities in the manuscript so that no individual could be traced. this approach was taken to maintain data authenticity in the context of naturalistic observation. participants i met were not told that they were simultaneously clients and co-researchers, so interactions occurred naturally without manipulation in speech or body language. in this way, i could record responses, expressions, and emotional dynamics in their pure form as they occur in everyday counseling situations. ethical considerations were still prioritized through strict confidentiality and the removal of all information that could lead to personal identification. yeyentimalla, y. ghmj (global health management journal) 2025, vol. 8, no. 3 329 3. case presentation case 1: meri -years of lying behavior reinforced by her mother meri (20 years old) was a final-semester student in the diploma iii in nursing program. the case began when her mother, who comes from the same hometown and shares family ties with me, contacted me on january 31, 2022, saying that meri had failed her final thesis for a diploma iii in nursing and was having issues with her main supervisor. i asked meri to meet me that afternoon at the campus counseling room (yeyentimalla, 2025). meri explained that her supervisor was angry because she had forged the supervisor’s signature on her thesis approval sheet. i acknowledged this as a serious offense and advised meri to apologize directly, but she claimed the supervisor refused to meet her. the next day, her mother called again and made a shocking revelation: they had given several million rupiah to the supervisor, who had even written the thesis. they now felt deceived because meri still failed. i tried to contact the supervisor to hear her perspective, but she responded aggressively, accusing me of blindly defending the student and threatening to report me to the police, calling the accusation a severe defamation. i urged meri to write a detailed chronology, but she was unresponsive. her answers were vague: “i don’t know,” “i forgot,” or “i didn’t pay attention.” when asked where the money was handed over, she said it was at a café she couldn’t name. as the campus counselor, i compiled a report with supporting documents, including a bank statement confirming a money transfer from meri’s mother on the date they mentioned. when the study program held a meeting with relevant parties, i wasn’t invited. meri’s mother later told me, “you should’ve just come, break in if needed. because you didn’t come, the meeting felt like a trial for us.” for me, as an educated person, attending without an invitation was not an option. her words reflected a weak emotional structure and a controlling dynamic that persisted throughout our interaction. mediation by the director concluded with a decision requiring meri to declare her story untrue and apologize. her supervisor demanded a video apology posted on social media, but i intervened to prevent this. a new supervisory team was assigned. yet meri showed no improvement. she became pregnant and got married one week before giving birth. her study period was extended to the tenth semester, but she still failed her thesis, child nursing, and maternity nursing courses. eventually, she was dismissed on september 5, 2024. meri later filed complaints against the institution to both a civil society organization and the ombudsman, but no misconduct was found. today, meri maintains a social media presence, falsely claiming to have graduated and become a nurse. to me, this represents soul stunting, a condition of undeveloped emotional maturity. she frequently lied, and her mother consistently covered for her. at one point, they even attempted to bribe me, an offer i firmly rejected. throughout the counseling process, patterns of control and playing victim remained. i have no regrets about recommending meri’s dismissal. in this conflict, i was the only one who truly grew and learned. case 2: sinta -caring for parents as the utmost duty sinta, a 19-year-old first-semester student in the applied bachelor of nursing program, introduced herself to me via whatsapp text message. her profile photo was blank. it was monday, november 6, 2023. her message came in at 6:09 a.m., requesting a meeting with me. as i was getting ready for the flag-raising ceremony that starts at 7:00 a.m., i responded at 6:43. “yes, you may meet me right after the ceremony.” instead of saying thank you, sinta asked: “what time does the ceremony end, ma’am, if i may ask?” i replied, “if you also attend the ceremony, you’d already know. that’s a strange question.” yeyentimalla, y. ghmj (global health management journal) 2025, vol. 8, no. 3 330 she went silent. for context, the first monday of each month includes a flag-raising ceremony attended by all faculty, staff, and students, typically lasting 30 minutes. a student being unaware of this struck me as odd. at 9:30 a.m., while i was working on my laptop, i heard a soft knock. a petite student appeared. i invited her in and asked her to sit. her voice was very quiet. she said she wanted to ask about the requirements for the basic nursing practicum. that question should have been directed to the course coordinator, not to me. still, i listened. she shared that she struggled to concentrate, had no friends, and received no emotional support from her family. i gave her advice about becoming a responsible individual, something already reflected in her communication style. i invited her to reflect on that morning. she had asked to meet, i responded immediately and gave her the first available slot. yet she asked what time the ceremony ended. such narrow thinking leads to unnecessary complications. i encouraged her to learn to appreciate others and to affirm the good in them. that’s the foundation of emotionally intelligent communication, confirmation, recognition (yeyentimalla, 2020). i gave her a copy of my book, confidence with professor rajawali: smart strategies for completing your degree (in indonesian, pede bersama professor rajawali: jurus jitu menyelesaikan studi). as she left, she said nothing, not even “thank you”, even though i had just advised her to practice gratitude. at the end of the semester, sinta came back to me because her gpa was below 2.75. she was accompanied by an older cousin. she said she felt sad because lecturers often scolded her for falling asleep in class. i offered guidance on self-management: get enough sleep at night, don’t delay assignments. i asked if she had read the book i gave her. she said no. i asked why. she answered, “i was lazy.” i glared. her cousin did too and immediately reprimanded her. the following semester, she still failed to reach the gpa minimum. this time she came with her father. they didn’t appear close. her father suggested the university improve its facilities, such as updating the library collection. i explained that our library is among the best in indonesia, his daughter simply refused to read. i asked her again if she had read the book i gave her, one that addresses emotional communication, clearly her issue. sinta didn’t seem interested. last semester, sinta applied for leave to care for her sick mother. on july 15, 2025, she extended the leave, this time because she herself was ill. when she first came to request the leave, i invited her to consider other options, such as hiring a nurse to care for her mother. i explained that if she took a leave, she would later have to study with junior classmates and might struggle to adjust. still, she and her father chose to proceed with the leave. two years have now passed. i have seen no progress in sinta’s communication skills. she only contacts me when she needs something. beyond that, she makes no effort to foster rapport or make our interactions pleasant. from observing her father, i sensed he was not a supportive figure. he once scolded his daughter in front of me. i suspect this dynamic is one of the main reasons sinta has not developed into a more confident individual. case 3: novin -soul stunting in a boundaryless home novin, a female student in a diploma iii nursing program, appeared quiet and unassuming. yet beneath her calm surface were three incidents of theft, targeting three classmates: a wallet, an iphone, and an atm card. the last case, involving vira’s bsi card, led to a police report after idr 1,688,000 was withdrawn. cctv footage captured novin and a man named ardika. ardika was novin’s boyfriend, whom she met on instagram two years earlier. unemployed and manipulative, he emotionally and financially exploited her. this is a clear case of love scamming, a rising digital-age crime where false romantic bonds are used to deceive and control. in recent months, novin frequently asked her parents for large sums of money, idr 8 million for a phone that was never purchased. the money likely went to ardika. the initial response came when police visited the hospital where students were undergoing clinical rotation. in the presence of supervisors and mentors, novin returned idr 1,500,000. however, idr 188,000 remained unpaid. yeyentimalla, y. ghmj (global health management journal) 2025, vol. 8, no. 3 331 the case was referred to the counseling unit. i met novin and told her: “your honesty today determines your path forward.” she claimed she owed only idr 100,000. i gave her three days to make amends: repay the money in person, apologize, and send me a photo of the meeting. i also contacted her mother for support. three days passed. no update. on the fourth day, i pressed firmly. they begged for one more day. i agreed. when the photo was finally sent, i noticed something odd: the cash vira held included small denominations, even idr 1,000 notes. suspicious, i contacted vira. she confirmed the remaining amount was idr 188,000, not idr 100,000, and submitted a bank notification. the supervisor also verified the details. i submitted this recommendation: “this student cannot be trusted. recommendation: dismissal. a softened approach may involve academic leave.” the program and department meetings in early july 2025 confirmed dismissal, softened by allowing novin to resign. her mother wept, pleading due to her cancer condition and novin being the family’s hope. i listened with empathy, but the decision stood. ample space had been offered for change, yet novin remained evasive, dishonest, and unaccountable. this case reveals how boundaryless parenting fosters soul stunting, producing diminished inner maturity, a weakened moral compass, and vulnerability to manipulation. love without limits is not a saving force. it becomes destructive. case 4: marissa -a harmonious family, a gracious daughter as a university counselor, i do not merely act as a gatekeeper, but as someone who proactively reaches out. on june 13 and 14, 2025, i accompanied a fellow lecturer on a clinical supervision visit for maternal nursing students at a local public health center. unexpectedly, the students were not wearing the mandated white uniforms, instead following instructions from the clinical instructor to wear casual attire. despite my colleague’s clear reminder the day before to comply with university regulations, none of the eight students informed her of the change. the conflict escalated when this duality of instructions went uncommunicated. my colleague became upset and canceled the clinical session. during the return trip, i listened to her and acknowledged her frustration. i immediately began thinking of a peaceful resolution. my strategy was to persuade the students to initiate reconciliation. however, i didn’t have their contact numbers. i decided to wait until monday, june 16, 2025, to reach out to puji, a former student now working at the health center, to help gather their contact information. puji provided all eight contact numbers. i chose to reach out to ana first and coached her on conflict resolution. i prepared a message for her to send to the lecturer. unfortunately, ana was unresponsive. instead of delivering the message herself, arif, the unhelpful group leader, stepped in. this diverted the message from its intended tone, and the lecturer became even more upset, as evidenced by her all caps replies. i then contacted another student. marissa. her response was swift, respectful, and compliant. i guided marissa to reach out to the lecturer with a message of apology and willingness to follow the new guidance for clinical placement. marissa quickly grasped the spirit of reconciliation and actively collaborated to resolve the conflict between her group and the supervising lecturer. her responsiveness enabled the group to restore their relationship with the lecturer and resume productive guidance. reconciliation occurred. the students and the lecturer met in the counseling room (ruang bk), and i volunteered to document the meeting as a photographer. as a token of appreciation, i gave marissa my book confident with professor rajawali (in indonesian, pede bersama professor rajawali), which documents successful communication practices during my doctoral studies. unlike other students who also received the book, marissa later confirmed she had finished reading it. she described it as enlightening and eye-opening, expanding her view of student–lecturer relationships as potentially warm and friendly. yeyentimalla, y. ghmj (global health management journal) 2025, vol. 8, no. 3 332 in our later conversations, marissa shared that she comes from a harmonious family. her parents are both educators: her father is a high school teacher and her mother teaches at the elementary level. marissa is the youngest, with a brother nine years her senior who is married and works in the capital of the regency. they are close and video call each other daily. in marissa’s family, open communication is key. her parents allow her to have healthy friendships in and beyond campus, and she is encouraged to express opinions and have autonomy. this affirms my hypothesis that children raised in democratic families tend to grow into emotionally healthy individuals. marissa quickly grasped the logic of reconciliation and actively collaborated to resolve the conflict between her group and the supervising lecturer. her responsiveness enabled the group to restore their relationship with the lecturer and resume productive guidance. 4. comparative analysis of four cases the four cases, namely meri, sinta, novin, and marissa, illustrate diverse developmental trajectories in higher education, shaped by contrasting family dynamics and parenting styles. similarities: each case involves a university student whose behaviors and emotional responses are deeply rooted in their upbringing. the presence or absence of emotional literacy, responsibility, and autonomy is visible in how these students face interpersonal conflicts or respond to academic expectations. all four cases underscore the role of family environments in shaping psychological maturity. differences: meri displays long-standing deceitful behavior, silently reinforced by her mother. her case reflects a deep-rooted lack of accountability and blurred boundaries in the parent-child relationship. sinta, in contrast, exemplifies a strong familial bond anchored in filial devotion. her priority is caregiving for aging parents, which may be noble, but potentially overshadows her academic focus and self-actualization. novin represents a case of emotional underdevelopment, stemming from a permissive parenting style. her passivity and avoidance behaviors signal a lack of internal discipline and direction. marissa stands apart as a portrait of emotional resilience and maturity. raised in a democratic and communicative household, she demonstrates initiative, respect, and clarity in problem-solving. her behavior reveals a healthy capacity for self-regulation and collaborative conflict resolution. these four cases collectively highlight that emotional and character development is not only an individual task but also a systemic outcome influenced by parenting quality. soul stunting in adulthood often reflects unprocessed or poorly nurtured emotional landscapes from childhood. in contrast, students raised with healthy emotional scaffolding tend to thrive academically, socially, and morally. this matrix summarizes the findings from the four cases presented here, covering five dimensions of soul development: (1) emotional maturity, (2) empathy, (3) ability to build healthy relationships, (4) tendency toward reactive or reflective thinking, and (5) problem-solving skills. matrix 1 illustrates that although the four cases come from diverse backgrounds and personal dynamics, their soul development can be distinctly mapped across the five key dimensions. three students (meri, sinta, novin) demonstrated significant limitations in most dimensions, particularly in emotional maturity, empathy, and reflective thinking. in contrast, marissa stood out as an example of soul strength, displaying optimal growth across all five dimensions. matrix 2 presents a comparative view of the five dimensions of soul development: emotional maturity, empathy, ability to build healthy relationships, reflective versus reactive thinking, and problem-solving, across the four cases. the table highlights both shared patterns and distinct differences. while meri, sinta, and novin display varying degrees of soul stunting, marissa stands out as the only case demonstrating strong soul strength. these contrasts provide a solid foundation for understanding the link between an individual’s initial condition and the intervention strategies applied, paving the way for deeper analysis in the discussion section. yeyentimalla, y. ghmj (global health management journal) 2025, vol. 8, no. 3 333 matrix 1. comparison of four cases across five dimensions of soul development dimension meri (soul stunting) sinta (soul stunting) novin (soul stunting) marissa (soul strength) emotional maturity easily triggered, struggles to regulate emotions; tends to withdraw under pressure highly sensitive, overly anxious, finds it hard to calm herself emotionally unstable, frequent mood swings, minimal selfawareness emotionally stable, able to regulate emotions even in difficult situations empathy low empathy, difficulty reading others’ feelings empathy blocked by excessive selffocused anxiety limited empathy, tends to judge quickly without understanding context high empathy, able to sense and respond to others’ emotional needs ability to build healthy relationship relationship tend to be transactional and fragile avoids deep emotional involvement struggles to maintain relationship due to unresolved conflicts builds equal, supportive, and long-term relationship reactive vs reflective thinking reactive, rarely considers long-term consequences reactive, often driven by fear reactive, makes emotional decisions without evaluation reflective, considers multiple perspectives before acting problem-solving skills avoids problem or blames others delay confrontation, avoids decisionmaking solves problems quickly but superficially, often causing new issues solves problems, constructively, considering all parties involved matrix 2. dimensions of soul development in four counseling cases case emotional maturity empathy ability to build healthy relationships reactive/reflective thinking problem-solving skills meri low low poor reactive weak sinta low moderate poor reactive weak novin low low poor reactive weak marissa high high strong reflective strong 5. discussion marissa's case represents the ideal outcome of democratic parenting: open communication with parents, autonomy, and emotional warmth. she has grown into a psychologically healthy individual, communicative and capable of recognizing truth reflectively. her emotional intelligence is evident in her ability to identify emotions, understand others’ perspectives, and rebuild broken relationships. in contrast, the cases of meri, sinta, and novin illustrate forms of soul stunting, a term used to describe psychological growth impairments caused by unhealthy parenting. meri exhibits long-term manipulative behavior reinforced by her mother's negative support. sinta appears responsible, yet experiences identity disorientation due to emotional pressure from caring for her parents at the cost of her academic focus. meanwhile, novin exhibits signs of passivity, lack of initiative, and dependence, traits stemming from a permissive parenting style that failed to establish healthy boundaries. diana baumrind’s (1967) classic theory classifies parenting styles into three categories: authoritarian, permissive, and authoritative (democratic). the author introduces the term “toxic parenting” to describe parenting that not only leans authoritarian or permissive, but also damages a child’s self-worth, either by reinforcing unhealthy behavior (meri’s case), by neglecting the child’s developmental needs (novin’s case), and excessive demand from parents (sinta’s case). daniel goleman’s (1995) theory of emotional intelligence emphasizes that recognizing and managing one’s own emotions, self-motivation, empathy, and social skills are crucial for life success. students experiencing soul stunting often struggle with these dimensions. “the emotional mind is far quicker than the rational mind” is goleman’s legendary statement, grounded in long-standing research in the field of emotional intelligence. yeyentimalla, y. ghmj (global health management journal) 2025, vol. 8, no. 3 334 in campus counseling practice, the counselor introduces the concept of emotionally intelligent communication a key approach. it is grounded in two core principles: emotional animation and emotional simulation. emotional animation refers to the courage to express positively-valenced emotions in both spoken and written dialogue, creating emotional safety. emotional simulation refers to the wisdom of processing feelings before expressing them, in order to preserve mutual relationships. these principles, once developed as soft skills, lay the foundation for authentic connections (yeyentimalla, 2020; yeyentimalla, et al., 2025). at its peak, emotional awareness produces emotional discernment, demonstrated by the counselor in resolving the conflict between marissa’s group and their clinical supervisor. the counselor recognized both the students’ dynamics and the supervisor’s personality, initiating, not just intervening but provoking in the positive sense, a shift in awareness and agency. marissa, as the selected student, took proactive steps toward resolution. the approach succeeded: a broken relationship was restored. these findings should also be understood within the framework of indonesia’s collectivistic culture, where harmony, respect for hierarchy, and group belonging are highly valued (triandis, 1994). in such contexts, open confrontation is often avoided, and emotional expression may be restrained to maintain social cohesion. while these norms can foster solidarity, they may also contribute to soul stunting by discouraging individuals from articulating personal struggles or dissenting views. this contrasts with individualistic cultures, where self-expression and personal autonomy are more strongly encouraged, potentially reducing the likelihood of prolonged emotional underdevelopment but increasing the risk of social fragmentation. in higher education settings, the collectivistic dynamic can result in students who outwardly conform yet inwardly experience unresolved emotional underdevelopment. understanding soul stunting through this cultural lens is essential for designing interventions that respect collective values while also promoting emotional growth and autonomy. understanding soul stunting through this cultural lens underscores the need for interventions that respect collective values while promoting emotional growth and autonomy. based on these insights, higher education institutions should consider integrating emotional intelligence and communication skills training into student development programs. creating safe spaces, both physical and virtual, where students can share their thoughts and feelings without fear of judgment is essential. counselors and lecturers should receive training in emotional discernment to better identify and address soul stunting, particularly in collectivistic contexts where such issues are often hidden beneath outward conformity. collaboration with student organizations can also help build peer support systems that normalize discussions around emotional well-being. while these recommendations present promising directions for practice, the present study has certain limitations. the findings are drawn from four case studies conducted within a specific cultural and institutional context, which may limit their generalizability. the naturalistic observation approach, while valuable for capturing authentic interactions, also means that not all relevant variables could be controlled or measured. future research could expand the sample size, include comparative studies across different institutions and cultural contexts, and explore longitudinal outcomes to strengthen the evidence base. 6. conclusion the presentation of these four cases affirms that the quality of family upbringing significantly influences the development of students’ mental well-being, as reflected in their readiness to respond to conflict and to engage in emotionally intelligent communication. democratic and loving parenting fosters emotionally healthy individuals who are cooperative and capable of managing conflict constructively. in contrast, permissive, authoritarian, or dysfunctional parenting contributes to soul stunting, a condition in which individuals appear mature by age but are hindered in emotional intelligence and social interaction. these findings underscore the importance of family involvement in student counseling, as well as the application of emotionally intelligent communication, communication that is attuned to one’s own and others’ emotions, and able to express them in safe and constructive ways. the principles of emotional animation and emotional simulation can be practiced and become essential keys in supporting generation z to face the challenges of the times. yeyentimalla, y. ghmj (global health management journal) 2025, vol. 8, no. 3 335 acknowledgment i extend my sincere gratitude to the editorial board of the global health management journal for the gracious invitation to contribute to this special edition commemorating international youth day, observed annually on august 12. it is a great honor to present this work, soul stunting in higher education: four case narratives from the campus counseling room in indonesia, as part of a collective effort to amplify the emotional realities of youth, realities that are often unseen, yet essential to be understood with empathy and care. to all young people across the world, i warmly wish you a meaningful international youth day. in the midst of an ever-changing and demanding world, may this message reach your heart: “be strong in spirit.” let your inner strength become the foundation upon which you face life’s challenges, nurture hope, and shape a healthier future, for yourself, for others, and for the world. oloh bujur, oloh tetek, ingilak hatalla. (dayak ngaju) insan yang benar dan tulus, diperkenan tuhan. (indonesian) those who are righteous and sincere are favored by god. (english) conflict of interest the author declares no conflict of interest. references baumrind, d. (1967). child care practices anteceding three patterns of preschool behavior. genetic psychology monographs, 75(1), 43-88. goleman, d. (1995). emotional intelligence: why it can matter more than iq. new york: bantam books. emotional intelligence: why it can matter more than iq by daniel goleman maslow, a.h. (1943). a theory of human motivation. psychological review, 50(4), 370-396. https://doi.org/10.1037/h0054346 nonaka, i., & takeuchi, h. (1995). the knowledge-creating company: how japanese companies create the dynamics of innovation. new york; oxford university press. the knowledge-creating company: how japanese companies create the dynamics ikujirō nonaka, hirotaka takeuchi polanyi, m. (1966). the study of man. the study of man: polanyi, michael: 9781614276562 triandis, h.c. (1994). culture and social behavior. new york: mcgraw-hill. culture and social behavior by harry c. triandis yeyentimalla. (2020). confidence with professor rajawali: smart strategies for completing your degree. jakarta: gramedia pustaka utama. [original work published in indonesian]. pede bersama professor rajawali yeyentimalla. 2025. akhir kisah mahasiswa stunting jiwa. dalam langkah setia di jalan pendidikan. [the closing chapter of a soul-stunted student. in faithful steps on the path of education]. anthology. yogyakarta: alineaku. [original work published in indonesian]. yeyentimalla, y., christyanni, y., & suryawati, s. (2025). a decade of growth: from social media to academic friendship. ghmj (global health management journal), 8(2), 236–244. https://doi.org/10.35898/ghmj821256 cite this article as: yeyentimalla, y. (2025). soul stunting in higher education: four case narratives from the campus counseling room in indonesia. ghmj (global health management journal), 8(3), 326–335. https://doi.org/10.35898/ghmj-831270 https://www.goodreads.com/book/show/26329.emotional_intelligence https://doi.org/10.1037/h0054346 https://books.google.co.id/books/about/the_knowledge_creating_company.html?id=b-qxrpau1-mc&redir_esc=y https://books.google.co.id/books/about/the_knowledge_creating_company.html?id=b-qxrpau1-mc&redir_esc=y https://www.amazon.com/study-man-michael-polanyi/dp/1614276560 https://www.goodreads.com/book/show/1602835.culture_and_social_behavior https://www.goodreads.com/book/show/1602835.culture_and_social_behavior https://georgescreek.org/reading/pede-bersama-professor-rajawali/ https://doi.org/10.35898/ghmj-821256 https://doi.org/10.35898/ghmj-821256 https://doi.org/10.35898/ghmj-831270 matrix 2. dimensions of soul development in four counseling cases references ghmj (global health management journal) 2024, vol. 7, no. 4 indonesian scholars’ alliance open access research article the 1st cirebon international health symposium: faculty of medicine, universitas swadaya gunung jati update on non-communicable diseases: global perspective on health challenges and innovation correlation between physical activity and cardiovascular endurance of the employees in universitas swadaya gunung jati, cirebon, indonesia salsabila carissa arsyana agestri1* , kati sriwiyati2 , pangeran akbar syah3 1 faculty of medicine, universitas swadaya gunung jati, indonesia, 2 department of basic medical science, faculty of medicine, universitas swadaya gunung jati, indonesia, 3 department of internal medicine, faculty of medicine, universitas swadaya gunung jati, indonesia. *corresponding author’s e-mail: salsabilaagestri@gmail.com doi: 10.35898/ghmj-741094 abstract background: cardiovascular endurance refers to a person's ability to perform activities involving the entire body at moderate to high intensity over extended periods. cardiovascular endurance is influenced by several factors, such as physical activity. moderate to high-intensity physical activity trains the body to exchange oxygen more efficiently and results in enhancing cardiovascular endurance. other factors that could contribute in cardiovascular endurance are smoking and body mass index (bmi). aims: to find the correlation between physical activity, bmi, smoking, and cardiovascular endurance among employees of universitas swadaya gunung jati, cirebon, indonesia. methods: it was an analytic observational study with a cross-sectional approach that used the gpaq physical activity questionnaire and cardiovascular endurance data that was obtained through the harvard step test involving 77 educational staff employees at universitas swadaya gunung jati. the analytical statistics used was spearman’s correlation test with a significance value of p = <0.05. results: most of the universitas swadaya gunung jati employee’s had moderate level of physical activity (44.2%) and very low cardiovascular endurance (37.7%). the analytical statistic showed a significant correlation between physical activity and cardiovascular endurance with a p-value of 0.034 and a spearman's r of 0.242. smoking has significant correlation with cardiovascular endurance with p value of 0.003 and spearman’s r of 0.338. bmi showed negative and weak correlation with cardiovascular endurance with p value 0.008 and spearman’s r -0.302. conclusion: there was a significant correlation between physical activity and cardiovascular endurance among the employees of universitas swadaya gunung jati, cirebon, indonesia. keywords: physical activity, cardiovascular endurance, body mass index, smoking. received: 25 september 2024 reviewed: 26 october 2024 revised: 17 november 2024 accepted: 30 november 2024 © 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:salsabilaagestri@gmail.com https://doi.org/10.35898/ghmj-741094 https://orcid.org/0009-0003-6334-2462 https://orcid.org/0009-0008-5865-2390 https://orcid.org/0000-0001-9636-4527 agestri, et. al. ghmj (global health management journal) 2024, vol. 7, no. 4 228 1. introduction cardiovascular endurance is the capacity to engage in full-body exercises at moderate to high intensities for prolonged periods of time. moderate to high-intensity physical activity trains the body to exchange oxygen more efficiently and results in enhancing cardiovascular endurance (cheng, chiu, & su, 2019). good cardiovascular endurance makes the body to be able to carry out daily activities lightly without getting tired quickly. according to who, globally, 1 in 4 adults does not meet the recommendation level of physical activity (world health organization, 2022). those who are less active have a 20% to 30% increased risk of death compared to those who are quite active. laporan riset kesehatan dasar 2018 reports that 33.5% of indonesians aged ≥ 10 are belong to the less active group (laporan riset kesehatan dasar, 2018). this number has increased from 2013, where as many as 26.1% of indonesians with an age range of ≥ 10 years were included in the less active group. as many as 37.5% of west java’s population within the same age range are included in the less active group. this number places west java among the top 10 provinces with the least active population. lack of physical activity causes a decrease in cardiovascular endurance. low cardiovascular endurance is one of the predictors of cardiovascular disease (franklin, eijsvogels, pandey, quindry, & toth, 2022). cardiovascular disease has become a serious problem affecting millions of people in the world, with the death toll continuing to increase from 12.1 million deaths in 1990 to 20.1 million deaths in 2021 (world heart federation, 2023). high levels of cardiovascular endurance are associated with a decrease in the incidence and mortality of cardiovascular disease (ezzatvar et al., 2021). physical activity refers to any movement of the body that the skeletal muscles generate and require the use of energy for. physical activity can refer to all movement, including during leisure time, transportation to and from a place, or as part of a person's work. sufficient intensity of physical activity can provide benefits for a person's cardiovascular health and endurance (world health organization, 2020). this can happen because physical activity can induce adaptation of several types of cells and tissues in the body, including mitochondrial biogenesis in skeletal muscle and heart muscle myocytes, as well as increasing aerobic respiration in these tissues. apart from that, physical activity can also increase cardiovascular endurance by improving the process of oxygen distribution in the body through vasodilation and angiogenesis (pinckard, baskin, & stanford, 2019). physical activity is part of human life, including for adults and university employees (tukuboya, malonda, & sanggelorang, 2020). currently, with rapid development in information and technology, as well as transportation, there have been changes in human activity and mobility. the convenience obtained with this development causes a decrease in activity and the occurrence of sedentary behavior, which can cause various health consequences including a decrease in cardiovascular endurance due to lack of physical activity (kusuma, syafei, & rilastiyo, 2019). a previous qualitative study by safi in 2022 stated that university employees spend approximately 60–70% of their waking hours in the workplace, with over 75% of this time spent being sedentary (safi, 2022). a previous study by tukuboya et al. in 2020 revealed that 47.9% of 48 university employees enganged in low physical activity (tukuboya et al., 2020). smoking and bmi are other factors that consistently link to cardiovascular endurance. smoking can cause plaque formation in the bloodstream, which can narrow blood vessels, disrupt oxygen delivery, and reduce cardiovascular endurance (jeon, kim, jeong, & so, 2021). a previous study also recorded that bmi influences cardiovascular endurance (singh et al., 2023). increased fat mass and left ventricle dysfunction that could happen in obese people result in decreased cardiac output, affecting blood volume and blood oxygen carrying capacity, hence decreasing cardiovascular endurance (takken et al., 2022). however, research on the correlation between physical activity, smoking, and bmi with cardiovascular endurance in university employees remains lacking. thus, it becomes important to study the correlation between physical activity and other factors that could affect cardiovascular endurance, such as smoking and bmi, among employees at universitas swadaya gunung jati, cirebon, indonesia. 229 ghmj (global health management journal) 2024, vol. 7, no. 4 agestri, et. al. 2. methods study design it was an observational study with cross-sectional design. the sample size for the study was calculated using slovin formula by taking permissible error as 10% with 90% confidence interval. meanwhile minimum sample size was calculated as n = 68. quota sampling was used for sampling technique. the exclusion criteria were pregnant woman, employees under musculoskeletal or cardiovascular therapy at the time of study, and employees with hypertension crisis at the time of study to minimalize risk of bias and adverse event. figure 1. subjects reqruitment measurements physical activity measured through the who global physical activity questionnaire which consist of 16 questions and divided into three sections: activity at work, travel to and from places, recreational activities, and one additional question about sedentary behavior asking about total sedentary time (world health organization, 2019). cardiovascular endurance obtained through the harvard step test (hartati & syafaruddin, 2020). this study also obtained some characteristics like age, bmi, and smoking habits that were asked with yes or no question. physical activity levels categorized as low, moderate, and high physical activity (world health organization, 2019). cardiovascular endurance categorized as very poor, poor, moderate, good, very good (hartati & syafaruddin, 2020). this study also obtained some characteristics like age, bmi, and smoking habits. bmi categorized as underweight, normal, overweight, obese i, and obese ii. smoking habits asked with yes or no question. statistical techniques acquired data were then analyzed using univariate statistics to summarize the data. kolmogorov-smirnov test determined that the data were not normally distributed (p = 0.000), thus the spearman correlation test was used to determine correlation between physical activity, sedentary behavior, bmi, smoking habits and cardiovascular endurance of the employee in universitas swadaya gunung jati with p-value <0.05 considered to be statistically significant. ethical clearance this study is inseparable from reciprocal correlation between the participants and researchers. all participants have received the explanation of the study and signed the informed consent to participate in this study. no data were obtained before the participant agreed to sign the informed consent. this study has been ethically approved from the health research ethics committee of faculty of medicine universitas swadaya gunung jati with ethical approval no.81/ec/fkugj/v/2024. employees agreed to be included in the study (n = 82) total sample (n = 77) excluded (n = 5) agestri, et. al. ghmj (global health management journal) 2024, vol. 7, no. 4 230 3. results respondent characteristics a total of 77 employees of universitas swadaya gunung jati participated in this study. there were 49 (63.6%) males and 28 (36.4%) females. most of the participants age were under <40 (57.1%). bmi of the majority of 29 participants (37.7%) were in grade i obesity category and 44 participants (55.8%) were smokers. regarding the participants physical activity, 34 participants (44.2%) reported moderate level of physical activity; 25 participants (32.5%) reported high level of physical activity; and 18 participants (23.4%) reported low level of physical activity. data recorded that 41 (53.2%) participants reported <420 minutes of sedentary behavior in a day, while 36 (46.8%) participants reported >420 minutes of sedentary behavior in a day. in terms of cardiovascular endurance, the majority of 29 participants (37.7%) reported very poor cardiovascular endurance; 9 participants (11.7%) reported poor cardiovascular endurance; 9 participants (11.7%) reported moderate cardiovascular endurance; 5 participants (6.5%) reported good cardiovascular endurance; and 25 participants (32.5%) reported very good cardiovascular endurance. (table 1) table 1. characteristics of the subject characteristics n % gender male 49 63.6 female 28 36.4 age <40 44 57.1 ≥40 33 42.9 body mass index underweight 2 2.6 normal 20 26 overweight 11 14.3 obese i 29 37.7 obese ii 15 19.5 smoking no 34 44.2 yes 43 55.8 physical activity low 18 23.4 moderate 34 44.2 high 25 32.5 sedentary behavior <420 minutes 41 53.2 ≥420 minutes 36 46.8 cardiovascular endurance very poor 29 37.7 poor 9 11.7 moderate 9 11.7 good 5 6.5 very good 25 32.5 table 2. characteristics of physical activity, sedentary behavior, and cardiovascular endurance median standard deviation min max physical activity 1680 2520.3 0 10320 sedentary behavior 420 201.1 60 960 cardiovascular endurance 66 42.54 21 208 231 ghmj (global health management journal) 2024, vol. 7, no. 4 agestri, et. al. bivariate analysis the bivariate test findings in this study are displayed in table 3 and indicate that there’s a significant correlation between physical activity and cardiovascular endurance with p-value 0.034 (p < 0.05), which suggests a substantial association between cardiovascular endurance and physical activity. the correlation coefficient (r) is 0.242, which means that the strength of the correlation between the two variables is positive and weak. in this study, the positive correlation indicates that as physical activity increases, cardiovascular endurance also tends to increase. there’s also significant correlation between smoking and cardiovascular endurance with a p-value 0.003 and a r-value 0.338, which means that the strength of the correlation is positive and weak. bmi exhibited a negative and weak correlation with cardiovascular endurance, with a p-value of 0.008 and a r-value of -0.302, indicating that a higher value for one variable corresponds to a lower value for the other variable. table 3. correlation between physical activity and cardiovascular endurance cardiovascular endurance p-value r spearmann’s rho physical activity 0.034 0.242 sedentary behavior 0.146 0.167 smoking 0.003 0.338 bmi 0.008 -0.302 4. discussion all respondents who participated in the study completed the gpaq physical activity questionnaire and underwent the harvard step test procedure. in this study, the majority of respondents were male, 49 (63.6%), while the remaining 28 (36.4%) were female. the majority of 44 participants (57.1%) were under 40 years old, while the other 33 (42.9%) were 40 years or older. according to table 2, out of 77 respondents, the minimum value for physical activity was 0 metminutes/week (metabolic equivalent task-minutes/week) and the maximum value was 10.320 metminutes/week, with a median value of 1.680 met-minutes/week. the minimum physical activity value of 0 met-minutes/week indicates that there are still employees at ugj who are considered inactive. based on the gpaq questionnaire assessment, a physical activity value below 600 met-minutes/week can be considered low, while the median value of 1.680 met-minutes/week falls into the moderate physical activity range. according to who physical activity recommendations, adults aged 18-64 are advised to participate in moderate-intensity aerobic activity for at least 150-300 minutes per week or high-intensity aerobic activity for at least 75-150 minutes per week in order to obtain health benefits, in addition with strength training that is recommended to be performed at least twice a week (world health organization, 2020). the data on sedentary behavior showed a minimum value of 60 minutes and a maximum value of 960 minutes, with a median of 420 minutes. ekelund's (2019) research indicates that sedentary behavior lasting longer than 8 hours per day is a risk factor for cardiovascular disease, particularly among individuals with low physical activity. conversely, individuals with adequate physical activity may mitigate the cardiovascular consequences of sedentary behavior. therefore, it is important to increase physical activity to mitigate the risk of cardiovascular disease associated with sedentary behavior (ekelund et al., 2019). the cardiovascular endurance data ranged from a minimum of 21 to a maximum of 208, with a median value of 66. the median cardiovascular endurance value of 66 falls into the moderate category of cardiovascular endurance. the findings of the harvard step test are predictive of vo2max, a measure of cardiovascular endurance that expresses the maximum amount of oxygen (in milliliters) that may be used per kilogram of body weight per minute (kim, oh, & kim, 2024). cardiovascular endurance reflects the ability of the heart, lungs, and circulatory system to work effectively and efficiently during continuous physical activity involving muscle groups at a certain intensity (zeiher et al., 2019). good cardiovascular endurance allows a person to engage in highintensity activities for longer periods without becoming easily fatigued. this is due to the well-trained heart, lungs, and blood vessels, which efficiently deliver oxygen to meet the body’s energy demands during activity (bjelica, milanović, aksović, zelenović, & božić, 2020). agestri, et. al. ghmj (global health management journal) 2024, vol. 7, no. 4 232 correlation between physical activity and cardiovascular endurance in this study, the spearman correlation test between physical activity and cardiovascular endurance showed a statistically significant result with p = 0.034 (<0.05) and r = 0.242, which means there is a weak positive correlation. this finding is consistent with (setiawan, 2021) study on 35 back office employees at rs omni alam sutera, which found a correlation between physical activity and cardiovascular endurance with a p-value of 0.024. however, this study's results differ from (wardani, 2021) study on 32 residents of puri bolon indah aged 28-35, which reported a p-value <0.001 and a higher correlation coefficient of r = 0.762, indicating a strong correlation between physical activity and cardiovascular endurance. adequate intensity and frequency of physical activity can impact an individual's cardiovascular endurance. intensity refers to the amount of weight or force required for the work or load performed, while frequency refers to how often a person engages in specific activities or work that requires muscle use. high frequency of physical activity ultimately leads to muscle strengthening, including the heart muscle, allowing the heart to work more efficiently with each contraction and pump blood more effectively, delivering necessary oxygen to cells during activity. this results in better energy fulfilment and reduced fatigue (bjelica et al., 2020). result of this study indicate a positive correlation between physical activity and cardiovascular endurance, meaning that higher physical activity is associated with higher cardiovascular endurance. the weak strength of the correlation between the two variables in this study suggests that other factors may influence the cardiovascular endurance of employees at universitas swadaya gunung jati. one such factor could be the high duration of sedentary behavior among these employees. data shows that the maximum sedentary time among ugj employees is 960 minutes (16 hours). sedentary behavior is negatively related to vo2max, which determines cardiovascular endurance (prince et al., 2024). excessive sedentary behavior is also known as a risk factor for cardiovascular disease, particularly in populations with low or moderate physical activity (lavie, ozemek, carbone, katzmarzyk, & blair, 2019). this study analyzed the correlation between sedentary behavior and cardiovascular endurance. the analytical statistics revealed that there’s no significant correlation between sedentary behavior and cardiovascular endurance among the employees of universitas swadaya gunung jati. other factors that may contribute to cardiovascular endurance include smoking habits and bmi. smoking negatively affects health as it increases blood pressure, heart rate, and the risk of coronary thrombosis, ultimately reducing the heart's ability to pump blood and supply oxygen and energy to body cells, leading to increased fatigue and decreased cardiovascular endurance (arifin et al., 2024). this study showed that smoking has a significant correlation with cardiovascular endurance among employees of universitas swadaya gunung jati with p = 0.003 and r = 0.338. another factor influencing cardiovascular endurance is body mass index (bmi), which includes body fat levels. previous study by (damayanti, 2021) discovered a significant correlation between body fat levels and cardiovascular endurance (p = 0.001). high body fat levels are known to negatively affect cardiovascular endurance because they can increase the workload on the heart and reduce diastolic filling, resulting in decreased vo2max capacity. this study also found a significant negative correlation between bmi and cardiovascular endurance among the employees of swadaya gunung jati, with p = 0.008 and r = -0.302, indicating a negative correlation between cardiovascular endurance. study limitations this study has several limitations, including the use of a study design that prevents establishing the causality of the variables. another limitation is that physical activity data were only obtained through questionnaire making it very possible to have self-reported bias, and this study only had a specific focus on employees at a single institution, which may limit generalizability. 233 ghmj (global health management journal) 2024, vol. 7, no. 4 agestri, et. al. 5. conclusion this study found a significant correlation between physical activity, bmi, and smoking, with cardiovascular endurance of the employees in universitas swadaya gunung jati, cirebon, indonesia. however, due to the cross sectional design of the study, the causality of the variables could not be addressed clearly. in addition, although there may be potential biases associated with self-reported data from the questionnaire, it is still important to consider the results of this study by conducting health promotion or practical interventions, such as implementing daily exercise practices at work. maintaining a healthy lifestyle, including doing more physical activity as recommended, weight management, and avoiding smoking habits could help improve cardiovascular health in workplace settings. universitas swadaya gunung jati could establish regular physical activity breaks and an-anti smoking program to enhance employee wellness and cardiovascular endurance suggestions for further researchers as a follow-up to this study, we recommend conducting a statistical analysis to identify potential factors influencing cardiovascular endurance that this study did not identify. different methods, such as experimental methods to compare cardiovascular endurance among different populations, longitudinal studies for a better understanding for the causal relationships, or taking a larger population sample can be carried out for further research. conflict of interest authors declared no conflict of interest on the findings and the publication. references arifin, d. z., aminarista, a., & rahman, l. h. (2024). gambaran perilaku merokok, tekanan darah dan tingkat kebugaran jasmani pada pekerja. journal of holistic community service, 1(2), 50-53. https://doi.org/10.51873/jhcs.v1i2.36 bjelica, b., milanović, l., aksović, n., zelenović, m., & božić, d. (2020). effects of physical activity to cardiorespiratory changes. turkish journal of kinesiology, 6(4), 164-174. https://doi.org/10.31459/turkjkin.832955 cheng, j. c., chiu, c. y., & su, t. j. (2019). training and evaluation of human cardiorespiratory endurance based on a fuzzy algorithm. international journal of environmental research and public health, 16(13). https://doi.org/10.3390/ijerph16132390 damayanti, c., & adriani, m. (2021). correlation between percentage of body fat with speed and cardiorespiratory endurance among futsal athletes in surabaya. national nutrition journal, 16(1), 53-61. https://doi.org/10.20473/mgi.v16i1.53-61 ekelund, u., brown, w. j., steene-johannessen, j., fagerland, m. w., owen, n., powell, k. e., … lee, i. m. (2019, july 1). do the associations of sedentary behavior with cardiovascular disease mortality and cancer mortality differ by physical activity level? a systematic review and harmonised meta-analysis of data from 850 060 participants. british journal of sports medicine. bmj publishing group. https://doi.org/10.1136/bjsports-2017-098963 ezzatvar, y., izquierdo, m., núñez, j., calatayud, j., ramírez-vélez, r., & garcía-hermoso, a. (2021, december 1). cardiorespiratory fitness measured with cardiopulmonary exercise testing and mortality in patients with cardiovascular disease: a systematic review and meta-analysis. journal of sport and health science. elsevier b.v. https://doi.org/10.1016/j.jshs.2021.06.004 franklin, b. a., eijsvogels, t. m. h., pandey, a., quindry, j., & toth, p. p. (2022, december 1). physical activity, cardiorespiratory fitness, and cardiovascular health: a clinical practice statement of the aspc part i: bioenergetics, contemporary physical activity recommendations, benefits, risks, extreme exercise regimens, potential maladaptations. american journal of preventive cardiology. elsevier b.v. https://doi.org/10.1016/j.ajpc.2022.100424 hartati, i., & syafaruddin. (2020). physical fitness profile of universitas sriwijaya using harvard step test. jeon, h. g., kim, g., jeong, h. s., & so, w. y. (2021). association between cigarette smoking and physical fitness level of korean adults and the elderly. healthcare (switzerland), 9(2). https://doi.org/10.3390/healthcare9020185 kim, j. s., oh, j. s., & kim, s. g. (2024). assessing maximal oxygen uptake: influence of leg length in the harvard step test and queen's college step test. wseas transactions on biology and biomedicine, 21, 227-233. https://doi.org/10.37394/23208.2024.21.23 kusuma, m. n. h., syafei, m., & rilastiyo, d. (2019). the effect of nutritional status, level of physical activity and hemoglobins on physical endurance. juara : jurnal olahraga, https://doi.org/10.33222/juara.v4i2.607 laporan riset kesehatan dasar 2018. (2018). jakarta : badan penelitian dan pengembangan kesehatan, departemen https://doi.org/10.51873/jhcs.v1i2.36 https://doi.org/10.31459/turkjkin.832955 https://doi.org/10.3390/ijerph16132390 https://doi.org/10.20473/mgi.v16i1.53-61 https://doi.org/10.1136/bjsports-2017-098963 https://doi.org/10.1016/j.jshs.2021.06.004 https://doi.org/10.1016/j.ajpc.2022.100424 https://doi.org/10.3390/healthcare9020185 https://doi.org/10.37394/23208.2024.21.23 https://doi.org/10.33222/juara.v4i2.607 agestri, et. al. ghmj (global health management journal) 2024, vol. 7, no. 4 234 kesehatan ri. https://repository.badankebijakan.kemkes.go.id/id/eprint/3514/ lavie, c. j., ozemek, c., carbone, s., katzmarzyk, p. t., & blair, s. n. (2019, march 1). sedentary behavior, exercise, and cardiovascular health. circulation research. lippincott williams and wilkins. https://doi.org/10.1161/circresaha.118.312669 pinckard, k., baskin, k. k., & stanford, k. i. (2019, june 4). effects of exercise to improve cardiovascular health. frontiers in cardiovascular medicine. frontiers media s.a. https://doi.org/10.3389/fcvm.2019.00069 prince, s. a., dempsey, p. c., reed, j. l., rubin, l., saunders, t. j., ta, j., … lang, j. j. (2024, april 1). the effect of sedentary behavior on cardiorespiratory fitness: a systematic review and meta-analysis. sports medicine. springer science and business media deutschland gmbh. https://doi.org/10.1007/s40279-023-01986-y safi, a., cole, m., kelly, a. l., zariwala, m. g., & walker, n. c. (2022). workplace physical activity barriers and facilitators: a qualitative study based on employees physical activity levels. international journal of environmental research and public health, 19(15). https://doi.org/10.3390/ijerph19159442 setiawan, h., munawwarah, m., & wibowo, e. (2021). hubungan aktivitas fisik dengan kebugaran dan tingkat stres pada karyawan back office rumah sakit omni alam sutera dimasa pandemi covid-19. physiotherapy health science, 3(1). https://doi.org/10.22219/physiohs.v3i1.16935 singh, h., esht, v., shaphe, m. a., rathore, n., chahal, a., & kashoo, f. z. (2023). correlation between body mass index and cardiorespiratory fitness to interpret health risks among sedentary university students from northern india: a correlation study. clinical epidemiology and global health, 20. https://doi.org/10.1016/j.cegh.2023.101254 takken, t., hulzebos, h. j., schmitz, m., van ooi, p. j., van beek, g., van galen, l., … van kesteren, j. (2022). is bmi associated with cardiorespiratory fitness? a cross-sectional analysis among 8470 apparently healthy subjects aged 18-94 years from the low-lands fitness registry. journal of science in sport and exercise, 4(3), 283-289. https://doi.org/10.1007/s42978-021-00143-z tukuboya, v. t., malonda, n. s. h., & sanggelorang, y. (2020). gambaran aktivitas fisik pada tenaga pendidik dan kependidikan fakultas kesehatan masyarakat universitas sam ratulangi selama masa pandemi covid-19. jurnal kesmas, 9(6). wardani, f. s. (2021). hubungan antara aktivitas fisik dengan kebugaran jasmani pada warga di puri bolon indah. world health organization. (2019). global physical activity questionnaire analysis guide gpaq analysis guide global physical activity questionnaire (gpaq) analysis guide. retrieved from http://www.who.int/chp/steps/gpaq/en/index.html world health organization. (2020). guidelines on physical activity and sedentary behavior. world health organization. (2022, october 5). physical activity. retrieved 2 january 2024, from https://www.who.int/newsroom/fact-sheets/detail/physical-activity world heart federation. (2023, may 23). deaths from cardiovascular disease surged 60% globally over the last 30 years: report. retrieved 10 january 2024, from https://world-heart-federation.org/news/deaths-from-cardiovasculardisease-surged-60-globally-over-the-last-30-years-report/ zeiher, j., ombrellaro, k. j., perumal, n., keil, t., mensink, g. b. m., & finger, j. d. (2019, december 1). correlates and determinants of cardiorespiratory fitness in adults: a systematic review. sports medicine open. springer. https://doi.org/10.1186/s40798-019-0211-2 cite this article as: agestri, s. c. a., sriwiyati, k., & syah, p. a. (2024). correlation between physical activity and cardiovascular endurance of the employees in universitas swadaya gunung jati, cirebon, indonesia. ghmj (global health management journal), 7(4), 227–234. https://doi.org/10.35898/ghmj-741094 https://repository.badankebijakan.kemkes.go.id/id/eprint/3514/ https://doi.org/10.1161/circresaha.118.312669 https://doi.org/10.3389/fcvm.2019.00069 https://doi.org/10.1007/s40279-023-01986-y https://doi.org/10.3390/ijerph19159442 https://doi.org/10.22219/physiohs.v3i1.16935 https://doi.org/10.1016/j.cegh.2023.101254 https://doi.org/10.1007/s42978-021-00143-z http://www.who.int/chp/steps/gpaq/en/index.html https://www.who.int/news-room/fact-sheets/detail/physical-activity https://www.who.int/news-room/fact-sheets/detail/physical-activity https://world-heart-federation.org/news/deaths-from-cardiovascular-disease-surged-60-globally-over-the-last-30-years-report/ https://world-heart-federation.org/news/deaths-from-cardiovascular-disease-surged-60-globally-over-the-last-30-years-report/ https://doi.org/10.1186/s40798-019-0211-2 https://doi.org/10.35898/ghmj-741094 indonesian scholars’ alliance ghmj (global health management journal) 2025, vol. 8, no. 1s open access research article the 1st cirebon international health symposium: faculty of medicine, universitas swadaya gunung jati update on non-communicable diseases: global perspective on health challenges and innovation potassium inwardly rectifying channel subfamily j member 11 (kcnj11) rs5219 gene polymorphism as a risk factor for type 2 diabetes mellitus in indonesia: a case control study annisa septiani putri* , tiar masykuroh pratamawati2 , donny nauphar2 1. faculty of medicine, universitas swadaya gunung jati, indonesia; 2. departement of genetics, faculty of medicine universitas swadaya gunung jati, indonesia. *corresponding author’s e-mail: septiania398@gmail.com doi: 10.35898/ghmj-81s1160 abstract background: diabetes mellitus (dm) is a chronic metabolic disease caused by the failure of the pancreas to produce the hormone insulin or ineffective use of the hormone insulin. it is estimated that 537 million adults aged 20-79 years worldwide suffer from dm. genetics is one of the risk factors involved in the pathophysiology of type 2 dm. the kcnj11 gene encodes the kir6.2 protein that is responsible for adenosine triphosphate-sensitive potassium ion channels (katp) synthesis in pancreatic beta cells plasma membrane. aims: this study aims to examine the kcnj11 rs5219 gene polymorphism as a risk factor for type 2 diabetes mellitus in cirebon population. methods: this case control study involved 29 cases of type 2 diabetes mellitus and 29 healthy controls with purposive sampling technique. sample data was obtained through the examination of blood sugar, dna extraction, pcr-rflp with eco24i restriction enzyme, then visualization of the results with gel electrophoresis. results: the frequency of g allele was found more in the case group (70%) while the frequency of a allele was found more in the control group (38%). the frequency of heterozygous ga genotype was found more in the control group (48.3%) and the frequency of homozygous mutant aa genotype was more in the case group (17.2%) compared to the control group (13.8%). chi-square test results obtained p-value 0.115, or value 2.318. conclusion: this study showed no significant association between potassium inwardly rectifying channel subfamily j member 11 (kcnj11) rs5219 gene polymorphism and the incidence of type 2 diabetes mellitus in cirebon population. keywords: kcnj11 gene; rs5219 polymorphism; type 2 diabetes mellitus. received: 29 december 2024 reviewed: 08 february 2025 revised: 10 march 2025 accepted: 30 april 2025. © 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:septiania398@gmail.com https://doi.org/10.35898/ghmj-81s1160 https://orcid.org/0009-0009-8098-6634 https://orcid.org/0000-0002-2844-9307 https://orcid.org/0000-0002-8708-4715 putri, et. al. ghmj (global health management journal) 2025, vol. 8, no. 1s 136 1. introduction type 2 diabetes mellitus (t2dm) is one of the most prevalent chronic diseases worldwide, characterized by insulin resistance, impaired insulin secretion, and hyperglycemia. in recent decades, t2dm has emerged as a major public health challenge in many countries, including indonesia, where the disease burden has significantly increased. according to the international diabetes federation (idf), the prevalence of diabetes in indonesia continues to rise, driven by factors such as an aging population, urbanization, sedentary lifestyles, and dietary changes. despite the clear association with lifestyle and environmental factors, it is now well-established that genetic predisposition plays a crucial role in the development of t2dm. genetic factors, specifically gene polymorphisms, have been identified as potential contributors to the susceptibility and pathophysiology of t2dm. among these genetic determinants, the kcnj11 gene polymorphism, particularly the rs5219 variant, has gained attention for its potential involvement in the onset and progression of t2dm. the kcnj11 gene encodes for the inwardly rectifying potassium channel subfamily j member 11 (katp channel), which plays a critical role in the regulation of insulin secretion from pancreatic beta cells. the functional importance of kcnj11 lies in its ability to mediate potassium ion flow across cell membranes, contributing to the regulation of electrical activity and the maintenance of cellular excitability in response to glucose stimulation. mutations or polymorphisms within the kcnj11 gene, such as the rs5219 variant, may alter the function of the katp channel, leading to dysregulated insulin release and ultimately promoting hyperglycemia and the development of t2dm. the rs5219 polymorphism has been implicated in the pathogenesis of t2dm in various populations, with studies suggesting that individuals carrying this variant may have an increased risk of developing the disease. however, the association between kcnj11 rs5219 and t2dm risk varies across different ethnicities and populations, highlighting the need for population-specific studies. in indonesia, where genetic studies on t2dm remain relatively limited, investigating the role of kcnj11 rs5219 gene polymorphism as a potential risk factor for t2dm is essential. indonesia is a diverse country with a rich tapestry of ethnic groups, each with distinct genetic backgrounds. understanding the genetic predispositions to t2dm in the indonesian population could provide valuable insights into the disease's epidemiology and contribute to more effective prevention and treatment strategies. to date, only a few studies have explored the association between kcnj11 polymorphisms and t2dm in southeast asian populations, and even fewer have specifically focused on indonesia. therefore, conducting a case-control study to examine the relationship between kcnj11 rs5219 gene polymorphism and the risk of t2dm in indonesia is of paramount importance. previous research in other populations has shown inconsistent results regarding the role of the kcnj11 rs5219 polymorphism in t2dm susceptibility. some studies have reported a significant association between the rs5219 variant and increased t2dm risk, while others have found no such correlation. these discrepancies may be attributed to differences in study design, sample size, and population characteristics. additionally, gene-environment interactions, such as dietary habits, physical activity, and metabolic profiles, may further modulate the influence of kcnj11 polymorphisms on t2dm risk. given the complex interplay between genetic and environmental factors in t2dm, it is crucial to explore these relationships in diverse populations, including those in indonesia, to better understand the genetic underpinnings of the disease. moreover, identifying genetic risk factors such as the kcnj11 rs5219 polymorphism could have significant implications for clinical practice and public health interventions. genetic screening for t2dm susceptibility may enable the early identification of high-risk individuals, allowing for targeted prevention efforts and personalized treatment strategies. for instance, individuals with the rs5219 polymorphism may benefit from more intensive lifestyle interventions, such as dietary modifications and increased physical activity, to reduce their risk of developing t2dm. furthermore, pharmacogenomic studies have suggested that certain kcnj11 polymorphisms may influence an individual’s response to specific antidiabetic medications, such as sulfonylureas. therefore, understanding the genetic landscape of t2dm in indonesia could pave the way for more effective, tailored treatment approaches that consider a patient's genetic makeup. despite the potential significance of the kcnj11 rs5219 polymorphism in t2dm, several challenges remain in elucidating its exact role in disease pathogenesis. the complex nature of t2dm, which involves the interaction of multiple genes and environmental factors, makes it difficult to establish a clear-cut relationship between any single genetic variant and disease risk. putri, et. al. ghmj (global health management journal) 2025, vol. 8, no. 1s 137 furthermore, the genetic diversity of the indonesian population adds an additional layer of complexity to studying gene-disease associations. therefore, the kcnj11 rs5219 gene polymorphism represents a promising candidate for investigating the genetic predisposition to t2dm in indonesia. while the role of this polymorphism in t2dm has been studied in various populations, its association with the disease in the indonesian population remains largely unexplored. the focus of this study was specifically to understand how genetic factor, specifically the kcnj11 rs5219 gene, influence t2dm. the aims of this study was to examine the association between the kcnj11 rs5219 gene polymorphism as a risk factor t2dm in the indonesia population. 2. methods 2.1 patient selection this study employed a case-control observational analytic design to investigate the association between the kcnj11 rs5219 gene polymorphism and the risk of type 2 diabetes mellitus (t2dm) in an indonesian population. a total of 58 participants were recruited for the study, consisting of 29 case subjects diagnosed with t2dm and 29 control subjects without t2dm. the case subjects were selected based on a clinical diagnosis of t2dm, confirmed through medical records and a review of laboratory results indicating elevated fasting blood glucose levels and hba1c values. the control group was matched to the case group by age and sex but did not have a history of diabetes or other major metabolic disorders. inclusion criteria for both groups required participants to be of indonesian descent and aged between 30 to 65 years to ensure a relevant study cohort. written informed consent was obtained from all participants, and the study was approved by the relevant ethical review board. genomic dna was extracted from peripheral blood samples collected from all participants using a standardized extraction method. the rs5219 polymorphism in the kcnj11 gene was genotyped using polymerase chain reaction (pcr) and restriction fragment length polymorphism (rflp) analysis. the genotyping procedure involved amplifying the target gene region, followed by digestion with specific restriction enzymes to identify the presence of the polymorphic variants. data on demographic characteristics, medical history, and lifestyle factors were collected through structured questionnaires and medical interviews. statistical analyses were performed to compare the frequency of the rs5219 polymorphism between case and control groups. odds ratios with 95% confidence intervals were calculated to assess the association between the kcnj11 polymorphism and t2dm risk. additionally, potential confounders such as age, sex, body mass index, and family history of diabetes were controlled for in the analyses to ensure robust and accurate results. 2.2 nucleic acid extraction after screening medical records and obtaining consent for sample collection, 3 ml of peripheral blood was drawn in edta for genetic analysis. the extraction kit used for blood extraction was tiangen dna/rna extraction kit. dna concentration was assessed using a maestrogen maestronano pro spectrophotometer. then, the extracted dna was stored at -20°c. 2.3 genetic analysis dna amplification was performed using a biorad t100 thermal cycler with forward primer: 5'-gac tct gca gtg agg ccc ta-3' and reverse primer: 5'-acg ttg cag ttg cct ttc tt-3'. the amplification protocol included denaturation at 95° for 5 minutes, 35 cycles consisting of 95° for 30 seconds, 60° for 30 seconds, 72° for 30 seconds, 72° for 9 minutes, and ending with 25° for infinity hold. a 1.5% gel electrophoresis confirmed the 178 bp pcr product using a biorad geldoc ez imager, to ensure that the dna had been amplified. after amplification, the product was cut with banii restriction enzyme. the restriction results were analyzed with a 1.5% agarose gel to observe rflp. the expected results on the agarose gel were genotypes gg (homozygous wildtype) cut to 28bp and 150bp, ga (heterozygous mutant) cut to 28bp, 150bp, and 178bp, and aa (homozygous mutant) cut to 178bp. putri, et. al. ghmj (global health management journal) 2025, vol. 8, no. 1s 138 2.4 data analysis the frequency of each genotype and allele was calculated and presented as a percentage. to determine the association between independent and dependent variables, univariate analysis was used to look at the distribution of genotypes and alleles in the kcnj11 snp rs5219 gene. the polymorphism at rs5219 g/a with type 2 dm was evaluated using contingency test with 2x2 table to obtain odds ratio and p-value. gambar 1 ilustrasi skema alur kerja penelitian 3. results 3.1 respondent characteristics table 1 provides a comprehensive breakdown of the characteristics of study participants by sex, presence of type 2 diabetes mellitus (t2dm), age group, and duration of t2dm. in the case group, there were 4 male participants and 25 female participants, making up 13.8% and 86.2% of the group, respectively. this indicates a predominantly female sample among those diagnosed with t2dm in the study. conversely, the control group comprised 17 males and 12 females, constituting 58.6% and 41.4% of the control subjects. the significant disparity between the sex distribution of the case and control groups suggests that the study might need to account for sex-related differences in t2dm prevalence and its impact on the study outcomes. the table clearly distinguishes between case and control subjects based on the presence of t2dm. in the case group, all 29 participants were diagnosed with t2dm, representing 100% of this group. this aligns with the study’s objective to analyze genetic factors specifically in individuals with t2dm. on the other hand, all 29 participants in the control group did not have t2dm, also representing 100% of this group. the complete segregation of t2dm status between the two groups ensures that any observed associations with the kcnj11 rs5219 polymorphism are specific to the disease group, providing clarity and focus to the analysis. age distribution in both case and control groups shows notable differences. among the case subjects, 5 participants (17.2%) were aged 30-44 years, 15 participants (51.7%) were aged 45-59 years, and 9 participants (31%) were aged 60-74 years. this distribution suggests a higher concentration of t2dm cases in the middle-aged to older age groups, which is consistent with the known epidemiology of t2dm, where the risk increases with age. in contrast, the control group had 9 participants (31%) in the 30-44 year age range, 16 participants (55.2%) in the 45-59 year range, and 4 participants (13.8%) in the 60-74 year range. the higher proportion of younger individuals in the control group compared to the case group may reflect age-related differences in disease onset and prevalence. the duration of t2dm disease among the case subjects was categorized into two ranges: 1-10 years and 11-20 years. out of the 29 case participants, 22 (75.9%) had been diagnosed with t2dm for 1-10 years, while 7 (24.1%) had the disease for 11-20 years. this indicates a predominance of relatively shorter disease patient selection dna extraction dna concentratio & purity check polymerase chain reaction amplicon visualization with agarose gel electrophoresis restriction enzyme digestion of amplicons digestion visualization with agarose gel electrophoresis data analysis putri, et. al. ghmj (global health management journal) 2025, vol. 8, no. 1s 139 duration among the case subjects, which may have implications for understanding the disease progression and its association with genetic factors. for the control group, there was no data provided on the duration of t2dm, as expected, since these participants did not have the disease. when comparing the characteristics between the case and control groups, several patterns emerge. the case group is notably older on average and has a higher proportion of females compared to the control group. this reflects the epidemiological trends of t2dm, where the disease is more prevalent in older adults and potentially more common among females in the studied population. the absence of data on the duration of t2dm disease in the control group emphasizes the focus on individuals with established t2dm for the genetic analysis. the observed differences in age, sex, and disease duration between the case and control groups are crucial for interpreting the study’s findings. the age and sex distribution may affect the generalizability of the results and highlight the need for considering these factors in the analysis of genetic polymorphisms. the predominance of females in the case group and the older age range suggest that these variables might interact with genetic risk factors in influencing the development of t2dm. it is important to recognize potential biases in the study based on the characteristics of the participants. the imbalance in sex distribution between the case and control groups could introduce bias if sex is an influential factor in the risk of t2dm. additionally, the higher average age of the case group may reflect a longer exposure to risk factors associated with t2dm, which could affect the interpretation of the genetic associations studied. future research should consider addressing the limitations identified in this table, such as balancing the sex distribution and including a more diverse age range. additional studies with larger sample sizes and more detailed demographic information will help to confirm the associations between kcnj11 polymorphisms and t2dm risk and provide a more comprehensive understanding of how these factors interact. in summary, table 1 provides a detailed overview of the demographic and clinical characteristics of the study participants, highlighting significant differences between case and control groups. these differences underscore the importance of carefully considering participant characteristics in genetic research and offer valuable insights for interpreting the study’s findings. (table 1). table 1 subject characteristics based on age, sex, t2dm disease, and duration of t2dm disease case control n % n n sex male female total 4 25 29 13,8% 86,2% 100% 17 12 29 58,6% 41,4% 100% t2dm disease yes no total 29 29 100% 100% 29 29 100% 100% age 30-44 45-59 60-74 total 5 15 9 29 17,2% 51,7% 31% 100% 9 16 4 29 31% 55,2% 13,8% 100% duration of t2dm disease 1-10 year 11-20 year total 22 7 29 75,9% 24,1% 100% 29 100% putri, et. al. ghmj (global health management journal) 2025, vol. 8, no. 1s 140 3.2 genotypic data the pcr amplification results are presented in figure 2(a), which shows a band at 178bp from ka 27-29, ka 04 and ka 16, which corresponds to control samples 27-29, control 04 and 06, respectively. the restriction enzyme results are shown in figure 2(b). furthermore, the uncut bands at 150bp and 28bp indicate the presence of the g allele, while the cut band at 178bp indicates the presence of the a allele. in figure 2(b), subject ca 04 has bands at 178bp, 150bp and 28bp, indicating the ga genotype. the genetic factors behind type 2 dm are believed to be multiple and complex. the kcnj11 gene encodes an inward-rectifier potassium ion channel (kir6.2). the kir6.2 protein, together with the high-affinity sulfonylurea receptor 1 (sur1), forms the katp channel. sur1 is encoded by the abcc8 gene located next to the kcnj11 gene. kir6.2 protein is a 390 amino acid protein with two transmembrane domains (m1 and m2) and intracellular n and c terminals. structurally, the kir6.2 tetramer forms a pore and four high-affinity sur1 subunits surround the pore of the katp channel located in the plasma membrane of pancreatic beta cells. this channel modulates insulin production and secretion through glucose metabolism.(haghvirdizadeh et al., 2015) figure 2. (a) pcr amplification results and (b) restriction enzyme digestion results. line ladder: 100bp dna ladder. figure 2(a) shows the pcr amplification result of 178bp before restriction enzyme (ka27, ka28, ka29, ka30, ka04, ka06). figure 2(b) shows line code ca: pcr-rflp samples no.4,9-16,18. line ca 09 & 12: genotype gg (wildtype homozygote). line ca 13: genotype aa (homozygote mutant). line ca 04,10,11,14-16,18: genotype ga (heterozygote mutant). putri, et. al. ghmj (global health management journal) 2025, vol. 8, no. 1s 141 the kcnj11 gene snps that have been detected include rs5219, which has received more attention due to its association with diabetes. the kcnj11 gene polymorphism rs5219 is caused by a guanine to adenine substitution at codon 23, which changes the amino acid glutamate to the amino acid lysine at codon 23 (glu23lyn) at the end of the kir6.2 protein and thus inhibits glucose-induced insulin secretion. these changes reduce the sensitivity of potassium channels to atp molecules, resulting in excessive channel activity and further inhibiting insulin secretion. (makhzoom et al., 2019) this study aims to serve as a knowledge base in indonesia by investigating the relationship between the kcnj11 rs5219 gene and type 2 dm through blood glucose levels. the results showed that the control group had more rs5219 g/a polymorphisms (38%), while the case group had less at 30%, as presented in table 2. examination of the frequency of rs5219 g/a snp genotypes in the case group showed 17 (58.6%) gg genotypes, 7 (24.1%) ga, and 5 (17.2%) aa genotypes. meanwhile, the control group had 11 (37.9%) gg genotypes, 14 (48.3%) ga, and 4 (13.8%) aa genotypes, as presented in table 3. it was also found that the control group had a lower frequency of the gg genotype than the cases, accompanied by a higher frequency of the ga genotype. table 2. allele frequency distribution allele case control n % n % g 41 70% 36 62% a 17 30% 22 38% total 58 100% 58 100% table 3. genotype frequency distribution genotype case control n % n % gg 17 58,6% 11 37,9% ga 7 24,1% 14 48,3% aa 5 17,2% 4 13,8% total 29 100% 29 100% 3.3 association of kcnj11 rs5219 gene polymorphism and type 2 diabetes mellitus the results of bivariate analysis in table 4 show that the case group has fewer rs5219 polymorphisms, namely 12 subjects (41.4%) and 17 subjects (58.6%) who do not have polymorphisms. whereas in the control group, there were 18 subjects (62.1%) who had polymorphisms and 11 subjects (37.9%) who did not have polymorphisms. the chi-square test results obtained a p-value of 0.115 which means there is no significant relationship. the results of further analysis obtained an or value of 2.318 and a ci value of 0.809-6.644 in this study. table 4. association of kcnj11 rs5219 gene polymorphism and type 2 dm polymorphism case control p or ci (95%) n % n % + 12 17 41,4% 58,6% 18 11 62,1% 37,9% 0,115 2,318 0,809-6,644 total 29 100% 29 100% putri, et. al. ghmj (global health management journal) 2025, vol. 8, no. 1s 142 4. discussion type 2 diabetes mellitus (t2dm) accounts for approximately 85-95% of all diabetes cases, making it a major health problem worldwide and leaving a heavy burden on the global economy. type 2 dm is a progressive hyperglycemic disease initially characterized by decreased sensitivity of peripheral tissues to plasma insulin, accompanied by gradual failure of pancreatic β-cells to maintain glucose homeostasis. (li et al., 2020) various environmental factors, advanced age, high body mass index (bmi), diet, lack of exercise, smoking, abnormal serum levels, genetics and their complex interactions are involved in the development of type 2 dm. (alqadri, 2022) genome-wide association studies (gwas) have recently identified more than 100 susceptibility loci for type 2 dm and identified various genetic markers significantly associated with type 2 dm. (aka et al., 2021) one of the polymorphisms in the kcnj11 gene that affects genetic expression is snp rs5219. several studies have observed the association between the kcnj11 rs5219 gene polymorphism and the risk of type 2 dm. however, there are inconsistent results in previous studies in asian populations. (keshavarz et al., 2014) the results obtained in this study were an odds ratio (or) of 2.318, meaning that someone who has the kcnj11 rs5219 gene polymorphism has a risk factor for the incidence of type 2 dm as much as 2.318 times greater than people who do not have the kcnj11 rs5219 gene polymorphism, although statistically the results of the chi-square test obtained a p-value of 0.115 concluded that there was no significant relationship between the kcnj11 rs5219 gene polymorphism and the incidence of type 2 dm, accompanied by a confidence interval (ci 95% = 0.809-6.644) between the kcnj11 rs5219 gene polymorphism and type 2 dm disease. the results of this study are in line with studies conducted in the population of northeast mexico and south india, where no association was found between the kcnj11 rs5219 gene polymorphism and type 2 dm, with a p-value >0.05. (gallardo-blanco et al., 2017; phani et al., 2014) however, this is in contrast to a casecontrol study in the syrian population and a meta-analysis in the american, east asian, european, and greater middle eastern populations that showed rs5219 in the kcnj11 gene was involved in the risk of type 2 dm with a p-value of 0.035. (makhzoom et al., 2019; moazzam-jazi et al., 2022) it is known that type 2 dm is a complex disorder caused by the interaction of several environmental factors and genetic factors, and the influence of the same genetic factors on the development of type 2 dm disease is not the same in humans, due to differences in environment and lifestyle. so variations from previous studies can occur. (makhzoom et al., 2019) therefore, it is recommended that future studies be conducted using larger samples and different populations in indonesia. this study also has limitations, namely not assessing other risk factors that can affect type 2 dm such as bmi, family history of dm, and lifestyle factors. in addition, this study did not calculate the hardy-weinberg balance, and did not report the genotype distribution model due to sample limitations. 5. conclusion in conclusion, approximately 62.1% of participants in this study who did not have type 2 dm had the kcnj11 rs5219 g/a gene polymorphism. in the case group, the distribution of rs5219 g/a snp genotypes was 17 (58.6%), 7 (24.1%), and 5 (17.2%) with gg, ga, and aa genotypes, respectively. in the control group, the breakdown was 11 (37.9%), 14 (48.3%), and 4 (13.8%) for the gg, ga, and aa genotypes regarding the rs5219 g/a snp genotype. statistical analysis showed an insignificant association between the kcnj11 rs5219 g/t gene polymorphism and type 2 dm. however, the odds ratio value showed that individuals with the kcnj11 rs5219 g/a gene polymorphism were 2.3 times more likely to develop type 2 dm. to present a more comprehensive understanding of the risk that is likely to occur in the indonesian population, future studies should include more subjects in this demographic to accurately determine allele frequencies. putri, et. al. ghmj (global health management journal) 2025, vol. 8, no. 1s 143 recommendation based on the results of this study, several important recommendations are proposed to strengthen the analysis of the association between kcnj11 gene polymorphisms and the risk of type 2 diabetes mellitus (t2dm). first, an increase in sample size is necessary to improve the statistical power and reliability of the results. larger samples will produce more representative data, strengthen the validity of conclusions, and allow more accurate detection of genetic variation and other factors that influence t2dm risk. second, balancing the sex distribution between case and control groups is a crucial aspect to reduce potential bias in the analysis of genetic risk factors. third, future studies are recommended to consider confounding variables in more detail, including lifestyle factors and family history, to provide a more comprehensive understanding of the interaction between genetics and environment in the development of t2dm. finally, the implementation of longitudinal studies may provide greater insight into the role of the kcnj11 gene polymorphism in the progression of t2dm over time, allowing observation of changes in genetic, physiological, and lifestyle factors that influence the course of the disease. by adopting these recommendations, future research is expected to yield a more comprehensive understanding and more reliable findings regarding the relationship between kcnj11 gene polymorphisms and t2dm, which in turn may contribute to the development of more effective preventive and therapeutic strategies. conflict of interest the authors are grateful to the universitas swadaya gunung jati 2024 internal research fund for funding this study. references aka, t. das, saha, u., shati, s. a., aziz, m. a., begum, m., hussain, m. s., millat, m. s., uddin, m. s., & islam, m. s. (2021). risk of type 2 diabetes mellitus and cardiovascular complications in kcnj11, hhex and slc30a8 genetic polymorphisms carriers: a case-control study. heliyon, 7(11). https://doi.org/10.1016/j.heliyon.2021.e08376 alqadri, n. (2022). independent case-control study in kcnj11 gene polymorphism with type 2 diabetes mellitus. saudi journal of biological sciences, 29(4), 2794–2799. https://doi.org/10.1016/j.sjbs.2022.01.008 gallardo-blanco, h. l., villarreal-perez, j. z., cerda-flores, r. m., figueroa, a., sanchez-dominguez, c. n., gutierrez-valverde, j. m., torres-muñoz, i. c., lavalle-gonzalez, f. j., gallegos-cabriales, e. c., & martinez-garza, l. e. (2017). genetic variants in kcnj11, tcf7l2 and hnf4a are associated with type 2 diabetes, bmi and dyslipidemia in families of northeastern mexico: a pilot study. experimental and therapeutic medicine, 13(2), 523–529. https://doi.org/10.3892/etm.2016.3990 haghvirdizadeh, p., mohamed, z., abdullah, n. a., haghvirdizadeh, p., haerian, m. s., & haerian, b. s. (2015). kcnj11: genetic polymorphisms and risk of diabetes mellitus. journal of diabetes research, 2015. https://doi.org/10.1155/2015/908152 keshavarz, p., habibipour, r., ghasemi, m., kazemnezhad, e., alizadeh, m., & omami, m. h. h. (2014). lack of genetic susceptibility of kcnj11 e23k polymorphism with risk of type 2 diabetes in an iranian population. endocrine research, 39(3), 120–125. https://doi.org/10.3109/07435800.2013.860607 li, y., shen, k., li, c., yang, y., yang, m., tao, w., he, s., shi, l., & yao, y. (2020). identifying the association between single nucleotide polymorphisms in kcnq1, arap1, and kcnj11 and type 2 diabetes mellitus in a chinese population. international journal of medical sciences, 17(15), 2379–2386. https://doi.org/10.7150/ijms.48072 makhzoom, o., kabalan, y., & al-quobaili, f. (2019). association of kcnj11 rs5219 gene polymorphism with type 2 diabetes mellitus in a population of syria: a case-control study. bmc medical genetics, 20(1). https://doi.org/10.1186/s12881-0190846-3 moazzam-jazi, m., najd-hassan-bonab, l., masjoudi, s., tohidi, m., hedayati, m., azizi, f., & daneshpour, m. s. (2022). risk of type 2 diabetes and kcnj11 gene polymorphisms: a nested case–control study and meta-analysis. scientific reports, 12(1). https://doi.org/10.1038/s41598-022-24931-x phani, n. m., guddattu, v., bellampalli, r., seenappa, v., adhikari, p., nagri, s. k., d’souza, s. c., mundyat, g. p., satyamoorthy, k., & rai, p. s. (2014). population specific impact of genetic variants in kcnj11 gene to type 2 diabetes: a case-control and meta-analysis study. plos one, 9(9). https://doi.org/10.1371/journal.pone.0107021 cite this article as: putri, a. s. p., pratamawati, t. m., & nauphar, d. (2025). potassium inwardly rectifying channel subfamily j member 11 (kcnj11) rs5219 gene polymorphism as a risk factor for type 2 diabetes mellitus in indonesia: a case control study. ghmj (global health management journal), 8(1s), 135– 143. https://doi.org/10.35898/ghmj-81s1160 https://doi.org/10.1016/j.heliyon.2021.e08376 https://doi.org/10.1016/j.sjbs.2022.01.008 https://doi.org/10.3892/etm.2016.3990 https://doi.org/10.1155/2015/908152 https://doi.org/10.3109/07435800.2013.860607 https://doi.org/10.7150/ijms.48072 https://doi.org/10.1186/s12881-019-0846-3 https://doi.org/10.1186/s12881-019-0846-3 https://doi.org/10.1038/s41598-022-24931-x https://doi.org/10.1371/journal.pone.0107021 https://doi.org/10.35898/ghmj-81s1160 ghmj (global health management journal) 2024, vol. 7, no. 3 indonesian scholars’ alliance © 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) open access research article disability and vulnerable groups inclusion in covid-19 policy and planning in sub-sahara african countries hussaini zandam1 , surajo kamilu sulaiman2,* , ashiru hamza mohammad3 , abdulwali sabo4 1 the lurie institute for disability policy, the heller school for social policy and management, brandeis university, waltham, ma, usa. 2 physiotherapy department, faculty of applied sciences, tishk international university, erbil, kurdistan, iraq. 3 godiya disability inclusion & development initiative, dutse, jigawa state, nigeria. 4 biostatistics and research methodology unit, school of medical sciences, universiti sains malaysia, malaysia. *corresponding author’s e-mail: surajo.sulaiman@tiu.edu.iq doi: 10.35898/ghmj-73999 abstract background: the covid-19 pandemic has caused an excess burden of disease in disabled and vulnerable populations. these populations may face an increased risk of contracting covid-19, greater demand for services and social support, and reduced access to treatment. despite various national and international efforts towards disability rights and inclusion, substantial gaps exist between disability rights legislation and its implementation. aims: to assess the inclusion of people with disability and other vulnerable groups in policy and planning documents related to the covid-19 pandemic response in sub-sahara africa. methods: we conducted content analysis using the equiframe policy analysis tool and assessed commitment to 12 vulnerable groups and 21 core human rights in policy and planning documents related to the covid-19 pandemic. we included documents on general pandemic response, stakeholder engagement, risk communication, and the covid-19 vaccine from five sub-sahara african countries, including nigeria, south africa, ethiopia, kenya, and zambia. results: the study highlights the varying degrees to which countries integrate disability, vulnerable groups, and other core human rights concepts into their covid-19 health policies and planning documents. only kenya mentioned disability in their pandemic response plan. however, all countries have explicitly mentioned disability in their stakeholder engagement plans. except for kenya, all countries have included disability in their risk communication plans. notably, south africa and zambia demonstrated extensive disability inclusion in their stakeholder engagement and vaccine plan. thus, these countries have the potential for comprehensive and inclusive health policymaking. in contrast, nigeria and ethiopia lag, therefore highlighting areas of improvement across all policy domains. conclusion: the findings emphasize the critical importance of not only mentioning disability and other vulnerable groups, but also ensuring the depth and quality of this inclusion. while there are positive strides in certain areas, there remains a consistent need for deeper and broader inclusion across all policy domains. keywords: disability, inclusion, covid-19, health policy, health services, africa. received: 10 september 2024 reviewed: 16 october 2024 revised: 03 november 2024 accepted: 05 november 2024. mailto:surajo.sulaiman@tiu.edu.iq https://doi.org/10.35898/ghmj-73999 https://orcid.org/0000-0002-4594-692x https://orcid.org/0000-0003-3927-8627 https://orcid.org/0000-0002-5063-7742 https://orcid.org/0000-0002-7630-7418 zandam, et.al. ghmj (global health management journal) 2024, vol. 7, no. 3 130 1. introduction empirical evidence shows that people with disabilities are the most vulnerable and are often overlooked in most communities, particularly in africa (mitra et al., 2013; world health organization, 2011). the continued systematic exclusion of people with disabilities, 80 percent of whom live in the global south, is perplexing given that the un 2030 agenda for sustainable development clearly mentioned the need to include people with disabilities 11 times in its text (united nations, 2018). regardless, people with disabilities are among the most marginalized populations since they endure the weight of inequity and vulnerability (banks et al., 2017; hume-nixon and kuper, 2018; jagoe et al., 2021). they are socially excluded and marginalized, with limited access to services such as healthcare, education, and employment, resulting in poverty and deprivations of safe housing, nutritious food, and healthy living, among others (banks et al., 2017; trani et al., 2018). although there have been significant national and international efforts towards disability rights and inclusion in the african continent, however, substantial gaps are still existing between legislation on disability rights and actions (madans et al., 2017; saran et al., 2020; undp, 2018). these gaps are generally rooted in omission in policy and planning that do not explicitly recognize the rights of disabled people to inclusion, and lacking integrated inclusive implementation plans, goals, and accountability mechanisms (lang et al., 2019). covid-19 has had a significant impact on life and society in sub-sahara africa, as well as in other parts of the world. despite relatively low covid-19 mortality rates in sub-sahara africa, components of the lockdown responses, including business and school closures, and limited health-care access, which were implemented during the pandemic, have deepened the disparity experienced by vulnerable populations including disabled people (hale et al., 2021). though disaggregated national data by disability for covid-19 infections and related deaths are currently not available in most african countries, emerging evidence suggests that the pandemic disproportionately impacted these populations in so many ways including, an increased risk of poor health outcomes from the disease, restricted access to mainstream health care and rehabilitation, and the negative social consequences of pandemic mitigation efforts (shakespeare et al., 2021). in terms of health, some people with disabilities are at an increased risk of contracting and dying from covid19—some due to increased medical vulnerability and/or a lack of accessible information about prevention (e.g. sign language interpretation, online or easy-to-read information), and some because care and support needs make social isolation more difficult (ahmad et al., 2020; boyle et al., 2020). people with disabilities, particularly those living in lowand middle-income countries (lmics), face severe barriers to healthcare services and support. people with disabilities in some african countries are unable to access healthcare services, such as icu beds and ventilator access, or obtain therapeutic treatments or rehabilitation, as well as medication, during the pandemic (mckinney et al., 2020; sabatello et al., 2020). findings from situational reports in some developing countries showed about 45 percent of people with disabilities were not receiving the necessary support for safe and independent living during the covid-19 pandemic (ukaid, 2020). these individuals would not wish to return to the pandemic status quo, which was a society with numerous barriers to participation. despite recognizing the various challenges faced by the disabled population, there is limited empirical research evaluating the extent to which sub-sahara african countries have included people with disabilities in their covid-19 policy and planning documents. existing studies have begun to explore the broader context of disability inclusion in african health systems during the pandemic (engelbrecht et al., 2023; sherry et al., 2024). however, there remains a significant gap in assessing the quality and depth of this inclusion, particularly in specific policy domains such as pandemic response, stakeholder engagement, risk communication, and vaccine planning. the inclusion of people with disabilities and other vulnerable populations in covid-19 response is critical for a postcovid inclusive and accessible society, which aligns with the un 2030 agenda for sustainable development. this study assessed the extent to which disability and vulnerable populations are incorporated into the covid-19 response policy and planning documents of sub-sahara african countries with the highest number of covid-19 cases, including nigeria, south africa, ethiopia, kenya, and zambia (africa cdc, 2021). if vulnerable populations inclusion is not addressed in the policy and planning documents explicitly, there is little chance that their needs will be addressed at the stage of implementation. 131 ghmj (global health management journal) 2024, vol. 7, no. 3 zandam, et.al. 2. methods design we conducted a content analysis using the equiframe tool to evaluate the inclusion of people with disabilities and other vulnerable groups in covid-19 policy and planning documents from five sub-sahara african countries: nigeria, south africa, ethiopia, kenya, and zambia. we selected only these five countries with the highest number of covid-19 cases to generate a manageable set of data. moreover, these countries are likely to have robust policies to mitigate the impact of covid-19 in their populations. content analysis was selected as the most appropriate method for this research due to its ability to systematically and objectively analyze textual data, allowing for the identification of patterns, themes, and the presence or absence of specific content within large sets of documents (vourvachis and woodward, 2015). data sources policy and planning documents were identified through an online search including governments, relevant ministries, agencies, donors and international organizations websites, and through reviewed research articles in which covid-19 policies of each country were studied. the search was conducted up to december 2022. eligibility criteria documents were included if they were specific to covid-19 and related to pandemic actions (including pandemic response, stakeholder engagement, communication, and vaccine) and are developed by or with the governments of the selected countries for national use. textual information from the policy and planning documents were analyzed using deductive content analysis with the aid of the equiframe tool. specifically, we used the equiframe tool to evaluate the inclusion of 21 fundamental human rights principles and 12 vulnerable groups, who are potentially vulnerable to exclusion from covid-19 response and recovery. the framework equiframe is a policy analysis tool designed to evaluate the alignment of policy and planning documents with 21 fundamental human rights principles essential for universal, equitable, and accessible healthcare (maclachlan et al., 2016; mannan et al., 2011). this tool assesses how well existing policies commit to these 21 core human rights concepts and considers 12 vulnerable groups, all within the framework of universal, equitable, and accessible healthcare (supplementary file). equiframe aims to systematically evaluate and compare health policies based on their technical content and design, enabling the assessment of strengths and weaknesses in terms of their promotion of fundamental human rights for health among vulnerable groups. we used the tool to evaluate the extent to which these 21 principles were integrated into documents addressing people with disabilities and other vulnerable populations during the covid-19 response and recovery efforts. scoring indices the five summary indices of equiframe are as follows: 1. mention of disability: each document was assessed on the criteria whether disability was mentioned as a group with potential vulnerability. 2. vulnerable group coverage (vg): a policy was examined with respect to the number of vulnerable groups mentioned out of the 12 vulnerable groups identified, and this ratio was expressed as a rounded-up percentage. in addition, the actual terminologies used to describe the vulnerable groups were extracted to allow for future qualitative analysis and crosschecking between raters. 3. core concept coverage (cc): a policy was examined with respect to the number of core concepts mentioned out of the 21 core concepts identified; and this ratio was expressed as a rounded-up percentage. in addition, the actual terminologies used to explain the core concepts within each document were extracted to allow for future qualitative analysis and cross-checking between raters. zandam, et.al. ghmj (global health management journal) 2024, vol. 7, no. 3 132 4. core concept quality (ccq): a policy was examined with respect to the number of core concepts within it that were rated 3 or 4 out of the 21 core concepts identified; that is, as either stating a specific policy action or intention to monitor that action. when several references to a core concept were found to be present, the top-quality score received was recorded as the final quality scoring for the respective concept. 5. overall summary ranking (quality of the policy): each document was given an overall summary ranking in terms of it being of low, moderate, or high standing according to the following criteria: i. high = if the policy achieved ≥50% on all of the three scores above (vg, cc, ccq). ii. moderate = if the policy achieved ≥50% on two of the three scores above. iii. low = if the policy achieved <50% on two or three of the three scores above. trustworthiness and rigor ensuring the trustworthiness of content analysis is critical, particularly in policy research, where the implications of findings can influence decision-making processes. the rigor of content analysis in this study is achieved through a systematic coding process using the equiframe policy analysis tool, which evaluates the inclusion of 21 fundamental human rights principles across the selected documents. this approach is consistent with the recommendations of (elo et al., 2014), who emphasize the importance of systematic coding and the use of predefined categories to enhance the credibility and dependability of content analysis. by adhering to these methodological standards, this study ensures that the findings are robust and reliable, providing valuable insights into the degree to which sub-sahara african countries have included disability and vulnerable groups in their covid-19 policies. 3. results our document search yielded 20 documents, four each from the five included countries. the content analysis of these covid-19 policy and planning documents is presented below regarding the following specific pandemic actions: primary pandemic response, stakeholder engagement, risk communication, and vaccine rollout. covid-19 primary pandemic response and preparedness table 1 assesses the primary pandemic response plans of the five countries, focusing on their mention of disability, the coverage of vulnerable groups and core concepts, and the quality of these concepts. apart from kenya, other nations have not explicitly mentioned disability in their main pandemic response plans. south africa and zambia scored zero in terms of vulnerable group coverage, meaning that none of the vulnerable groups was included in their primary pandemic response. however, south africa, despite not mentioning disability, leads in terms of core concept coverage and quality. this suggests a broad inclusiveness of human rights concepts, even if disability and other vulnerable groups are not directly addressed. zambia lags in all metrics. covid-19 stakeholder engagement plan table 2 presents the stakeholder engagement plans of the countries, highlighting the importance of inclusive policymaking and planning by considering various stakeholders, including persons with disabilities. all countries have explicitly mentioned disability in their stakeholder engagement plans. however, kenya, zambia, and south africa stand out with high-quality policies, thus implying inclusivity and depth in their policymaking and planning. despite nigeria having high vg% and cc% coverages, its ccq% pulls its overall quality to a moderate rating, this shows lack of specific policy action or intention to monitor that action in nigeria’s stakeholder engagement plan. on the other hand, ethiopia lags in all metrics. 133 ghmj (global health management journal) 2024, vol. 7, no. 3 zandam, et.al. table 1: assessment of covid-19 primary pandemic response and preparedness by countries document disability vg% cc% ccq% quality of the policy 1 nigeria national covid-19 pandemic multi-sectoral response plan, 2020 no 17 38 45 low 2 kenya covid-19 emergency response plan, 2020 yes 33 44 47 low 3 south africa preparedness and response plan for novel coronavirus, 2020 no 0 52 68 moderate 4 ethiopia national emergency preparedness and response plan for covid-19, 2020 no 50 33 42 low 5 zambia covid-19 emergency response and health system preparedness plan, 2020 no 0 15 35 low note: vg= vulnerable group coverage, cc= core concept coverage, ccq=core concept quality table 2: assessment of covid-19 stakeholder engagement plan and by countries document disability vg% cc% ccq% quality of the policy 1 nigeria stakeholder’s engagement plan (sep), 2020 yes 83 71 45 moderate 2 kenya stakeholder engagement plan (sep), 2020 yes 75 62 57 high 3 south africa stakeholder engagement plan (sep), 2020 yes 58 75 57 high 4 ethiopia covid-19 emergency response project: stakeholder engagement plan (sep), 2020 yes 42 38 33 low 5 zambia covid-19 emergency stakeholder engagement plan (sep), 2020 yes 75 62 57 high note: vg= vulnerable group coverage, cc= core concept coverage, ccq=core concept quality covid-19 risk communication plan table 3 delves into the risk communication strategies of the five countries. most countries have highlighted disability in their strategies, with kenya being a notable exception. however, the overall "high" rating of kenya's policy suggests strengths in other areas of risk communication. ethiopia, which includes a mention of disability, also stands out with its "high" rating, reflecting a comprehensive approach to risk communication. nigeria scores the highest in vg%, and its cc% and ccq% are also good, thus implying an inclusive approach to risk communication and deployment of specific policy action or commitment to monitor that action in nigeria’s risk communication plan. south africa, despite a good cc% score, lags in vg% and ccq%, which affects its overall rating, therefore lagging behind the four countries. thus, south africa low vg% implies lack of inclusion in its risk communication plan while low ccq% demonstrates lack of specific policy action or intention to monitor that action in south africa’s risk communication plan. zandam, et.al. ghmj (global health management journal) 2024, vol. 7, no. 3 134 table 3: assessment of covid-19 risk communication plan by countries document disability vg% cc% ccq% quality of the policy 1 nigeria risk communication and community engagement strategy, 2020 yes 83 71 52 high 2 kenya national communication and community engagement for corona virus, 2020 no 58 71 57 high 3 south africa government communication strategy on covid-19, 2020 yes 25 52 38 low 4 ethiopia risk communication and community engagement strategy on covid-19, 2020 yes 58 57 61 high 5 zambia risk communication and community engagement strategy on covid-19, 2020 yes 58 52 48 moderate note: vg= vulnerable group coverage, cc= core concept coverage, ccq=core concept quality covid-19 vaccine plan table 4 scrutinizes the vaccine policies and deployment plans of the countries. nigeria and ethiopia have not mentioned disability in their vaccine policies or deployment plans, highlighting lack of inclusivity in their policies. south africa's vaccine policy stands out as the most comprehensive and of high quality, showing a remarkable inclusion of disabled and other vulnerable groups, in addition to provision of specific policy action or commitment to monitor that action in their vaccine plan. despite zambia's moderate scores in vg%, cc%, and ccq%, its overall policy is rated high due to inclusivity and availability of specific policy action in their vaccine plan. on the other hand, nigeria's policy is notably lacking in all metrics. this shows lack of inclusivity and specific policy action in nigeria’s vaccine plan. table 4: assessment of covid-19 vaccine plan countries document disability vg% cc% ccq% quality of the policy 1 nigeria vaccine policy, 2021 no 0 33 10 low 2 kenya national covid-19 vaccine deployment plan, 2021 yes 50 54 42 moderate 3 south africa covid-19: vaccine strategy, 2021 yes 83 85 75 high 4 ethiopia national implementation guideline for expanded program on immunization, 2021 no 25 43 33 low 5 zambia national covid-19 vaccine deployment plan, 2021 yes 58 57 57 high note: vg= vulnerable group coverage, cc= core concept coverage, ccq=core concept quality 135 ghmj (global health management journal) 2024, vol. 7, no. 3 zandam, et.al. 4. discussion disability inclusion is paramount, especially during health emergencies, as people with disabilities might face unique challenges that need to be addressed. inclusion of people with disabilities and other vulnerable groups in covid-19 response planning is crucial to ensure that the needs of all individuals are addressed and no one is left behind (banks et al., 2021; gashaw et al., 2021; oliveira et al., 2022). this study provide important insights into the quality of policies related to the covid-19 pandemic in the five african countries with highest number of covid-19 cases during the pandemic (africa cdc, 2021). our finding shows significant policy implications for disabled and vulnerable populations. it was discerned that the mention of disability and other vulnerable groups and quality assessments varied across the countries. one of the most striking observations across the countries is the inconsistent mention of disability in the various policy and planning documents. for instance, kenya stands out in its covid-19 primary pandemic response plan by including disability. however, its omission in the risk communication document is a concern. moreover, fewer vulnerable groups were included and there was no mention of a specific policy action or intention to monitor the action in kenya’s primary pandemic response. this inconsistency might lead to gaps in implementation, potentially leaving people with disabilities less informed or at greater risk. ethiopia and nigeria, especially in their vaccine policies, fail to mention disability. this oversight can have significant implications, potentially excluding persons with disabilities from equitable access to vaccines or not addressing their specific needs during vaccination drives. one plausible explanation for these inconsistencies across countries could be the lack of exclusive mention of disability and other vulnerable groups or failure to identify specific policy action and commitment to implement and monitor that action. mere mention of disability or vulnerable groups isn't sufficient. the depth of inclusion, as evidenced by the core concept coverage and quality, is crucial. for example, south africa consistently showcases robust policies, especially in their stakeholder engagement and vaccine strategy. their comprehensive approach suggests a strong commitment to human rights and inclusivity. this can position south africa as a leader in the sub-sahara african region, setting an example for an inclusive health policymaking. on the other hand, ethiopia, despite some strong points in risk communication, shows inconsistencies, especially in its stakeholder engagement plan. this suggests that while there might be efforts towards inclusive communication, broader stakeholder engagement might be lacking. this can lead to policies that do not fully address the needs or concerns of all groups. hence, people with disabilities and other vulnerable groups should be given a specific attention in policy-making to ensure their needs are met. although some countries have shown promising tendencies in inclusive policy making, nigeria for example, lags in coverage of people with disabilities and vulnerable groups in its primary pandemic response plan. this raises concerns about the potential for overlooking the unique challenges faced by these groups during the pandemic, potentially leading to inequitable health outcomes or access to resources. additionally, ethiopia, in its vaccine plan, also lags in vulnerable group coverage. this could imply a potential disconnect between policymakers and these groups, leading to policies that might not fully address the needs and priorities of people with disabilities and vulnerable populations, in their diversity, thus leaving them behind (pearce et al., 2022). the overall policy rankings serve as a snapshot of each country's commitment to inclusive and equitable health policymaking and planning. zambia, for instance, achieves a "high" ranking in its stakeholder engagement plan, suggesting robust strategies for inclusive dialogue. however, it receives a "low" ranking in its primary pandemic response plan, indicating areas of improvement in broader health policymaking. kenya shows strengths in stakeholder engagement and risk communication—despite not mentioning disability in the risk communication—but has a "low" ranking in its primary pandemic response plan. this points towards potential challenges in translating inclusive dialogue and communication into comprehensive policies. the results of this study are consistent with findings from (engelbrecht et al., 2023), which noted the inconsistent inclusion of disability in african health systems during the covid-19 pandemic. similar to their scoping review, our analysis found that while countries like south africa demonstrate a relatively comprehensive approach to inclusivity, others, such as nigeria and ethiopia, continue to lag in explicitly incorporating disability considerations in their policies. contrary to some findings in the literature, such as those by (sherry et al., 2024), which suggested that south africa had a robust framework for disability inclusion during the pandemic, our study zandam, et.al. ghmj (global health management journal) 2024, vol. 7, no. 3 136 found that while south africa performed well in risk communication and vaccine plans, it did not explicitly mention disability or included vulnerable groups in its primary pandemic response plan. this shows that even in countries with robust frameworks, there may still be critical gaps that need addressing. strengths and limitations this study provides new insights by not only identifying the presence or absence of disability inclusion but also evaluating the quality of this inclusion using the equiframe tool. our findings show that merely mentioning disability or vulnerable groups is insufficient—what matters is the depth and quality of that inclusion. this study is one of the first to apply a structured content analysis tool like the equiframe across multiple african countries’ covid-19 policies, offering a comparative perspective that was previously lacking. however, the study is not without limitations, for instance, we focused on only five countries with the highest reported cases of covid-19 during the peak of the pandemic. moreover, the use of a structured framework like the equiframe tool does not allow room for inductive analysis, and only documents that are available online were included in our analysis. hence, there is a need for further research on the quality of covid-19 policies in african countries. for instance, future studies should include a representative sample of african countries to provide a holistic picture of disability and vulnerable groups inclusion in health emergencies policies like the covid-19 pandemic. moreover, further studies should evaluate the extent to which covid-19 policies are implemented and examine the impact of these policies on disabled and vulnerable groups. recommendations overall, our findings provide important information for policymakers, researchers, and other stakeholders interested in improving the quality of covid-19 policies in african countries. policy makers should prioritize the explicit and deliberate mention of disability and other vulnerable groups in health planning policies, recognizing the unique challenges faced by vulnerable groups including people with disabilities during health crises. additionally, they should focus on the depth and quality of disability inclusion, ensuring that policies are comprehensive and actionable. national stakeholders, including advocacy groups and civil society organizations, play a vital role in holding governments accountable for inclusive health policymaking. they should actively engage with policy makers to advocate for the rights and needs of vulnerable groups and people with disabilities. researchers and public health practitioners should continue to study and promote the best practices for inclusive health policymaking. they should provide evidence-based recommendations to policy makers and program managers to enhance the inclusivity and effectiveness of health policies and programs. 5. conclusion findings of this study underscore the critical importance of not only including vulnerable groups in health policies but also ensuring the depth and quality of this inclusion. kenya, south africa, and zambia demonstrate the potential for comprehensive and inclusive health policymaking. in contrast, nations like nigeria and ethiopia highlight the areas of improvement, especially in consistently integrating disability and other vulnerable groups across all policy domains. for all countries, there's an imperative to continually reassess and refine their policies, especially in ensuring that they are both inclusive and actionable, specific policy actions need to be identified and commitment to implement and monitor the action need to be articulated. as health crises like the covid-19 pandemic evolve, the policies must also be dynamic and adapt to the changing needs of all citizens, especially the most vulnerable. lack of inclusive policies will continue to deepened the healthcare disparity between the general population and vulnerable groups—including people with disability—in the short term and failure to attain universal healthcare coverage and sustainable development in the long run. lastly, it would be useful to examine the extent to which covid-19 policies in african countries are implemented effectively and the impact of these policies on the health outcomes of populations. 137 ghmj (global health management journal) 2024, vol. 7, no. 3 zandam, et.al. conflict of interest there is no conflict of interest. nothing to disclosure. supplementary supplementary files are accessible through following link, providing detailed information on the specific sections of the equiframe tool employed by the authors: https://inschool.id/s-ghmj_zandam_2024 references africa cdc. (2021), "coronavirus disease 2019 (covid-19) africa cdc", africa cdc dashboard, available at: https://africacdc.org/covid-19/ (accessed 12 september 2023). ahmad, a., chung, r., eckenwiler, l., ganguli-mitra, a., hunt, m., richards, r., saghai, y., et al. (2020), "what does it mean to be made vulnerable in the era of covid-19?", the lancet, lancet publishing group, vol. 395 no. 10235, pp. 1481-1482, https://doi.org/10.1016/s0140-6736(20)30979-x banks, l.m., davey, c., shakespeare, t. and kuper, h. (2021), "disability-inclusive responses to covid-19: lessons learnt from research on social protection in lowand middle-income countries", world development, elsevier ltd, january, https://doi.org/10.1016/j.worlddev.2020.105178 banks, l.m., kuper, h. and polack, s. (2017), "poverty and disability in lowand middle-income countries: a systematic review", plos one, public library of science, vol. 12 no. 12, https://doi.org/10.1371/journal.pone.0189996 boyle, c.a., fox, m.h., havercamp, s.m. and zubler, j. (2020), "the public health response to the covid-19 pandemic for people with disabilities", disability and health journal, elsevier inc., vol. 13 no. 3, doi: 10.1016/j.dhjo.2020.100943. https://doi.org/10.1016/j.dhjo.2020.100943 elo, s., kääriäinen, m., kanste, o., pölkki, t., utriainen, k. and kyngäs, h. (2014), "qualitative content analysis", sage open, vol. 4 no. 1, p. 215824401452263, https://doi.org/10.1177/2158244014522633 engelbrecht, m., ngqangashe, y., mduzana, l., sherry, k. and ned, l. (2023), "disability inclusion in african health systems' responses during covid-19: a scoping review", african journal of disability, vol. 12, doi: 10.4102/ajod.v12i0.1284. https://doi.org/10.4102/ajod.v12i0.1284 gashaw, t., hagos, b. and sisay, m. (2021), "expected impacts of covid-19: considering resource-limited countries and vulnerable population", frontiers in public health, frontiers media s.a., vol. 9, p. 474, https://doi.org/10.3389/fpubh.2021.614789 hale, t., angrist, n., goldszmidt, r., kira, b., petherick, a., phillips, t., webster, s., et al. (2021), "a global panel database of pandemic policies (oxford covid-19 government response tracker)", nature human behaviour, nature research, vol. 5 no. 4, pp. 529-538, https://doi.org/10.1038/s41562-021-01079-8 hume-nixon, m. and kuper, h. (2018), "the association between malnutrition and childhood disability in lowand middle income countries: systematic review and meta-analysis of observational studies", tropical medicine & international health : tm & ih, trop med int health, vol. 23 no. 11, pp. 1158-1175, https://doi.org/10.1111/tmi.13139 jagoe, c., mcdonald, c., rivas, m. and groce, n. (2021), "direct participation of people with communication disabilities in research on poverty and disabilities in low and middle income countries: a critical review", plos one, plos one, vol. 16 no. 10, https://doi.org/10.1371/journal.pone.0258575 lang, r., schneider, m., kett, m., cole, e. and groce, n. (2019), "policy development: an analysis of disability inclusion in a selection of african union policies", development policy review, blackwell publishing ltd, vol. 37 no. 2, pp. 155-175, https://doi.org/10.1111/dpr.12323 maclachlan, m., mannan, h., huss, t., munthali, a. and amin, m. (2016), "policies and processes for social inclusion: using equiframe and equipp for policy dialogue: comment on "are sexual and reproductive health policies designed for all? vulnerable groups in policy documents of four european countries and their involvement i", international journal of health policy and management, kerman university of medical sciences, vol. 5 no. 3, pp. 193-196, https://doi.org/10.15171/ijhpm.2015.200 madans, j., loeb, m. and eide, a.h. (2017), "measuring disability and inclusion in relation to the 2030 agenda on sustainable development", open access, vol. 4 no. 1, pp. 1164-1179. mannan, h., amin, m. and maclachlan, m. (2011), "the global health press dublin". mckinney, e.l., mckinney, v. and swartz, l. (2020), "covid-19, disability and the context of healthcare triage in south africa: notes in a time of pandemic", african journal of disability, aosis, vol. 9, https://doi.org/10.4102/ajod.v9i0.766 mitra, s., posarac, a. and vick, b. (2013), "disability and poverty in developing countries: a multidimensional study", world development, pergamon, vol. 41 no. 1, pp. 1-18, https://doi.org/10.1016/j.worlddev.2012.05.024 https://inschool.id/s-ghmj_zandam_2024 https://doi.org/10.1016/s0140-6736(20)30979-x https://doi.org/10.1016/j.worlddev.2020.105178 https://doi.org/10.1371/journal.pone.0189996 https://doi.org/10.1016/j.dhjo.2020.100943 https://doi.org/10.1177/2158244014522633 https://doi.org/10.4102/ajod.v12i0.1284 https://doi.org/10.3389/fpubh.2021.614789 https://doi.org/10.1038/s41562-021-01079-8 https://doi.org/10.1111/tmi.13139 https://doi.org/10.1371/journal.pone.0258575 https://doi.org/10.1111/dpr.12323 https://doi.org/10.15171/ijhpm.2015.200 https://doi.org/10.4102/ajod.v9i0.766 https://doi.org/10.1016/j.worlddev.2012.05.024 zandam, et.al. ghmj (global health management journal) 2024, vol. 7, no. 3 138 oliveira, m., braga, m.f., bueno, a., de sousa, d.p., pigozi, p.l., moryia, r. and akerman, m. (2022), "actions during the covid19 pandemic to protect the most vulnerable population: what is the potency amid chaos?", health promotion international, oxford academic, vol. 37 no. 2, https://doi.org/10.1093/heapro/daab122 pearce, e., kamenov, k., barrett, d. and cieza, a. (2022), "promoting equity in health emergencies through health systems strengthening: lessons learned from disability inclusion in the covid-19 pandemic", international journal for equity in health, biomed central ltd, vol. 21 no. 3, pp. 1-7, https://doi.org/10.1186/s12939-022-01766-6 sabatello, m., landes, s.d. and mcdonald, k.e. (2020), "people with disabilities in covid-19: fixing our priorities", american journal of bioethics, routledge, july, https://doi.org/10.1080/15265161.2020.1779396 saran, a., white, h. and kuper, h. (2020), "evidence and gap map of studies assessing the effectiveness of interventions for people with disabilities in low-and middle-income countries", campbell systematic reviews, wiley blackwell, vol. 16 no. 1, https://doi.org/10.1002/cl2.1070 shakespeare, t., ndagire, f. and seketi, q.e. (2021), "triple jeopardy: disabled people and the covid-19 pandemic", the lancet, elsevier, vol. 397 no. 10282, pp. 1331-1333, https://doi.org/10.1016/s0140-6736(21)00625-5 sherry, k., ned, l. and engelbrecht, m. (2024), "disability inclusion and pandemic policymaking in south africa: a framework analysis", scandinavian journal of disability research, vol. 26 no. 1, pp. 227-243, https://doi.org/10.16993/sjdr.1066 trani, j.f., bakhshi, p., brown, d., lopez, d. and gall, f. (2018), "disability as deprivation of capabilities: estimation using a large-scale survey in morocco and tunisia and an instrumental variable approach", social science and medicine, elsevier ltd, vol. 211, pp. 48-60, https://doi.org/10.1016/j.socscimed.2018.05.033 ukaid. (2020), "impact of covid-19 on the lives of people with disabilities: insight and stories from bangladesh and kenya", i2i innovation to inclusion. undp. (2018), "disability inclusive development in undp", undp.org, available at: https://www.undp.org/publications/disability-inclusive-development-undp. united nations. (2018), un flagship report on disability and development. vourvachis, p. and woodward, t. (2015), "content analysis in social and environmental reporting research: trends and challenges", journal of applied accounting research, vol. 16 no. 2, pp. 166-195, https://doi.org/10.1108/jaar-042013-0027 world health organization. (2011), world report on disability, https://doi.org/10.1111/j.1741-1130.2011.00320.x cite this article as: zandam, h., sulaiman, s. k., mohammad, a. h., & sabo, a. (2024). disability and vulnerable groups inclusion in covid-19 policy and planning in sub-sahara african countries. ghmj (global health management journal), 7(3), 129–138. https://doi.org/10.35898/ghmj-73999 https://doi.org/10.1093/heapro/daab122 https://doi.org/10.1186/s12939-022-01766-6 https://doi.org/10.1080/15265161.2020.1779396 https://doi.org/10.1002/cl2.1070 https://doi.org/10.1016/s0140-6736(21)00625-5 https://doi.org/10.16993/sjdr.1066 https://doi.org/10.1016/j.socscimed.2018.05.033 https://www.undp.org/publications/disability-inclusive-development-undp https://doi.org/10.1108/jaar-04-2013-0027 https://doi.org/10.1108/jaar-04-2013-0027 https://doi.org/10.1111/j.1741-1130.2011.00320.x https://doi.org/10.35898/ghmj-73999 indonesian scholars’ alliance ghmj (global health management journal) 2025, vol. 8, no.1 open access research article strengthening hiv education and health promotion in schools: a case study of ‘aisyiyah junior high school bantul, indonesia dhesi ari astuti1,* , muhammad saleh2 , nurul kurniati3 , siti fatimah4 , cindy putri febrianti5 , khoirunnisah hasibuan6 1 center for women's, family, and disaster studies, midwifery study program, faculty of health sciences, universitas aisyiyah yogyakarta, 2 law study program of universitas siber muhammadiyah, yogyakarta, indonesia, 3 department of midwifery, faculty of health siciences, universitas 'aisyiyah yogyakarta, indonesia, 4 midwifery program, faculty of nursing and health science, universitas muhammadiyah banjarmasin, indonesia, 5 midwifery professional education program and applied bachelor of midwifery, politeknik tiara bunda, indonesia, 6 department of midwifery, faculty of health, universitas aufa royhan, padangsidimpuan, indonesia. *corresponding author’s e-mail: dhesi@unisayogya.ac.id doi: 10.35898/ghmj-811147 abstract background: adolescents are a strategic target in preventing hiv/aids and drug abuse. the number of incidences of hiv among children aged 1–14 years has reached 14,150 cases. this number is increased by 700–1,000 each year. in the future, teenagers have the potential to spread information and conducive change, leading society toward a healthier paradigm dealing with hiv/aids and drugs. aims: this recent study is to conduct an assessment of the hiv risks and preventions of hiv at ‘aisyiyah junior high school bantul in order to strengthening hiv education and health promotion in schools. methods: this research was conducted using a qualitative approach with all the students of aisyiyah junior high school bantul. focused interviews were conducted to analyze the promotion and prevention of hiv, facilities and infrastructure, access to hiv information, and hiv advocacy in schools. results: this study highlights several challenges in hiv education at ‘aisyiyah junior high school bantul, indonesia. students mostly rely on limited sources like internet articles and school activities for hiv information, but there's a noticeable lack of accessible, comprehensive resources. the school has adequate facilities, including a health unit, but these aren’t being fully utilized for hiv education. while there are some efforts in advocacy, both internal and external, they aren’t as effective as they could be. overall, the school’s prevention initiatives need more focus and direct engagement with hiv topics, alongside better access to information to truly make a difference. conclusion: the primary factor in preventing hiv among adolescents is knowledge. therefore, providing access facilitates infrastructure and makes teenagers the agents of prevention of hiv. in addition, advocacy in the form of promotion and prevention can be conducted. keywords: adolescents' health education; hiv/aids risks and preventions, school health advocacy; health promoting schools. received: 04 november 2024 reviewed: 20 november 2024 revised: 15 december 2024 accepted: 02 january 2025. © 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:dhesi@unisayogya.ac.id https://doi.org/10.35898/ghmj-811147 https://orcid.org/0000-0002-2325-6346 https://orcid.org/0009-0000-4786-3784 https://orcid.org/0000-0003-2155-8399 https://orcid.org/0000-0002-4500-8837 https://orcid.org/0000-0001-7877-8371 https://orcid.org/0000-0002-7500-2954 astuti, et. al. ghmj (global health management journal) 2025, vol. 8, no.1 14 1. introduction the age range of adolescents is from 10 years old to before turning 18. the endeavor of the health of adolescents aims to prepare adolescents to become healthy, intelligent, high-quality, productive adults and to participate in maintaining, preserving, and improving their health. the health of adolescents requires a lot of attention because adolescents experience significant physical, psychological, and social changes. one of the endeavors of the health of adolescents is the prevention and control of infectious diseases (health ministry, 2023). prevention of mother-to-child transmission of hiv (pmtct) has been implemented in indonesia since 2005, but currently, the number of hiv cases in children aged 1–14 years has reached 14,150 cases. this number increases by approximately 700–1,000 children with hiv each year (tarmizi, 2023). pmtct is an effective intervention with a health promotion approach. pmtct is carried out through comprehensive and continuous hiv prevention and handling activities in four components (prongs), one of which is prong 1, namely prong 1 prevention of hiv transmission in reproductive women (health ministry, 2015). home-based care using a pmtct handbook significantly improves women's perception of hiv/aids prevention in mother-to-child transmission, offering a practical approach for public health centers and home care settings in purwokerto, indonesia (walin, et. al., 2017). teenagers are a strategic target to prevent hiv/aids and drug abuse. in the future, teenagers have the potential to spread information and make conducive changes that will lead society towards a healthier paradigm dealing with hiv/aids and drug abuse. a lot of articles have analyzed hiv, its management, obstacles, and impacts. sentinel surveillance in gia lai, vietnam, highlights key modifiable risk factors for hiv among people who inject drugs (pwid), emphasizing the need for enhanced harm reduction interventions and continuous monitoring of high-risk behaviors (hoang, et. al., 2018). the issue of stigma as a non-health problem poses a major challenge in society. the issue of the inaccuracy of the result of the hiv test based on the respondents’ answers in the research. however, in the era of antiretroviral therapy, asking respondents in bio-behavioral surveys to self-report their hiv status is important for measuring and improving access and coverage of services for the care, treatment, and prevention of hiv infection. it is also crucial for estimating the magnitude of unmet needs in addressing the hiv epidemic and for accurately interpreting behaviors related to the transmission and spread of hiv infection (johnston, 2016). moreover, azmi (2017) argues that comprehensive hiv and aids knowledge plays a crucial role in encouraging young people to uptake hiv testing, but poor knowledge among the 15-24 age groups in merauke, papua, significantly limits testing efforts. the “era of three zeros” emphasizes the urgent need for research related to data mapping, particularly regarding hiv risk and prevention strategies. progressive women characterized by their innovative thinking are equipped to develop knowledge grounded in faith. these women possess a firm and wise mindset, holding steadfast to their beliefs while balancing religious values and knowledge. they adopt a middle path, avoiding extremes, whether liberal, conservative, or fundamentalist. in some studies, hiv is often linked to the misconception of it being a “karma disease” associated with negative behaviors. however, the evolution of hiv transmission has shown that it can occur not only through unsafe sexual practices but also via breast milk and blood, such as through blood transfusions. assessment serves as the initial step to identify potential based on a rich database and can subsequently guide effective prevention strategies. the world health organization (who) strongly supports efforts to prevent the impact of hiv on the most affected and at-risk populations. one key strategy to reduce hiv transmission among adolescents is health promotion. according to who recommendations, implementing health promotion can effectively help eliminate hiv transmission. this process encourages individuals to take control of their health and develop healthier habits. health promotion plays a vital role in preventing hiv transmission among adolescents by educating them about the importance of prevention. through this initiative, it is expected that adolescents will change their attitudes and behaviors regarding hiv, facilitated by health education and advocacy efforts (wiley, 2014). this study aims to investigate hiv risk and prevention of students with a religious education background. 15 astuti, et. al ghmj (global health management journal) 2025, vol. 8, no.1 2. methods study design/ research procedures this research employed a qualitative approach by conducting focused, face-to-face interviews between the researcher and the subjects being studied. the duration of each interview minimum 30 minutes until data saturation and focused on identifying themes related to hiv risk and prevention efforts at ‘aisyiyah junior high school. the open-questions centered on promoting and preventing hiv, as well as exploring facilities and infrastructure, access to hiv information, and advocacy in schools. the participants included students from each class at ‘aisyiyah junior high school bantul. data triangulation will be performed using documents, observations, and insights from the relevant teacher involved in the research. measurements this research utilized qualitative methods that focused on the perspectives of the respondents. a structured interview technique was employed, with predetermined themes guiding the discussions. data were collected through interviews with teachers and students from each class at ‘aisyiyah junior high school bantul. additionally, triangulation was achieved through the analysis of documents, observations, and input from the responsible teachers. statistical techniques qualitative research utilizes analysis techniques based on the framework developed by braun and clarke (2006). it employs thematic analysis, which includes the following steps: familiarizing oneself with the data, coding the qualitative data, developing themes, reviewing those themes, defining and naming the emerging themes, and preparing an analysis report with the assistance of nvivo 12 software. ethical clearance the research was conducted after obtaining approval from the research ethics committee on 17 september 2024, and has been approved by ethical committee universitas aisyiyah yogyakarta with number no.3982/kepunisa/ix/2024. 3. results the data and theme mapping in this research highlight the risk for and prevention of hiv at ‘aisyiyah junior high school bantul. this qualitative study analyzed the data using thematic analysis, focusing on the key information provided by the informants. the researchers utilized nvivo 12 software during the analysis process. the themes that emerged from this research are specifically related to the risk for addressing and preventing hiv. picture 1. emerging themes based on picture 1, the emerging themes from the interviews include three key areas: access to information on hiv, facilities and infrastructure, and advocacy, promotion, and prevention of hiv. astuti, et. al. ghmj (global health management journal) 2025, vol. 8, no.1 16 the theme on the access information on hiv this theme describes how the informants obtain information related to hiv. the majority of informants obtain information about hiv through articles on the internet, libraries, and school activities. it is shown as follows: “sometimes in the library, hallway, or while reading articles, the information i find is often what appears on social media, right?” — informant 1 (a). “i learned about hiv from my teacher during the pancasila strengthening program in p5, but i don’t remember much.” — informant 3 (b). the interviews indicate a significant lack of accessible information about hiv for teenagers. one informant noted that information about hiv is not widely disseminated: “there is a lack of distribution of leaflets from the health center. the leaflets focus more on anemia. in this health center, we don’t have any materials on hiv/aids; it’s mostly about anemia.” — informant d. “i have never heard about hiv at all.” — informant 2 (o). this lack of information has prompted schools to take the initiative to spread knowledge about hiv and reproductive health through various educational activities. “yes (school assignment) — (informant dl). “for the female students who do not pray, we usually hold specific activities. sometimes we include this information in our school subjects. additionally, for those outside the classroom, we provide information about hygiene and other related topics. we also touch on reproductive health, although not in a comprehensive way. we once had a session with a doctor who discussed reproductive health, including diseases like syphilis and hiv. we may not have covered everything yet, but perhaps our friends can contribute more later.” — informant w. the school’s efforts to address the gaps and limitations in the information provided to students are commendable and worthy of emulation. students often find it challenging to understand or may misinterpret information due to a lack of guidance from knowledgeable individuals. it is recommended that healthcare professionals take a more active role in disseminating information related to hiv/aids to teenagers, as they are a strategic target for prevention efforts. facilities and infrastructure this theme outlines the facilities and infrastructure available at the school, as well as its accessibility to health services. according to the interview, the school's location is strategic, providing easy access to health services. it also boasts adequate facilities to support health needs, including the presence of a school health unit. “close to the state hospital, rsud panembahan senopati bantul,” informant 1 (a). “there is a nearby clinic,” informant 1 (a). “when the female students are in their period, they go to the school health unit, according to my female friends,” informant 3 (b). these adequate facilities should be further optimized. it's essential not only to provide curative services but also to implement promotional activities. the officer assigned to the school health unit must be a professional in their field and should actively engage in health promotion whenever students visit. this can be achieved by creating simple educational materials related to hiv/aids. brochures or posters could be made available for students to view and take with them during their visits, helping to fill the information gap about hiv/aids. consequently, students can gain a better understanding and knowledge of this important topic. 17 astuti, et. al ghmj (global health management journal) 2025, vol. 8, no.1 advocacy of hiv regarding of the prevention of hiv in schools this theme outlines the advocacy efforts aimed at reducing hiv in schools. advocacy can be conducted by internal parties, such as supervisors from the school health unit, health-related organizations, and teachers engaged in relevant activities. additionally, external parties, including healthcare workers, university educators, police, and non-governmental organizations focused on hiv issues, can also play a crucial role in advocacy. however, based on interviews, it appears that while advocacy exists, it is not being implemented optimally. “there are classes for girls in the library, the health center, and speech courses offered by lecturers,” informant 1 (a). “the doctor comes every tuesday (visit), every tuesday...” (informant dl) while there are existing advocacy efforts in schools, implemented by both internal and external parties, some informants view these initiatives as suboptimal. they believe that not all parties play significant roles in advocating for hiv prevention. “there are no (institutions coming to schools to provide health information)” informant 1 (a). “from the police, they haven’t (come),” informant 3 (b) “within the school, there is a doctor who visits every tuesday to facilitate health information, but i have never heard (about any peer educator groups),” informant 2 (o). the interviews also reveal that current advocacy efforts have not effectively addressed the issue of hiv. “if it is specifically about hiv, it seems that we often invite professionals, but they discuss the reproductive system in general. it’s more like how the general reproductive system works, and one of our missions is to protect teenagers from dating and so on,” (informant dl). “there are also sessions from the community health center about hiv and reproductive health, but not much (male genital changes),” informant 2 (o). the advocacy has not been maximized and communicated clearly; thus, the issue of hiv among adolescents is still considered taboo and should not be discussed. this makes the informant uncomfortable to ask the health staff at the school about the issue. “how should i put it, the school health unit has a doctor who visits once a week, allowing students to ask questions or receive medical examinations. the focus is not solely on hiv/aids or reproductive health. later on, adi, the ninth-grade science teacher, encouraged students to create posters related to the reproductive system, hiv/aids, and other relevant topics. these posters were created by the ninth-grade students as part of their science lessons. that’s my perspective, ma’am,” (informan dl). the school is committed to continuously supporting its students by implementing several behavioral rules that must be followed. these rules serve as basic preventive measures, with the hope of fostering good character in each student. “the school has specific rules regarding interactions among teenagers and discipline, which are outlined in a rulebook distributed during orientation or at the beginning of the school year. this rulebook includes a point system that awards both positive and negative points. for instance, students earn positive points for achievements, participation in organizations, or representing the school. conversely, they receive negative points for rule violations, such as dating,” (informant dl). the school aims to continuously enhance the quality of its students, encouraging them to become agents of change. the goal is to foster healthy social interactions among peers. the advocacy efforts made by the school are commendable and should be leveraged by external parties who share similar objectives, particularly regarding hiv awareness. astuti, et. al. ghmj (global health management journal) 2025, vol. 8, no.1 18 promotion and prevention of hiv this theme addresses the promotion and prevention of hiv initiatives undertaken by schools, which serve as educational organizers and the primary authority in establishing regulations for students. the interview indicates that the school has implemented clear rules regarding interactions among students, particularly between genders, as well as regulations concerning the use of narcotics. “dating is not allowed,” informant 2 (o). “unsafe interactions like dating are prohibited, and there are preventive measures against drug,” informant 2 (o). the existing regulations are complemented by promotions focused on hiv awareness, including the display of informative posters. these posters address not only health issues but also the consequences of promiscuity. “there are some posters about hiv, including warnings, symptoms, and transmission methods, located in the school health unit. however, i don’t visit the health unit often, and i haven’t seen any posters in the classroom,” informant 3 (b). “the restrooms are separated by gender, and information on reproductive health is usually provided by the school health unit specifically for female students. unfortunately, there’s no additional information offered outside of the health unit,” informant 3 (b). the efforts made to help students recognize health issues in general have been quite beneficial. however, hiv-related issues have not been adequately addressed. “it is very helpful (referring to school regulations). for example, certain regulations prevent interactions because individuals are not mahram (religious rules),” informant 1 (a). “there are no specific school regulations; everything is general,” informant 1 (a). “there is no prevention strategy for hiv/aids. typically, we only provide iron supplements every week,” (informant w). the preventive and promotional measures implemented by the school reflect a strong commitment from the internal parties, such as the education organizers, who prioritize moral and ethical values in shaping students’ character. however, there is room for improvement. direct explanations about hiv are extremely beneficial, as they enhance teenagers’ understanding of this issue. increasing teenagers’ knowledge about hiv will empower them to share information on the topic, promoting a healthier societal perspective on hiv/aids and drug use. 4. discussion the primary factor influencing adolescents in hiv prevention is knowledge (sadela et al., 2020). the more information provided to teenagers, the more effective their hiv prevention behaviors become. however, most sources of information about hiv/aids are not frequently accessed because teenagers often do not seek out information on how the virus is transmitted or how to prevent its transmission. as a result, many teenagers tend to ignore information about hiv/aids found in printed or electronic media (aulia rahmi et al., 2023). media significantly influences hiv prevention among adolescents through the roles of health workers, family, peers, knowledge, and attitudes (sadela et al., 2020). the use of the internet among teenagers is closely linked to their awareness of hiv/aids (hapitria et al., 2021; srivastava et al., 2021). access to information via media is crucial for preventing hiv among teenagers, as it is readily available through various channels, including printed materials like posters and brochures, and electronic media such as advertisements on tv or youtube. this accessibility enables teenagers to acquire valuable information, empowering them to lead healthy lives and adopt preventive behaviors (puji et al., 2021; sadela et al., 2020). additionally, research indicates a significant relationship between reading about hiv/aids in magazines, listening to information about it on the radio, and watching tv programs related to hiv/aids and the level of knowledge among teenagers (zari & soedirman, 2022). 19 astuti, et. al ghmj (global health management journal) 2025, vol. 8, no.1 the use of social media significantly impacts hiv/aids prevention. through these platforms, teenagers can enhance their understanding by communicating, sharing information, and educating themselves about the risks and prevention of the disease. social media increases awareness, knowledge, and sexual education among youths, which can help prevent them from engaging in risky sexual behaviors that elevate the risk of hiv/aids infection. platforms such as social networking sites and online journals serve as effective tools for health education and promotion aimed at preventing hiv/aids among teenagers in indonesia (putri et al., 2022; yusnita, 2021). additionally, edutainment provides clearer health information about hiv/aids to generation z, who prefer obtaining information through videos. this type of information can significantly influence their perspective on hiv/aids (ismayati et al., 2023). ensuring access to information for teenagers from marginalized communities, low socioeconomic backgrounds, and those with limited education is crucial (srivastava et al., 2021). teenagers who have a strong understanding of hiv can help reduce its transmission. conversely, a lack of knowledge can contribute to increased transmission rates, as awareness about hiv prevention can come from various sources including media, health workers, family, and peers (sadela et al., 2020). they typically gather information about hiv/aids from schools, social media, the internet, and public health initiatives, with sexual education in schools playing a pivotal role in enhancing their understanding. despite the abundance of available information, some teenagers still harbor misconceptions regarding the transmission and prevention of hiv/aids. to improve teenagers’ understanding of hiv/aids and to decrease stigma, sustainable, fact-based educational programs are essential. access to media and technology alone isn’t enough to reduce stigma, as a study in yogyakarta revealed persistent misconceptions about lgbt individuals and hiv/aids despite good media access (astuti, et. al., 2017). while social media can effectively share accurate information, it also poses the risk of spreading misinformation if not carefully monitored, highlighting the need for better education and responsible media use to promote understanding and inclusivity. while technology and social media can effectively disseminate accurate information to teenagers, they also carry the risk of spreading misinformation if not properly monitored (suryawan et al., 2023). the role of healthcare professionals is crucial, especially for teenagers. these medical experts actively provide knowledge and counseling about health to help prevent hiv infection. reliable information can significantly influence adolescents' mindsets and understanding of preventive behaviors. the more effectively health officers perform their roles, the better the preventive behaviors exhibited by adolescents (sadela et al., 2020). health professionals can positively impact hiv prevention among teenagers. their active involvement in communicating and educating about the importance of primary prevention encourages adolescents to pay more attention to their health and adopt hiv prevention behaviors (sadela et al., 2020). helping adolescents build better knowledge and attitudes about drugs and sexual health is essential. studies from cirebon and bali show that comprehensive education can guide teens toward healthier choices, reducing the risks of drug abuse and unsafe sexual behaviors (permana & khasanah, 2019 ; pradnyani, et. al., 2019). these days, adolescents are easily influenced when it comes to forming their identities. positive attitudes toward them can lead to beneficial behaviors in hiv prevention (sadela et al., 2020). adolescents are particularly vulnerable to diseases because they often follow the behavior of their peers. if their peer group exhibits positive behavior, it is likely that they will too; conversely, negative peer influence can lead to poor behavior. during this developmental stage, adolescents frequently engage in risky experiments, such as promiscuity and smoking. they may also experiment with drugs without fully understanding the consequences. therefore, it is crucial for health professionals and families to actively provide information about the factors that contribute to deviant behaviors (sadela et al., 2020). previous research has indicated that peers play a significant role in preventing teenage pregnancies (firdausa et al., 2019). after engaging in peer education programs, students demonstrate an increase in their knowledge. this improvement is largely due to the comfortable environment peers create for sharing information, their ability to influence one another, and the strong personal relationships they maintain. additionally, peers possess a solid understanding of each other’s social and cultural backgrounds and have knowledge about hiv/aids, which makes the information more readily accepted. they can effectively encourage and motivate their peers to adopt positive attitudes towards hiv/aids-related issues. moreover, the information students have about hiv/aids also comes from other sources, including mass media and websites (safitri, 2021). astuti, et. al. ghmj (global health management journal) 2025, vol. 8, no.1 20 the role of teachers is crucial for adolescents in preventing sexually transmitted diseases (stds). research has indicated a connection between teachers' involvement in the pik-krr program and adolescents' attitudes toward std prevention efforts (maesaroh et al., 2021). family plays an equally vital role, as adolescents need guidance during this formative period to understand healthy behaviors. at this stage, they are often exploring their identity and may struggle with decision-making. in terms of social interactions, it's important for them to choose their friends wisely to avoid engaging in promiscuous behaviors. thus, families are key in educating adolescents about the consequences of promiscuity on their health. they should inform young people about the risks associated with detrimental behaviors that can lead to hiv infection. by doing so, families contribute to the primary prevention of stds, ultimately enhancing the health status of adolescents (sadela et al., 2020). teenagers still require guidance to select the information they receive, so the information will not directly influence them. the information obtained by teenagers from the mass media has not yet been used as a guideline for healthy and responsible sexual behavior (puji et al., 2021). the role of the family, especially parents, must be able to control the movements of teenagers. parents’ beliefs and control over adolescent behavior significantly impact how they communicate with their children about sexuality (puji et al., 2021). previous research has shown that students with a background in religious education have an optimistic attitude and behave according to religious values, enabling them to firmly reject interactions and actions that could harm themselves and others (sari, 2019). the development and integration of youth-friendly hiv, programs to encourage parent-adolescent communication about sex and hiv, and teacher training and resources to raise awareness of hiv, act as first responders, and provide community referrals are among the strategic opportunities and initiatives. in order to change sociocultural and political contexts of vulnerability, youth-led peer education programs were essential to the hiv response. they promoted hiv prevention and sexual health awareness for youth, as well as the resilience and socioeconomic empowerment of peer educators themselves (newman et al., 2022). the limitation of this study such as the interview was taken in the single school that might increasing the bias data. strengths of this study include meaningful research design, implementation, and interpretation of results, and triangulation of data. further research should build on quantitative research to evaluate students' hiv knowledge and also exploring the collaboration model with local healthcare facilities to enhance school based health education. 5. conclusion the key to preventing hiv among adolescents is knowledge. media plays a significant role in influencing adolescent behavior, particularly regarding the risk impact and strategies for hiv prevention. this influence comes from various sources, including health professionals, family, and peers, as well as their overall knowledge and attitudes. consequently, teenagers can act as advocates for spreading information about hiv/aids prevention. they can help facilitate access to resources, improve infrastructure, and engage in advocacy efforts focused on promotion and prevention. to address risk settings and service gaps in the areas of education, family, and peer relationships, as well as to create integrated, youth-friendly healthcare systems and organizations, multilevel and multicomponent interventions are required. importantly, the effectiveness of hiv prevention and care is limited by strong political and societal restrictions on sexual health and rights for young people, which must be taken into account when implementing social and structural interventions. the stakeholder collaboration may increase the participation of community and increasing the awareness the hiv risk and prevention. conflict of interest there is no conflict of interest in this research. 21 astuti, et. al ghmj (global health management journal) 2025, vol. 8, no.1 references astuti, d. a., asri hidayat, r. z. h., widyastari, d. a., & sinaga, d. m. (2017). 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. j health re. vol, 31(4). https://doi.org/10.14456/jhr.2017.33 aulia rahmi, s., hamdillah skripsa, t., studi adminstrasi kesehatan, p., sains teknologi dan kesehatan mulia yogyakarta, i., & studi kedokteran gigi, p. (2023). hubungan keterpaparan sumber informasi dengan perilaku pencegahan hiv/aids pada remaja sma/ smk di kelurahan lirboyo the relationship between exposure to information sources and hiv/ aids prevention behaviour in adolescents at lirboyo. iv(i). azmi, n. (2017). the association between hiv and aids knowledge and uptake of hiv testing among sexually active young population age 15-24 in district merauke, papua province, indonesia. in proceedings of the international conference on applied science and health (no. 1, pp. 393-399). https://publications.inschool.id/index.php/icash/article/view/862 firdausa, b. i., aprilea, t. n., & muthmainnah. (2019). hubungan peran guru dan teman sebaya terhadap perilaku pencegahan kehamilan remaja di sma pgri 1 sidoarjo. j agric med community health, 44(4), 52–60. https://proceedings.ums.ac.id/index.php/semnasfik/article/view/2811/2774 hapitria, p., lestari, f. n., & widiyanti, r. (2021). analisis faktor yang berhubungan dengan perilaku remaja dalam pencegahan hiv/aids di rw 15 kelurahan kecapi kecamatan harjamukti kota cirebon tahun 2021. journal of midwifery science and women’s health, 2(1), 1–8. https://doi.org/10.36082/jmswh.v2i1.279 hoang, t. n., pham, d. t., & nguyen, h. t. t. (2018). sentinel surveillance for hiv among people who inject drugs at gia lai province, vietnam. ghmj (global health management journal), 2(2), 2531. https://doi.org/10.35898/ghmj-22201 ismayati, n., rifai, a., & rahayu, t. (2023). media informasi kesehatan untuk pencegahan hiv/aids yang disukai generasi z: upaya penurunan kasus hiv/aids di kalangan remaja di indonesia. tibanndaru : jurnal ilmu perpustakaan dan informasi, 7(1), 54. https://doi.org/10.30742/tb.v7i1.2824 johnston, l. g. (2016). the importance of assessing self-reported hiv status in biobehavioural surveys. bulletin of the world health organization, published online 2016 apr 25. https://doi.org/10.2471/blt.15.162933. kemenkes. (2015). pedoman manajemen program pencegahan penularan hiv dan sifilisdari ibu ke anak. kementrian kesehatan republik indonesia. kemenkes. (2017). program pengendalian hiv aids dan pims fasilitas kesehatan tingkat pertama. retrieved from siha.kemkes.go.id. kemenkes. (2023). siklus hidup remaja 10-18 tahun. retrieved from https://ayosehat.kemkes.go.id/kategoriusia/remaja maesaroh, prihartini, a. r., & widiastuti, f. (2021). hubungan peran guru dalam program pik krr dengan sikap remaja dalam upaya pencegahan penyakit menular seksual. jurnal publikasi kebidanan, 12(2), 1–15. pemkab. (2015, november 25). pemkab buleleng. retrieved from remaja menjadi sasaran strategis pencegahan hiv/aids dan narkoba: https://prokomsetda.bulelengkab.go.id/informasi/detail/berita_instansi/remajamenjadi-sasaran-strategis-pencegahan-hiv-aids-dan-narkoba-13 permana, a. o. r., & khasanah, u. (2019). the correlation of adolescent's knowledge and attitude to drugs with adolescent's drug abuse behavior in the community health center of kesunean, cirebon. in proceedings of the international conference on applied science and health, 4, 128134. https://publications.inschool.id/index.php/icash/article/view/625 pradnyani, p. e., putra, i. g. n. e., & astiti, n. l. e. p. (2019). knowledge, attitude, and behavior about sexual and reproductive health among adolescent students in denpasar, bali, indonesia. ghmj (global health management journal), 3(1), 31-39. https://doi.org/10.35898/ghmj-31554 puji, l. k. r., melizsa, m., ratnaningtyas, t. o., hasanah, n., & ambarwati, d. (2021). hubungan pengetahuan, peran media massa dan peran keluarga terhadap perilaku seks pranikah siswa-siswi smk muhammadiyah lebaksiu. edu dharma journal: jurnal penelitian dan pengabdian masyarakat, 5(2), 52. https://doi.org/10.52031/edj.v5i2.176 putri, p., madani, j. f., dewi, k. r., & miolda, p. r. (2022). pengaruh penggunaan media sosial terhadap pencegahan hiv / aids pada remaja di indonesia. seminar nasional kesehatan masyarakat upnvj, 202–217. sadela, r., rindu, r., & darmadja, s. (2020). pengaruh enam variabel terhadap perilaku pencegahan hiv pada remaja. jurnal ilmiah kebidanan indonesia, 10(03), 125–137. https://doi.org/10.33221/jiki.v10i03.750 https://doi.org/10.14456/jhr.2017.33 https://publications.inschool.id/index.php/icash/article/view/862 https://proceedings.ums.ac.id/index.php/semnasfik/article/view/2811/2774 https://doi.org/10.36082/jmswh.v2i1.279 https://doi.org/10.35898/ghmj-22201 https://doi.org/10.30742/tb.v7i1.2824 https://doi.org/10.2471/blt.15.162933 https://ayosehat.kemkes.go.id/kategori-usia/remaja https://ayosehat.kemkes.go.id/kategori-usia/remaja https://prokomsetda.bulelengkab.go.id/informasi/detail/berita_instansi/remaja-menjadi-sasaran-strategis-pencegahan-hiv-aids-dan-narkoba-13 https://prokomsetda.bulelengkab.go.id/informasi/detail/berita_instansi/remaja-menjadi-sasaran-strategis-pencegahan-hiv-aids-dan-narkoba-13 https://publications.inschool.id/index.php/icash/article/view/625 https://doi.org/10.35898/ghmj-31554 https://doi.org/10.52031/edj.v5i2.176 https://doi.org/10.33221/jiki.v10i03.750 astuti, et. al. ghmj (global health management journal) 2025, vol. 8, no.1 22 safitri, s. (2021). peer education sebagai upaya pencegahan hiv/aids. jurnal abdimas kesehatan (jak), 3(1), 87. https://doi.org/10.36565/jak.v3i1.161 srivastava, s., chauhan, s., patel, r., & kumar, p. (2021). a study of awareness on hiv/aids among adolescents: a longitudinal study on udaya data. scientific reports, 11(1), 1–8. https://doi.org/10.1038/s41598-02102090-9 suryawan, n. w., bachrun, e., prayitno, s., bhakti, s., mulia, h., relationship, t., parenting, b., & behavior, s. (2023). jpkm jurnal profesi kesehatan masyarakat. 4(1), 1–7. tarmizi. (2023, mei 9). sehat negeriku. retrieved from kasus hiv dan sifilis meningkat, penularan didominasi ibu rumah tangga: https://sehatnegeriku.kemkes.go.id/baca/rilis-media/20230508/5742944/kasus-hiv-dansifilis-meningkat-penularan-didominasi-ibu-rumah-tangga/ ugm. (2015). pkmk fkkmk ugm, 2015, layanan hiv & aids yang komprehensif dan berkesinambungan (lkb): peran pemerintah daerah dan masyarakat sipil. walin, w., sulistyowati, d. i. d., mardiyono, m., & ratifah, r. (2017). home based care by providing prevention of mother to-child transmission (pmtct) handbook on women's perception of hiv/aids prevention in mother to child in purwokerto. proceedings of the international conference on applied science and health, 1, 103109. https://publications.inschool.id/index.php/icash/article/view/819 who. (2023, juli 13). hiv and aids. retrieved from https://www.who.int/news-room/fact-sheets/detail/hiv aids?gclid=cj0kcqia2kitbhciarisappmehjk4sthqr0-t57s98kh_72febymobsy6o_9mn2lopmmccxy7ey6zoaauh7ealw_wcb wiley. (2014). introduction to health promotion. edited by a. snelling. jossey bass. retrieved from https://www.ncbi.nlm.nih.gov/pubmed/25933806. yusnita, m. (2021). relationship between social media exposure and adolescents’ knowledge, attitude and behaviour to hiv/aids prevention. jurnal komunikasi indonesia, 10(1). https://doi.org/10.7454/jkmi.v10i1.1019 zari, a. p., & soedirman, o. (2022). preventif: jurnal kesehatan masyarakat hubungan akses informasi dengan perilaku pencegahan hiv/aids pada remaja di indonesia. preventif : jurnal kesehatan masyarakat, 13(2), 365–374. http://jurnal.fkm.untad.ac.id/index.php/preventif cite this article as: astuti, d. a., saleh, m., kurniati, n., fatimah, s., febrianti, c. p., & hasibuan, k. (2025). strengthening hiv education and health promotion in schools: a case study of ‘aisyiyah junior high school bantul, indonesia. ghmj (global health management journal), 8(1), 13–22. https://doi.org/10.35898/ghmj-811147 https://doi.org/10.36565/jak.v3i1.161 https://doi.org/10.1038/s41598-021-02090-9 https://doi.org/10.1038/s41598-021-02090-9 https://sehatnegeriku.kemkes.go.id/baca/rilis-media/20230508/5742944/kasus-hiv-dan-sifilis-meningkat-penularan-didominasi-ibu-rumah-tangga/ https://sehatnegeriku.kemkes.go.id/baca/rilis-media/20230508/5742944/kasus-hiv-dan-sifilis-meningkat-penularan-didominasi-ibu-rumah-tangga/ https://publications.inschool.id/index.php/icash/article/view/819 https://www.who.int/news-room/fact-sheets/detail/hiv%20aids?gclid=cj0kcqia2kitbhciarisappmehjk4sthqr0-t57s98kh_72febym-obsy6o_9mn2lopmmccxy7ey6zoaauh7ealw_wcb https://www.who.int/news-room/fact-sheets/detail/hiv%20aids?gclid=cj0kcqia2kitbhciarisappmehjk4sthqr0-t57s98kh_72febym-obsy6o_9mn2lopmmccxy7ey6zoaauh7ealw_wcb https://www.who.int/news-room/fact-sheets/detail/hiv%20aids?gclid=cj0kcqia2kitbhciarisappmehjk4sthqr0-t57s98kh_72febym-obsy6o_9mn2lopmmccxy7ey6zoaauh7ealw_wcb https://www.ncbi.nlm.nih.gov/pubmed/25933806 https://doi.org/10.7454/jkmi.v10i1.1019 http://jurnal.fkm.untad.ac.id/index.php/preventif https://doi.org/10.35898/ghmj-811147 template ghmj 2024 ghmj (global health management journal) 2025, vol. 8, no. 3 indonesian scholars’ alliance open access perspectives for the love of sisi: peer support and friendship in navigating health adversity velisiwe gasa* , nomanesi madikizela-madiya1 , mishack thiza gumbo2 , meahabo dinah magano3 , enid manyaku pitsoane4 , vimbi petrus mahlangu5 , soul shava (rip)2 , khabonina grace nkumane6 , pertunia rebotile machaisa5 , thembi phala7 , loyiso luvalo1 , abraham motlhabane2 , sibusiso d. ntshangase8 , monki muriel moseki8 1. department of educational foundations, college of education, university of south africa, pretoria, south africa; 2. department of science and technology education, college of education, university of south africa, pretoria, south africa; 3. department of tuition support and facilitation of learning, university of south africa, pretoria, south africa; 4. directorate for counselling and career development, university of south africa, pretoria, south africa; 5. department of educational leadership and management, college of education, university of south africa, pretoria, south africa; 6. department of language education, arts and culture, college of education, university of south africa, pretoria, south africa; 7. department of early childhood education, college of education, university of south africa, pretoria, south africa; 8. department of psychology of education, college of education, university of south africa, pretoria, south africa. *corresponding author’s e-mail: gasavg@unisa.ac.za doi: 10.35898/ghmj-831250 abstract health adversity, whether due to chronic illness, disability, or severe medical conditions, often leads to emotional, social, and psychological challenges. while much research has focused on clinical care, growing attention is paid to peer support and friendship as crucial non-clinical resources. the experience of sisi, a person living through health adversity, offers an illustrative case of how love and social connection can play a transformative role in coping and resilience, even if it is for a short while. this paper explores the importance of peer support and friendship in enhancing empowerment, maintaining personal identity, and encouraging meaning-making during health-related adversity. it seeks to contribute knowledge on how social relationships function as sources of emotional comfort and as mechanisms that enable individuals to reframe their experience and maintain a strong sense of self in times of illness. the narratives show that peer support and friendship are essential facilitators of psychological empowerment, assisting individuals in feeling more in control and competent even in the face of adversity. relationships with peers protect identity by affirming personal narratives beyond the illness. furthermore, they act as informal support systems that augment medical interventions, frequently improving quality of life and psychological resilience. peer connection can assist individuals in viewing illness not merely as a medical experience but as a collective human experience characterized by connection and meaning. the insights underscore the necessity for more comprehensive, person-centered strategies in health care that acknowledge love, friendship, and social connection as vital elements of recovery and resilience. keywords: health adversity; peer support; empowerment; identity; meaning-making. received: 04 july 2025 reviewed: 07 july 2025 revised: 17 july 2025 accepted: 30 august 2025. © 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:gasavg@unisa.ac.za https://doi.org/10.35898/ghmj-831250 https://orcid.org/0000-0002-3402-4268 https://orcid.org/0000-0002-4629-2913 https://orcid.org/0000-0001-6760-4341 https://orcid.org/0000-0001-7562-0333 https://orcid.org/0000-0001-9331-5383 https://orcid.org/0000-0002-8251-750x https://orcid.org/0000-0003-4103-0559 https://orcid.org/0000-0001-7373-3051 https://orcid.org/0000-0002-5182-6502 https://orcid.org/0000-0002-0111-5331 https://orcid.org/0000-0003-1312-2448 https://orcid.org/0000-0002-3874-4959 https://orcid.org/0000-0002-3181-9495 https://orcid.org/0000-0002-8128-4978 321 ghmj (global health management journal) 2025, vol. 8, no. 3 gasa, et. al. 1. introduction experiencing significant health adversity can completely change a person’s life, often bringing on physical, emotional, and social challenges that extend far beyond medical symptoms (boehmer et al., 2023). this narrative draws from resilience theory to understand a friend’s ability to adapt and thrive despite health adversity. the theory originated from the work of norman garmezy, emmy werner, michael rutter and ann masten. they define resilience as the ability and strength to adapt and thrive in adversity (southwick et al., 2014; van breda, 2018). protective and promotive factors are some of the elements that sustain resilience (fleming & ledogar, 2008; gasa, 2013). therefore, peer support and genuine friendship become critical lifelines, offering practical help, emotional comfort, and a shared understanding, fostering resilience and hope (dennis et al., 2020; litchfield et al., 2018). in addition, peer support fosters meaning-making, empowers, and preserves personal identity. in this narrative, meaning-making refers to a situation where individuals cope with health adversity, find purpose, and maintain a meaningful well-being. empowerment refers to the process where individuals gain control over their health adversity. this empowerment enables individuals to preserve their identities. identity preservation refers to maintaining one's sense of self despite health adversities (who, 2009; reitzes & mutran, 2006; park, 2022). the story of sisi highlights how peer support and friendship serve not merely as social niceties but as vital forces that help individuals navigate the complexities of terminal illness. recent research highlights that individuals with health conditions often find unique value in peer connections (heisler, 2019). these connections can lessen feelings of isolation, empower individuals with knowledge, and assist them in reclaiming agency over their narratives (perry et al., 2021). friendships formed in the context of health adversity are vital because they offer hope and companionship through the uncertainty of medical journeys (docherty et al., 2022). moreover, narratives of friendship and peer support demonstrate that human connection can act as a buffer against the psychological and social strains of chronic illness. despite adversity, shared laughter, mutual encouragement, and emotional solidarity remind individuals that they are more than their diagnoses, reinforcing identity, purpose, and quality of life (boehmer et al., 2023; perry et al., 2021). the narratives indicate how love and friendship exemplify the transformative power of peer support in helping people endure, adapt, and even thrive amid significant health challenges. 2. a sudden turn of events it was in 2017 when sisi first shared the feeling of numbness in one of her hands. we witnessed her condition progressing. she would update us on her illness in many casual meetings where a group of colleagues used to relax, dance and enjoy some meals after strenuous academic duties. she was comfortable sharing this experience with us because we had become more than just colleagues to each other. our relationship had an element of trust as we spent time socially and shared social and academic experiences. some scientists mentioned trust as one of the elements of friendship (black et al., 2024; doyle, 2002; holt-lunstad, 2017). as we reflected on our trusting experiences with sisi, we realized that had we succumbed to the principles of neoliberalism (busch, 2023; demirtaş, 2024), which promote individualism, this kind of trust would not have been developed, and she would have suffered alone privately. she left early in one of our casual meetings because she was flying out of the country that evening for one of her academic projects. when she came back a few months later, both hands were numb, and the condition was escalating. we could not believe what we were witnessing, but something huge was happening to this hard-working young woman we loved. by then, there was still hope as she had not confirmed the fatality of her condition to us. at some point, sisi finally broke the news that her doctors had confirmed that she suffered from motor neurone disease (mnd), that it was incurable, progressive, and terminal. we were all shocked. as colleagues and friends, we did not know what to say except to be there for her. her illness progressed to a state where he could not walk and was wheelchair-bound. however, as she was still active in coming to work, we often chatted with her at her office. she would show her remarkable strength and become the one comforting us and cracking some jokes as usual. she continued her professional duties; she did not want to stay and wait for the inevitable. as an academic, she continued to teach her students via online tools, supervise her master's and doctoral (m&d) students, write and publish articles, secure research funding, and attend academic conferences. gasa, et. al. ghmj (global health management journal) 2025, vol. 8, no. 3 322 3. the birth of the support initiative: for the love of sisi in 2020, covid-19 struck and disrupted everything. colleagues and friends were separated, which caused much stress because everything was shut down. everyone was crushed by loneliness; the only thing we could think of was those who were sick, as they were isolated and had nothing to keep themselves busy. one of those was sisi. so, we decided to devise a plan to be there for her. in june 2020, a group of sisi's colleagues and friends came together to start an initiative to support her. an online meeting was organized where we discussed our support strategy. it was agreed that this initiative would be called 'for the love of sisi'. everyone agreed that we would organize online prayer meetings, send her messages of comfort, hold online chats as a group, and contribute financially every month as a gesture that we were there with her. there was no prescription for financial contribution; it was from the heart. although the university was paying her salary and had appointed a personal assistant, the medical expenses she required cost her more than what her medical aid could cover. besides, one personal assistant the university appointed was insufficient because she needed support throughout the day and night. therefore, she needed to appoint additional caregivers to take care of her day and night. that made her friends and colleagues think of supporting her financially as well. the financial contribution was nothing compared to the emotional and spiritual support that peers and friends offered her. as the visibility of the support group began, sisi became stronger and spoke positively during our engagements with her. at the end of each online chat, she would thank us and indicate how her family appreciates the kind of support given to her. most people in her family and village were amazed by this gesture, as we did this of our own accord. nothing was compelling us to do this except love, friendship, and collegiality. we would send her well wishes through videos and messages on her birthdays. this support not only benefited her but also healed us, giving us a sense of purpose and hope. as the years went by, some group members faced other challenges and could not contribute financially but knowing that they were with us in spirit, encouraged us to continue with the good course. in january 2022, a delegation of five friends visited her hometown, an eight-hour drive from our work campus. little did we know it was the last time we would see her alive. as if she knew that her time was drawing nearer, she sent us a song that we still cherish. the song's title is 'wena nkosi uyazi', meaning ‘oh lord, you know’. we continued with our usual support as we did not know it was a goodbye. on 6 july 2022, we received the devastating news that sisi had passed on. we were aware of her condition, but it was hard to accept that she was gone. 4. perspectives four perspectives are formulated as playing an important role in health adversity: empowerment, identity preservation, meaning-making and emotional comfort. empowerment the peer support empowered sisi to use her agency to continue working and generated several publications while bedridden. she was devoted to her postgraduate students despite her condition. she was constantly communicating with them. she used to forward us emails and whatsapp messages that she exchanged with her students. from 2017 to 2021, she graduated six master's and four doctoral students. in 2021 alone, she graduated two doctoral students and one master's student, which is very rare for a supervisor to have three postgraduate students complete in a year. some of her students graduated in subsequent years as they were about to complete their studies when she passed on. we believe that this impressive outcome was partly motivated by the support she received from her peers, in addition to her resilience amid the health adversity. she had control over her health adversity, which enabled her to persevere in her work for the sake of her students and her identity. most importantly, however, the testimony to the above narrative is illustrated by the following tribute from one of her students (dr stefani chabwera) who graduated after her passing. 323 ghmj (global health management journal) 2025, vol. 8, no. 3 gasa, et. al. "dr ……. (sisi) was cordial and very professional. she made me feel that i had great potential and always gave me positive remarks about my studies. the passing of my supervisor left me in a dark space, which urged me to write a poem to honour and express my gratitude to her." the poem titled: couldn’t you wait? part of the poem expresses the following: the shrinking wick had sunk… but couldn’t you just wait for me as testimony of your true love? i watched in agony as the trembling wick sank deeper into the melting wax that continued to flow enveloping the undesirable blanket of darkness as you couldn’t wait for me anymore from this tribute, one can deduce that she continued to persistently support her students despite her most adverse level of sickness. identity preservation sisi had this strength that nobody could explain; she refused to be written off as long as her body, soul and mind were still connected. she attended academic conferences in person and virtually and expressed her enjoyment of being part of the conferences. in 2019, she was already in a wheelchair, and that is where her tenacity was shown. she attended a conference in victoria falls, outside our country, where she served as an organizing committee member. she was always part of this committee, and she could have excused herself from it, but she insisted that she wanted to continue serving. she enjoyed the conference because peers and friends ensured that she was always comfortable. we shared all the good memories on our flight back home. the same year, she was invited as a motivational speaker during the young academics programme. in the feedback at the end of the program, several participants mentioned her talk as one of the highlights. she applied and secured research funding for her research project. the reviewers of her application remarked that she was a diligent and meticulous candidate. she was also bestowed with the 'courage in adversity award' by the institutional women's forum in 2019. her courage, will, perseverance, and strength were recognized. this reflection suggests that she maintained her willingness to be the best academic, and the support that she received strengthened her to preserve her sense of self despite the health adversity. the peers and friends did not rule her out because of her condition. meaning-making there were so many messages and voice notes that sisi shared with us, which suggested that she finally understood and found meaning in her situation. among those messages was the following appreciation note: hello friends, family and colleagues. before we part to focus on holidays with our families, i thought i should share this with you. a friend of mine in christ sent me a song that touched me so profoundly. for some reason, it made me understand my situation clearly. all along, i have been asking questions with no answers, and many people also had questions but no answers. i know for sure that most of you would trade your possessions for my health if you could. for that, i am forever grateful to all of you for your love, prayers and financial support. i know that god is with me, as the song says. in that song, i got my answer, and i have peace. stay protected and enjoy your festive season. i love and appreciate all of you. despite the pains and suffering she had been through during this process, she finally had to make sense of the situation. she maintained her purpose and understanding of what it means to be an academic. the appreciation note indicates that she dedicated her coping ability to peers, friends, and family. emotional comfort we also identified emotional comfort as one of the outcomes of our interaction with her, which empowered her in meaning-making to preserve her identity. we drew this from the extracts that various peers and friends sent to her. some of her friends used words such as admiration, inspiration, trust, strength, resilience, positivity, and motivation, suggesting that they were also emotionally inspired by her power while supporting her in many respects. gasa, et. al. ghmj (global health management journal) 2025, vol. 8, no. 3 324 for example:  my darling sisi, you are forever in my heart …. i greatly admire your strength; you are my true inspiration. in you, i have learned a sense of trust that cannot be broken, a depth of love sometimes unspoken. praying for you always…. velisiwe  your strength and resilience inspire me. may god grant you more days to smile and motivate others. peace and love. nomanesi  you are an inspirational woman of vigour; you have embraced the challenges with a positive mind. i pray to god that you continue to be safe and showcase his good will through you. bunki  sisi, i admire your resilience against all odds. keep hanging in there. soul shava (rip) others were encouraging her to stay strong, assuring her of their support. for example: stay strong, sisi. keep well and know that i give you my full support. love you always. rebotile mkhaya, i think of you all the time. be strong. looking forward to visiting you soon when i am home. sibusiso there were messages of hope that she was not alone because god, her friends and peers were with her. they were meant to motivate her to know that her mentorship, selflessness, love, and wisdom were admired. some of the messages were in her vernacular to show how close the friends were to her. for example:  you are a wonderful soul. i always remember you in my prayers. "do not be afraid—i am with you! i am your god—let nothing terrify you! i will make you strong and help you; i will protect you and save you" (isaiah 41:10). mishack  you are dearly loved, and every time i think about you, i see the love of god and his grace. i do not doubt god's grace; you are a living testimony. if we were to increase the pages of the bible about what god has done in the 21st century, i would include your name and god's grace. meahabo  sisi, do not fear, says the lord, for i am with you. do not be dismayed, for i am your god. i will strengthen and help you; i will uphold you with my righteous right hand. vimbi  dadewethu, mashobane, seloku sihlalele ethembeni lokuthi umdali wezinsuku onguphezukonke enze isimanga akupholise ngoba ungumdali wethu. mntungwa, mbulazi. khabonina  be strong, god is in control. abraham  may the holy spirit give you the wisdom & power to do the daily tasks, may you feel loved, have hope, & know that better days are coming. monkie  siyambonga ophezulu, for all the pleasure of allowing us to have you and chat to you. trust in him to keep you safe and healthy. strength and love to you, sontuli. loyiso  sisi, you might be far away, but just know you are always in my thoughts and prayers. may the lord give you strength and heal you. love you. thembi when considered collectively, her story demonstrates that peer support and friendship are not peripheral but central to navigating health adversity. they serve as relational resources that offer comfort, empower individuals, preserve identity, and facilitate meaning-making. this implies that academia and healthcare systems or institutions should recognize and nurture these social bonds as integral to holistic care and well-being for individuals facing health adversity. in addition, these institutions should fund peer-led programs and create policies that protect physical and virtual spaces for social connection and support. health care institutions should train professionals to value patients’ social networks. further research on how peer support fosters resilience and identity in times of health adversity should be conducted. 5. conclusion the above narratives reflect how support from peers and friends can boost the morale of sick colleagues so that they can be able to work and function as willing and expected. therefore, these perspectives can be considered to advance policies regarding institutional or peer-led practices to support those with health adversity. it is important to recognize the necessity of friendship and peer care as vital dimensions of health support systems. sadly, however, when death has decided, it does not change its path. despite resilience, courage, empowerment, identity preservation, meaning-making and emotional support, it stole her. conflict of interest there is no conflict of interest. nothing to disclose. 325 ghmj (global health management journal) 2025, vol. 8, no. 3 gasa, et. al. acknowledgement we appreciate the following colleagues who started the initiative with us: mubi mavuso, zingiswa jojo, tonny matjila, dan tlale, linda mkhuma, lineo toolo, poloko masuelele, maphefo motitswe, lindelani mnguni, mpho dichaba, mapheleba lekhetho, dikeledi mahlo, awelani mudau, sindile ngubane, joseph dhlamini, masello phajane, sithabile ntombela, mapula mabusela, sharon mampane, thabisile maphumulo, ramodungoane tabane, tshilidzi netshitangani references black, m. h., kuzminski, r., wang, j., ang, j., lee, c., hafidzuddin, s., & mcgarry, s. (2024). experiences of friendships for individuals on the autism spectrum: a scoping review. review journal of autism and developmental disorders, 11(1), 184–209. https://doi.org/10.1007/s40489-022-00332-8 boehmer, u., lee, s. d., & clark, m. a. (2023). social support and quality of life in individuals facing chronic illness: a systematic review. health & social care in the community, 31(1), e1–e15. https://doi.org/10.1155/2023/1841944 busch, l. (2023). knowledge for sale: the neoliberal takeover of higher education. mit press. demirtaş, m. (2024). reproduction of subjectivity: neoliberalism and friendship, journal for cultural research, 28(4), 301– 314. https://doi.org/10.1080/14797585.2024.2358530 dennis, c. l., et al. (2020). peer support interventions for individuals with chronic conditions: a systematic review and metaanalysis. health psychology review, 14(3), 353–376. docherty, s., cohn, r. d., & corry, m. (2022). adolescent and young adult experiences living with chronic illness: a qualitative study. journal of pediatric nursing, 62, 20–26. doyle, m. e. & smith, m. k. (2002). ‘friendship: theory and experience’, the encyclopaedia of pedagogy and informal education. https://infed.org/mobi/friendship-some-philosophical-and-sociological-themes/ fleming j, ledogar r. j. (2008). resilience, an evolving concept: a review of literature relevant to aboriginal research. pimatisiwin. 6(2), 7-23. pmid: 20963184; pmcid: pmc2956753. gasa, v. g. (2013). resilience in the context of learners and youth raised in grandparent-headed families. commonwealth youth and development, 11(1), 22-31. heisler, m. (2019). overview of peer support models to improve chronic disease management and outcomes. chronic illness, 15(3), 206–220. holt-lunstad, j. (2017). friendship and health. the psychology of friendship, 233-248. https://doi.org/10.1093/acprof:oso/9780190222024.003.0014 litchfield, i., et al. (2018). the role of social networks in the management of chronic illness: a narrative synthesis. bmc family practice, 19, 45. park c. l. (2022). meaning making following trauma. front psychol. 23(13), 844891. https://doi.org/10.3389/fpsyg.2022.844891 perry, b., et al. (2021). peer support for people living with chronic conditions: a systematic review. patient education and counseling, 104(12), 2844–2855. reitzes, d. c. & mutran, e. j. (2006). self and health: factors that encourage self-esteem and functional health. the journals of gerontology: series b, 61(1), s44–s51, https://doi.org/10.1093/geronb/61.1.s44 southwick, s. m.,. bonanno, g. a., masten, a. s., panterbrick, c. & yehuda, r. (2014). resilience definitions, theory, and challenges: interdisciplinary perspectives. european journal of psychotraumatology, 5(1), 25338. https://doi.org/10.3402/ejpt.v5.25338 van breda, a. d. (2018). a critical review of resilience theory and its relevance for social work. social work/maatskaplike werk, 54(1), 1-18. https://doi.org/10.15270/54-1-611 world health organization. (2009). patient empowerment and health care. available from: https://www.ncbi.nlm.nih.gov/books/nbk144022/ cite this article as: gasa, v., madikizela-madiya, n., gumbo, m. t., magano, m. d., pitsoane, e. m., mahlangu, v. p., shava, s., nkumane, k. g., machaisa, p. r., phala, t., luvalo, l., motlhabane, a., & ntshangase, s. d. (2025). for the love of sisi: peer support and friendship in navigating health adversity. ghmj (global health management journal), 8(3), 320–325. https://doi.org/10.35898/ghmj-831250 https://doi.org/10.1007/s40489-022-00332-8 https://doi.org/10.1155/2023/1841944 https://doi.org/10.1080/14797585.2024.2358530 https://infed.org/mobi/friendship-some-philosophical-and-sociological-themes/ https://doi.org/10.1093/acprof:oso/9780190222024.003.0014 https://doi.org/10.3389/fpsyg.2022.844891 https://doi.org/10.1093/geronb/61.1.s44 https://doi.org/10.3402/ejpt.v5.25338 https://doi.org/10.15270/54-1-611 https://www.ncbi.nlm.nih.gov/books/nbk144022/ https://doi.org/10.35898/ghmj-831250 indonesian scholars’ alliance ghmj (global health management journal) 2025, vol. 8, no. 2s x open access research article the 1st cirebon international health symposium: faculty of medicine, universitas swadaya gunung jati update on non-communicable diseases: global perspective on health challenges and innovation examination of coliform and escherichia coli contamination in refilled drinking water in cirebon regency, indonesia ana naela shonia1* , hikmah fitriani2 , mohammad erwin indrakusuma3 1. faculty of medicine, universitas swadaya gunung jati, cirebon, indonesia (45132); 2. department of basic medical science, faculty of medicine, universitas swadaya gunung jati, cirebon, indonesia (45132); 3. department of parasitology, immunology, and microbiology, faculty of medicine, universitas swadaya gunung jati, cirebon, indonesia (45132). *corresponding author’s e-mail: naelashoniaana@gmail.com doi: 10.35898/ghmj-82s1224 abstract background: refillable drinking water is a commonly used source of water for the public. contamination of this water can lead to various diseases, including waterborne diarrhea. coliform bacteria and escherichia coli are indicators of faecal contamination and can cause waterborne diseases. this study aims to determine whether coliform and escherichia coli are present in refillable drinking water in cirebon regency. aims: to identify the presence of coliform and escherichia coli bacteria in refillable drinking water in cirebon regency. methods: this descriptive study employed purposive sampling to collect six samples of refillable drinking water from six different depots located in cirebon regency. each sample was tested four times using various laboratory tests, including nutrient agar, mac conkey agar, gram staining, imvic, and tsia. results: all samples showed the presence of coliform (100%), as shown by the mac conkey agar test indicating lactose fermentation and gramme staining revealing rod-shaped bacteria. however, escherichia coli was not found (0%) in any of the samples. the results of the mac conkey agar test as a lactose fermenter, gram staining showing rod-shaped bacteria, and imvic tests showed the following profile: indole +, mr +, vp -, citrate -, and tsia: a/a, h₂s -, gas +. while escherichia coli was absent, the detection of other coliforms suggests persistent hygiene issues; citrobacter freundii and klebsiella were found to be coliform bacteria. conclusion: no escherichia coli were detected in any of the samples, but coliform bacteria were found in 6 out of 6 samples (100%). the maintenance of refillable drinking water depots is crucial for public health. owners must frequently clean and disinfect the reservoirs to prevent contamination. additionally, authorities are responsible for regularly monitoring the hygiene and sanitation of these depots. keywords: coliform; escherichia coli; refillable drinking water. received: 03 july 2025 reviewed: 15 july 2025 revised: 25 july 2025 accepted: 15 august 2025. © 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:naelashoniaana@gmail.com https://doi.org/10.35898/ghmj-82s1224 https://orcid.org/0009-0009-5932-4142 https://orcid.org/0009-0006-8248-867x https://orcid.org/0009-0002-7587-4186 shonia, et. al. ghmj (global health management journal) 2025, vol. 8, no. 2s 276 1. introduction refill water depots are companies that process raw water into drinking water and then market it directly to consumers. the price of refill drinking water is more affordable compared to bottled drinking water, so refill water is the choice compared to branded drinking water (arumsari et al., 2021). the central statistics agency stated that 40.64% of indonesian households use refill water as their source of drinking water (muhammad, 2023). water can be a medium for transmitting disease to humans if it has been polluted and contaminated by pathogenic microorganisms such as bacteria (rophi, 2022). detection of microbiological contamination such as escherichia coli and coliform bacteria is the key to drinking water quality. drinking water quality is an important aspect of health. water contaminated with coliform bacteria indicates potential contamination, while escherichia coli is a type of bacteria included in the coliform group that shows more serious faecal contamination (saputri et al., 2020). water that has been contaminated with escherichia coli and coliform bacteria that are transmitted through water and can cause public health problems, one of which is diarrhea. waterborne disease is a disease transmitted through drinking water that is directly contaminated with pathogenic microorganisms or substances in the air. most waterborne diseases are characterised by diarrhea involving excessive expulsion of large amounts of water, often resulting in dehydration and possible death (khairunnida et al., 2020). escherichia coli is a rod-shaped bacterium that is gram negative, facultative anaerobic, does not form spores, and is a natural flora in the mammalian intestine. escherichia coli can cause complications such as dehydration, chronic diarrhea, and haemolytic uraemic syndrome, which are often suffered by children under 5 years of age and over 60 years of age. escherichia coli can be found in soil, vegetables, undercooked meat, and air (mueller et al., 2023). based on who data from 2015, diarrhea causes around 688 million people to become sick, and 499,000 deaths worldwide occur in children under 5 years of age (kemenkes, 2017). based on the 2019 indonesian health profile, the number of diarrhea sufferers in indonesia is 2,549 people, and the case fatality rate (cfr) is 1.14% (nariswari et al., 2023). the prevalence of diarrhea in west java province based on the 2018 riskesdas was recorded at 1,287 (10.40%) children with diarrhea in the age group under 1 year, 5,312 (13.43%) children with diarrhea in the age group 1-4 years, 12,806 (6.98%) children with diarrhea in the age group 5-14 years, and 12,409 (7.24%) children with diarrhea in the age group 15-24 years. meanwhile, in cirebon city, the incidence of diarrhea in 2018 was 789 cases of diarrhea. according to the decree of the minister of health of the republic of indonesia nomor. 492/menkes/per/iv/2010, the microbiological parameters that need to be checked in drinking water are the absence of detection of coliform and escherichia coli bacteria in 100 ml of water samples. there is no current research on the coliform and escherichia coli identification test using nutrient agar, mac conkey, gram staining, imvic, and tsia media tests in cirebon, west java. this study was conducted to identify the presence of coliform and escherichia coli bacteria by using nutrient agar, mac conkey, gram staining, imvic, and tsia media tests from refillable drinking water in cirebon regency. 2. methods this study uses a descriptive method with nutrient agar, mac conkey agar, gramme staining, imvic, and tsia. in this study, 6 samples were obtained from refill drinking water depots located in cirebon regency using the purposive sampling technique that considers cleanliness and sanitation. based on urban balance, six depots are chosen, and they are then randomly assigned based on predetermined criteria, like the requirement that the water source be from the regional drinking water company / perusahaan daerah air minum (pdam) source. the inclusion criteria in this study were refill drinking water depots located in cirebon regency, and the exclusion criteria were refill drinking water whose owners refused to be sampled. glass bottles that have already been sanitised in an autoclave set to 130 degrees celsius are used to collect water samples. the container is first sanitised before the water is collected, and then it is carried to the testing location in a sterile box that has already been sterilised. using a micropipette during the test in the biosafety cabinet samples are taken in previously sanitised petri dishes and are cultured in an incubator to prevent contamination. the test standard based on the decree of the minister of health of the republic of indonesia shonia, et. al ghmj (global health management journal) 2025, vol. 8, no. 2s 277 nomor 492/menkes/per/iv/2010 states that the microbiological parameters that must be examined in drinking water include the absence of escherichia coli and coliform bacteria in 100 milliliters of water samples. this study has received scientific approval and ethical approval issued by the ethics commission of the faculty of medicine, swadaya gunung jati university, cirebon no.9/ec/fkugj/iv/2024. 3. results shown in table 1, out of all the samples that used nutrient agar media to count the number of colonies, sample 1 had the highest number of bacteria with total number of bacteria 2.533 cfu/ml. the lowest were found in the sample 6 with total number of bacteria 73 cfu/ml. according to table 2, 6/6 samples cultivated on mac conkey media were lactose fermenter. table 3 indicates that 6/6 samples that underwent gram staining contained gram negative. based on table 4, the results show that 6/6 samples tested for imvic contained characteristics of coliform bacteria and no characteristics of escherichia coli bacteria were found. table 1. nutrient agar media test results samples repetition number of colonies total number of bacteria 1 one 362 cfu/100 ml2 2.533 cfu/ml two 610 cfu/100 ml2 three 962 cfu/100 ml2 four 598 cfu/100 ml2 2 one 57 cfu/100 ml2 272 cfu/ml two 56 cfu/100 ml2 three 71 cfu/100 ml2 four 88 cfu/100 ml2 3 one 11 cfu/100 ml2 216 cfu/ml two 26 cfu/100 ml2 three 116 cfu/100 ml2 four 63 cfu/100 ml2 4 one 320 cfu/100 ml2 694 cfu/ml two 135 cfu/100 ml2 three 61 cfu/100 ml2 four 178 cfu/100 ml2 5 one 314 cfu/100 ml2 1556 cfu/ml two 390 cfu/100 ml2 three 468 cfu/100 ml2 four 384 cfu/100 ml2 6 one 34 cfu/100 ml2 73 cfu/ml two 4 cfu/100 ml2 three 22 cfu/100 ml2 four 13 cfu/100 ml2 shonia, et. al. ghmj (global health management journal) 2025, vol. 8, no. 2s 278 table 2. mac conkey media test results no sample repetition lactose fermenter non lactose fermenter 1 one + two + three + four + 2 one + two + three + four + 3 one + two + three + four + 4 one + two + three + four + 5 one + two + three + four + 6 one + two + three + four + table 3. gram staining results no sample repetition result 1 one gram negative two gram negative three gram negative four gram negative 2 one gram negative two gram negative three gram negative four gram negative 3 one are not done two are not done three are not done four gram negative 4 one gram negative two gram negative three gram negative four gram negative 5 one gram negative two gram negative three gram negative four gram negative 6 one gram negative two gram negative three gram negative four gram negative shonia, et. al ghmj (global health management journal) 2025, vol. 8, no. 2s 279 table 4. imvic media test results no sample repetition description indol methyl red voges proskauer citrate 1 one + + two + + three + + four + + 2 one + two + three + four + + 3 one are not done are not done are not done are not done two are not done are not done are not done are not done three are not done are not done are not done are not done four + + 4 one + + two + + three + + four + + 5 one + two + three + four + + 6 one + + two + + three are not done are not done are not done are not done four are not done are not done are not done are not done shonia, et. al. ghmj (global health management journal) 2025, vol. 8, no. 2s 280 out of all the samples that used nutrient agar media to count the number of colonies, sample 1 had the most bacteria, with a total of 2.533 cfu/ml. the lowest concentrations were found in sample 6, with a total of 73 cfu/ml. six out of six samples grown on mac conkey media fermented lactose. after undergoing gram staining, gram negative was found in six of the six samples. the results show that none of the six samples tested for imvic had features of escherichia coli, but they did show signs of coliform bacteria. a number of samples were not gramstained following the mac conkey test since the findings indicated colours other than red, which is not indicative of gram-negative bacteria. several samples were not tested using the imvic test since they were found to be grampositive bacteria, whereas this study only evaluated gram-negative bacteria. table 5. tsia test results no sample repetition description 1 one k/k two k/k three k/k four k/k 2 one k/k two a/k three a/k, gas four k/a 3 one are not done two are not done three are not done four k/a 4 one a/k two k/k three a/a four a/k 5 one a/a two a/a, h2s three a/a four a/k 6 one a/k two k/k three are not done four are not done observation: tsia : triple sugar iron agar k/k: red slant and red butt (red/red or alkaline (k)/ alkaline (k) a/k : red slant and red butt (red/red or alkaline (k)/ alkaline (k) k/a : red slant and red butt (red/red or alkaline (k)/ alkaline (k) a/a : red slant and red butt (red/red or alkaline (k)/ alkaline (k) h2s : hydrogen sulfide shonia, et. al ghmj (global health management journal) 2025, vol. 8, no. 2s 281 observation: mca : mac conkey agar na: nutrient agar imvic: indol, methyl red, voges proskauer, citrate tsia : triple sugar iron agar k/k: red slant and red butt (red/red or alkaline (k)/ alkaline (k) a/k : red slant and red butt (red/red or alkaline (k)/ alkaline (k) k/a : red slant and red butt (red/red or alkaline (k)/ alkaline (k) a/a : red slant and red butt (red/red or alkaline (k)/ alkaline (k) h2s : hydrogen sulfida 4. discussion the results of the study that has been conducted on the escherichia coli content test in refill drinking water in kedawung district found that 6 samples did not contain escherichia coli, and there were coliform bacteria in the refill drinking water. coliform bacteria are classified as pathogenic bacteria. the presence of these bacteria determines whether the water or sample is contaminated with pathogenic bacteria or not. the presence of these bacteria is usually caused by contamination, and most coliform bacteria reside in the intestines of humans and animals. this study used the nutrient agar test, mac conkey, gram staining, imvic and tsia biochemical tests. the identification test results for 6 samples planted on mac conkey agar media showed that all the bacteria that grew were lactose fermenters. mac conkey agar can distinguish gram-negative bacteria based on their lactose metabolism and is a selective medium that only grows gram-negative bacteria. then, gram-negative bacteria that table 6. microbiological test results of refill drinking water sample repetition mca gram stain cfu/ml2 imvic tsia identification coliform escherichia coli 1 one + 362 --++ k/k citrobacter freundii + two + 610 --++ k/k citrobacter freundii + three + 962 --++ k/k citrobacter freundii + four + 598 --++ k/k citrobacter freundii + 2 one + 57 ---+ k/k citrobacter freundii + two + 56 --+a/k citrobacter koseri + three + 71 --+ a/k, gas klebsiella sp. + four + 88 --++ k/a enterobakter sp. + 3 one n.a 11 n.a n.a n.a n.a n.a two n.a 26 n.a n.a n.a n.a n.a three n.a 116 n.a n.a n.a n.a n.a four + 63 -++k/a klebsiella aerogenes + 4 one + 320 --++ a/k pseudomonas sp. + two + 135 --++ k/k pseudomonas sp. + three + 61 --++ a/a enterobakter sp. + four + 178 --++ a/k pseudomonas sp + 5 one + 314 +--a/a klebsiella oxytoca + + two + 390 --+ a/a, h2s citrobacter freundii + three + 468 +--a/a morganella sp. + four + 384 --++ a/k enterobakter sp. + 6 one + 34 --++ a/k enterobakter sp. + two + 4 --++ k/k enterobakter sp. + three n.a 22 n.a n.a n.a n.a n.a four n.a 13 n.a n.a n.a n.a n.a shonia, et. al. ghmj (global health management journal) 2025, vol. 8, no. 2s 282 ferment lactose will form pink colonies, while bacteria that do not ferment lactose will form white colonies. bacteria that grow will differ in mac conkey agar media based on the speed and ability of its lactose fermentation (jung, et al., 2024). nutrient agar media contain meat extract and peptone for the growth of most bacteria and are a universal medium for bacterial growth. 13 the study counted bacteria using colony forming unit (cfu), which measures how many bacterial colonies are present in each gramme or milliliter of the sample, based on the number of plates, the dilution factor, and the volume used. the pour plate method has the advantage of being able to count bacteria that are worthy of being counted, excluding dead bacteria. additionally, this method can grow both gram-negative and gram-positive bacteria, such as escherichia coli and staphylococcus aureus, and allows these bacteria to spread throughout the media (azizah et al., 2020). gram-negative bacteria produce a red colour because it is related to the content of mac conkey media, such as lactose, neutral red (ph indicator), bile salts, and crystal violet. the growth of gram-positive bacteria is inhibited by the content of crystal violets and bile salts. microorganisms that ferment lactose will produce organic acids, especially lactic acid, which will lower the ph. neutral red is a ph indicator that changes from pale white to bright red/pink when the ph drops below 6.8. the six samples were bacilli or rods, so they were in the gramnegative bacteria group. bacteria can be classified as gram-negative because after being washed with alcohol, the bacteria lost the crystal violet dye and were then stained using safranin, a second red dye. alcohol will release the dye in some bacteria but remain in other bacteria. the cell wall in bacteria will affect the colour difference in gram staining. the cell wall of gram-negative bacteria has three layers; the outer layer is made of lipopolysaccharide, which gets washed away by alcohol when stained with safranin, making it turn red. the use of lugol's iodine creates a bond between crystal violet and iodine, which enhances the staining of bacteria. ethanol creates holes in gram-negative bacteria, which have many layers of fat that dissolve in ethanol, allowing the crystal violet iodine complex to stay attached to the cell wall; as a result, gram-negative cells become clear. therefore, the violet crystal colour cannot stick to gram-negative bacteria. this condition also causes gramnegative bacteria to be able to bind the red colour of safranin (amin et al., 2023). the imvic test is a biochemical test consisting of indole, methyl red, voges proskauer and citrate to distinguish the type of bacteria based on the differences in the genus and species of certain bacteria. in the research that has been done, there is one positive sample. biochemical tests are carried out to determine the limited morphology of bacteria such as bacilli, cocci and spirals, so biochemical tests are needed to determine the nature of bacteria by seeing bacteria reacting to chemical compounds. to determine the nature of bacteria, it is necessary to add different reagents (umarudin et al., 2020). positive indole test is seen from the formation of a red ring and means that the bacteria have the ability to form indole from the breakdown of the amino acid tryptophan after adding kovac's reagent (putri et al., 2023). positive methyl red test is seen from the change in colour of the media to red after being dripped using methyl red reagent and means that the bacteria can produce acid and have the ability to oxidise glucose. this test is positive for escherichia coli. 18 the voges-proskauer test checks if bacteria can make acetyl methyl carbinol (acetoin) by breaking down glucose into acid. if the colour changes to red after adding alpha-naphthol and koh reagents, it indicates that the bacteria can form acetoin; however, escherichia coli does not produce acetoin, resulting in a negative test result. the citrate test functions to see if bacteria can use citrate as a carbon source (umarudin et al., 2020). tsia is a test that checks for the production of glucose, lactose, sucrose, and gas, which are then fully oxidised to create carbon dioxide and hydrogen gas with the help of the format hydrogenase enzyme. accumulation of gas under the tube occurs due to the chemical process of hydrogen gas that is not dissolved in the medium (apriani et al., 2014). in the tsia test, the bottom and slant are yellow, indicating that there is a change in the acidic atmosphere in the butt and slant. meanwhile, if the butt is red and the slant shows a yellow colour, it can be concluded that the bacteria only ferment glucose (apriyanthi et al., 2022). coliform bacteria and escherichia coli serve as indicators for assessing the quality of drinking water. the presence of coliform bacteria in drinking water at refill drinking water depots indicates poor drinking water quality. the cause of drinking water sources being contaminated by coliform bacteria is leachate from septic shonia, et. al ghmj (global health management journal) 2025, vol. 8, no. 2s 283 tanks; the source of groundwater is influenced by the distance from the septic tank to the well. in addition, if the raw water is not optimally processed, for example, in drinking water reservoirs, ultraviolet radiation is not used in disinfection. in addition, the maintenance filters for all refill water tanks are inadequate; this issue is likely due to filters that have been used for a long time. other factors that cause refill water in cirebon regency to contain coliform bacteria include the filler water reservoir not being kept clean and how long the raw water is stored in the reservoir tank, thus affecting the quality of the raw water source. the refill water reservoir's placement beside the road, the unhygienic behaviour of workers, and the lack of regular inspections for drinking water are all contributing factors (putri et al., 2023). this evidence is in line with the research conducted by rezkina k and roslina a with the title comparison of growth of escherichia coli and salmonella sp. on the first and second days at the refill drinking water depot, the results were obtained that there was no growth of escherichia coli and salmonella sp. on drinking water obtained from the depot. in the study, escherichia coli bacteria were not found in refillable drinking water because sampling was conducted only once and did not consider the length of storage at the depot; subsequently, bacteria were detected using nutrient agar media, mac conkey agar, and gramme staining, followed by confirmatory tests using imvic and tsia. (rezkina et al., 2024). the detection of other coliform s suggests persistent hygiene issues. owners of refillable drinking water depots must frequently clean and disinfect the reservoir, and authorities are required to regularly monitor the hygiene and sanitation of drinking water depots. 5. conclusion coliform bacteria were found in refilled drinking water in cirebon regency, and no escherichia coli bacteria were found in refilled drinking water in cirebon regency. while escherichia coli was absent, the detection of other coliform s suggests persistent hygiene issues. owners of refillable drinking water depots must frequently clean and disinfect the reservoir, and authorities are required to regularly monitor the hygiene and sanitation of drinking water depots. the limitation of this study is the small sample size, which is due to several depot owners refusing to allow their refillable drinking water to be used as a research sample, along with the limited geographical spread. the suggestion for further research is to obtain a larger sample that accurately represents the distribution of refillable drinking water depots across the cirebon district, and to further investigate the impact of piping inlets on the chemical and microbiological quality of refilled drinking water. conflict of interest there is no conflict of interest. references amin ss., ghozali tz., efendi mrs. (2023). identifikasi bakteri dari telapak tangan dengan pewarnaan gram. jurnal kimia dan ilmu lingkungan. (1), 30-35. https://ojs.ejournalunigoro.com/index.php/chemviro/article/view/563/409 apriani dgy, putri dmsf, widiasari ns. (2022). gambaran umum tingkat pengetahuan ibu tentang diare pada balita di desa baler bale agung, kabupaten jembrana tahun 2021. j heal med sci. 1(3):15-26. https://pusdikra-publishing.com/index.php/jkes/article/view/714 apriani, bintari nwd, ilsan na, istyanto f, suhartati r, dewi rk, zuraida, herlina, inggraini m, djasfar sp, nur j, setiawan d, wijayanti dr, safari wf. (2014). bakteriologi untuk mahasiswa kesehatan. masagena mandiri medica. makassar; (20). apriyanthi dprv., laksmita as., widayanti np. (2022). identifikasi bakteri kontaminan pada gelang tri datu. jurnal biologi makassar, 7(2). https://journal.unhas.ac.id/index.php/bioma/article/view/21214 arumsari, f., joko, t., & darundiati, y. h. (2021). hubungan higiene sanitasi depot air minum dengan keberadaan bakteri escherichia coli pada air minum isi ulang di kecamatan mondokan kabupaten sragen. media kesehatan masyarakat indonesia, 20(2), 75–82. https://doi.org/10.14710/mkmi.20.2.75-82 azizah, a., & soesetyaningsih, e. (2020). akurasi perhitungan bakteri pada daging sapi menggunakan metode hitung cawan. berkala sainstek, 8(3), 75. https://doi.org/10.19184/bst.v8i3.16828 https://ojs.ejournalunigoro.com/index.php/chemviro/article/view/563/409 https://pusdikra-publishing.com/index.php/jkes/article/view/714 https://journal.unhas.ac.id/index.php/bioma/article/view/21214 https://doi.org/10.14710/mkmi.20.2.75-82 https://doi.org/10.19184/bst.v8i3.16828 shonia, et. al. ghmj (global health management journal) 2025, vol. 8, no. 2s 284 hijriani, h., agustini, n. a., & karnila, n. a. (2020). pengetahuan perilaku hidup bersih sehat (phbs) pada anak dengan diare di rumah sakit umum kelas b kabupaten subang. jurnal health sains, 1(5), 288–293. https://doi.org/10.46799/jhs.v1i5.51 jung b, hoilat gj. mac conkey medium. [updated 2024 sep 10]. in: statpearls [internet]. treasure island (fl): statpearls publishing; 2025 jan-. available from: https://www.ncbi.nlm.nih.gov/books/nbk557394 kementerian kesehatan. (2010). peraturan menteri kesehatan republik indonesia nomor 492/menkes/per/iv/2010 tentang persyaratan kualitas air minum. khairunnida, g. r., rusmini, h., maharyuni, e., & warganegara, e. (2020). identifikasi escherichia coli penyebab waterborne disease pada air mimun kemasan dan air mimunm isi ulang. jurnal ilmiah kesehatan sandi husada, 12(2), 634–639. https://doi.org/10.35816/jiskh.v12i2.370 masruroh, m., sudaryo, m. k., & nurlina, a. (2022). situasi masalah kesehatan penyakit menular di kabupaten cirebon. higeia (journal of public health research and development), 6(4), 237–249. https://doi.org/10.15294/higeia.v6i4.58645 mueller m, tainter cr. infeksi escherichia coli. [diperbarui 13 juli 2023]. dalam: statpearls [internet]. treasure island (fl): statpearls publishing; 2024 jan-. https://www.ncbi.nlm.nih.gov/books/nbk564298/ muhammad n. persentase rumah tangga indonesia berdasarkan sumber air minum utama. katadata media network. 2023:1-8. nariswari i, musdalifah e. (2023). diare akut berair dengan dehidrasi ringan hingga sedang. pendidikan kedokteran berkelanjutan, fakultas kedokteran, universitas muhammadiyah surakarta. https://proceedings.ums.ac.id/kedokteran/article/view/2806 putri sg, yanti, erfina, khafifa n. (2023). analisis kuantitatif bakteri coliform pada air minum di depot air minum isi ulang di desa tahoa, kabupaten kolaka. jurnal biopedagogia. 5(1). http://jurnal.borneo.ac.id/index.php/biopedagogia/article/view/3569 rezkina, n. k., & roslina, n. a. (2024). perbandingan pertumbuhan escherichia coli dan salmonella sp pada hari pertama dan hari kedua di depot air minum isi ulang. jurnal kedokteran dan kesehatan publikasi ilmiah fakultas kedokteran universitas sriwijaya, 11(1), 22–31. https://doi.org/10.32539/jkk.v11i1.225 rophi, a. h. (2022). analisis mutu air secara mikrobiologi pada perlindungan mata air di kelurahan sentani kota distrik sentani kota kabupaten jayapura. bio-lectura jurnal pendidikan biologi, 9(1), 42–54. https://doi.org/10.31849/bl.v9i1.9257 saputri, e. t., & efendy, m. (2020). kepadatan bakteri coliform sebagai indikator pencemaran biologis di perairan pesisir sepuluh kabupaten bangkalan. juvenil jurnal ilmiah kelautan dan perikanan, 1(2), 243–249. https://doi.org/10.21107/juvenil.v1i2.7579 umarudin, adniyana ga, rohayanti, slamet ns, sembiring f, rakanita y, sari nky, sumariangen ab, kurniati i, yuliawati, permatasari aaap, merdekawarti f, dermawan a. (2020) bakteriologi 2. medika sains indonesia. yuliandi, n. n. e., apriani, n., & marantika, n. a. v. (2022). identifikasi cemaran bakteri escherichia coli pada ayam broiler di pasar pos duri jakarta barat. jurnal ilmu kedokteran dan kesehatan indonesia, 2(2), 25–29. https://doi.org/10.55606/jikki.v2i2.362 cite this article as: shonia, a. n., fitriani, h., & indrakusuma, m. e. (2025). examination of coliform and escherichia coli contamination in refilled drinking water in cirebon regency, indonesia. ghmj (global health management journal), 8(2s), 275–284. https://doi.org/10.35898/ghmj-82s1224 https://doi.org/10.46799/jhs.v1i5.51 https://www.ncbi.nlm.nih.gov/books/nbk557394 https://doi.org/10.35816/jiskh.v12i2.370 https://doi.org/10.15294/higeia.v6i4.58645 https://www.ncbi.nlm.nih.gov/books/nbk564298/ https://proceedings.ums.ac.id/kedokteran/article/view/2806 http://jurnal.borneo.ac.id/index.php/biopedagogia/article/view/3569 https://doi.org/10.32539/jkk.v11i1.225 https://doi.org/10.31849/bl.v9i1.9257 https://doi.org/10.21107/juvenil.v1i2.7579 https://doi.org/10.55606/jikki.v2i2.362 https://doi.org/10.35898/ghmj-82s1224 template ghmj 2024 ghmj (global health management journal) 2025, vol. 8, no. 2 indonesian scholars’ alliance open access research article strengthening laboratory capabilities in improving hiv/aids and other diseases support in zimbabwe crossman mayavo* department of management sciences, midlands state university, harare, zimbabwe (9055) *corresponding author’s e-mail: mayavoc@gmail.com doi: 10.35898/ghmj-82992 abstract background: laboratory services are always overlooked by the governments when it comes to funding, and they are mostly left behind in terms of newer testing technologies, however, in zimbabwe, there has been a tremendous improvement in laboratory support through the partners and donors. aims: the objective of the study was to review the progress made in strengthening laboratory capabilities in improving hiv/aids and other disease support in zimbabwe. methods: this study adopted a qualitative research method based on secondary data collected from laboratory documentation, including websites such as sadcas. the study focused mainly on laboratories scattered around zimbabwe, on the improvements made in support of hiv care in zimbabwe. results: the results show that there has been a great improvement in terms of laboratory performance and management through support from various donors interested in hiv/aids, tb and malaria. furthermore, the results show that there are currently 13 public health laboratories accredited to sadcas, several improvements in employee support, and new technologies are being employed throughout the zimbabwean laboratories for both hiv and tb care. additionally, the laboratory information system is functional and now helps to send laboratory results to clinics and patients for patient management by all the clinics and hospitals. conclusion: however, concerns regarding reliance on and the sustainability of these partnerships remain a challenge if they sever ties with the laboratory services, as the funding from the government is not adequate to support the laboratory’s full independence. as for the policy makers, they can help to improve the funding gaps to enable sustainability in the long run so that the gains acquired will not go to waste if the donors and partners decide otherwise, as is happening with usaid and pepfar funding. keywords: laboratory; testing; governments; hiv/aids; disease; diagnosis. received: 20 may 2025 reviewed: 11 july 2025 revised: 18 july 2025 accepted: 26 july 2025. © 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:mayavoc@gmail.com https://doi.org/10.35898/ghmj-82992 https://orcid.org/0000-0002-1066-9432 ghmj (global health management journal) 2025, vol. 8, no. 2 mayavo, c. 246 1. introduction laboratories are frequently overlooked by governments, development organisations, and other stakeholders in plans to improve healthcare systems in developing countries (mayavo, 2023). laboratories are fundamental and essential parts of healthcare systems, providing clinical staff and patients with test results that serve as the foundation for disease diagnosis and treatment (adekoya et al., 2025; gregson et al., 2021). sub-saharan africa continues to experience the negative effects of working with some of the world's worst-equipped and underresourced laboratories, notwithstanding the expansion of global health programs during the past ten years or so. as a result, by 2012, the world health organization (who), the united nations millennium development goals (unmdg), and the us president's emergency plan for aids relief (pepfar) blueprint all called for strengthened national laboratory systems as an essential part of scaling up human immunodeficiency virus (hiv) and tuberculosis (tb) prevention and treatment programme (hamel et al., 2015). according to the zimbabwe national hiv sentinel surveillance surveys conducted in 2015, the country's overall hiv-1 prevalence has stayed around 14% (zimbabwe national aids prevalence report, 2015). from 2004 to 2021, pepfar grants were given to the centre for disease control to promote the creation of prevention, care, and treatment programs in botswana, nigeria, malawi, tanzania and zimbabwe (cdc, 2012). to deliver evidence-based hiv prevention in these states, pepfar collaborated with the aids prevention initiative, a group established with financing from the bill and melinda gates foundation. based on these hiv preventive initiatives, programmes began funding antiretroviral treatment (art) operations at various hospitals and clinics, including the procurement of testing commodities in the laboratory (elendu et al., 2025; howard et al., 2012). by 2009, cdc and zimbabwe national quality assurance programme (zinqap) signed a contract with cdc, where zinqap managed funds for the laboratory services in zimbabwe which included procurement of commodities, equipment, provision of fuel on quarterly basis and support and supervision as a way of increasing laboratory efficiency in support of hiv/aids care (mayavo, 2023; mayavo & saruchera, 2024). this arrangement minimised laboratory stock-outs, key members of staff were retained in critical positions such as coordinator, logistics officer (lo), information manager (it), and the chief medical laboratory scientist. these were stationed at the national microbiology reference laboratory, which is one of the key pillars of laboratory services in zimbabwe. it was decided from the start of the centre for disease control (cdc), clinton health access initiatives (chai), john snow inc. (jsi) and (chemonics have taken over from jsi), president's emergency plan for aids relief (pepfar) initiatives that a crucial part of the capacity-building efforts would be devoted to laboratory infrastructure, with a matching growth in logistics management for supply, procurement and laboratory staff training to ensure sustainability. in order to achieve long-lasting improvements in laboratory capacity and infrastructure, they integrated lessons learned from previously established art laboratories in other countries when creating the program frameworks and plans (dacombe, et al., 2016; safi et al., 2020). in this paper, i describe the organisational framework that resulted in the establishment of continuous quality improvements to increase laboratory capacity in zimbabwe over the years of programme funding (2007–2024). additionally, i emphasise teamwork and provide information on specific techniques and methodologies that have been proven to be crucial for significant laboratory progress in a setting with limited resources, especially in zimbabwe. 2. literature review historical neglect of laboratory services and impact on health outcomes the errors occur when the laboratory is neglected, which impacts negatively on health outcomes as 80% of medical decisions are influenced by the laboratory information or data (kane, 2009). additionally, the laboratory is a critical component of the modern healthcare system, providing essential diagnostic capacity to inform treatment decisions and health interventions. however, in the low to middle-income countries, laboratories have been historically underfunded and neglected. this stems from many factors such as poor investment in health infrastructure, lack of trained staff and limited access to more advanced equipment and technology (robert et al., 2022). historically, 247 mayavo, c. ghmj (global health management journal) 2025, vol. 8, no. 2 laboratory services were relegated to a secondary role in health services delivery, overshadowed by other health priorities such as patient care and vaccination programmes. furthermore, in africa, the emphasis on the primary health care system contributed to the marginalisation of laboratory services. additionally, resources were being allocated to clinical areas, which led to poor investments in the laboratory infrastructure, trained personnel and modern equipment (chihaka & dhlakama, 2009). in zimbabwe, due to political and economic crises from 1990 to around the 2000s, degradation of health services, including laboratory services, eventually, the laboratory services becoming dysfunctional, relegating their capacity to provide accurate and timely diagnostics services. however, the impact of neglect of laboratory on disease outcome, according to the world health organisation (2018); 1) delayed treatment and diagnosis: hiv/aids is an example where failure to have functional laboratory, timely and accurate diagnostic tests would not be achieved, and there is also a misdiagnosis. 2) increased mortality and morbidity rate: in low to middle-income countries, hiv/aids, tb need precise laboratory testing for effective treatment and management. in zimbabwe, historically, weakened laboratories contributed to the rise in preventable deaths from various diseases, adding to health inequalities. 3) ineffective health surveillance: failure to have reliable laboratory data generated means diseases would go untreated or poorly managed, especially in resource-limited settings the neglect of laboratory services has severe consequences on diseases outcome in lmic. addressing the neglect of laboratory services, will strengthen the laboratory infrastructure and ensure proper funding and integrating laboratory services into broader health policies and programmes. additionally, laboratory services enhance disease detection, improve treatment accuracy and eventually save lives and providing a good foundation for a better and healthier future. global and regional context of laboratory services the global context is that laboratory services’ recognition has grown over the years, and thanks to covid-19, that has amplified the need for a strong laboratory system. globally, the laboratory’s role has been recognised and a need to have a robust system for improving the public health and disease control system (mayavo, 2024). the global context now recognises the strengthening diagnostic capacity, ensuring the promotion of quality assurance and biosafety. at the regional stage, it is said that world health organisation and centre for disease control (cdc) are working hard to strengthen laboratory system in the african continent such as 1) capacity building through training of laboratory staff and provision of technical assistance, 2) they are promoting quality control and accreditation and 3) they are promoting regional networks of laboratory for increased resource sharing and collaborations. however, covid-19 played a key role in zimbabwe to bring a turnaround of laboratory services as they managed the pandemic (who, 2020), and the laboratory system now can-do molecular diagnosis with realtime rt-pcr. additionally, the laboratory services can do testing using genexpert technology, which has improved laboratory testing at the provincial level, and they have also improved on quality assurance and are being established to strengthen laboratory services through trainings. similarities of african countries there are similarities in terms of challenges faced by zimbabwe and other african countries (lingg et al., 2016; ondoa et al., 2017) in terms of laboratory services, and they are as follows: 1. lack of funding: the impact of lack of funding is poor laboratory performance, lack of current and modern equipment for testing, impacting laboratory supplies as well as personnel. 2. human resource shortage: african countries face brain drain, and most of the laboratories operate without trained and experienced personnel, a lack of opportunities, including low pay, which leads to migration to ngos and other non-african countries. 3. poor laboratory infrastructure: most african medical laboratories are poorly equipped, with poor safety adherence and infection control mechanisms. ghmj (global health management journal) 2025, vol. 8, no. 2 mayavo, c. 248 4. lack of coordination: this leads to duplication of activities and causes inefficiencies (sadc report, 2009) 5. quality assurance: this is one area that is lacking across the continent in ensuring the quality and reliability of laboratory tests. 6. biosafety is often weak, without protocols, posing a risk to laboratory personnel and the general populace. however, the same african countries differ in the way they approach health services, such as laboratory as some have progressed while others have not. for example, zimbabwe have implemented a national laboratory policy and strategic plans as a guide to laboratory system development. other countries focused on strengthening district and primary health systems and accordingly, some established regional and international networks to facilitate resource sharing and collaborations (nzombe et al., 2014; ondoa et al., 2020). laboratory facilities the process of choosing a clinic or hospital for the development of laboratory capacity to support hiv care, including early infant diagnosis (eid), necessitated considering a variety of factors, including the patient load, existing infrastructure, location compared to other program facilities, and local politics. to find potential clinics, the laboratory services’ (nmrl) initiatives coordinated and conferred with local partners and funding agencies, since there were some who were already on the ground, their experiences were key in decision making (kruk et al., 2018). after an identification of a hospital or any suggested, a site inspection was carried out to evaluate the infrastructure for the laboratory, and the staff that was already in place. because of the subpar infrastructure that was already in place, such as the absence of reliable electricity service or running water, there were frequently significant barriers to laboratory development (aluttis et al., 2013; elendu et al., 2025). utility dependability was crucial because the laboratory testing protocol required substantial use of electricity-driven instruments. where electricity was in short supply, the funders would provide funding for the procurement and installation of solar systems and generators including renovations where necessary. where uni-directional was possible, the renovations would provide for such, or recommendations were put forward for consideration with the full committee responsible for such activities. provision of laboratory equipment a needs analysis was the first step in the preliminary laboratory modifications, which also included guaranteeing a dependable supply of water and energy, a backup generator, security, and enough air conditioning capacity. while there was already a patchwork of hiv diagnostics, clinical chemistry, haematology, and cd4+ cell count analysers in situ at national, central, provincial and district hospital laboratories, the programmes expanded and improved access to these essential technologies. we made an effort to supply the same equipment manufacturer and type for all laboratories in compliance with the who's maputo declaration (2008), promoting platform standardisation across facilities. the standardisation of laboratory equipment made it easier to acquire spare parts, expedite training and maintenance, and lower costs overall through larger orders (olalere, gatome-munyua, 2020). the selection criteria also included the availability of in-country servicing and the expected sustainability of manufacturers, vendors, and platforms. following the national rapid test algorithm guidelines adopted in zimbabwe in 2020, hiv tests using chembio and syphilis tests were offered for hiv testing (figure 1). the tiebreaking factor for inconsistent results is insti. the cyflow counter or cyflow ii platform for flow cytometry was used to undertake immunologic monitoring of patients' cd4+ cell counts. the manual cobas amplicor hiv-1 monitor test and the automatic were used for eid testing at the nmrl, mutare and bulawayo sites and were used to assess hiv vls in order to track the effectiveness of virologic treatment. provincial and central hospital laboratories carried out haematology testing using the mindray bc-3200 or any other machine similar to that, where a buffer stock would be kept. unfortunately, due to a lack of funding or commitment from the partner, where drug resistance was supposed to be assessed using the version 2.0 of the viroseq genotyping system (abi genetic analyser 3130) (see figure 2 below), no reagents were procured for the operationalisation of the machine until it developed some problems. 249 mayavo, c. ghmj (global health management journal) 2025, vol. 8, no. 2 figure 1. hiv testing national algorithm used in zimbabwe source: (gregson et al., 2021); quantification report, (2022) figure 2. abi genetic analyser 3130 source: university of delaware (2023) ghmj (global health management journal) 2025, vol. 8, no. 2 mayavo, c. 250 improvement of the laboratories in zimbabwe in many laboratories, improving efficient, logical sample processing requires physical changes to pre-existing buildings or reconfigurations. the ideal sample flow for a laboratory was defined, starting at the arrival bench where samples were logged and divided as required. aliquots of the sample were then moved to laboratory stations for standard testing such as eid, bacteriology, serology, where such names exist, for example at nmrl. following this, the samples were moved to storage and finally to a station where the results were recorded and delivered to the data entry personnel so that they could be entered into the patients' database in the laboratory information management systems (lims). different parts of the assay process were carried out in separate rooms for more complex tests, such as deoxyrobinucleic acid polymerase chain reaction (dna pcr), with access limited to trained laboratory personnel in order to reduce the possibility of contamination. the proper handling of biohazard waste was ensured, for example, at nmrl, where one of the vl machines (biomeriux) was producing cyanide and biosafety and fire preparedness procedures were reviewed and updated. laboratory security was improved by both physical and signs as provided for in the quality management system, staff trainings were provided for all who work in the laboratory. laboratory data were kept up to date in accordance with national requirements and kept secure in places with stringent access controls. the commodity supply perspective in order to maximise the efficiency of purchasing equipment and consumables, procurement procedures were developed from the government level (procurement regulations) and the funders’ level (sops). these procedures ranged from increasing the use of cold chain and non-cold chain reagents and holding regular meetings with local laboratory logistics and to collaborating with supply chain management systems (scms) and the clinton health access initiative (chai) and other funders in order to obtain the necessary test kits. 5 national pharmaceutical company (natpharm) warehouses were used, two in the south (bulawayo and masvingo) and one in the central (national pharmaceutical council hq, harare) and one in the western part of the country (chinhoyi), to keep all the materials for distribution to the laboratory sites. to organise and accelerate the distribution of supplies to the sites, a laboratory logistics manager and a deputy were employed through jsi, and then currently chemonics, and their offices are situated at the natpharm hq in harare, where they provide guidance and distribution of all the commodities. they collaborated to do this with natpharm, and the transport system is from the natpharm side, which sees the other general employees, such as the driver and the assistants, including the warehouse employee and the servicing of the fleet. recently, due to cold storage commodities for vl and other tests, the global fund acquired more cold chain trucks to support the zimbabwe laboratory commodities supply system (zilacods). training for laboratory personnel the initial training and mentoring of the central, provincial and district satellite laboratories was largely the responsibility of the national reference laboratory. the national reference laboratory is charged with the responsibility of conducting training for all laboratory staff and reporting issues that require attention to either local site management or higher levels of program management (sadc secretariat, 2015). the workshops vary depending on the availability of funding for such activity. in the case of the laboratory work, trainings were conducted within a specific laboratory and other workshops were conducted at a chosen central place or two workshops were conducted, one in the northern and the other in the southern region. trainings on quality issues was done at each laboratory, no matter how far they are with accreditation process, mentors were employed per province and one at the national level. additionally, other workshops were conducted in different locations (s) and normally had 40 to 50 participants. this kind of gathering was perfect for enhancing laboratory quality overall, discussing modifications to program policy, reaching consensus on decisions, and enabling smaller laboratory groups to work closely with more seasoned peers. furthermore, funders also helped the laboratory to conduct workshops on a strategic plan where key stakeholders are gathered mainly for one week out of station planning for the laboratory's way forward, and normally this happens at the beginning of the year, guided by a technical advisor or laboratory services directorate. 251 mayavo, c. ghmj (global health management journal) 2025, vol. 8, no. 2 bioengineering a good laboratory infrastructure requires regular equipment maintenance, especially in environments with restricted resources. the global fund has been responsible for the service contract management of the laboratory equipment, where they would advertise for the local companies representing the various equipment on the ground to provide quotations for the services (global fund, 2013). after the approval, the engineers from various companies would go around the country servicing the machines, and the logistics officer has been responsible for overseeing such activities, and the same office confirms whether the machines were serviced or not from the laboratory staff on the ground. additionally, where equipment parts became an issue, the engaged companies were responsible for sourcing such parts and a duty-free was provided by the ministry of health and child care, through the logistics office or nmrl (ministry of health and child care, 2022). however, the companies were responsible for making sure that their bioengineers are trained thoroughly by their parent company, such as becton dickinson (bd), etc. most laboratories featured on-site engineers with various levels of specialisation. the engineers were travelling to other sites for predetermined repairs as well as regularly planned periodic preventive maintenance. furthermore, these companies have been responsible for making sure that they retain and train the engineers to be able to service and maintain the laboratory equipment. laboratory information management system using lmis data management team led by the it manager, they created an intuitive electronic medical records system that allowed for the consolidation of all laboratory data from the provincial, central and national levels. these important program areas were, whenever possible, connected by local computer networks within each location. senaite utility software tools were designed to import electronic laboratory results directly into databases when possible or man-made entered using the data entry officers recruited through the global fund at the national level, eid centres such as mutare and mpilo laboratories, and then scientists in other laboratories (kruk et al., 2018; zimuto et al., 2016). the senaite is an open-source system which is as good as crm, it can help the laboratory to record laboratory results, to store and management of the same. however, the laboratory in zimbabwe only uses it for laboratory information systems. additionally, laboratories are equipped with state-ofthe-art computers desktop computers with an internet connection so that laboratory data entered can communicate with the program and use it as a resource. 3. methods laboratories were set up utilising a top-down paradigm, with the national microbiology reference laboratory (nmrl) at the centre supporting central and provincial laboratories and basic health clinics (figure 1). this study adopted a qualitative research method based on secondary data collected from laboratory documentation, including websites such as sadcas (butcher, 2022). the study focused mainly on laboratories in districts, provinces and central within zimbabwe, on the improvements made in support of hiv/tb care in zimbabwe. the inclusion criteria were that the laboratory is participating in the accreditation process and are at district, provincial and central levels (see figure 3) and is a public health facility. however, the exclusion was that the laboratory is not participating in the accreditation process and the lower-level laboratories such as those stationed at clinics. additionally, private laboratories were not included in this study. the central and core laboratory is the national microbiology reference laboratory (nmrl) and logistics department are responsible for overseeing these other laboratories, logistics is responsible for the provision of equipment and testing reagents and other supporting commodities, and the nmrl oversees the testing side of these other laboratories and related research institutions that have extensive hiv art programs (ministry of health and child care, 2022). haematology, clinical chemistry, and hiv serology tests were all offered by central and provincial laboratories under hospital management. additionally, they may hold plasma samples for viral load (vl) testing and dried blood spot (dbs) samples for early baby diagnosis for up to two weeks before being transported to a related national laboratory. primary health clinics are smaller medical facilities that offer primary care, test people for hiv quickly, take blood samples for further testing, and refer patients to central or provincial health care institutions (ministry of health and child care, 2021). ghmj (global health management journal) 2025, vol. 8, no. 2 mayavo, c. 252 figure 1: integrated laboratory tier system source: adapted from national health laboratory strategic plan (2021) 4. results by 2017, only one public laboratory had been accredited by sadcas due to great support from various funders (gf responsible for scientists and data officers), scms responsible for procurement of commodities to avoid stockouts. currently, as i write this paper, zimbabwe is seated at 13 public health medical laboratories accredited to sadcas and still maintaining their statuses after the assessments and reassessments by the statutory board (guzel & guner, 2009). the accredited laboratories are a mixed bag, i.e. the central, provincial and national laboratories (see sadcas website). all laboratories are housed in permanent structures with running water, electricity, backup generators and solar systems, and other necessities; nmrl and other public medical laboratories underwent significant improvements to ensure smooth operation and long-term sustainability, with funding from various donors. the logical workflow re-modelling of the molecular and level 3 laboratories are two notable examples of successful laboratory reorganisation. rapid test methods, automated haematology, clinical chemistry, laser-based cd4+ cell enumeration, vl quantification, and baby dna pcr diagnosis were and are all used at the provincial and central laboratory sites to offer hiv sero-diagnosis. hiv fast testing, haematology, clinical chemistry, and cd4+ cell count enumeration were all accessible through the central, provincial and district laboratories. with the cobas ampliprep/taqman hiv-1 test, version 2.0, the laboratory (nmrl) began switching to automated vl equipment in late 2017. for tb, only two sites had a hain machine for testing, that is, bulawayo tb laboratory and the nmrl, and dedicated scientists were employed through the global fund and tb programme (global fund, 2013). “we started screening particular groups at two locations for mdr-tb using mtbdrplus test and suggested the nationwide tb control program use this test for broader national surveillance”, one scientist said. this statement was in connection with tb related scale-up where they started with only two sites which were funded by various donors, but they have since increased to many tb testing sites using current technologies. with the assistance of chai and the us centres for disease control and prevention (cdc) office, laboratories with pcr testing capacity were also able to perform eid testing of dbs samples in support of the national early infant diagnosis (eid) program (haeri mazanderani et al., 2017; sirirungsi et al., 2016). greater security measures were also added to stock management as reporting to the national logistics is done every first week of the month electronically, the reporting is taken as a consumption 253 mayavo, c. ghmj (global health management journal) 2025, vol. 8, no. 2 monitoring tool, and where an anomaly appears, the responsible laboratory should explain such. stock cards are in use for every commodity supplied to the station, whether from the donor or the government (bendavid, 2016; rechel & mckee, 2012). test costs were decreased for vl testing performed with manual roche amplicor kits and other platforms from as high as usd50.00 to as low as usd14.00, depending on the test performed and the platform (elsbernd et al., 2022). 5. discussion the aim of providing the best possible healthcare was enlarged by the training and mentorship activities beyond enhancements of certain laboratory services to support the ongoing art programmes. the programmes aimed to go beyond art delivery and include the advantages of new equipment technologies and procedures throughout the hospitals and clinics. for instance, different hospital departments were allowed to employ portable tbdiagnostic x-ray equipment because of the donor support. we discovered that using training-of-trainer and stepdown training methods was a very cost-effective method of distributing training throughout program laboratories and local laboratory systems and this was a similar approach taken in quality management systems, which have seen many laboratories being accredited to sadcas. centralised laboratory conferences improved communication between laboratory staff and program administration. the program personnel had continuous assurance of standardisation across all program laboratories thanks to these central administration and partners who continuously fund the laboratory sector (church & naugler, 2019). now with the coming in of social media technology, the staff in the set-up can share the success story and challenges, easily assist each other with problem solving, which has seen an upward performance of the laboratory services and the programme managers. these regional trainings covered a wide range of topics, including reorganizing the laboratory staff, beginning a trial of a new diagnostic point-of-care platform, and troubleshooting an assay that was performing outside of expectations, coordination with clinical and pharmaceutical training teams was sought in order to increase and inform laboratory members of any updates to other program areas that could have an influence on laboratory operations, such as the introduction of new medications or drug regimens with a special toxicity concern, and to incorporate laboratory issues into their trainings (ferrando & lorenzo-seva, 2018; hamel et al., 2015b; kruk et al., 2012). laboratory logistics unit always make sure that the breakdowns are kept to a bare minimum as a way of avoiding expiries, which means they are actively engaging the suppliers who are responsible for the equipment dotted around the country. this makes sure that sustainability is always maintained, as well as a cost-cutting measure. where there are concerns, the directorate of laboratory services and the partners work together to find lasting solutions. both computerised data capture and better test results distribution to clinical staff and patients saw notable improvements. the possibility of transcription errors was reduced through the employment of data capturers funded by the global fund (global fund, 2013). when compared to the previous technique, which exclusively used handwritten logs and was done by the scientists, the inclusion of data captures decreased the turnaround times for laboratory results by a good number of days. the ability to make changes quickly as laboratory technology advanced was one benefit of developing a laboratory-specific database system called the laboratory information system. the creation and implementation of an electronic database for gathering patient laboratory information and then sending reports across local networks to the clinic was one of the benefits of a laboratory information system (ajzen, 1991; ferrando & lorenzo-seva, 2018; hamid et al., 2022). the tools provided quick results transmission from the laboratory to clinics, as well as to the patient is also advised to visit the clinic through an sms stating that your results are out visit the clinic for assistance. the communication of laboratory results to the clinical decision-making team and the patient was one of the missing links in hiv, and therefore, the patient will be helped to maintain adherence to the treatment regimen. ghmj (global health management journal) 2025, vol. 8, no. 2 mayavo, c. 254 6. conclusion the laboratory performance system in zimbabwe has improved so much compared to the early 2000s years when it was difficult to find hiv/aids/tb testing centres and a lack of personnel (dupwa et al., 2019; elendu et al., 2025; isah, 2025). currently, the workload is being shared with the help of partners and donors who have managed to maintain the procurement of commodities and services, recruitment of qualified personnel from scientists to support staff. several public health medical laboratories are accredited to international standards (iso 15189). this progress has a positive influence, and this research would encourage the policy makers to look at the whole health system to move in the same direction with the laboratory services. the study concluded that improving laboratory performance assists the government as it moves closer to meeting its 2030 agenda, mainly sdg 3. additionally, the study has concluded that the government of zimbabwe should not fold hands, but should take the gesture by the donors to improve their funding capacity such that when some of them pulls out like what happened with usaid and pepfar, the government would be in a position to take over the whole system and maintain the standards set up by the donors and partners. study limitation the study did not collect data from the users of the laboratory system but used various websites and documents available to support the objective of this study. i would think that maybe if the data were collected from the laboratory service employees and users of the services, the results may be a bit different, however, the websites used are well-trusted sources across the african region. the paper is limited to the current settings with the zimbabwe laboratory landscape considering that some donors such as pepfar, usaid were disbanded by the united state of america president recently. this may have implications on the gains laboratory had gained through the years (akingbola et al., 2025; meyer-rath et al., 2025). additionally, this paper is not a systematic review or meta and may not capture the full landscape of the laboratory services in zimbabwe and around the world. conflict of interest i declare that no conflict of interest regarding this paper. references adekoya, a., okezue, m. a., & menon, k. (2025). medical laboratories in healthcare delivery: a systematic review of their roles and impact. laboratories, 2(1), 8. https://doi.org/10.3390/laboratories2010008 akingbola, a., adegbesan, a., mariaria, p., isaiah, o., & adeyemi, e. (2025). a pause that hurts: the global impact of halting pepfar funding for hiv/aids programs. infectious diseases, 57(4), 378–384. https://doi.org/10.1080/23744235.2025.2464857 aluttis et al. (2013). public health capacity in the eurpoean union. bendavid, e. (2016). past and future performance: pepfar in the landscape of foreign aid for health. current hiv/aids reports, 13(5), 256–262. https://doi.org/10.1007/s11904-016-0326-8 chihaka, s. and dhlakama, d. (2009). ‘developing a national health strategy 2008–2013’. working consultative document. ministry of health and child welfare. church, d. l., & naugler, c. (2019). benefits and risks of standardization, harmonization and conformity to opinion in clinical laboratories. critical reviews in clinical laboratory sciences, 56(5), 287–306. https://doi.org/10.1080/10408363.2019.1615408 dacombe, r, bates, i, bhardwaj, m, wallis, s, & pulford, j. (2016). an analysis of approaches to laboratory capacity strengthening for drug resistant infections in low and middle income countries. (pp. 1–148). liverpool school of tropical medicine. https://doi.org/10.3390/laboratories2010008 https://doi.org/10.1080/23744235.2025.2464857 https://doi.org/10.1007/s11904-016-0326-8 https://doi.org/10.1080/10408363.2019.1615408 255 mayavo, c. ghmj (global health management journal) 2025, vol. 8, no. 2 dupwa, b., kumar, a. m. v., tripathy, j. p., mugurungi, o., takarinda, k. c., dzangare, j., bara, h., & mukeredzi, i. (2019). retesting for verification of hiv diagnosis before antiretroviral therapy initiation in harare, zimbabwe: is there a gap between policy and practice? transactions of the royal society of tropical medicine and hygiene, 113(10), 610–616. https://doi.org/10.1093/trstmh/trz047 elendu, c., amaechi, d. c., elendu, t. c., amaechi, e. c., elendu, i. d., akpa, k. n., oloyede, p. o., adegbola, m. o., & idowu, o. f. (2025). shaping sustainable paths for hiv/aids funding: a review and reminder. annals of medicine & surgery, 87(3), 1415–1445. https://doi.org/10.1097/ms9.0000000000002976 global fund. (2013). audit of global fund grants to the republic of zimbabwe (pp. 1–42). 1 http://audit-publicdisclosure.undp.org/view_audit_rpt_2.cfm?audit_id=1089 gregson, s., moorhouse, l., dadirai, t., sheppard, h., mayini, j., beckmann, n., skovdal, m., dzangare, j., moyo, b., maswera, r., pinsky, b. a., mharakurwa, s., francis, i., mugurungi, o., & nyamukapa, c. (2021). comprehensive investigation of sources of misclassification errors in routine hiv testing in zimbabwe. journal of the international aids society, 24(4). https://doi.org/10.1002/jia2.25700 haeri mazanderani, a., moyo, f., & sherman, g. g. (2017). missed diagnostic opportunities within south africa’s early infant diagnosis program, 2010–2015. plos one, 12(5), e0177173. https://doi.org/10.1371/journal.pone.0177173 hamel, d. j., sankalé, j.-l., samuels, j. o., sarr, a. d., chaplin, b., ofuche, e., meloni, s. t., okonkwo, p., & kanki, p. j. (2015). building laboratory capacity to support hiv care in nigeria: harvard/apin pepfar, 2004–2012. african journal of laboratory medicine, 4(1), 10 pages. https://doi.org/10.4102/ajlm.v4i1.190 howard, a. a., gasana, m., getahun, h., harries, a., lawn, s. d., miller, b., nelson, l., sitienei, j., & coggin, w. l. (2012). pepfar support for the scaling up of collaborative tb/hiv activities. jaids journal of acquired immune deficiency syndromes, 60(supplement 3), s136–s144. https://doi.org/10.1097/qai.0b013e31825cfe8e isah, m. (2025). new era for zimbabwe polio lab after biggest upgrade in 20 years. new era for zimbabwe polio lab after biggest upgrade in 20 years. https://ehealthafrica.org/new-era-for-zimbabwe-polio-lab-after-biggestupgrade-in-20-years/ kruk, m. e., gage, a. d., arsenault, c., jordan, k., leslie, h. h., roder-dewan, s., adeyi, o., barker, p., daelmans, b., doubova, s. v., english, m., garcía-elorrio, e., guanais, f., gureje, o., hirschhorn, l. r., jiang, l., kelley, e., lemango, e. t., liljestrand, j., … pate, m. (2018). high-quality health systems in the sustainable development goals era: time for a revolution. the lancet global health, 6(11), e1196–e1252. https://doi.org/10.1016/s2214-109x(18)30386-3 lingg, m., wyss, k., & durán-arenas, l. (2016). effects of procurement practices on quality of medical device or service received: a qualitative study comparing countries. bmc health services research, 16(1), 362. https://doi.org/10.1186/s12913-016-1610-4 mayavo, c. (2023). towards the development of a sustainable procurement framework for improved operational efficiency in donor-funded procurements in the zimbabwean public health laboratory services. university of the witwatersrand. mayavo, c. (2024). donor-funded procurement effectiveness in the public health medical laboratory services: examining the moderation role for government policy in donor-support. ghmj (global health management journal), 7(2), 55– 65. https://doi.org/10.35898/ghmj-72984 mayavo, c., & saruchera, f. (2024). donor-funded procurement determinants and effectiveness of procurement in the public health medical laboratory services: examining the mediating factors. international journal of procurement management, 20(5), 1–19. https://doi.org/10.1504/ijpm.2024.138755 meyer-rath, g., jamieson, l., mudimu, e., imai-eaton, j. w., & johnson, l. f. (2025). the cost of the plunge: the impact and cost of a cessation of pepfar-supported services in south africa. cold spring harbor laboratory. https://doi.org/10.1101/2025.04.22.25326207 ministry of health and child care (2021). national health laboratory strategic plan. harare, zimbabwe ministry of health and child care. (2022). national quantification for laboratory commodities (pp. 1–42). ministry of health and child care. nzombe, p., luman, e. t., shumba, e., mangwanya, d., simbi, r., kilmarx, p. h., & zimuto, s. n. (2014). maximising mentorship: variations in laboratory mentorship models implemented in zimbabwe. african journal of laboratory medicine, 3(2), 8 pages. https://doi.org/10.4102/ajlm.v3i2.241 olalere, n., gatome-munyua, a. (2020). public financing for health in abuja: 15% of an elephant is not 15% of a chicken. africa renewal. ondoa, p., ndlovu, n., keita, m.-s., massinga-loembe, m., kebede, y., odhiambo, c., mekonen, t., ashenafi, a., kebede, a., & nkengasong, j. (2020). preparing national tiered laboratory systems and networks to advance diagnostics in africa and meet the continent’s health agenda: insights into priority areas for improvement. african journal of laboratory medicine, 9(2). https://doi.org/10.4102/ajlm.v9i2.1103 https://doi.org/10.1093/trstmh/trz047 https://doi.org/10.1097/ms9.0000000000002976 http://audit-public-disclosure.undp.org/view_audit_rpt_2.cfm?audit_id=1089 http://audit-public-disclosure.undp.org/view_audit_rpt_2.cfm?audit_id=1089 https://doi.org/10.1002/jia2.25700 https://doi.org/10.1371/journal.pone.0177173 https://doi.org/10.4102/ajlm.v4i1.190 https://doi.org/10.1097/qai.0b013e31825cfe8e https://ehealthafrica.org/new-era-for-zimbabwe-polio-lab-after-biggest-upgrade-in-20-years/ https://ehealthafrica.org/new-era-for-zimbabwe-polio-lab-after-biggest-upgrade-in-20-years/ https://doi.org/10.1016/s2214-109x(18)30386-3 https://doi.org/10.1186/s12913-016-1610-4 https://doi.org/10.35898/ghmj-72984 https://doi.org/10.1504/ijpm.2024.138755 https://doi.org/10.1101/2025.04.22.25326207 https://doi.org/10.4102/ajlm.v3i2.241 https://doi.org/10.4102/ajlm.v9i2.1103 ghmj (global health management journal) 2025, vol. 8, no. 2 mayavo, c. 256 ondoa, p., van der broek, a., jansen, c., de bruijn, h., & schultsz, c. (2017). national laboratory policies and plans in sub-saharan african countries: gaps and opportunities. african journal of laboratory medicine, 6(1). https://doi.org/10.4102/ajlm.v6i1.578 rechel & mckee. (2012). organisational models for delivering essential public health capacity in europe. robert, e., zongo, s., rajan, d., & ridde, v. (2022). contributing to collaborative health governance in africa: a realist evaluation of the universal health coverage partnership. bmc health services research, 22(1), 753. https://doi.org/10.1186/s12913-022-08120-0 sadcas website: https://www.sadcas.org/accreditedorganizations?field_organization_type_tid=11&title=&field_country_value=zw &field_accreditation_number_value=&page=3 sadc secretariat. (2015). functions and minimum standards for national reference laboratories in the sadc region (pp. 1–25). safi, m., bertram, m. l., & gulis, g. (2020). assessing delivery of selected public health operations via essential public health operation framework. international journal of environmental research and public health, 17(17), 6435. https://doi.org/10.3390/ijerph17176435 sirirungsi, w., khamduang, w., collins, i. j., pusamang, a., leechanachai, p., chaivooth, s., ngo-giang-huong, n., & samleerat, t. (2016). early infant hiv diagnosis and entry to hiv care cascade in thailand: an observational study. the lancet hiv, 3(6), e259–e265. https://doi.org/10.1016/s2352-3018(16)00045-x university of delaware (2023). abi genetic analyser 3130. https://www.dbi.udel.edu/resources-and-facilities/dnasequencing-genotyping-center zimuto, s., mtambara, a., cheng, b., cunningham, b., taruvinga, r., boeras, d. i., & simbi, r. (2016). quality assurance for point-of-care testing in zimbabwe. african journal of laboratory medicine, 5(2). https://doi.org/10.4102/ajlm.v5i2.448 cite this article as: mayavo, c. (2025). strengthening laboratory capabilities in improving hiv/aids and other diseases support in zimbabwe. ghmj (global health management journal), 8(2), 245–256. https://doi.org/10.35898/ghmj-82992 https://doi.org/10.4102/ajlm.v6i1.578 https://doi.org/10.1186/s12913-022-08120-0 https://www.sadcas.org/accreditedorganizations?field_organization_type_tid=11&title=&field_country_value=zw&field_accreditation_number_value=&page=3 https://www.sadcas.org/accreditedorganizations?field_organization_type_tid=11&title=&field_country_value=zw&field_accreditation_number_value=&page=3 https://doi.org/10.3390/ijerph17176435 https://doi.org/10.1016/s2352-3018(16)00045-x https://www.dbi.udel.edu/resources-and-facilities/dna-sequencing-genotyping-center https://www.dbi.udel.edu/resources-and-facilities/dna-sequencing-genotyping-center https://doi.org/10.4102/ajlm.v5i2.448 https://doi.org/10.35898/ghmj-82992